Metacognitive Therapy for Depression in Adults: A Waiting List Randomized Controlled Trial with Six Months Follow-Up

Do Patient's Interpersonal Problems Improve Following Metacognitive Therapy? A Systematic Review and Meta-Analysis

Metacognitive therapy (MCT) aims to modify dysfunctional metacognitions that are thought to be universal determinants of emotional distress and psychological dysfunction more generally. MCT is an effective treatment for emotional distress symptoms, but less is known about its effect for other types of psychological problems. Interpersonal problems are common in psychological disorders and should be improved following psychotherapy. Therefore, we conducted a systematic review and meta-analysis of trials on the effects associated with MCT for interpersonal problems among adults with mental health disorders published until 15 November 2023 using PubMed, Cochrane Library and PsycNet. Trials with a minimum of 10 participants were included. A total of six studies based on five trials reported on the effectiveness of MCT for interpersonal problems and met our inclusion criteria. Two trials evaluated MCT for patients with major depressive disorders, two for patients with anxiety disorders and one for borderline personality disorder. Three of the trials were randomized controlled trials. Four of the trials reported follow-up data but varied in their time-points. The within-group effect size estimate from pretreatment to posttreatment across five trials was large (g = 0.865, 95% CI [0.512-1.218]). Our results indicate that MCT is an effective treatment for improving interpersonal problems in individuals with common mental disorders, even though the treatment is short and primarily concern improving mental regulation through modifying metacognitions. While this finding is in line with metacognitive theory, more trials evaluating personality and interpersonal functioning are needed to draw firm conclusions.

Patient motivation and adherence in metacognitive therapy for major depressive disorder: an observational study

The aim of this observational study was to examine the predictive and discriminant validity of patient motivation and adherence in metacognitive therapy (MCT) for depression. Motivational development for recovered- and non-recovered patients was also investigated. Motivation in sessions 1, 4, and 7 was measured using the Motivational Interviewing Skill Code 2.5 (MISC) in a 10-session trial of MCT for depression (N = 37). Adherence was assessed with the CBT compliance measure in session 7. The Beck Depression Inventory measured treatment outcome at 3-year follow-up. Recovered patients developed significantly more change talk and taking steps, and less sustain talk, as therapy progressed, compared to non-recovered patients. Evidence of the predictive validity of motivation in sessions 1 and 4 was limited. Higher sustain talk and taking steps in session 7 were significant predictors of more and less depressive symptoms, respectively. There was a moderate-strong correlation between motivation and adherence. The results confirm the predictive value of MISC in sessions 7 of MCT for depression, and establish differential motivational development between recovered and non-recovered patients. Subsequent research should clarify the discriminant validity and temporal relationships between motivation, adherence, and other clinical variables.

Symptom Change during Waitlist for Medicated and Nonmedicated Patients with Chronic Depression

INTRODUCTION

Patients seeking psychotherapy often spend time on waitlist (WL), the effect of which is largely unknown. WL patients may forego alternative non-psychotherapeutic assistance and thus do more poorly than had they not been placed on a WL. The course of symptoms might also be influenced by use of antidepressant medication (ADM), an issue that remains unexplored in the literature.

OBJECTIVE

In a naturalistic setting, WL symptom change before inpatient psychotherapy (mean weeks of waiting = 22.6) was assessed in a sample (N = 313) of chronically depressed patients.

METHODS

Using the Beck Depression Inventory-II, patients' symptoms were tracked at assessment, when admitted to treatment (i.e., after WL), at posttreatment and 1-year follow-up. Multilevel growth curve analysis was used to examine waitlist change for the whole sample as well as for ADM users and nonmedicated patients.

RESULTS

Symptoms were reduced significantly from assessment to admittance (Cohen's d = 0.47). Symptoms reduced less for ADM users (d = 0.39) than for nonmedicated patients (d = 0.65).

CONCLUSION

The findings indicate that chronically depressed patients experience a decrease in symptoms during WL, quite likely due to treatment expectations. We discuss whether less symptom improvement for ADM users could be attributed to iatrogenic comorbidity and a higher degree of demoralization in this group.

Cognitive processes associated with emotional disorders: implications for efficient psychological treatments

BACKGROUND

Emotional disorders (EDs) are the most prevalent worldwide. Despite psychotherapies are their treatment of choice, there are difficulties to apply them properly in mental health services. Since literature shows that cognitive processes are associated with anxiety and depressive symptoms, more information is needed in order to improve psychological treatments.

AIMS

To determine the relation between cognitive factors with specific and non-specific ED symptoms in order to promote the development of accurate psychological treatments.

METHODS

We analyzed the relation between rumination, worry, and metacognition with generalized anxiety, panic, and depression disorder symptoms from a clinical sample of 116 individuals through correlation and linear regression analyses.

RESULTS

Although each specific disorder had a closer link with a particular cognitive process, all general ED symptoms were associated with the three cognitive factors studied.

CONCLUSIONS

For "pure" disorders, targeting a concrete cognitive process might be an optimal therapeutic option. However, due to the high comorbidity among EDs, we support the dissemination of the transdiagnostic treatment approach in which all cognitive factors are taken into account.

Factors associated with the high susceptibility to depression of women during the perimenopause

OBJECTIVE

This study investigated the factors associated with the high susceptibility of perimenopausal women to depression.

METHODS

A total of 66 perimenopausal women participated in this study. The Zung self-rating depression scale (SDS) was used to evaluate the intensity of depressive symptoms. The modified Kupperman index (KI) was used to assess common perimenopausal symptoms. Psychosocial factors were assessed via the Eysenck Personality Questionnaire, attitudes toward menopause checklist, and metacognition questionnaire (MCQ). Levels of serum estradiol, testosterone, and progesterone were determined.

RESULTS

There were statistically significant associations between SDS standard score and the KI scale score (β = .361, p = .001), years of education (β = -.309, p = .005), and F3 cognitive self-consciousness score of MCQ (β = -.234, p = .032; adjusted R²  = .264, F = 8.759, p < .001).

CONCLUSIONS

High susceptibility to depression of perimenopausal women may be related to lower educational level, more severe perimenopausal symptoms, and altered metacognition.

Effectiveness of Metacognitive Therapy in Patients With Depression and Comorbid Anxiety Symptoms: A Case Series From India

Metacognitive therapy (MCT) is a transdiagnostic intervention used to treat different psychiatric disorders. This intervention is based on the concept that persistent emotional distress is a consequence of a particular way of responding to negative thoughts and emotions. MCT for depression and anxiety aims at targeting rumination, worry, and the dysfunctional metacognitive beliefs underlying these thought processes. The purpose of this study was to explore MCT as a treatment for adult patients with depression (either major depressive disorder (MDD) or recurrent depressive disorder, dysthymia, or mixed anxiety depressive disorder) with comorbid anxiety symptoms. Four men diagnosed with depressive disorder with comorbid anxiety symptoms seeking treatment from the outpatient clinic of the Department of Psychiatry at the All India Institute of Medical Sciences, New Delhi, were recruited for the study. Each patient received 10 individual weekly sessions of MCT, lasting up to 1 hour each. Participants were assessed at baseline, post-intervention (right after completing MCT), and at one-month and two-month follow-ups. Primary outcome measures were a reduction in the severity of depression, anxiety, worry, and rumination. Secondary outcome measures were changes in dysfunctional metacognitive beliefs about worry and rumination. All outcomes were assessed via self-report using standardized questionnaires at baseline, post-intervention, one-month, and two-month follow-up. Data for all the outcome measures (at baseline, post-intervention, one month, and two-month follow-up) were plotted on a graph for visual examination. Additionally, we calculated clinically significant change (≥50% reduction in symptom severity and one other standardized criteria for clinically significant changes) for all the primary outcome measures across the above-mentioned four time points. All four men were single, well-educated, and had a mean age of 25.5±4.79 years. Their mean illness duration was 21±0.64 months. None of them had ever received any psychotherapy for their current illness. They had severe depressive and anxiety symptoms at baseline. Three participants had high scores on the rumination and worry scales. At post-intervention, all the participants had significant improvement on all the primary outcome measures, and they maintained their gains on follow-up assessments. Our study generated preliminary evidence supporting the effectiveness of MCT in treating depressive disorders with comorbid anxiety symptoms in the Indian context.

Metacognitions and brooding predict depressive symptoms in a community adolescent sample

Depressive symptoms are prevalent in adolescence, and girls have higher levels of depressive symptoms and depressive disorder than boys. Rumination and especially brooding, seem to be a central maintaining factor of depressive symptoms, where metacognitions about rumination play a prominent role in maintaining depressive rumination. There is a sex difference in adults in depressive disorder. The current investigation of a high school / community sample of adolescents aged 16-20 from Norway (N = 1198, 62.2% women) found that adolescent women had higher scores than men on all relevant measures: Depressive symptoms, negative and positive metacognitions, pondering, and brooding. A path model for predicting depressive symptoms showed that the major factors for both sexes were negative metacognitions and brooding. The predictors of depressive symptoms were invariant across sex and age groups, suggesting similar underlying mechanisms across these groups. The overall findings suggest that metacognitive therapy may be an efficient intervention for depressive symptoms among adolescents.

Long-term efficacy of metacognitive therapy and cognitive behaviour therapy for depression

OBJECTIVE

To examine the two-year outcomes for depression, anxiety, cognitive and global social functioning after cognitive behavioural therapy (CBT) and metacognitive therapy (MCT) for depression.

METHOD

Participants were 31 adults with a diagnosis of major depressive disorder in a randomised pilot study comparing MCT and CBT. Therapy modality differences in change in depression and anxiety symptoms, dysfunctional attitudes, metacognitions, rumination, worry and global social functioning were examined at the two-year follow-up for those who completed therapy.

RESULTS

Significant improvements, with large effect sizes, were evident for all outcome variables. There were no significant differences in outcome between CBT and MCT. The greatest change over time occurred for depression and anxiety. Large changes were evident for metacognitions, rumination, dysfunctional attitudes, worry and global social functioning. Sixty-seven percent had not experienced a major depression and had been well during all of the past year, prior to the follow-up assessment.

CONCLUSION

The finding at end treatment, of no modality specific differences, was also evident at two-year follow-up. Although CBT and MCT targeted depression, improvements were much wider, and although CBT and MCT take different approaches, both therapies produced positive change over time across all cognitive variables. CBT and MCT provide treatment options, that not only improve the longer-term outcome of depression, but also result in improvements in anxiety, global social functioning and cognitive status.

What is the short-term remission rate for people with untreated depression? A systematic review and meta-analysis

BACKGROUND

Depression is one of the prevalent mental illnesses and leading cause of global disease burden. However, most people with depression do not access treatment. Remission without treatment may occur in some cases of depression. This study aimed to estimate the short-term remission (natural recovery) from untreated depression.

METHODS

A systematic review and meta-analysis was registered on PROSPERO and conducted following PRISMA guidelines. EMBASE, PsycINFO, and PubMed were searched, supplemented with an additional hand search to identify studies reporting natural recovery from untreated depression. Study selection and screening were carried out by three independent reviewers. Methodological quality assessment of the included studies was conducted. Remission was defined as no longer meeting the diagnostic criteria or scoring below the cut off points of the validated tools as reported by the included studies. The data were synthesized using narrative summary and random-effects meta-analysis.

RESULTS

Sixteen waitlist-controlled trial studies were included in the systematic review and meta-analysis. The duration of follow-up ranged from 4 to 12 weeks with a median duration of 8 weeks. The overall pooled remission from untreated depression was 12.5%, 95% confidence interval (7.8, 18.0%). Due to lack of published data, we were unable to determine if the severity of depression symptoms was associated with remission rates.

CONCLUSIONS

Short-term remission from depression without treatment is uncommon. Across studies, 8 - 18% of people remitted without treatment within 12 weeks. Waitlist control groups may not represent all persons with depression.

Metacognitive therapy and work-focused interventions for patients on sick leave due to anxiety and depression: study protocol for a randomised controlled wait-list trial

BACKGROUND

Common mental disorders such as depression and anxiety are major contributors to the global burden of disease. Affected individuals suffer reduced quality of life, impaired functioning and reduced capacity to work. Maintaining employment is an important determinant for health and wellbeing, and the economic impact of depression and anxiety is a significant societal expense. Treatments providing effective symptom reduction and helping patients return to work (RTW) would thus have substantial public health benefits. The present study will explore the effectiveness of metacognitive therapy (MCT) and work-focused interventions on reducing symptoms and increasing RTW rates for patients on sick leave due to depression and anxiety.

METHODS

The study is a randomised controlled wait-list trial (RCT; N = 240). The intervention group will receive protocol-based MCT and work-focused interventions immediately after inclusion. The control condition is a wait-list control group. All patients will receive up to 12 weekly sessions. The study context is a Norwegian outpatient clinic part of a national programme aimed at reducing sick leave. The co-primary outcomes are change in RTW and symptoms of depression and anxiety at the end of treatment. In addition to self-report, sick leave will also be collected from national registries from 2 years prior to intervention to 4 years after intervention. Symptoms of scores will be collected by self-report at pre- and post-treatment and at 6 and 12 months follow-up after treatment. A cost-effectiveness analysis will use total cost and quality-adjusted life-years as the secondary outcomes.

DISCUSSION

There is broad consensus on the importance of identifying treatment that effectively reduces depression and anxiety symptoms and aids RTW. This study is an important contribution to the field as it is the first RCT on MCT and work-focused interventions for patients on sick leave due to anxiety and depression.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03301922 . Registered on October 4, 2017.

Empirical Evidence of the Metacognitive Model of Rumination and Depression in Clinical and Nonclinical Samples: A Systematic Review and Meta-Analysis

Rumination is considered a cognitive vulnerability factor in the development and maintenance of depression. The metacognitive model of rumination and depression suggests that the development of rumination and its association with depression partly depends on metacognitive beliefs. Two metacognitive beliefs about rumination have been identified: positive beliefs about its utility and negative beliefs about the uncontrollability and its negative social consequences. We conducted a systematic review and meta-analysis aimed: (1) to analyze the associations between metacognitive beliefs and rumination and depression; (2) to test the metacognitive model, using a Two-Stage Structural Equation Modeling approach (TSSEM). Literature search retrieved 41 studies. These 41 studies (N = 10,607) were included in the narrative synthesis and meta-analysis, and 16 studies (N = 4477) were comprised for the TSSEM. Results indicated metacognitive beliefs are associated with rumination and depression. Measures on metacognitive beliefs about rumination indicated that positive beliefs showed moderate associations with rumination (r = 0.50), and low with depression (r = 0.27); whereas negative beliefs showed moderate associations with both rumination (r = 0.46) and depression (r = 0.49). These results were consistent across studies using different instruments to measure metacognitive beliefs, and in both clinical and nonclinical samples. Moreover, results of the TSSEM analyses showed that the metacognitive model had a good fit. In sum, our results are in line with the metacognitive model of rumination and depression, highlighting that metacognitive beliefs are relevant factors to understand why people ruminate and get depressed. Future directions and clinical implications are discussed.

Effectiveness of brief group transdiagnostic therapy for emotional disorders in primary care: A randomized controlled trial identifying predictors of outcome

AbstractBrief transdiagnostic psychotherapy is a possible approach for emotional disorders in primary care. The objective of the present randomized controlled trial was to determine its effectiveness compared with the treatment as usual based on pharmacological interventions in patients with mild/moderate symptoms. In addition, emotional regulation strategies and cognitive factors were studied as potential predictors. Participants (N = 105) were assigned to brief group therapy based on the Unified Protocol (n = 53) or treatment as usual (n = 52). They were assessed before and after the interventions. Mean differences and stepwise regression analyses were performed. Brief group transdiagnostic psychotherapy was more effective than medication in reducing all clinical symptoms (p = .007 for generalized anxiety; p = .000 for somatization; p = .000 for panic disorder; and p = .041 for depression) and in modifying emotional regulation strategies and cognitive processes (p = .000 for cognitive reappraisal, expressive suppression, worry, rumination, and metacognition) with moderate/high effect sizes. Besides, it was found that these variables acted as predictors of the therapeutic change. It is concluded that brief therapies could be an accurate treatment for mild/moderate emotional disorders in primary care due to their cost-effective characteristics.

A meta-analysis on heart rate variability biofeedback and depressive symptoms

Heart rate variability biofeedback (HRVB) has been used for a number of years to treat depressive symptoms, a common mental health issue, which is often comorbid with other psychopathological and medical conditions. The aim of the present meta-analysis is to test whether and to what extent HRVB is effective in reducing depressive symptoms in adult patients. We conducted a literature search on Pubmed, ProQuest, Ovid PsycInfo, and Embase up to October 2020, and identified 721 studies. Fourteen studies were included in the meta-analysis. Three meta-regressions were also performed to further test whether publication year, the questionnaire used to assess depressive symptoms, or the interval of time between T0 and T1 moderated the effect of HRVB. Overall, we analysed 14 RCTs with a total of 794 participants. The random effect analysis yielded a medium mean effect size g = 0.38 [95% CI = 0.16, 0.60; 95% PI =  - 0.19, 0.96], z = 3.44, p = 0.0006. The total heterogeneity was significant, QT = 23.49, p = 0.03, I2 = 45%, which suggested a moderate variance among the included studies. The year of publication (χ2(1) = 4.08, p = 0.04) and the questionnaire used to assess symptoms (χ2(4) = 12.65, p = 0.01) significantly moderated the effect of the interventions and reduced heterogeneity. Overall, results showed that HRVB improves depressive symptoms in several psychophysiological conditions in adult samples and should be considered as a valid technique to increase psychological well-being.

Feasibility and outcome of metacognitive therapy for major depressive disorder: a pilot study

BACKGROUND

Several studies have shown the effectiveness of Metacognitive Therapy (MCT) in treating different mental disorders. Most of these studies were performed in English speaking countries using the original English version of the manual. Our study aimed to examine the feasibility of the translated MCT manual in a sample of German patients with major depressive disorder.

METHODS

Twenty outpatients (6 male, 14 female, mean age 42.1y) with major depressive disorder were included. The main outcome was drop-out rate and satisfaction with the treatment; secondary outcomes were changes in metacognitive beliefs assessed with the metacognitive questionnaire 30 (MCQ-30), and symptom reduction measured with the Beck Depression Inventory-2 sum score (BDI-2).

RESULTS

No drop-outs during the treatment and the follow-up phase were observed. Patients and therapists were highly satisfied with MCT treatment. The MCQ-30 significantly declined over the treatment course, paralleled by a significant reduction of the BDI-2 sum scores (from 29 ± 8.6 at T0 to 8.4 ± 9.6 at the end of treatment). The average treatment duration was 10 ± 4 sessions.

CONCLUSIONS

Applying the German version of the manual for Metacognitive Therapy proved to be feasible in the treatment of depressed patients in an outpatient setting. The treatment was well tolerated by German patients. Outcome in terms of reduction of depressive symptoms was good. Remarkable is the comparably short treatment duration which should be investigated further in future studies.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00023644, 17.11.2020 (retrospectively registered).

Temporal and Reciprocal Relations Between Worry and Rumination Among Subgroups of Metacognitive Beliefs

Metacognitive theory provides strong foundation for hypothesizing relations between worry and rumination among subgroups of metacognitive beliefs. However, empirical exploration of prospective and reciprocal relations between worry and rumination are lacking. This study investigated the stability and relations between worry and rumination to better understand how they influence each other over time, and how different levels of metacognitive beliefs affect relations between (i) initial and future worry, and initial and future rumination, and (ii) the cross-lag relations between worry and rumination. Overall, 482 (Females = 63%) participants (Mean age = 26 years) participated in a two-wave data collection and completed the Metacognition Questionnaire (MCQ-30), the Ruminative Response Scale and the Penn State Worry Questionnaire (PSWQ). A multigroup two-wave autoregressive cross-lagged model was estimated. Multigroup autoregression analyses revealed that independent of participants being in the high or low metacognition group, initial levels of worry predicted future levels of worry, as was the case for rumination. Multigroup cross-lagged analyses revealed that initial levels of worry did not predict future levels of rumination in both high and low levels of metacognitions. However, initial rumination predicted future levels of worry in the high metacognitions group, which was not the case for the low metacognitions group. Thus, high levels of metacognitions do not only strengthen the relation between both present and future worry, present and future rumination, but also present rumination with future worry. This finding may imply that those with rumination related conditions at present are more likely in the future to show both rumination and worry related conditions. Conversely, those with worry related conditions show future worry related conditions. These findings may have implications for a clinical sample regarding the high complexity of rumination conditions that may proceed with multifinality causal pathways especially for individuals with high levels of metacognitions. This complexity may be a possible explanation for the limited success in other traditional treatment of rumination related conditions and the relatively high relapse rates for such conditions in clinical samples.

Metacognitive beliefs in depressed in-patients: adaptation and validation of the short version of the Metacognitions Questionnaire (MCQ-30) for French clinical and non-clinical samples

BACKGROUND

The short form of the Metacognitions Questionnaire (MCQ-30) is a brief multi-dimensional measure which explores the metacognitive processes and beliefs about worry and cognition that are central to the vulnerability and maintenance of emotional disorders.

AIMS

The first aim of the study was to create and validate a French version of the MCQ-30 in a non-clinical and a clinical sample of depressed in-patients.

METHOD

A French adaptation of the MCQ-30 was administered to a sample of 467 individuals from the general population and 73 hospitalized patients with major depressive disorder. Internal consistency was measured by Cronbach's alpha reliability coefficients. Factor structure was assessed using a confirmatory factor analysis on the non-clinical group and a multi-trait-multi-method analysis on the psychiatric group. Criterion validity was explored by comparing the scores of the two samples. Measures of rumination, worry and depression were used to explore convergent validity.

RESULTS

Confirmatory factor analysis in the non-clinical sample indicated that the French version of the MCQ-30 has the same factor structure as the MCQ-30's original five-factor solution. In the clinical sample, the multi-trait-multi-method analysis revealed discrepancies with the original factor structure, and the MCQ-30 and its subscales were less reliable. Our results provide evidence of a convergent validity. The MCQ-30 scores were also able to discriminate between psychiatric and non-clinical samples.

CONCLUSIONS

Our results show that the French version of the MCQ-30 is a valid instrument for measuring metacognitive beliefs in non-clinical population. Further research is needed to support its use among depressed in-patients.

Metacognitive Therapy versus Cognitive Behaviour Therapy in Adults with Major Depression: A Parallel Single-Blind Randomised Trial

In the last forty years therapy outcomes for depression have remained the same with approximately 50% of patients responding to treatments. Advances are urgently required. We hypothesised that a recent treatment, metacognitive therapy (MCT), might be more effective, by targeting mental control processes that directly contribute to depression. We assessed the clinical efficacy of MCT compared to current best psychotherapy practice, CBT, in adults with major depressive disorder. A parallel randomized single-blind trial was conducted in a primary care outpatient setting. This trial is registered with the ISCRTN registry, number ISRCTN82799488. In total 174 adults aged 18 years or older meeting Diagnostic and Statistical Manual of Mental Disorders IV criteria for major depressive disorder were eligible and consented to take part. 85 were randomly allocated to MCT and 89 to CBT. Randomisation was performed independently following pre-treatment assessment and was stratified for severity of depression (low < 20 vs high > =20) on the Hamilton Depression Rating Scale (HDRS) and on sex (male/female). Assessors and trial statisticians were blind to treatment allocation. Each treatment arm consisted of up to 24 sessions of up to 60 minutes each, delivered by trained clinical psychologists. The co-primary outcome measures were assessor rated symptom severity on the HDRS and self-reported symptom severity on the Beck Depression Inventory II (BDI-II) at post treatment. Secondary outcomes were scores six months post treatment on these measures and a range of symptom and mechanism variables. A key trial design feature was that each treatment was implemented to maximize individual patient benefit; hence time under therapy and number of sessions delivered could vary. Treated groups in the trial were very similar on most baseline characteristics. Data were analyzed on the basis of intention to treat (ITT). No differences were found on the HDRS at post treatment or follow-up (-0.95 [-2.88 to 0.98], p = 0.336; and -1.61 [-3.65 to 0.43], p = 0.122), but floor effects on this outcome were high. However, a significant difference favouring MCT was found on the BDI-II at post treatment (-5.49 [95% CI -8.90 to -2.08], p = 0.002), which was maintained at six-month follow-up (-4.64 [-8.21 to -1.06], p = 0.011). Following MCT 74% of patients compared with 52% in CBT met formal criteria for recovery on the BDI-II at post treatment (odds-ratio=2.42 [1.20 to 4.92], p = 0.014). At follow-up the proportions were 74% compared to 56% recovery (odds-ratio=2.19 [1.05 to 4.54], p = 0.036). Significant differences favouring MCT, also maintained over time, were observed for most secondary outcomes. The results were robust against controlling for time under therapy and when outcomes were assessed at a common 90 day mid-term time-point. Limitations of the study include the use of only two therapists where one treated 69% of patients, possible allegiance effects as the study was conducted in an established CBT clinic and the chief investigator is the originator of MCT and group differences in time under therapy. Never the less evidence from this study suggests that MCT had considerable beneficial effects in treating depression that may exceed CBT.

Citalopram and metacognitive therapy for depressive symptoms and cognitive emotion regulation in patients with major depressive disorder: A randomized controlled trial

BACKGROUND

Metacognitive therapy (MCT) is a new psychotherapy for depression. This study was conducted to compare the effectiveness of citalopram and MCT on major depressive disorders (MDDs).

MATERIALS AND METHODS

A total of 36 patients with MDD were randomly assigned into three groups of citalopram (n = 12), MCT (n = 16), and control (n = 8). MCT group received ten sessions of metacognition therapy. Citalopram group received 20-40 mg citalopram, and the control group did not receive any interventions. Outcomes were measured using the Beck Depression Inventory-II, Metacognition Questionnaire-30, and Cognitive-Emotion Regulation (CER) Questionnaire. Data were analyzed with ANCOVA using SPSS version 18.

RESULTS

Depression score reduction was significant in both citalopram and metacognitive groups (P < 0.05). However, there was only a statistically significant difference between MCT and control group in CER and metacognition.

CONCLUSION

MCT and citalopram both are effective in symptom reduction in MDD. Furthermore, MCT could lead to more improvement in metacognition, depression symptoms, and CER than citalopram, when treating MDDs.

Group metacognitive therapy for adolescents with anxiety and depressive disorders: A pilot study

OBJECTIVE(S)

The metacognitive model suggests that beliefs about cognition maintain repetitive negative thinking (RNT), a transdiagnostic process that underlies commonly comorbid, emotional disorders. To date, there has been the limited application of metacognitive therapy (MCT) to adolescents. This study aimed to evaluate a six-session group transdiagnostic MCT program for adolescents with anxiety and/or depressive disorders.

METHOD

Participants (N = 10; 3 male, 7 female; average age 15.2 years) completed measures of metacognition and RNT at assessment, baseline period, during treatment, and at 1- and 3-month follow-ups.

RESULTS

Nine participants attended all six treatment sessions and one discontinued after four sessions. At posttreatment and follow-ups, the majority of participants no longer met diagnostic criteria for anxiety or depressive disorders and evidenced a clinically significant or reliable change in metacognitions and RNT.

CONCLUSIONS

Results suggest that group MCT is promising in terms of acceptability and effectiveness for adolescents with anxiety and/or depressive disorders.

Metacognitive Therapy for Depression: A 3-Year Follow-Up Study Assessing Recovery, Relapse, Work Force Participation, and Quality of Life

A major challenge in the treatment of depression has been high relapse rates following treatment. The current study reports results from a 3-year follow-up of patients treated with metacognitive therapy (MCT). Thirty-four of the 39 patients enrolled in the original study attended assessment (participation rate of 87%). There were large reductions in symptoms of depression, anxiety, interpersonal problems, and worry, as well as metacognitive beliefs. Three patients fulfilled diagnostic criteria for axis-I disorders: one with depression and two with generalized anxiety disorder. Sixty percent had not experienced any new depressive episodes in the 3-year follow-up period, and the static relapse rates were low (11-15%). Recovery rates ranged from 69 to 97% depending upon the four different criteria used. Nevertheless, 26% had sought out treatment for depression or other psychological difficulties. Most patients (70%) had experienced negative life events in the follow-up period, but these events did not influence current depression severity. Return to work outcomes were encouraging, as eight out of 13 patients that had been on benefits were no longer receiving benefits. Life satisfaction ratings showed mean scores around 70 (on a 0-100 scale) and showed a moderate to strong negative correlation with depression severity. In conclusion, MCT appears to be promising with respect to long-term effect. Randomized controlled trials should investigate if the long-term effect of MCT surpasses that of other evidence-based treatments for depression.

Breaking the Cybernetic Code: Understanding and Treating the Human Metacognitive Control System to Enhance Mental Health

The self-regulatory executive function (S-REF) model explains the role of strategic processes and metacognition in psychological disorder and was a major influence on the development of metacognitive therapy. The model identifies a universal style of perseverative negative processing termed the cognitive attentional syndrome (CAS), comprised of worry, rumination, and threat monitoring in the development of disorder. The CAS is linked to dysfunctional metacognitions that include beliefs and plans for regulating cognition. In this paper, I extend the theoretical foundations necessary to support further research on mechanisms linking metacognition to cognitive regulation and effective treatment. I propose a metacognitive control system (MCS) of the S-REF that can be usefully distinguished from cognition and is comprised of multiple structures, information, and processes. The MCS monitors and controls activity of the cognitive system and regulates the behavior of neural networks whose activities bias the way cognition is experienced. Metacognitive information involved in the regulation of on-line processing includes metacognitive beliefs, metacognitive procedural commands, and more transient cybernetic code. Separation of the cognitive and metacognitive systems and modeling their relationship presents major implications concerning what should be done in therapy and how it should be done. The paper concludes with an in-depth consideration of methods that strengthen the psychological basis of psychotherapy and aid in understanding and applying metacognitive therapy in particular. Finally, limitations of the model and implications for future research on self-awareness, self-regulation, and metacognition are discussed.

A test of the goodness of fit of the generic metacognitive model of psychopathology symptoms

BACKGROUND

Common mental disorders such as depression and anxiety frequently co-occur and may share etiological mechanisms. The metacognitive model is based on the principle that there are common pathological mechanisms across disorders that account for comorbidity and therefore can be conceptualized in one generic model. A central prediction of the model is that particular metacognitive beliefs concerning the value of worry, and the uncontrollability and danger of cognition are positively correlated with psychopathology symptoms. In the present study, we set out to test the overall fit of this model by assessing generic metacognitive beliefs and judgements of attention control capacity as predictors of common and frequently co-occurring emotional distress symptoms.

METHODS

In a cross-sectional design, 645 participants gathered at convenience completed a battery of self-report questionnaires.

RESULTS

Structural equation modelling indicated a good model fit for the generic metacognitive model, and the predictors accounted for 93% of the variance in distress consisting of depression-, generalized- and social anxiety symptoms.

CONCLUSIONS

This finding supports the generic model and the implication that it can be used as a basis to formulate and treat multiple presenting problems.

A Randomized Controlled Trial of Metacognitive Therapy for Depression: Analysis of 1-Year Follow-Up

This paper reports the 1-year follow-up results from a randomized controlled trial (RCT), which examined the efficacy of metacognitive therapy (MCT) for unipolar depression compared to a waiting condition. Thirty-nine patients with major depression were offered MCT and were divided into two conditions; immediate MCT with 10 weekly sessions or a waiting period that had a 10-week delayed MCT start. Two participants dropped out during the waiting condition. Thirty-four patients participated in the follow-up assessment. Based on the intent-to-treat sample and all patients, 67% were classified as recovered, 13% improved, and 20% were unchanged at 1-year follow-up. For the completers sample 73% recovered, 12% improved, and 15% were unchanged. Five of the 31 patients (13%) that were in remission at post-treatment experienced relapse at 1-year follow-up. Within-group effect sizes were large for reductions in symptoms of depression (d = 2.09) and anxiety (d = 1.16) at 1-year. Treatment response was associated with reductions in rumination, worry, and metacognitive beliefs as predicted by the metacognitive model, but reductions in metacognitions independently predicted reductions in depression scores from pre-treatment to 1-year follow-up. The results suggest that treatment gains are stable at 1-year follow-up. The study sets the stage for future research, which should evaluate MCT over a longer term and compare it with active treatments using suitably powered RCTs.

A Comparison of Metacognitive Therapy in Current Versus Persistent Depressive Disorder - A Pilot Outpatient Study

Background: Metacognitive therapy (MCT) is a modern approach with demonstrated efficacy in current major depressive disorder (MDD). The treatment aims to modify thinking styles of rumination and worry and their underlying metacognitions, which have been shown to be involved in the initiation and perpetuation of MDD. We hypothesized that metacognitive therapy may also be effective in treating persistent depressive disorder (PDD). Methods: Thirty depressed patients (15 with MDD; 15 with PDD) were included. Patients in both groups were comparable on depression severity and sociodemographic characteristics, but PDD was associated with more former treatments. Metacognitive therapy was applied by trained psychotherapists for a mean of 16 weeks. Results: We observed a significant improvement of depressive symptoms in both groups, and comparable remission rates at the end of treatment and after 6 months follow-up. Furthermore, we observed significant and similar levels of improvement in rumination, dysfunctional metacognitions, and anxiety symptoms in both groups. Limitations: The study is limited by the small sample size and a missing independent control group. The effect of the therapeutic alliance was not controlled. The quality of depression rating could have been higher. Conclusions: We demonstrated that metacognitive therapy can successfully be applied to patients with PDD. The observed results were comparable to those obtained for patients with current major depressive disorder. Further studies with larger groups and a randomized design are needed to confirm these promising initial findings.

A Preliminary Evaluation of Transdiagnostic Group Metacognitive Therapy in a Mixed Psychological Disorder Sample

Objective: Comorbidity is common among anxiety and depression. Transdiagnostic treatment approaches have been developed to optimize treatment and offer a more unified approach suitable for individuals with comorbidities. Metacognitive therapy (MCT) is a transdiagnostic therapy for psychological disorder and is based on the metacognitive model. The present study is a service evaluation of the outcomes associated with group MCT delivered to unselected patients at a Danish outpatient clinic.

Methods: A total of 131 self-diagnosed patients received 6 sessions of group MCT. Symptoms of anxiety and depression were measured by the Hospital Anxiety and Depression scale (HADS) and metacognition was assessed using the Cognitive Attentional Syndrome-1 (CAS-1). Participants were assessed at pre-treatment, post-treatment, and at 6 months follow-up as per usual clinic protocol. Linear mixed-effects regressions were used to assess the transdiagnostic effects of group MCT. Treatment effect sizes are reported for subgroups based on participant’s reason for seeking treatment (anxiety, depression, or comorbid). Effect sizes were not conducted for the depression subgroup given the limited number of participants. Clinically significant change is reported for all subgroups.

Results: Group MCT was associated with large effect sizes for symptoms of anxiety and depression for patients seeking treatment for anxiety (d = 1.68), or comorbid (1.82). In addition, 66.7% of patients were classified as recovered at post-treatment, and 12.9% were classified as improved. These results were largely maintained at 6-month follow-up.

Conclusion: These preliminary findings support the continued use of group MCT in the current outpatient clinic and suggest that it may be an efficacious and cost-effective treatment when delivered in “transdiagnostic” groups.

Effectiveness of metacognitive interventions for mental disorders in adults-A systematic review and meta-analysis (METACOG)

We evaluated the effectiveness and acceptability of metacognitive interventions for mental disorders. We searched electronic databases and included randomized and nonrandomized controlled trials comparing metacognitive interventions with other treatments in adults with mental disorders. Primary effectiveness and acceptability outcomes were symptom severity and dropout, respectively. We performed random-effects meta-analyses. We identified Metacognitive Training (MCTrain), Metacognitive Therapy (MCTherap), and Metacognition Reflection and Insight Therapy (MERIT). We included 49 trials with 2,609 patients. In patients with schizophrenia, MCTrain was more effective than a psychological treatment (cognitive remediation, SMD = -0.39). It bordered significance when compared with standard or other psychological treatments. In a post hoc analysis, across all studies, the pooled effect was significant (SMD = -0.31). MCTrain was more effective than standard treatment in patients with obsessive-compulsive disorder (SMD = -0.40). MCTherap was more effective than a waitlist in patients with depression (SMD = -2.80), posttraumatic stress disorder (SMD = -2.36), and psychological treatments (cognitive-behavioural) in patients with anxiety (SMD = -0.46). In patients with depression, MCTherap was not superior to psychological treatment (cognitive-behavioural). For MERIT, the database was too small to allow solid conclusions. Acceptability of metacognitive interventions among patients was high on average. Methodological quality was mostly unclear or moderate. Metacognitive interventions are likely to be effective in alleviating symptom severity in mental disorders. Although their add-on value against existing psychological interventions awaits to be established, potential advantages are their low threshold and economy.

The Efficacy of Metacognitive Therapy: A Systematic Review and Meta-Analysis

Background: Metacognitive therapy (MCT) continues to gain increased ground as a treatment for psychological complaints. During the last years, several clinical trials on the efficacy of MCT have been published. The aim of the current study was to provide an updated meta-analytic review of the effect of MCT for psychological complaints.

Methods: We conducted a systematic search of trials on MCT for young and adult patients with psychological complaints published until January 2018, using PsycINFO, PubMed, the Cochrane Library, and Google Scholar. Trials with a minimum of 10 participants in the MCT condition were included.

Results: A total of 25 studies that examined a variety of psychological complaints met our inclusion criteria, of which 15 were randomized controlled trials. We identified only one trial that was conducted with children and adolescents. In trials with adult patients, large uncontrolled effect size estimates from pre- to post-treatment and follow-up suggest that MCT is effective at reducing symptoms of the targeted primary complaints, anxiety, depression, and dysfunctional metacognitions. The comparison with waitlist control conditions also resulted in a large effect (Hedges' g = 2.06). The comparison of MCT to cognitive and behavioral interventions at post-treatment and at follow-up showed pooled effect sizes (Hedges' g) of 0.69 and 0.37 at post-treatment (k = 8) and follow-up (k = 7), respectively.

Conclusions: Our findings indicate that MCT is an effective treatment for a range of psychological complaints. To date, strongest evidence exists for anxiety and depression. Current results suggest that MCT may be superior to other psychotherapies, including cognitive behavioral interventions. However, more trials with larger number of participants are needed in order to draw firm conclusions.

Metacognition - What did James H. Flavell really say and the implications for the conceptualization and design of metacognitive interventions

In the last two decades years, several interventions have been designed for people with major psychological disorders that all have "metacognitive" in their name: Metacognitive Therapy (MCT), Metacognitive Training (e.g., for people with psychosis) and Metacognitive Reflection and Insight Therapy (MERIT). Two of these interventions are primarily targeted at patients with schizophrenia. Prompted by a recent discussion about what constitutes "true" metacognitive treatment, we will first explore the original concept of metacognition as defined by James H. Flavell. Then, we will describe each approach in detail before highlighting how each intervention picks up on slightly different aspects of Flavell's original metacognitive construct. We will also discuss inherent problems with the label "metacognition."

Metacognitive Therapy for Depression Reduces Interpersonal Problems: Results From a Randomized Controlled Trial

Interpersonal problems are significantly elevated in patients with depression. Metacognitive therapy (MCT) for depression does not address interpersonal problems but is associated with large reduction in depressive symptoms. The main aim of the current study was to explore whether MCT leads to improvements in interpersonal problems in patients with depression. The study was a waitlist controlled trial and assessments took place at pre- and post-treatment as well as 6-month follow-up. At pre-treatment, the sample had more interpersonal problems compared to samples from other studies of psychiatric outpatients. MCT was associated with large reductions in interpersonal problems. Level of interpersonal problems were not related to poorer treatment response. MCT, which does not directly target interpersonal problems, worked well for patients with depression and interpersonal problems. Future research should compare MCT with other evidence-based treatments for patients with depression and interpersonal problems.

A Randomized Controlled Trial Comparing the Attention Training Technique and Mindful Self-Compassion for Students With Symptoms of Depression and Anxiety

The Attention Training Technique (ATT) and Mindful Self-Compassion (MSC) are two promising psychological interventions. ATT is a 12-min auditory exercise designed to strengthen attentional control and promote external focus of attention, while MSC uses guided meditation and exercises designed to promote self-compassion. In this randomized controlled trial (RCT), a three-session intervention trial was conducted in which university students were randomly assigned to either an ATT-group (n = 40) or a MSC-group (n = 41). The students were not assessed with diagnostic interviews but had self-reported symptoms of depression, anxiety, or stress. Participants listened to audiotapes of ATT or MSC before discussing in groups how to apply these principles for their everyday struggles. Participants also listened to audiotapes of ATT and MSC as homework between sessions. Participants in both groups showed significant reductions in symptoms of anxiety and depression accompanied by significant increases in mindfulness, self-compassion, and attention flexibility post-intervention. These results were maintained at 6-month follow-up. Improvement in attention flexibility was the only significant unique predictor of treatment response. The study supports the use of both ATT and MSC for students with symptoms of depression and anxiety. Further, it suggests that symptom improvement is related to changes in attention flexibility across both theoretical frameworks. Future studies should focus on how to strengthen the ability for attention flexibility to optimize treatment for emotional disorder.

Improving the effectiveness of psychological interventions for depression and anxiety in the cardiac rehabilitation pathway using group-based metacognitive therapy (PATHWAY Group MCT): study protocol for a randomised controlled trial

Background

Anxiety and depression are prevalent among cardiac rehabilitation patients but pharmacological and psychological treatments have limited effectiveness in this group. Furthermore, psychological interventions have not been systematically integrated into cardiac rehabilitation services despite being a strategic priority for the UK National Health Service. A promising new treatment, metacognitive therapy, may be well-suited to the needs of cardiac rehabilitation patients and has the potential to improve outcomes. It is based on the metacognitive model, which proposes that a thinking style dominated by rumination, worry and threat monitoring maintains emotional distress. Metacognitive therapy is highly effective at reducing this thinking style and alleviating anxiety and depression in mental health settings. This trial aims to evaluate the effectiveness and cost-effectiveness of group-based metacognitive therapy for cardiac rehabilitation patients with elevated anxiety and/or depressive symptoms.

Methods/Design

The PATHWAY Group-MCT trial is a multicentre, two-arm, single-blind, randomised controlled trial comparing the clinical- and cost-effectiveness of group-based metacognitive therapy plus usual cardiac rehabilitation to usual cardiac rehabilitation alone. Cardiac rehabilitation patients (target sample n = 332) with elevated anxiety and/or depressive symptoms will be recruited across five UK National Health Service Trusts. Participants randomised to the intervention arm will receive six weekly sessions of group-based metacognitive therapy delivered by either cardiac rehabilitation professionals or research nurses. The intervention and control groups will both be offered the usual cardiac rehabilitation programme within their Trust. The primary outcome is severity of anxiety and depressive symptoms at 4-month follow-up measured by the Hospital Anxiety and Depression Scale total score. Secondary outcomes are severity of anxiety/depression at 12-month follow-up, health-related quality of life, severity of post-traumatic stress symptoms and strength of metacognitive beliefs at 4- and 12-month follow-up. Qualitative interviews will help to develop an account of barriers and enablers to the effectiveness of the intervention.

Discussion

This trial will evaluate the effectiveness and cost-effectiveness of group-based metacognitive therapy in alleviating anxiety and depression in cardiac rehabilitation patients. The therapy, if effective, offers the potential to improve psychological wellbeing and quality of life in this large group of patients.

Trial registration

UK Clinical Trials Gateway, ISRCTN74643496, Registered on 8 April 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2593-8) contains supplementary material, which is available to authorized users.

Group Metacognitive Therapy vs. Mindfulness Meditation Therapy in a Transdiagnostic Patient Sample: A Randomised Feasibility Trial

Two transdiagnostic therapies for treating psychological disorder are Metacognitive Therapy (MCT) and Mindfulness Based Stress Reduction (MBSR). These two approaches have yet to be compared and therefore the current study aimed to evaluate the feasibility of a study of group MCT and MBSR in treating anxiety and depression. A feasibility trial with 40 participants (aged 19-56) was conducted. Patients were randomly assigned to receive either eight weeks of group MCT or MBSR. The primary outcome was feasibility which included recruitment rates, retention and treatment acceptability. The primary symptom outcome was the Hospital Anxiety and Depression Scale (HADS) total score, which provided an overall measure of distress. Both treatments were found to be acceptable with low attrition and similar ratings of acceptability. Changes in outcomes were analyzed based on the intention-to-treat principle using mixed effect models. Preliminary analyses revealed that MCT was more effective in treating anxiety and depression in comparison to MBSR, and in reducing both positive and negative metacognitive beliefs. Reliable improvement rates favoured MCT at post-treatment and 6-month follow up. Both treatments appeared to be feasible and acceptable in treating transdiagnostic samples; however, a larger, definitive trial is required. The limitations and directions for future research are discussed.