Psychological treatment of depressive rumination
Introduction
Depressive rumination is defined as a response style characterized by repetitive thinking about the symptoms, causes, meanings, and consequences of depression, for example, repeated dwelling on questions like ‘Why did this happen to me? Why do I feel like this? Why do I always react this way?’ [1, 2]. Recent theoretical work has proposed that unresolved goals produce rumination but also that pathological rumination is a mental habit — an automatic cognitive response conditioned to triggering stimuli such as low mood [3••]. Rumination has been identified as a major psychological risk factor for depression, and, hence, as a treatment target. In this review, I consider the background, evidence, and future directions for the psychological treatment of rumination.
Section snippets
Why is rumination an important treatment target?
Although there are effective psychotherapies for depression, less than a third of patients show sustained remission and rates of relapse are high after recovery, indicating a pressing need for better treatments. Targeting mechanisms identified in the maintenance of depression is one approach mooted to improve treatment efficacy and durability. Rumination is a strong candidate mechanism because it has been robustly implicated in the onset and maintenance of depression. In large-scale
Metacognitive therapy
Metacognitive therapy is based on the hypothesis that rumination is initiated by positive metacognitive beliefs about the usefulness of rumination and then exacerbated by negative metacognitive beliefs about the negative consequences of rumination [23]. Metacognitive therapy focuses on challenging these metacognitive beliefs and trains patients to disengage their attention from self-focus to external stimuli. To date, metacognitive therapy has only been examined in a small open case series for
Rumination-focused CBT (RFCBT)
RFCBT [21, 25••, 26] is theoretically informed by experimental research indicating that there are distinct modes of processing during repetitive thinking with distinct consequences [8]: an abstract, decontextualized, and global style, characteristic of depressive rumination, which causally contributes to its maladaptive consequences including poor problem-solving and increased emotional reactivity, relative to a concrete, specific, and contextualized style [27, 28, 29]. Whilst still grounded
Mindfulness-based CBT
Another treatment hypothesized to reduce rumination is Mindfulness-based CBT (MBCT). MBCT is a psychosocial group-based relapse prevention programme that incorporates meditational practice within the framework of CBT principles as a means to increase resilience against depression [34]. A key element is mindfulness practice in which participants learn experientially to maintain their attention to their breath, thoughts, and feelings, and to hold such experiences in awareness, in a non-judgmental
Cognitive bias modification
Cognitive bias modification (CBM) uses systematic practice that introduces training contingencies to modify automatic patterns of processing selectivity, for example, by selectively reinforcing attention towards positive relative to negative words [40]. It has provided evidence that cognitive biases causally contribute to anxiety and depression symptoms and is being developed as a stand-alone or adjunct treatment, with encouraging albeit mixed results [41]. Because CBM can be automated through
Conclusion
In this review, we saw that there are good theoretical and empirical reasons to hypothesize that targeting rumination may enhance treatments for depression. Recent trials of CBT that explicitly targeted rumination support this hypothesis, with large between-treatment group effect sizes that compare favourably to existing treatments and with changes in rumination repeatedly mediating symptom improvement. RFCBT and MBCT look most promising as their benefits have been replicated in multiple RCTs
References and recommended reading
Papers of particular interest, published within the period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Acknowledgements
This article describes work supported by a NARSAD Young Investigator Award and an UK Medical Research Council Experimental Medicine grant to the author.
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