Journal of Behavior Therapy and Experimental Psychiatry
Decision-making and risk aversion among depressive adults
Introduction
Clinical observation and empirical research point to abnormal responses to both positive and negative stimuli among individuals with unipolar depression. Significant loss of interest or pleasure in daily activities is a diagnostic feature of depression (APA, 1994), while negative cognitive schemas or biased information processing also are evident among depressed individuals (Beck et al., 1979, Bower, 1981). A greater understanding of responsivity to valenced stimuli in depression has the potential to inform effective treatments, and vice versa. For example, treatments that address a depressed patient's behavioral responses to positive and negative stimuli have been found to be effective in reducing depressive symptoms (Dimidjian et al., 2006, Jacobson et al., 1996). Behavioral activation treatments for unipolar depression are theorized to work by encouraging patients to approach and engage in rewarding activities and contexts, and to inhibit the behavioral withdrawal often characteristic of depression (Jacobson, Martell, & Dimidjian, 2001). Though behavioral withdrawal may help patients protect themselves from potentially aversive situations (e.g., spending less time with a loved one to avoid rejection or staying home from work to avoid negative feedback from an employer), persistent avoidance also reduces the availability of potentially rewarding stimuli.
In line with treatment outcome studies examining behavioral activation, laboratory-based studies have demonstrated a processing bias toward increased engagement with negative stimuli in depressed individuals when compared to non-depressed controls. For example, depressed individuals have been shown to label mildly happy facial expressions as sad or neutral (Surguladze et al., 2004). Compared to non-depressed controls, depressed individuals responded faster to stimuli cued by a negative word (Mathews et al., 1996, Mogg et al., 1995) or sad face (Gotlib, Krasnoperova, Yue, & Joormann, 2004). In conjunction with a processing bias away from positive stimuli and toward negative stimuli, individuals with unipolar depression may react differently to reward and punishment than their non-depressed counterparts. On a task involving recognition of previously learned stimuli, non-depressed controls modified their response criteria to maximize monetary rewards and minimize punishments, while depressed individuals did not change their style of responding (Henriques & Davidson, 2000). Risk taking, which has been defined as behavior that has the potential for rewards as well as negative consequences (Jessor, 1998, Lejuez et al., 2003), also may be affected by negative mood or depression. Depressed individuals score higher on self-report measures of harm avoidance, including increased responsiveness to signals of aversive stimuli (Joffe, Bagby, Levitt, Regan, & Parker, 1993); however, behavioral correlates of self-reported harm avoidance among depressed individuals have not been reported in the literature. Among healthy controls, individuals who have been induced to a negative mood indicated less risk taking on a self-report measure (Yuen & Lee, 2003), compared to responses before the induction. Other studies using non-clinical samples, however, have indicated no effect of induced negative mood or of naturally occurring low moods on risk taking (Clark et al., 2001, Hockey et al., 2000). Given the relative lack of behavioral data on risk taking in depressed individuals as well as inconsistencies in findings among analogue samples, further research is necessary to determine the effects of depression and depressive symptoms on risk taking behavior in the laboratory.
One behavioral laboratory task that frequently has been used to examine risk taking is the Iowa Gambling Task (IGT; Bechara et al., 1994, Bechara et al., 1997, Damasio, 1994). In this task, participants are presented with four decks of cards. Each time a participant chooses a card, he or she receives a monetary reward, and may receive a monetary penalty. Some of the card decks involve very high rewards and similarly high penalties (the “risky” decks), with an unfavorable reward-to-punishment ratio; other decks involve lower rewards and penalties, but a favorable reward-to-punishment ratio. Task success requires the participant to decide, through trial and error, to choose non-risky decks rather than risky decks. Accordingly, the IGT task can be thought of as a test of one's ability to discern the relative benefit of avoiding punishment over pursuing reward. Several clinical groups have demonstrated poor performance on the IGT (relative to control groups), by choosing predominantly from risky decks, perhaps indicating problems with risk aversion in these groups. Such groups include individuals with damage to the ventromedial prefrontal cortex (Bechara, Damasio, & Damasio, 2000), individuals with a history of suicidality (though not those with a history of affective disorder; Jollant et al., 2005), and persons with sociopathic traits (Mitchell, Colledge, Leonard, & Blair, 2002) or chronic pain (Apkarian et al., 2004). We are not aware of any studies investigating risk aversion using the IGT with individuals experiencing current depressive symptoms.
The primary purpose of the present study was to examine the hypothesis that depression is associated with higher responsivity to negative feedback (i.e., punishment) relative to reward. In line with theoretical accounts of risk taking (Jessor, 1998, Lejuez et al., 2003), we used the IGT to measure decision-making associated with positive and negative feedback. We hypothesized that depressive individuals would demonstrate higher responsivity to negative feedback, through a pattern of initially sampling from all card decks, followed by a sharp decrease in the number of cards chosen from risky decks toward the latter trials of the task. In contrast, we hypothesized that control individuals would demonstrate a similar pattern, but with a less pronounced decrease in choices from risky decks toward the latter trials of the task. Given that the design of the task favors harm avoidance over pursuit of reward, the greater attention to negative stimuli and harm avoidance in the depressive group is hypothesized to drive faster learning. The control group is hypothesized to demonstrate relatively less rapid learning due to greater motivation to pursue the high rewards of the risky decks.
Section snippets
Participants
A total of 85 participants (44 controls, 41 depressive individuals) were recruited for the study. The study protocol was approved by the Institutional Review Board of the Duke University Health System. This study was part of a joint recruitment effort for several concurrent studies of emotion regulation and psychopathology. Participants were recruited via local newspaper and web site advertisements, as well as via flyers posted in campus and medical center locations. Advertisements for
Data screening and transformations
The distribution characteristics were examined, and Kolmogorov–Smirnov tests were used to examine whether the dependent variables of interest were normally distributed. The number of cards from risky decks and net money earned were normally distributed and there were no outliers; therefore, no data transformations were performed.
Depression and response to negative feedback
The primary hypotheses were as follows: (a) both controls and depressed participants would initially sample randomly from the decks, but would then develop an aversion
Discussion
Consistent with previous studies, all participants learned to avoid the risky decks over the course of the task, with significant declines in the number of risky cards selected over time. Depressive participants chose fewer risky cards across the entire task compared to control participants and showed a trend toward winning more money overall. This result only partially supports our hypotheses, in that the depressive group showed better performance across the entire task on average, rather than
Acknowledgements
Work on this manuscript was partially supported by NIMH K23 MH01614-01A3 (T.R.L.) and NIMH T32 MH070448 (M.J.S.). In addition, this study was supported by the Conte Centers for the Neuroscience of Depression under NIMH Grant P50 MH60451 (P.I.: Krishnan). We thank our numerous research assistants for their help in data collection and entry, and our participants for the generous use of their time.
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