Silke Huffziger

Rumination, distraction, and mindful self-focus in depressed patients.

Rumination has been proposed as a cognitive risk factor for the onset and maintenance of depression. In parallel, mindfulness interventions have shown to reduce the risk for recurrence of depressive episodes. This study aimed to investigate effects of short periods of induced rumination, distraction, and mindful self-focus on sad mood in depressed patients and to assess possible moderator effects of habitual variables on respective mood changes. Seventy-six depressed patients 3.5 years after discharge from inpatient treatment were subjected to negative mood induction and subsequently randomly assigned to a rumination, distraction, or mindful self-focus induction. Habitual aspects of rumination, distraction, and mindfulness were assessed by questionnaires. Compared to rumination, the induction of a mindful self-focus and of distraction showed clear beneficial effects on the course of negative mood. While habitual distraction predicted better mood outcomes across all conditions, patients high in habitual mindfulness tended to show stronger negative mood reduction specifically after the induction of a mindful self-focus. This study indicates that - similar to distraction - an experimentally induced mindful self-focus is able to reduce negative mood in depressed patients. Implications regarding possible subgroups of patients who might particularly benefit from mindfulness-based interventions are discussed.

Decreased cortisol response to awakening is associated with cognitive vulnerability to depression in a nonclinical sample of young adults.

Due to its high intraindividual stability, the cortisol awakening response (CAR) may be regarded as a trait measure of the dynamics of the HPA-axis activity. The present study aimed at investigating associations of the CAR with rumination as a cognitive vulnerability marker for depression assessed by both a trait measure and by experimental manipulation. After induction of sad mood by viewing a sad sequence of a movie, 42 healthy university students were randomly induced to either ruminatively self-focus on their feelings or to distract themselves from their mood by concentrating on respective text cards for 8min. Trait rumination and distraction were measured by the Response Styles Questionnaire (RSQ) at baseline (T0), while current mood was recorded before (T1) and after (T2) the mood induction as well as after the rumination/distraction induction (T3) using the Positive and Negative Affect Schedule (PANAS). Basal saliva cortisol levels were measured independently on a different day. After mood induction, levels of mood were lowered significantly. Participants subsequently induced to ruminate kept their negative mood whereas participants induced to distract themselves showed a reduction in negative mood. Self-focused trait rumination amplified low mood in both induction conditions. A decreased CAR was associated with self-focused rumination and with less improvement of sad mood after induced distraction. We conclude that the two variables apparently share specific vulnerability qualities towards depression by hampering the adaptive shift of attention to external cues during dysphoric moods, probably involving lowered disinhibition of task-irrelevant negative emotional processing. The present study provided first indications of a possible relationship between a cognitive vulnerability marker for depression and characteristics of basal neuroendocrine activity regarding their association with the course of experimentally induced dysphoric mood.

A longitudinal study of rumination and distraction in formerly depressed inpatients and community controls.

The response styles theory (S. Nolen-Hoeksema, B. E. Wisco, & S. Lyubomirsky, 2008) supposes that ruminative coping is a cognitive risk factor for the course of depression, whereas distractive coping has protective effects. The authors present a longitudinal study on reciprocal relations between coping styles and depressive symptoms. They investigated 82 formerly depressed inpatients 4 weeks, 6 months, and 3.5 years after hospital discharge together with 76 age- and gender-matched community controls. Depressive symptoms predicted future symptom-focused rumination over the initial short-term interval in both samples. In former inpatients, this predictive effect was also significant over the subsequent long-term interval. Symptom-focused rumination and distraction were significant predictors of future depressive symptoms across both intervals, with sample-specific effects. In the community sample, symptom-focused rumination predicted more depressive symptoms, whereas in former inpatients, distractive coping predicted fewer depressive symptoms over time. The authors conclude that interventions aimed at reducing rumination should preferably be applied in preventive and early intervention settings, although in individuals with a history of more severe and long-standing depression rumination might gradually lose its capacity to predict the further illness course. In these persons, interventions should particularly strengthen distractive coping.

Measuring depression with a well-being index: further evidence for the validity of the WHO Well-Being Index (WHO-5) as a measure of the severity of depression.

BACKGROUND In recent years, the WHO Wellbeing Index (WHO-5) has been used as a screening measure for depression. Nevertheless, research on the validity of this measure in the context of clinical depression is sparse. QUESTIONS The aim of the present study was to investigate the measurement invariance of the WHO-5 across depressed and non-depressed individuals, as well as the shape and specificity of its relationship to measures of depression severity. METHOD Of the 414 subjects who completed the WHO-5 and the Beck Depression Inventory-II (BDI-II), 207 had a diagnosis of a major depressive episode (MDE). A subsample also completed the Beck Anxiety Inventory (BAI) and was assessed by clinicians using the Hamilton Depression Rating Scale (HAM-D) and the Hamilton Anxiety Rating Scale (HAM-A). RESULTS The WHO-5 demonstrated strong measurement invariance regarding the presence or absence of a current MDE. The WHO-5 showed a very high negative association with self- and observer-rated measures of depressive symptoms, especially in the range of mild to moderate symptoms. These associations were still substantial after controlling for measures of anxiety symptoms. LIMITATIONS In addition to a diagnostic interview, only one measure for self- and observer-rated symptoms of depression was used. Furthermore, the observer-rated measure was only assessed in one subsample that exhibited a somewhat restricted range of depression severity. CONCLUSION Although this index was originally designed as a measure of well-being, the results support the use of the WHO-5 in the context of depression research.

Effects of mood and rumination on cortisol levels in daily life: An ambulatory assessment study in remitted depressed patients and healthy controls

The influence of naturally occurring emotional and cognitive experiences on hypothalamic-pituitary-adrenal axis (HPAA) activity is still underinvestigated, particularly in clinical populations. The present study examined effects of mood and rumination on cortisol levels in daily life in remitted depressed patients with recurrent episodes or a chronic precourse (n=31) and healthy controls (n=32). Ambulatory assessment of subjective variables (valence, calmness, energetic-arousal, ruminative self-focus), daily stressors, and saliva cortisol samples was performed five times a day on two consecutive workdays, whereby cortisol was collected 20min after the subjective assessments. In addition, depressive symptoms and trait rumination (brooding, reflection) were measured retrospectively. Multilevel models revealed that remitted depressed patients showed lower cortisol activity compared to healthy controls. Depressive symptoms and trait rumination did not predict HPAA activity, whereas, by controlling for daily stressors, higher daily means of ruminative self-focus and lower daily means of valence, energetic arousal and calmness were associated with higher daily cortisol levels. Separate analyses per group revealed that mean daily ruminative self-focus predicted higher cortisol in both samples. In contrast, lower daily means of calmness, but also of valence and energetic arousal, were significantly linked to higher cortisol output only in healthy controls, but not in the patient sample. These findings indicate that naturally occurring rumination and low mood are associated with increased activation of the HPAA in daily life. Moreover, our data revealed a potentially reduced mood-cortisol coupling in remitted recurrent depression, possibly indicating that during the course of recurrent depression HPAA activation might become less responsive toward subtle emotional experiences in natural contexts.

Induced ruminative and mindful attention in everyday life: An experimental ambulatory assessment study

BACKGROUND AND OBJECTIVES Rumination has been proposed as a risk factor for depression, while mindful attention might be protective. Differential effects of these attention foci have so far only been examined in the laboratory. Therefore, we conducted an experimental ambulatory assessment study using ruminative and mindful attention inductions in everyday life to examine their effects in a natural context. METHODS Fifty young adults carried palmtops over three weekdays (rumination induction day, mindful attention induction day, noninduction day; randomized cross-over design). Ten times a day, participants rated ruminative self-focus and mood. On the induction days, they were additionally subjected to 3-min inductions of ruminative or mindful attention at each assessment. RESULTS The two induction modes exhibited differential immediate effects on ruminative self-focus and mood. While induced rumination immediately deteriorated valence and calmness, induced mindful attention specifically enhanced calmness. Depressive symptoms did not moderate these effects. While overall longer term effects of the inductions were missing, the mindful attention day was associated with slightly increasing positive valence over the day. LIMITATIONS The results need to be replicated in high-risk and patient samples to demonstrate the clinical significance of identified effects. CONCLUSIONS Results confirm the emotional relevance of rumination and mindful attention in real world settings. Future work may test whether adaptive attention-focusing instructions delivered in daily life can support clinical interventions.

Response styles to depressed mood affect the long-term course of psychosocial functioning in depressed patients

BACKGROUND Components of psychosocial functioning represent both relevant mental health outcomes and predictors for the further course of illness in patients with depression and other mental illnesses. Determinants of these outcomes beyond residual symptom levels have rarely been investigated. The present study aimed at investigating prospective effects of demographic variables, depression levels, and response styles to depressed mood on future psychosocial functioning outcomes in depressed patients. METHODS We followed up a sample of unipolar depressed inpatients (n=71) one, six, 42, and 66 months after hospital discharge. At each measuring point, patients were assessed with regard to diagnostic status, symptom levels, response styles, subjective quality of life (QoL), and interviewer-rated social and occupational functioning. Longitudinal data were analyzed using time-lagged linear models. RESULTS Controlled for age, sex, and concurrent depression levels, higher symptom-focused rumination predicted lower future QoL in the psychological domain and lower social and occupational functioning. In parallel, higher levels of habitual distraction predicted higher future QoL in the psychological domain. Effects were comparable for men and women. CONCLUSION Given that response styles to depressed mood appear not only to affect the course of depressive symptoms but also future psychosocial outcomes, it is of particular relevance to address these coping styles in psychological therapies for depression and high-risk groups. Future controlled intervention studies should investigate possible specific mechanisms of how response styles may affect psychosocial outcomes.

Examining the Relation Between Mood and Rumination in Remitted Depressed Individuals A Dynamic Systems Analysis

Cognitive theories of recurrent depression suggest that the relationship between mood and cognition is altered by previous depressive episodes. In individuals remitted from depression (RMD) this would be linked to a larger susceptibility for new depressive symptoms. This study explored whether the association between mood and rumination indeed is different between RMD and nondepressed controls relying on dynamic systems theory (DST). From DST we selected entropy, defined here as the level of unpredictability in the relation between mood and rumination, as the main variable of interest. Daily electronic dairy measures of mood and rumination were administered in 31 RMD patients and 32 healthy controls. The results indicate that mean levels of rumination and negative mood were elevated in RMD compared with controls. At the group level, entropy did not differ significantly and entropy was also not associated with the number of episodes. However, entropy predicted depressive symptoms in the RMD group and the brooding subtype of rumination in both groups at the 6-month follow-up. These data are specific for entropy and were not obtained using mean levels of momentary mood and rumination.

Research letter: emotional reactivity to induced rumination predicts 1-year levels of depressive symptoms.

Ruminative coping in response to negative mood has been proposed as a vulnerability factor for depression. Habitual rumination negatively affects the course of dysphoric or depressive episodes, and an experimentally induced ruminative self-focus reliably impairs short-term emotional and cognitive processing in dysphoric individuals (e.g. Joorman & Siemer, 2004 ; Rimes & Watkins, 2005 ; Donaldson et al. 2007 ; Kuehner et al. 2007, 2009 ; Nolen-Hoeksema et al. 2008). However, the predictive value of individual reactivity to induced rumination, i.e. to an induced state of dysfunctional cognitive processing, has so far not been studied, although high reactivity towards a rumination priming procedure in dysphoric subjects could indicate a vulnerability factor for depression. In a recent experimental investigation (Kuehner et al. 2009), we randomized a non-clinical sample of 60 young adults after negative mood induction into a rumination, distraction, and mindful self-focus induction condition. In this study, induced rumination prolonged dysphoric mood and was linked to an increase in dysfunctional attitudes. In a subsample of participants scoring high on the Beck Depression Inventory (BDI-II), induced rumination also affected the cortisol stress response during the experimental session. The aim of the present study was to expand previous research by exploring the role of individual emotional reactivity to induced rumination for the natural longitudinal course of depressive symptoms. For this purpose, we conducted a 1-year follow-up of the Kuehner et al. (2009) cohort. Our hypothesis was that higher individual levels of emotional reactivity to an induced ruminative self-focus at baseline would predict deterioration of depressive symptoms over time. In contrast, we did not expect respective longitudinal associations for the remaining induction conditions (distraction, mindful self-focus). Accordingly, the proposed effect difference across conditions should be demonstrated by a significant statistical interaction of emotional reactivity by induction group in the prediction of follow-up symptoms. Follow-up participants were 56 undergraduate students (93.5% of the original cohort) from different faculties at the University of Mannheim, Germany. The follow-up examination took place after the experimental data of our study had been submitted. Full description of the experimental study is given by Kuehner et al. (2009). Briefly, participants were subjected to a negative mood induction, consisting of sad music and recall of negative life events for 6 min, and were subsequently randomly assigned to a rumination, distraction, or mindful self-focus induction for 8 min, with respective statements presented on cards (adapted paradigm from Lyubomirsky et al. 2003). Depressive symptoms at baseline (before negative mood induction) and after 12 months were assessed with the BDI-II. The Positive and Negative Affect Schedule (PANAS) was employed during the experimental session to assess mood change as a consequence of negative mood induction (T1–T2) and of response induction (rumination, distraction, mindful self focus, T2–T3). For the present analysis, we chose the PANAS negative affect (NA) difference score from T2 to T3 (PANAS-NA-T2T3) to assess individual emotional reactivity to response induction. The NA subscale of the PANAS was preferred over the positive affect (PA) subscale due to its broader empirical evaluation within the context of self-focused attention paradigms (e.g. Mor & Winquist, 2002)#. We performed a multiple regression analysis with BDI-II scores at follow-up as the dependent variable, and BDI-II scores at baseline, group status (rumination versus other conditions

Cognitive and affective trait and state factors influencing the long-term symptom course in remitted depressed patients

), PANAS-NA-T1T2, PANASNA-T2T3, and interaction of group status by PANASNA-T2T3 as independent variables. In addition, partial correlations between PANAS-NA-T2T3 and BDI-II scores at follow-up, controlled for BDI-II scores at baseline, were calculated separately for the rumination and the remaining condition. The follow-up sample consisted of 29 women and 27 men aged 19–28 years (mean¡S.D.=22.1¡2.6). Baseline BDI-II scores did not differ between response