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Assessing treatments used to reduce rumination and/or worry: A systematic review

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Perseverative cognitions such as rumination and worry are key components of mental illnesses such as depression and anxiety. Given the frequent comorbidity of conditions in which rumination and worry are present, it is possible that they are underpinned by the same cognitive process. Furthermore, rumination and worry appear to be part of a causal chain that can lead to long-term health consequences, including cardiovascular disease and other chronic conditions. It is important therefore to understand what interventions may be useful in reducing their incidence. This systematic review aimed to assess treatments used to reduce worry and/or rumination. As we were interested in understanding the current treatment landscape, we limited our search from 2002 to 2012. Nineteen studies were included in the review and were assessed for methodological quality and treatment integrity. Results suggested that mindfulness-based and cognitive behavioural interventions may be effective in the reduction of both rumination and worry; with both Internet-delivered and face-to-face delivered formats useful. More broadly, it appears that treatments in which participants are encouraged to change their thinking style, or to disengage from emotional response to rumination and/or worry (e.g., through mindful techniques), could be helpful. Implications for treatment and avenues for future research are discussed.
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Assessing treatments used to reduce rumination and/or worry:
A systematic review.
Dawn Querstret Mark Cropley
School of Psychology, University of Surrey School of Psychology, University of Surrey
d.querstret@surrey.ac.uk mark.cropley@surrey.ac.uk
Abstract
Perseverative cognitions such as rumination and worry are key components of mental illnesses
such as depression and anxiety. Given the frequent comorbidity of conditions in which
rumination and worry are present, it is possible that they are underpinned by the same cognitive
process. Furthermore, rumination and worry appear to be part of a causal chain that can lead to
long-term health consequences, including cardiovascular disease and other chronic conditions. It
is important therefore to understand what interventions may be useful in reducing their
incidence. This systematic review aimed to assess treatments used to reduce worry and/or
rumination. As we were interested in understanding the current treatment landscape, we limited
our search from 2002 to 2012. Nineteen studies were included in the review and were assessed
for methodological quality and treatment integrity. Results suggested that mindfulness-based and
cognitive behavioural interventions may be effective in the reduction of both rumination and
worry; with both Internet-delivered and face-to-face delivered formats useful. More broadly, it
appears that treatments in which participants are encouraged to change their thinking style, or to
disengage from emotional response to rumination and/or worry (e.g., through mindful
techniques), could be helpful. Implications for treatment and avenues for future research are
discussed.
Keywords: Rumination, Worry, Perseverative cognition, Systematic review
1. Introduction
The aim of this systematic review was to assess treatments used to reduce rumination
and/or worry.
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The definition of rumination and worry
There are many definitions of worry and rumination. The most often used definition of
worry suggests that it constitutes a chain of thoughts and images that are affectively negative and
relatively uncontrollable (Borkovec, Robinson, Pruzinsky, & DePree, 1983; Borkovec, Ray, &
Stober, 1998). Descriptively, worry is dominated by negatively valenced thought activity, most
often about negative events we are afraid will occur in the future (Borkovec et al., 1998).
However, although worry is often associated with negative effects, it may also have some value.
For example, day-to-day worries may function to motivate the individual to deal with a
perceived threat that is causing worry (Davey, 1993); and many of these daily worries appear to
be related to problem-solving. For example, in a study by Szabo & Lovibond (2002) students
were asked to self-monitor and record worry-related thoughts when they worried at least a little.
These reported thoughts were then categorised by independent raters and over half of the
thoughts involved problem solving; e.g., worrying about how to resolve a dispute with a friend,
break up with a respective other, or make a plan for the coming day/s. The other half were more
stereotypically worry-related thoughts such as anticipating bad outcomes or self-blame for events
or situations that had not turned out as planned. Therefore, worry could be a constructive process
(if the process results in a solution to a perceived problem) or a non-constructive process (if not
focussed on solving a problem; or if an appropriate solution cannot be arrived at).
When it comes to rumination, there are many different definitions, all of which share the
common experience of repetitive, intrusive, negative cognitions (see Papageorgiou & Siegle,
2003). Some of these definitions are narrow. For example, Nolen-Hoeksema's (1991) well-
known definition of depressive rumination suggests that the focus of rumination is on one's own
depressive symptoms. Other definitions are very broad. For example, Martin & Tesser (1996), in
their self-regulation model of ruminative thought, define rumination in the context of thinking
about one's own goals, suggesting that this thinking may occur in the absence of immediate
environmental cues. According to Martin & Tesser (1996) there are three mechanisms by which
ruminative thinking can be stopped: distraction, disengagement from the goal, and goal
attainment.
The link between rumination and worry
Recurrent negative thinking or thought is a primary component of mood-related
emotional disorders. Research regarding rumination and/or worry has been dominated by
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clinical/health psychology, with rumination and worry thought to be implicated in the aetiology
of a number of psychological disorders, e.g., depression and anxiety (Lyubomirsky, Caldwall, &
Nolen-Hoeksema, 1998; Mellings & Alden, 2000), and associated with increased physical
symptom reporting (Hazlett & Haynes, 1992), intrusive off-task thoughts (Sarason, Pierce, &
Sarason, 1996), negative self-evaluations, diminished feelings of control and feelings of
helplessness (Lyubomirsky, Kasri, & Zehm, 2003). Furthermore, laboratory studies have shown
prolonged physiological arousal and delayed recovery in individuals who ruminate or who are
asked to recall stressful events (Glynn, Christenfeld, & Gerin, 2002; Ironson et al., 1992;
Lampert, Jain, Burg, Batsford, & McPherson, 2000; Roger & Jamieson, 1988).
Barlow & DiNardo (1991) proposed that worry is “fundamentally a presenting
characteristic of all anxiety disorders with the possible exception of simple phobia” (p. 115); and
worry also occurs frequently in major depression (Chelminski & Zimmerman, 2003). Although
studies tend to examine worry in relation to anxiety and rumination in relation to depression, a
few studies have looked at the effects of both of these forms of repetitive thinking. For example,
Segerstrom, Tsao, Alden, & Craske (2000) examined the effects of these processes concurrently
and found that repetitive thought of either kind was related to both anxious and depressed
symptoms. More recently, McLaughlin, Borkovec & Sibrava (2007) induced worry and
rumination in a student sample to assess whether or not they affected mood in the same, or
different, ways. They found that worry and rumination were both associated with increases in
anxiety, depression and negative affect, and with decreases in positive affect. Interestingly, their
analysis also indicated that shifting from worry to rumination resulted in decreased anxiety and
increased depression; and shifting from rumination to worry created an opposing pattern.
Therefore, when the two forms of thinking occur sequentially, it appears worry is
associated with predominantly anxious affect, and rumination is associated with predominantly
depressive affect. As such, both processes appear to lead to the generation of negative mood
states; with the different outcomes reflective of the focus or content of rumination or worry
respectively. These findings are further supported by the results of prior studies conducted
separately on worry and rumination. For example, Segerstrom, Stanton, Alden, & Shortridge
(2003) found that negative affectivity is generated by negative thinking of any type; Chelminski
& Zimmerman (2003) found that worry occurs in depression; and Nolen-Hoeksema (2000) found
that rumination predicts the onset of anxiety. These findings suggest a shared component to these
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forms of repetitive thinking and a considerable research base supports this showing that anxiety
and depression are frequently comorbid (Brown & Barlow, 1992; Brown, Campbell, Lehman,
Grisham, & Mancill, 2001; Kessler et al., 1994; Kessler, Sonnega, Bromet, Hughes, & Nelson,
1995; Kessler et al., 1998). This comorbidity may be explained in a number of ways: firstly, it is
possible that having one disorder increases the risk of developing another; alternatively, it is
possible that anxiety and mood disorders may develop from the same underlying predisposition
(Barlow, 2002).
In line with the notion that these disorders may develop from the same underlying
predisposition, one possibility is that both of these disorders are underpinned by a similar
cognitive process. For Brosschot, Gerin & Thayer (2006) rumination and worry represent
different but related manifestations of the same underlying cognitive process. The difference in
these constructs is reflected in a different focus of “content” (e.g., future focussed in worry; past
focussed in rumination); however, they are purported to share an underlying cognitive process
which maintains psychophysiological arousal. This process is labelled ‘perseverative cognition’
and is defined as: “the repeated or chronic activation of the cognitive representation of one or
more psychological stressors” (Brosschot et al., 2006, p.114). Our unique ability as humans
means that we can look back and learn from the past, and we can look ahead to plan for the
future; however, this may also lead to ‘ruminating’ about the past, or ‘worrying’ about the future
(Brosschot, Verkuil & Thayer, 2010). While psychological stressors themselves do not involve
direct physical danger, they are composed of perceived threats to the physical or psychological
integrity of the individual (Broschott et al., 2010). It is these cognitive representations, or
thoughts, that result in a “fight-or-flight” response (Frijda, 1988), which is followed by a casade
of biological and physiological changes in the body. These changes begin in the brain and cause
peripheral responses to stress such as increased heart rate and blood pressure; and higher levels
of stress hormones such as cortisol (Lovallo, 2004).
Evidence in the literature suggests that perseverative cognition (e.g., rumination and
worry) in addition to having direct physiological effects, also mediates the prolonged effects of
stressors. Some researchers have considered the relationship between rumination/worry and
somatic disease or somatic complaints; with suggestive evidence for a prospective relationship.
For example, Brosschot & van den Doef (2006) reported that a total of 1 week's worry duration
was prospectively related to health complaints in high school and college students. Trait
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rumination has been prospectively related to self-reported physical health issues one year later
(Thomsen et al., 2004); and cross-sectional relationships have been found between trait
rumination and health complaints (Lok & Bishop 1999) and between frequency of worry about
conflicting goals and somatisation (Emmons & King, 1988). Furthermore, with regards to
verifiable disease outcome, a tendency to worry has been shown to predict a second myocardial
infarction (Kubzansky et al., 1997).
Other researchers have considered the relationship between worry/rumination and
endocrine, neuroendocrine and physiological responses (e.g. cardiac activity; blood pressure).
Chronic activation of the hypothalamic-pituitary-adrenal axis (predominantly cortisol release) is
purported to increase an individual's susceptibility to many disease states. This is thought to be
due to suppression of the immune system which has multiple pathological effects, e.g.,
dysregulation of metabolism and hippocampal degeneration (Brosschot et al., 2006). Several
studies have shown that rumination and worry are associated with abnormal immune responses
and elevated levels of cortisol. For example, trait rumination has been associated with higher
morning salivary cortisol (Schlotz, Hellhammer, Schulz, & Stone, 2004); and a higher number of
several types of luekocytes (white blood cells of the immune system involved in defending the
body against disease; Thomsen et al., 2004). Other studies have reported that participants
reporting high levels of trait worry had fewer natural killer (NK) cells (Segerstrom, Solomon,
Kemeny & Fahey, 1998); and that high trait worry was related to suppression of an expected
increase in NK cells when exposed to fear-evoking situations (Segerstrom, Glover, Craske &
Fahey, 1999).
People with chronically elevated heart rates (HR), and reduced heart rate variability
(HRV; an indicator of parasympathetic activity), are at increased risk for all-cause mortality
(Palatini & Julius, 1997); and reduced HRV has also been associated with increased risk of
developing hypertension and other cardiovascular disorders (Thayer & Friedman, 2004; Stein &
Kleiger,1999). A sustained level of high blood pressure (BP) is also a risk factor for many
diseases including cardiovascular disease (CVD) and diabetes (Schwartz et al., 2003).
Researchers have shown that both dispositional measures of, and experimentally induced, worry
are associated with low HRV and high HR (Lyonfields, Borkovec & Thayer, 1995; Thayer,
Friedman & Borkovec, 1996). Furthermore, trait rumination has been associated with slower HR
recovery after cognitive stress tasks (Roger & Jamieson, 1988); and state, but not trait, worry has
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been related to high HR (Dua & King, 1987). Elevated BP has also been associated with
anticipation before emotional events in several studies; e.g., in students anticipating oral defence
of their PhD (van Doornen & van Blokland, 1992), prior to dental treatment (Brand et al., 1995),
and mental arithmetic (Contrada, Wright & Glass, 1984). In addition, multiple studies showed
that emotional reactivity (which is strongly related to worry and rumination) was positively
related to resting BP (Melamed, 1987), ambulatory BP (Melamed, 1996), and to high risk levels
of lipids (fats) in blood plasma (Melamed, 1994).
Taken together, these findings appear to suggest that perseverative cognition (e.g.,
rumination, worry) is associated with decreased parasympathetic activity and increased
sympathetic nervous system activity (Brosschott et al., 2006). Decreased parasympathetic
activity suggests that rumination or worry are likely and independent risk factors for CVD;
furthermore, low parasympathetic activity has also been found to characterise depression and
anxiety disorders (Lyonfields et al., 1995; Thayer et al., 1996; Friedman & Thayer, 1998;
Friedman et al., 1993). Interestingly, depression and anxiety are increasingly documented as
important risk factors for cardiovascular and other disorders (e.g., Kawachi et al., 1994; Wulsin,
Vaillant & Wells, 1999). Therefore it is possible that worry and rumination may serve as
mediators of the relationship between anxiety and depression with CVD (Brosschot et al., 2006).
Another possibility is that anxiety and depression are underpinned by a shared mood trait
such as negative affect (McLaughlin et al., 2007). Watson, Clark, & Tellegen (1988) characterise
negative affect (NA) as a general dimension of subjective distress and "unpleasurable
engagement that subsumes a variety of aversive mood states" (p.1063); e.g., fear, nervousness,
guilt, contempt, anger, disgust. Trait NA has been shown to roughly correspond to the
personality factor anxiety/neuroticism; and Tellegen has also suggested that high levels of NA
(both state and trait) are major distinguishing features of depression and anxiety, respectively
(Tellegen, 1985). McLaughlin et al. (2007) suggest that this is the shared underlying factor
which fosters rumination and/or worry. The positions of Brosschot et al. (2006) and McLaughlin
et al. (2007) are compatible in as much as a predisposition to engage in perseverative cognition
with a negative focus may potentially be causal in the development of anxiety and/or depression.
Worry and rumination appear to worsen, not resolve, negative emotional states (Morrow &
Nolen-Hoeksema, 1990; Nolen-Hoeksema & Morrow, 1993); furthermore, both forms of
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perseverative cognition are associated with over-general memory and a high level of abstract as
opposed to concrete processing (e.g., Watkins & Teasdale, 2001; Williams, 1996).
In a comprehensive review, Brosscot et al. (2006) suggested that perseverative cognition (e.g.,
rumination, worry) may be part of a causal chain that can lead to long-term health consequences,
including cardiovascular disease and other chronic conditions and illnesses. A position that
appears to be supported by the research presented above. Given the prevalence of perseverative
cognition (e.g., rumination, worry) in the aetiology of different illnesses and conditions, it is
important to understand what interventions may be useful in reducing the incidence of
rumination and/or worry.
1.1. Objectives
The objective of this systematic review was to assess treatments used to reduce
rumination and/or worry.
1.2. Criteria for inclusion/exclusion
Study aims and design. An initial review of the literature highlighted that there were
very few studies explicitly designed to target rumination or worry. Therefore we expanded our
inclusion criteria such that studies had to either: 1. explicitly treat rumination/worry; or 2.
include secondary measures for the effects of treatment on rumination/worry. Studies in which
rumination or worry was measured, but where they were only tested as mediators/moderators for
changes in other study variables, were not included. The following study designs were eligible
for inclusion: randomised controlled trials (RCT); randomised clinical controlled trials; clinical
controlled trials; waitlist controlled trials; randomised trials; cohort studies; quasi-experimental
studies.
Study status. Only articles from peer reviewed journals (January, 2002 Dec, 2012) and
written in English were eligible for inclusion. We limited our search to research published from
2002 to 2012 because we were interested in understanding the current landscape with regards to
treatments utilised in the reduction of rumination and/or worry.
Participants. This review considered studies of adults (>18 years of age) only. We
included studies where participants were drawn from both clinical and non-clinical (e.g., general
population, students) populations. Studies including participants with depression, anxiety (or a
specific anxiety disorder, e.g., social phobia, generalised anxiety disorder, etc.) or a mixture of
depression and anxiety were eligible for inclusion in the review. Studies including participants
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with learning disabilities or severe mental disorder (e.g., schizophrenia, bipolar disorder,
depression with psychotic symptoms, psychosis, serious suicidal thoughts) or alcohol or
substance abuse were not eligible for inclusion.
Types of outcome measures. Studies were eligible for inclusion if they utilised primary
or secondary measures for rumination and/or worry: e.g., Ruminative Response Scale (RRS;
Nolen-Hoeksema, 1991), or equivalent; Penn State Worry Questionnaire (PSWQ; Meyer, Miller,
Metzger, & Borkovec, 1990), or equivalent.
1.3. Search strategy for identification of studies.
The following electronic databases were examined in December, 2012: PsycINFO;
PsycARTICLES; Medline; the Cochrane Library database of systematic reviews; and the Centre
for Reviews and Dissemination (CRD) database.
The search in PsycInfo, PsycARTICLES and Medline made use of the following search
terms: 1 Rumination; 2 Ruminat* AND thought(s) OR thinking; 3 Perseverative AND thought(s)
OR thinking; 4 Repetitive AND thought(s) OR thinking; 5 Intrusive AND thought(s) OR
thinking; 6 Negative AND thought(s) OR thinking; 7 Worry; 8 Worry AND thought(s) or
thinking; 9 Anxi*; 10 Anxi* AND thought(s) OR thinking; 11 Stress AND thought(s) OR
thinking; 12 Depress* AND thought(s) OR thinking; 13 #1 OR #2 OR #3 OR #4 OR #5 OR #6
OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 AND intervention OR randomis(z)ed
controlled trial OR RCT OR Controlled trial OR “Waitlist controlled trial” OR
“Randomis(z)ed trial” OR Cohort” OR “Quasi-experimental”. The search in CRD and
Cochrane Library databases made use of the following terms: 1 Rumination; 2 Perseverative
AND thought(s) OR thinking; 3 Repetitive AND thought(s) OR thinking; 4 Intrusive AND
thought(s) OR thinking; 5 Negative AND automatic thought(s) OR thinking; 6 Worry; 7 Stress; 8
Depression AND thought(s) OR thinking.
Brackets indicate where search terms were entered twice with the different spellings.
Search terms were selected based on common key terms identified during an initial search of the
literature and related reviews.
2. Methods
The authors screened abstracts and titles of articles against the inclusion criteria and full
text versions of potentially relevant articles were obtained for more detailed analysis. In total,
108 articles were obtained and reviewed. Of these, 89 were excluded from this review for the
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following reasons: not intervention study, no measure of rumination or worry (or
rumination/worry measured but direct effects not reported), sample not adults, participants
inappropriate, duplicate data (outcomes reported elsewhere), and sample too small (e.g., case
studies). The remaining 19 articles were included in this review. Figure 3.1 shows a summary of
study selection and exclusion.
2.1. Description of included studies
The search of the databases resulted in 19 articles meeting the inclusion criteria
(N=1778). Details of included studies can be seen in Table 3.1, and details of treatment duration
and protocols can be reviewed in Table 3.2. The majority of studies were described as
randomised controlled trials (RCT; N=15); two were studies described as waitlist controlled
designs (WLC), and two studies were described as randomised designs (with no control group).
Seven studies drew their participants from clinical environments (e.g., hospitals; GP practices);
four studies utilized students; and eight studies were run with participants recruited from the
general population. Measures of rumination and/or worry were included in the majority of
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studies as secondary measures. However, one study (Watkins et al., 2011) tested an intervention
specifically designed to reduce rumination; and other studies stipulated that measuring change in
rumination and/or worry was a primary aim (Andersson et al., 2012; Campbell, Labelle, Bacon,
Faris, & Carlson, 2012; Ekkers et al., 2011; Jain et al., 2007; Wolitzky-Taylor & Telch, 2010).
Most studies assessed change in either worry (N=9) or rumination (N=8), however two studies
(Robins, Keng, Ekblad, & Brantley, 2012; van Aalderen et al., 2012) assessed change in worry
and rumination.
Table 3.1. Details of included studies
Study
Country
Study
type
Sample type
Attrition
Rate (N)
Andersson et al. (2012)
Sweden
RCT
Clinical; GAD
7% (6)
Campbell et al. (2012)
Canada
WLC
Clinical; cancer patients
17% (13)
Ekkers et al. (2011)
Netherlands
RCT
Clinical; Dep; >65yrs
26% (24)
Feldman et al. (2010)
USA
Rand
Students
0%
Jain et al. (2007)
USA
RCT
Students
22% (23)
Leichsenring et al. (2009)
Germany
Rand
Clinical; GAD
8% (5)
Paxling et al. (2011)
Sweden
RCT
Gen Pop’n; GAD
8% (7)
Robins et al. (2012)
USA
WLC
Gen Pop’n
26% (15)
Robinson et al. (2010)
Australia
RCT
Gen Pop’n; GAD
7% (12)
Shapiro et al. (2008)
USA
RCT
Students
6% (3)
Steinmetz et al. (2012)
USA
RCT
Hurricane Ike survivors
5.5%(10)
Titov et al. (2010)
Australia
RCT
Gen Pop’n; GAD; PD; SP
16% (14)
Van Aalderen et al. (2012)
Netherlands
RCT
Clinical; Dep
6% (14)
Vollestad et al. (2011)
Norway
RCT
Gen Pop’n; GAD; PD;
SAD
14% (11)
Watkins et al. (2009)
England
RCT
Gen Pop’n; Dys
0% (0)
Watkins et al. (2011)
England
RCT
Clinical; Dep
9.5% (4)
Watkins et al. (2012)
England
RCT
Clinical; Dep
15% (18)
Westra et al. (2009)
Canada
RCT
Gen Pop’n; GAD
18% (14)
Wolitzky-Taylor & Telch
(2010)
USA
RCT
Students; academic worry
26% (29)
Study type: RCT=Randomised Controlled Trial; WLC=Waitlist Controlled Trial; Rand=multiple randomised
treatment groups, no control group. Sample type: GAD=Generalised Anxiety Disorder diagnosis; PD=Panic
Disorder diagnosis; SP=Social Phobia diagnosis; SAD=Social Anxiety Disorder diagnosis; Dys=dysphoria (sub-
clinical low mood); Dep=Depression diagnosis; clinical=participants recruited from clinical environment (e.g.
hospital; GP practice); Gen Pop’n=recruited from general population
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The majority of studies (N=14) assessed treatments that were delivered face-to-face
either in group format or one-to-one; however, five studies assessed Internet-based interventions.
Four of these studies assessed Internet-based cognitive behaviour therapy (iCBT) against other
internet-based treatments (Andersson et al., 2012; Paxling et al., 2011; Robinson et al., 2010;
Titov, Andrews, Johnston, Robinson, & Spence, 2010); whilst the other study assessed a web
tool (My Disaster Recovery website) which was developed specifically for survivors of
Hurricane Ike in the USA (Steinmetz, Benight, Bishop, & James, 2012), against an information
only website. Andersson et al. (2012) compared iCBT with Internet-based psychodynamic
treatment (iPDT) in participants with generalised anxiety disorder (GAD); Paxling et al. (2011)
assessed the efficacy of iCBT against a waitlist control condition for participants with GAD;
Robinson et al. (2010) compared the efficacy of clinician assisted iCBT to technician assisted
iCBT in participants with GAD; and Titov et al. (2010) compared the efficacy of iCBT against a
waitlist control condition for a mixed sample of anxiety disorders (GAD, social anxiety disorder
[SAD], and panic disorder [PD]).
In the case of interventions delivered face-to-face, three studies compared CBT-based
interventions against either waitlist control conditions or other interventions. Leichsenring et al.
(2009) compared the efficacy of CBT against short-term psychodynamic psychotherapy for
participants with GAD; Watkins et al. (2011) compared rumination-focussed CBT plus treatment
as usual against treatment as usual alone in participants with depression; and Westra, Arkowitz,
& Dozois (2009) assessed the effect of adding motivational interviewing techniques to CBT for
participants with GAD. Seven studies assessed mindfulness-based interventions against either
waitlist control conditions or other treatments. Out of these seven studies, four studies assessed
the efficacy of mindfulness-based stress reduction (MBSR). Campbell et al. (2012) assessed the
effect of participation in MBSR on attention, rumination and resting blood pressure in female
cancer patients; Robins et al. (2012) assessed the effect of participation in MBSR on emotional
experience and expression; Shapiro, Oman, Thoresen, Plante, & Flinders (2008) compared
MBSR against another meditation-based relaxation programme - Easwaran’s Eight Point
Programme (EPP) for change in mindfulness; and Vollestad, Sivertsen, & Nielsen (2011)
assessed the efficacy of MBSR in the treatment of anxiety. The remaining three studies assessed
other mindfulness-based treatments. Specifically, Feldman, Greeson, & Senville (2010)
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compared mindful-breathing, progressive muscle relaxation, and loving-kindness meditation for
effect on negative reactions to repetitive thoughts; Jain et al. (2007) compared mindful-
meditation to relaxation training for their effects on distress, positive states of mind, rumination
and distraction; and van Aalderen et al. (2012) assessed mindfulness-based cognitive therapy for
the treatment of depression. Finally, in the remaining four studies, Ekkers et al. (2011) assessed
competitive memory training (COMET) in the treatment of depression and rumination; Watkins,
Baeyens, & Read (2009) compared concreteness training (CNT) against bogus CNT for the
treatment of dysphoria; Watkins et al. (2012) compared guided self-help concreteness training
against guided self-help relaxation training in the treatment of depression; and Wolitzky-Taylor
& Telch (2010) compared worry exposure against expressive writing and Audio-photic
stimulation (APS) for the reduction of academic and general worry in students.
Treatment duration ranged from a single 90 minute session with testing immediately after
the session (Feldman et al., 2010), to a maximum of 30 weeks of treatment (Leichsenring et al.,
2009); however, in the majority of studies (N=15) treatment varied from 4 weeks to 8 weeks. For
most studies, treatment occurred on a weekly basis, either through online modules to be
completed in the internet-based treatments or through face-to-face sessions with therapists either
in group format or one-to-one format. Change in rumination and/or worry scores was assessed
pre- and post-treatment in all studies, and 12 studies also reported follow-up data. Follow-up
periods ranged from two months to three years; however, most studies followed up between
three and six months post-treatment.
2.2. Methodological quality and treatment integrity
The 19 studies included in this review were assessed by both authors separately; and then
together. Any disagreements were resolved by discussion between the authors.
Methodological quality of included studies
We assessed the included studies against three criteria from Jadad et al. (1996;
participants randomised; study described as double blinded; and withdrawals/drop-outs
described; see Table 3.3, below), and against one other criterion developed by the authors for this
study (quality of statistical analysis). We’ve made our assessment of the above criteria based on
the information provided in the published studies.
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Participants randomised. According to Jadad et al. (1996): “A method to generate the
sequence of randomization will be regarded as appropriate if it allowed each study participant to
have the same chance of receiving each intervention and the investigators could not predict
which treatment was next(p.11). In this review, and in line with the guidelines from Jadad et
al., if the study was described as randomised (which included the use of words such as randomly,
random, and randomisation) we awarded the study one point. If the method of randomisation was
Table 3.3. Methodological quality of included studies
Study name
Participants
randomised?
(0-2)
Study described as
double-blinded?
(0-2)
Withdrawals/drop-
outs described?
(0-1)
Total
score
(0-5)
Andersson et al. (2012)
2
0b
0c
2
Campbell et al. (2012)
0a
0b
1
1
Ekkers et al. (2011)
2
0b
1
3
Feldman et al. (2010)
0a
0b
0
0
Jain et al. (2007)
2
0b
1
3
Leichsenring et al. (2009)
1d
0b
1
2
Paxling et al. (2011)
2
0b
1
3
Robins et al. (2012)
1d
0b
0c
1
Robinson et al. (2010)
2
0b
0c
2
Shapiro et al. (2008)
1e
0b
1
2
Steinmetz et al. (2012)
1f
0b
0c
1
Titov et al. (2010)
2
0b
0
2
Van Aalderen et al. (2012)
2
0b
1
3
Vollestad et al. (2011)
1d
0b
1
2
Watkins et al. (2009)
1d
0b
0c
1
Watkins et al. (2011)
2
0b
1
3
Watkins et al. (2012)
2
0b
1
3
Westra et al. (2009)
2
0b
0c
2
Wolitzky-Taylor & Telch (2010)
2
0b
0c
2
Higher scores = better study quality; aNo randomisation or method of randomisation not appropriate; bNot
described as double blinded; cNo description of reasons for participants dropping out or withdrawing;
dStudy states participants randomly allocated to groups but provides no detail on process; eGood
randomisation process but participants allowed to change groups after randomisation due to schedule
clashes; fRestricted randomisation
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17
described and it was appropriate (e.g., table of random numbers, computer generated, etc.) we
gave the study an extra point; however, if the method of randomisation was described and it was
inappropriate (e.g., methods of allocation using date of birth, date of admission, hospital
numbers, or alternation), we deducted a point. The range of possible points for randomisation
was 0-2.
Eleven studies were awarded 2 points as their method of randomisation was well
described and appropriate; two studies (Campbell et al., 2012; Feldman et al., 2010) received 0
points because they did not randomise participants; and six studies received 1 point for a number
of reasons. Firstly, some of the studies stated that participants were randomised but did not
provide detail on the randomisation process (Leichsenring et al., 2009; Robins et al., 2012;
Vollestad et al., 2011; Watkins et al., 2009). These studies may have employed appropriate
processes of randomisation but the lack of detail made it difficult for us to assess; and best
practice suggests that randomisation processes should be reported in full. Secondly, one of the
studies had a good randomisation process but then participants changed condition after
randomisation had occurred (Shapiro et al., 2008); and finally, one study employed restricted
randomisation (Steinmetz et al., 2012).
Study described as double-blinded. According to Jadad et al. (1996) “a study must be
regarded as double blind if the words “double blind” are used” (p. 11). Where studies used the
words “double blind” we awarded one point. We then gave an additional point if the method of
double blinding was described and it was appropriate; however, where the method of double
blinding was described and it was not appropriate, we deducted a point. Therefore the range of
possible scores for this criterion was 0-2. None of the studies included in this review were
described as double blinded and therefore all received 0 as their score for this criterion. This does
not reflect poorly on the designs of these studies. In reality, it is often very difficult to achieve
double-blinding in studies in which participants are receiving psychological therapeutic
interventions, especially when these interventions are delivered to participants in groups.
Withdrawals / drop-outs described. According to Jadad et al. (1996) participants who
were included in the study but did not complete treatment or who were not included in the
analysis must be described. It is considered good practice to detail the number of withdrawals or
drop-outs and to state the reasons for this. In order for a study to be awarded a point for this
criterion, they must have included a statement with regards to withdrawals/drop-outs. Where a
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18
study has included no such detail they were not awarded a point. The range of possible points for
this criterion is 0-1. Ten studies received 1 point for this criterion. The remaining nine studies
received 0 points as they did not include a statement with regards to reasons for participants
withdrawing/dropping out.
Quality of statistical analysis. With regards to statistical analysis we were interested in
the risk of introducing bias through the use of inappropriate techniques used when conducting
intention-to-treat (ITT) analysis; or if the authors did not complete ITT analysis when a
significant number of participants dropped out of treatment. In almost all randomised study
designs, participants dropping out of treatment results in missing data. If there are only a few
missing outcomes this will not be of major concern; however, when attrition rates are high, the
method of dealing with missing data becomes important. Missing data is common and one
review found that in approximately half of all RCTs outcomes were missing for more than 10%
of participants (Wood, White, & Thompson, 2004). If authors decide to omit data for participants
whose data is incomplete, instead only analysing “completers” of treatment, this approach loses
power, and bias may be introduced (Altman, 2009). Best practice dictates that ITT principles be
adopted in all randomised trials. For example, the Consolidated Standards of Reporting Trials
(CONSORT) statement for improving the quality of reports of RCTs states that all participants in
each group should be analysed by “intention-to-treat” principles (Moher, Schulz, & Altman,
2001). In an ITT analysis all randomised participants are included in the analysis in their
allocated groups, irrespective of treatment adherence or completion (Altman, 2009).
When we assessed the 19 studies in this review against this criterion, we evaluated the
following points: Was ITT analysis performed?; If ITT analysis was not performed, was this
appropriate (i.e., no drop-outs)?; If ITT analysis was performed, what was the method used for
data imputation?; If ITT analysis was performed, were the results from both the ITT and
‘completer’ samples reported? We also considered the attrition rate as studies with lower attrition
rates would suffer less with regards to impact of data imputation. The majority of studies (N=15)
stated that ITT analysis was performed. Out of the four studies which did not perform ITT
analysis, in two studies (Feldman et al., 2010; Watkins et al., 2009), ITT analysis was not
appropriate as the study design precluded attrition; however, the other two studies (Robins et al.,
2010; Westra et al., 2009) only reported “completers” and this may have introduced significant
bias in the results as the attrition rates were relatively high (26% and 18% respectively).
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19
Therefore, these studies may have overestimated the efficacy of treatment and the results should
be viewed with caution.
One of the main issues surrounding ITT analysis is how missing data is dealt with. One
of the simplest and most commonly used method of imputing missing data is “last observation
carried forward” (LOCF) analysis, in which missing final values of the outcome variable are
replaced by the last known value before the participant was lost to follow-up. Even though this is
a simple and easy method, there are strong grounds for not using it. LOCF assumes that the
missing final value/s would be the same as the last recorded value/s; and this assumption is often
implausible because dropping-out or withdrawing from treatment is likely to be associated with
response to treatment (e.g., failure to respond; Altman, 2009). In studies of therapeutic or
psychological treatments, often participants are assessed prior to treatment commencing,
immediately after the end of treatment, and then they are followed up some time after treatment
was finished (e.g., 6 months). If the last available observation is the pre-treatment observation
(because the participant dropped out after randomisation but before treatment completion), there
is obvious scope for the introduction of bias, especially when the participant attrition rate is high.
Simple imputation methods (like LOCF) overestimate the reliability and precision of estimates,
and the power of the study to assess the treatment. When data is missing, the sample size is
reduced; however, simple imputation methods fail to take this into account and therefore tend to
underestimate the variability of the results. There are other methods for imputing missing data
(e.g., mixed model analyses; multiple imputation) which carry less risk of bias but these are more
difficult to perform and thus, the LOCF method remains dominant.
In the studies in which ITT analysis was performed, nine studies (Campbell et al., 2012;
Jain et al., 2007; Leichsenring et al., 2009; Robinson et al., 2010; Steinmetz et al., 2011; Titov et
al., 2010; Vollestad et al., 2011; Watkins et al., 2011; Watkins et al., 2012) employed the LOCF
method for data imputation; and five of these studies (Campbell et al., 2012; Jain et al., 2007;
Titov et al., 2010; Vollestad et al., 2011; Watkins et al., 2012) had an attrition rate of greater than
10 percent. However, Jain et al. (2007) and Vollestad et al. (2011) evidenced best practice by
reporting results for both ‘completer’ and ITT samples providing assurance that the attrition rate
did not compromise reported results; and Watkins et al. (2011) and Watkins et al. (2012)
conducted sensitivity analysis to ensure that drop-outs did not adversely affect their results.
Therefore, these four studies have mitigated the risk of using LOCF method. Campbell et al.
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20
(2012) and Titov et al. (2010) only reported ITT sample results and both had relatively high
attrition rates (17% & 16% respectively); therefore their results may have been biased and should
be viewed with caution. The remaining three studies using the LOCF method (Leichsenring et
al., 2009; Robinson et al., 2010; Steinmetz et al., 2011) had relatively low attrition rates (8%, 7%
and 5.5% respectively) therefore the risk of bias was quite low for these studies.
The remaining six studies which performed ITT analysis were considered low risk in
terms of introducing bias. Five studies employed methods for data imputation that are more
robust than LOCF, e.g., mixed model analyses or multiple imputation (Andersson et al. 2012;
Ekkers et al., 2011; Paxling et al., 2011; Van Aalderen et al., 2012; Wolitzky-Taylor & Telch,
2010); and two of these studies further evidenced best practice by reporting both ‘completer’ and
ITT sample results (Paxling et al., 2011; Wolitzky-Taylor & Telch, 2010). The remaining study
(Shapiro et al., 2008) stated they performed ITT analysis but they did not clarify method of data
imputation and they reported ITT results only; therefore, it was difficult to assess this study
against this criterion. However, as they had a very low attrition rate (3%), the risk of bias was
considered low for this study.
Treatment integrity of included studies
Treatment integrity of included studies was assessed against two criteria from Foa &
Meadows (1997) gold standards for treatment integrity (valid and reliable measures; manualised,
replicable, specific treatments) and a further criterion created for this study (intervention
delivered consistently). Table 3.4 shows a summary of level of risk of bias for each of these
criteria for each of the included studies; and we expand on the summarised data in the text
below.
Foa & Meadows (1997) suggest the use of measures with good psychometric properties.
Because this systematic review aimed to assess the efficacy of treatments in the reduction of
rumination and/or worry, we assessed the validity and reliability of rumination and/or worry
measures included. Only one study (Feldman et al., 2010) has been classified as potentially high
in risk of bias as this study stated that they created their ‘repetitive thought’ and ‘reaction to
repetitive thought’ items for the purposes of the study. This is not a statement about the veracity
of the created items; it is purely a reflection that this measure has not been validated in any other
studies so we cannot be sure of its validity or reliability. All other studies were considered low
risk as they employed well validated and reliable measures. With regards to worry, all eleven
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studies measuring worry used the Penn State Worry Questionnaire (PSWQ; Meyer et al., 1990).
Regarding rumination, five studies used the Response Styles Questionnaire (RSQ; Nolen-
Hoeksema & Morrow, 1991); two studies used the Rumination-reflection questionnaire (RRQ;
Trapnell & Campbell, 1999); one study used the Rumination on Sadness Scale (RSS; Raes,
Hermans, & Eelen, 2003); one study used the Daily Emotion Report (DER; Nolen-Hoeksema,
Morrow & Fredrickson, 1993); and one study created their own items.
Table 3.4. Assessment of treatment integrity in included studies
Study name
Valid and
reliable
measures?*
Manualised,
replicable, specific
treatments?*
Intervention
delivered
consistently?#
Andersson et al. (2012)
Low
Low
Low
Campbell et al. (2012)
Low
Low
Low
Ekkers et al. (2011)
Low
Low
Low
Feldman et al. (2010)
Higha
Low
Low
Jain et al. (2007)
Low
Low
Low
Leichsenring et al. (2009)
Low
Low
Low
Paxling et al. (2011)
Low
Low
Low
Robins et al. (2012)
Low
Low
Low
Robinson et al. (2010)
Low
Low
Low
Shapiro et al. (2008)
Low
Low
Low
Steinmetz et al. (2012)
Low
Low
Low
Titov et al. (2010)
Low
Low
Low
Van Aalderen et al. (2012)
Low
Low
Low
Vollestad et al. (2011)
Low
Low
Low
Watkins et al. (2009)
Low
Low
Low
Watkins et al. (2011)
Low
Low
Low
Watkins et al. (2012)
Low
Low
Low
Westra et al. (2009)
Low
Low
Low
Wolitzky-Taylor & Telch
(2010)
Low
Low
Low
*Based on Foa & Matthews’ (1997) “gold standards” for treatment outcome trials; #criteria added
for this systematic review; Low=low risk of bias; Unclear= insufficient detail to evaluate risk;
High=high risk of bias; n/a=not applicable to this study design; aItems created by the authors for
this study so not validated or reliable
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22
Foa & Meadows (1997) suggest the use of treatment protocol manuals to ensure
consistency and all studies in this review satisfied this standard. All of the studies in this review
used manualised or proceduralised processes for treatment; therefore all are considered low risk.
However, the use of manualised treatment protocols does not necessarily translate into consistent
delivery of treatment. We considered factors such as whether or not treatments had been assessed
for adherence to treatment manuals and experience of treatment providers. We also considered
whether or not the quality of face-to-face treatments had been assessed independently. We
classified all of the studies included in this review as ‘low risk of bias with regards to
intervention delivery. Some of the studies had the advantage of absolute consistency as the
intervention was delivered online; however, even those studies where the intervention was
delivered face-to-face either to participants individually or in groups were considered low risk
due to rigorous standards and quality assessment.
3. Results
The following results represent a narrative synthesis of all included studies. Given the
heterogeneous nature of the studies included in this review (e.g., participants drawn from
different populations and varied interventions delivered in different formats) it was not
appropriate or feasible to conduct a meta-analysis. Petticrew & Gilbody (2004) suggest that
studies with the best methodological quality should contribute more to the results of systematic
reviews and this is the approach we adopted.
3.1. Effects of treatment on self-reported rumination
Ten out of the 19 studies reported results regarding effect of treatment on rumination. Six
of these studies utilised mindfulness-based or relaxation-focussed treatments delivered in group
format in face-to-face sessions. Campbell et al. (2012), Robins et al. (2012), and Shapiro et al.
(2008) employed mindfulness-based stress reduction (MBSR); while Van Aalderen et al. (2012)
assessed mindfulness-based cognitive therapy (MBCT). In the other two studies, Feldman et al.
(2010) assessed mindful-breathing (MB) against progressive muscle relaxation (PMR) or loving-
kindness-meditation (LKM); and Jain et al. (2007) assessed mindful-meditation (MM) against
relaxation training (RT).
Campbell et al. (2012) reported a significant reduction in rumination at the end of
treatment for participants who had taken part in their eight-week MBSR programme when
compared with participants in a waitlist control condition. However, this study did not randomise
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participants, and performed ITT analysis using LOCF with high attrition rates, therefore the
results should be treated with caution. Robins et al. (2012) reported no significant reduction in
rumination for participants in their eight week MBSR programme at the end of treatment;
however, gains had been made by the MBSR over waitlist control group when participants were
followed up two months post-treatment. As Robins et al. (2012) did not perform ITT analysis
and only reported ‘completers’ (with a high rate of attrition) these results must also be viewed
with caution. Shapiro et al. (2008) compared participation in an eight-week MBSR programme
against another meditation-based programme (EPP) and found that increases in mindfulness (in
the MBSR group) mediated a significant reduction in rumination, and MBSR was considerably
more effective than EPP in reducing rumination. Furthermore, participants who had taken part in
the MBSR programme showed further gains, through decreased levels of self-reported
rumination, when followed-up two months after treatment. Randomisation was compromised in
this study due to some participants changing condition after randomisation had been completed;
however, this study was considered sound in other areas. Van Aalderen et al. (2012) reported that
participants who had taken part in their eight-week MBCT programme reported significantly
lower levels of rumination than participants in the waitlist control condition after treatment had
ended.
Feldman et al. (2010) assessed change in negative reaction to repetitive thoughts
(rumination); and concluded that participants who took part in mindful-breathing (MB) reported
a significantly greater reduction in negative reaction to repetitive thoughts than those in the
progressive muscle relaxation (PMR) or loving-kindness-meditation (LKM) conditions.
Interestingly, in this study participants in the MB condition reported a significantly greater
increase in repetitive thoughts than participants in either the PMR or LKM conditions. Jain et al.
(2007) assessed mindful-meditation (MM) against relaxation training (RT) and found that
participants in the MM group reported significantly less ruminative and distractive thoughts than
participants in either the RT or waitlist control groups (which were not significantly different to
one another).
The remaining four studies assessing change in self-reported rumination delivered their
interventions via face-to-face format. Three of these studies were individual face-to-face
treatment formats (Watkins et al., 2009; Watkins et al., 2011; and Watkins et al., 2012), whereas
the final study delivered their training face-to-face in group format (Ekkers et al., 2011). Two
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24
studies (Watkins et al., 2009; Watkins et al., 2012) assessed concreteness training (CNT) which
involves training individuals to be more concrete and specific in their thinking. In the study by
Watkins et al. (2009), CNT was assessed against bogus CNT (BogusCNT = matched with CNT
for treatment rationale, experimenter contact, and treatment duration but without the active
“concrete thinking” component) for reduction of rumination in individuals with dysphoria (low
mood). Participants attended an initial training session and then practiced the learned techniques
for a period of seven days - with the support of audio CD exercises (CNT condition) or a website
they could access (BogusCNT condition). After seven days, when participants were assessed,
they found that participants in the CNT and BogusCNT groups reported significantly lower
levels of self-reported rumination, when compared to participants in a waitlist control condition;
and the two treatment groups were not significantly different to one another. In the other study,
Watkins et al. (2012) assessed self-guided CNT (CNTself) against self-guided relaxation training
(RTself) in the treatment of depressed individuals. Participants in this study attended for an
initial training session and then practiced at home over the course of six weeks with the support
of exercises recorded on audio CD and detailed workbooks. They found that participants from
the CNTself condition reported significantly lower levels of rumination than participants in
either the RTself or waitlist control conditions. Furthermore, when the self-help response became
habitual (at follow-up); participants in the CNTself group reported significantly lower levels of
rumination than participants in the RTself group.
Watkins et al. (2011) evaluated rumination-focussed CBT (RF-CBT) against a waitlist
control condition in the treatment of depression. The duration of this treatment varied from 12 to
24 weeks depending on client need and results showed that participants taking part in the RF-
CBT programme reported significantly lower levels of rumination than those in the waitlist
control condition after treatment was completed. Finally, Ekkers et al. (2011) considered the
efficacy of competitive memory training (COMET) which is a seven-week cognitive behavioural
intervention, involving weekly group sessions and homework, for the treatment of depression
and rumination. COMET is designed to target underlying cognitive processes instead of the
content of dysfunctional cognitions; therefore, its aim was to change the amount of involvement
the patient has with their cognitions, rather than to change the negative emotions and thoughts
themselves (Ekkers et al., 2011). They found that participants in the COMET condition reported
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25
significantly reduced levels of rumination when compared to the waitlist control group; and 27%
of participants achieved a clinically significant reduction in rumination.
3.2. Effects of treatment on self-reported worry
Eleven out of the 19 included studies reported results with regards to change in self-
reported worry. Six of these studies assessed treatments with a cognitive behaviour therapy
(CBT) focus against either a waitlist control condition or other treatments (Andersson et al.,
2012; Leichsenring et al., 2009; Paxling et al., 2011; Robins et al., 2012; Robinson et al., 2010;
Titov et al., 2010; Westra et al., 2009). Out of these studies, four delivered their interventions via
the Internet; while the other two studies delivered their interventions via individual face-to-face
sessions (Leichsenring et al., 2009; Westra et al., 2009).
Andersson et al. (2012) evaluated an eight-week Internet-based CBT (iCBT) programme
against an eight-week Internet-based Psychodynamic therapy (iPDT) programme. They found
that participants in both the iCBT and iPDT conditions reported significantly lower self-reported
worry than participants in a waitlist control group, and that there was no significant difference in
treatment effectiveness between the Internet-delivered treatments. Furthermore, these differences
were maintained at three month and 18 month follow-up. Paxling et al. (2011) and Titov et al.
(2010) evaluated eight-week iCBT programmes against a waitlist control condition and found
that worry was significantly reduced in those participants taking part in the iCBT programme in
comparison to the waitlist control condition. Furthermore, these gains were maintained at follow-
up: at three months (Titov et al., 2010), at 12 months and at three years (Paxling et al., 2011).
However, results from the study by Titov et al. (2010) should be viewed with caution as the
authors used the LOCF method in ITT analysis with a high attrition rate. Robinson et al. (2010)
compared the efficacy of a six week Clinician-Assisted iCBT (CA-iCBT) programme to a six
week Technician-Assisted iCBT (TA-iCBT) programme. They found that both treatments were
equally effective at reducing worry when compared with the waitlist control group immediately
post-treatment. Interestingly, at the three month follow-up, while the TA-iCBT had maintained
treatment gains, the CA-iCBT group had made further gains.
Leichsenring et al. (2009) compared CBT to psychodynamic psychotherapy (PDP) and
assessed worry as a secondary measure. Participants in this study attended weekly or fortnightly
sessions with a CBT or psychodynamic therapist for up to 30 weeks. They found that participants
in the CBT group reported significantly lower levels of self-reported worry than participants in
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26
the PDP condition; and that treatment gains were maintained at six month follow-up. In the study
by Westra et al. (2009), the effect of adding motivational interviewing prior to CBT (MI-CBT)
was assessed against CBT with no pre-treatment (NP-CBT). All participants attended an eight-
week CBT programme conducted through individual face-to-face sessions with a CBT therapist;
however, participants in the MI-CBT group additionally had 4 weekly sessions of motivational
interviewing treatment prior to commencing their CBT programme. Results showed that
participants in the MI-CBT reported significantly lower levels of self-reported worry than those
in the NP-CBT group. Interestingly, the authors reported that MI-CBT appeared most effective
for participants with the highest worry scores at baseline; and whilst there was some evidence of
relapse at six month follow-up, when participants were followed up at 12 months, treatment
gains were again evident. However, this study reported results for ‘completers’ only and had a
relatively high attrition rate, therefore their findings may be inflated and the results should be
viewed with caution.
Two of the remaining four studies (Robins et al., 2012; Vollestad et al., 2011) assessed
eight-week MBSR programmes, delivered via group face-to-face sessions, against waitlist
control conditions. Both studies reported significant reduction in self-reported worry for
participants from the MBSR group versus those in the waitlist control condition; furthermore,
treatment gains were maintained at follow-up in both studies. However, the results from Robins
et al. (2012) should be viewed with caution as they did not conduct ITT analysis in spite of the
fact that they had a high rate of attrition (26%); and this may have resulted in an overestimation
of treatment effect. Steinmetz et al. (2012) assessed the efficacy of a specialist website - My
Disaster Recovery (MDR) - designed to help survivors of Hurricane Ike increase coping self-
efficacy, against an information only (IO) website and waitlist control condition. The same
information was essentially presented in both conditions; however, in the MDR site, participants
enjoyed a more interactive experience (e.g., through self-tests and video vignettes). Participants
were encouraged to access the sites as much as possible over a period of 30 days. After 30 days,
results showed that participants in the MDR condition reported significantly reduced self-
reported worry that those participants accessing the IO website or in the waitlist control
condition.
In one of the remaining two studies, Van Aalderen et al. (2012) reported that participants
who had taken part in their eight-week MBCT programme reported significantly lower levels of
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self-reported worry than participants in the waitlist control condition after treatment had ended.
The final study (Wolitzky-Taylor & Telch, 2010) evaluated worry exposure (WE), expressive
writing (EW), and Audio-Photic Stimulation (APS) against a waitlist control condition for the
reduction in self-reported academic and general worry. Audio-photic stimulation (APS) - also
called Audio-visual entrainment (AVE) - is a form of therapy used to promote relaxation and
treat stress-related disorders (Wolitzky-Taylor & Telch, 2010). In the current study APS was
delivered via a device consisting of an iPod-sized control panel which connected into
headphones emitting a programmable pulsing sound (similar to that of a beating heart) and
sunglasses that emit programmable bursts of orange flickering light (Wolitzky-Taylor & Telch,
2010). All treatments comprised of an initial face-to-face training session and then self-practice
over the course of four weeks. Results showed that WE and APS were significantly more
effective than EW (which did not differ significantly from the waitlist control condition) at post-
treatment. At follow-up (three months), all treatments had maintained gains; however,
participants in the EW condition had made the most significant improvement with regards to
reduction in worry, potentially suggesting a delayed treatment effect. Summarised results for all
included studies can be viewed in Table 3.5.
Table 3.5. Summarised results of all included studies
Study
Study Groups
Follow-up?
Rumination/worry findings
Andersson et
al. (2012)
iCBT vs.
iPDT vs.
WC
3mth &
18mth
Worry: post-treatment - significant reduction in worry for both
treatment groups in comparison to control (no significant difference
between ICBT and IPDT groups); at 3 mth follow-up same as
post-treatment; 18 mth follow-up - significant difference from pre-
to 18 mth follow-up for ALL groups
Campbell et al.
(2012)
MBSR vs.
WC
None
Rumination: MBSR group reported significantly lower levels of
rumination than WLC group
Ekkers et al.
(2011)
COMET+TAU
vs. TAU
None
Rumination: Patients in TAU+COMET condition reported
significantly reduced rumination when compared with control group
for both rumination measures; 27% of patients achieved clinically
significant reduction in rumination
Study groups: iCBT=Internet-based Cognitive Behaviour Therapy; iPDT=Internet-based Psycho-dynamic treatment;
MBSR= Mindfulness-Based Stress Reduction; COMET=COmpetitive MEmory Training; WC=Waitlist Control;
TAU=Treatment As Usual.
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Table 3.5. Summarised results of all included studies (cont’d)
Study
Study Groups
Follow-up?
Rumination/worry findings
Feldman et al.
(2010)
MB vs. PMR vs.
LKM
None
Repetitive thought: Negative reaction to repetitive thoughts is
reduced in the MB condition relative to the other two conditions;
increased frequency of repetitive thoughts in the MB vs. other
two conditions; however, decreased levels of negative reaction
to repetitive thoughts in MB condition
Jain et al.
(2007)
MM vs. RT vs. WC
None
Rumination and distraction: Participants in the MM group
showed significantly greater reduction in ruminative and
distractive thoughts to those in the RT and control groups, which
were not significantly different to each other
Leichsenring et
al. (2009)
PDP vs. CBT
6mths
Worry: CBT significantly more effective than psychodynamic
psychotherapy at reducing symptoms of worry; treatment effects
maintained at 6 mth follow-up
Paxling et al.
(2011)
iCBT vs. WC
12mth &
3 years
Worry: significantly reduced for those in the guided Internet-
delivered CBT condition vs. WLC; treatment effects maintained
at 1yr and 3yr follow-up
Robins et al.
(2012)
MBSR vs. WC
2mths
Rumination: no significant difference for MBSR group from
pre- to post-treatment; however, significant difference between
pre-treatment and follow-up as MBSR and waitlist groups
combined (after WL group completed MBSR training)
Worry: significant reduction pre- to post-treatment; and pre- to
follow-up
Robinson et al.
(2010)
CA-iCBT vs. TA-
iCBT vs. WC
3mths
Worry: At post-treatment both treatment groups equally
efficacious at reducing worry symptoms no change in WLC
group; At 3mth follow-up TA assisted group has maintained
treatment gains, CA assisted group has made further gains
Shapiro et al.
(2008)
MBSR vs. EPP vs.
WC
2mths
Rumination: Increases in mindfulness mediated a significant
reduction in rumination in MBSR participants; further gains
made at follow-up
Steinmetz et al.
(2012)
MDR vs. IO vs.
usual care (control)
None
Worry: MDR website significantly better at reducing self-
reported worry than information only or usual care
Titov et al.
(2010)
iCBT vs.
WC
3mths
(treatment
group only)
Worry: Significant reduction in worry for ICBT group from pre-
treatment to post-treatment and from pre-treatment to follow-up
Van Aalderen
et al. (2012)
MBCT+TAU vs.
TAU
3mths
Rumination and worry: MBCT+TAU group significantly
reduced levels of rumination and worry than TAU group
Vollestad et al.
(2011)
MBSR vs.
WC
6mths
Worry: significant reduction in self-reported worry for those in
MBSR condition vs. WLC; treatment gains maintained at 6mth
follow-up
Study groups: MB=Mindful breathing; PMR=Progressive muscle relaxation; LKM=Loving-kindness meditation;
MM=Mindfulness Meditation; RT=Relaxation Training; CBT=Cognitive Behaviour Therapy; PDP=Psychodynamic
Psychotherapy; iCBT=Internet-based Cognitive Behaviour Therapy; TA-iCBT=Technician-Assisted iCBT; CA-
iCBT=Clinician-Assisted iCBT; EPP= Easwaran’s Eight-Point Program; MDR=My Disaster Recovery website;
IO=Information Only website; MBSR= Mindfulness-Based Stress Reduction; MBCT=Mindfulness-Based Cognitive
Therapy; WC=Waitlist Control; TAU=Treatment As Usual.
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29
Table 3.5. Summarised results of all included studies (cont’d)
Study
Study Groups
Follow-up?
Rumination/worry findings
Watkins et al.
(2009)
CNT vs.
BogusCNT vs.
WC
None
Rumination: significantly reduced rumination in the CNT &
BogusCNT conditions vs. WLC; however, there was no
significant difference between CNT & BogusCNT groups
Watkins et al.
(2011)
RF-CBT vs.
WC
None
Rumination: Participants in the RFCBT group significantly
lower levels of self-reported rumination at post-treatment when
compared with those in WLC
Watkins et al.
(2012)
TAU (control) vs.
TAU+CNTself vs.
TAU+RTself
3mths &
6mths
Rumination: at post-treatment TAU+CNTself resulted in
significantly reduced levels of self-reported rumination than
TAU or TAU+RTself; TAU+CNTself was significantly more
effective than TAU+RTself when self-help response became
habitual
Westra et al.
(2009)
MI-CBT vs.
NP-CBT
6mths &
12mths
Worry: MI-CBT group showed significantly greater reduction in
worry than CBT alone (NP-CBT)
Wolitzky-
Taylor & Telch
(2010)
WE vs.
EW vs.
APS vs.
WC
3mths
Academic worry & General worry: WE and APS were
significantly more effective than EW which did not differ
significantly from WLC post-treatment. At follow-up, all
treatments maintained gains; however, EW made the most
significant gain
Study groups: CNT=Concreteness Training; BogusCNT=Bogus Concreteness Training; RF-CBT=Rumination-Focussed
Cognitive Behavioural Therapy; CNTself=Self-help concreteness training; RTself=Self-help relaxation training; MI-
CBT=Motivational Interviewing pre-treatment + CBT; NP-CBT=No pre-treatment + CBT; MI-CBT=Motivational Interviewing
pre-treatment + CBT; NP-CBT=No pre-treatment + CBT; WE=Worry exposure; EW=Expressive Writing; APS=Audio-Photic
Stimulation; WC=Waitlist Control.
4. Discussion
This systematic review aimed to assess treatments utilised for the reduction of rumination
and/or worry. Most of the studies included in the review evidenced fair to excellent
methodological quality and treatment integrity. Nevertheless, there were a few studies for which
we suggest results should be viewed with caution, predominantly due to the quality of statistical
analysis. Robins et al. (2010) and Westra et al. (2009) did not conduct ITT analysis, choosing
only to report findings from “completers” of treatment. In the context of significant attrition rates
in these two studies (26% and 18% respectively), there is a risk that effect sizes have been
overestimated. Campbell et al. (2012) and Titov et al. (2010) did conduct ITT analysis but chose
to do so using the LOCF method for imputation of missing data. If their attrition rates had been
low, the risk of bias would also be very low; however, their attrition rates were relatively high
(17% and 16% respectively), therefore we also view their results with caution. Whilst LOCF is
not the only method for the imputation of missing data, it is still the most widely used; however,
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30
given repeated warnings about the dangers of using the LOCF method it seems clear that its use
as the sole form of analysis should be discontinued (Lane, 2008; Shapiro, 2001; Barnes,
Mallinckrodt, Lindborg, & Carter, 2008; Streiner, 2002).
Furthermore, the heterogeneous nature of the included studies may make generalisation
difficult. For example, the studies included samples drawn from clinical, general adult and
student populations; and employed various interventions delivered in different formats. This
means that we could not compare effect sizes using meta-analyses as we may well expect the
effect sizes of treatment, due to baseline differences in symptoms, and differences in ability to
engage with treatment, to be quite different from each other. However, as our aim was to assess
treatments used in the reduction of rumination and/or worry, and the majority of studies used the
same well-validated measures for these constructs, we maintain they can be assessed against
each other narratively. It is worth noting also that many of the studies included in this review
reported substantially lower dropout rates than those reported in comparable studies in the
clinical literature. For example, a recent meta-analysis reported average dropout rates of between
18% and 20% for psychodynamic or CBT-based treatments (Swift & Greenberg, 2012). This
may be reflective of the difference study populations included and may reflect a higher level of
baseline functioning in the participants included in these studies. It may be that some of the
treatments which appear effective here may be less effective if participants were showing greater
symptom severity at baseline. However, this is speculation and a detailed analysis of the
difference in efficacy of treatment in different populations, whilst beyond the scope of this
systematic review, presents an interesting avenue for future research.
In spite of these limitations, this systematic review suggests that mindfulness-based and
cognitive behavioural interventions may be useful in the treatment or reduction of both
rumination and worry. Irrespective of delivery mode, both Internet-delivered and face-to-face
delivered formats appear to be useful. However, it is worth noting that most of the Internet-
delivered interventions in this review were CBT-based interventions. Whether or not
mindfulness-based interventions would be as effective if delivered via the Internet is worthy of
further exploration. Treatments in which participants are encouraged to change their thinking
style, or to disengage from emotional response to rumination or worry (e.g., through mindful
techniques), may be helpful. For example, treatments which enable participants to adopt more
concrete and specific thinking (Watkins et al., 2009; Watkins et al., 2012), or which cognitively
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31
restructure thinking in a more positive and constructive way (e.g., through CBT), appear to
reduce rumination and worry. Perhaps interventions which require active mental engagement are
useful because active mental engagement interferes with the more passive cognitive processes of
rumination and/or worry? However, this is speculation and also requires further empirical work.
Within the literature, worry, rumination, and many other cognitive processes (e.g.,
anticipatory stress; intrusive thoughts) are generally considered to be separate constructs,
conceptually close but not equated with one another (Brosschot et al., 2006). This is not our
position. We believe they are linked and are potentially underpinned by the same cognitive
process, that of perseverative cognition (Brosschot et al., 2006). If this is the case, we would
expect to see similar treatments proving effective for conditions for which worry and/or
rumination are key components (e.g., depression and anxiety disorders). Findings from the
studies included in this review may offer support for our position as similar formats of
intervention appear to be helpful in reducing self-reported rumination and/or worry. There were
two studies which measured the change in both rumination and worry (Robins et al., 2012; Van
Aalderen et al., 2012) and in both of these studies rumination and worry were reduced by the
same intervention. If rumination and worry represent different manifestations of perseverative
cognition (Brosschot et al., 2006), it is possible that treatments are working by interfering with
this process, thereby reducing both rumination and worry; however, we do accept that there are
also potentially other explanations for this and, as mentioned above, this provides an interesting
avenue for future research. In addition, this review has not explored in detail the components of
the included studies to reach an understanding of the specific shared mechanisms of the effective
treatments; another avenue for future research.
Interestingly, in the study by Feldman et al. (2010), the authors did not seek to reduce
rumination; instead, the focus was on the reduction of negative evaluation of repetitive thoughts.
Likewise, the study by Ekkers et al. (2011) aimed to reduce participants’ involvement with their
cognitions, rather than to reduce cognitions in general or to change anything content-related.
This suggests that rumination and/or worry per se may not be the issue but that an individual’s
emotional response to the process of perseverative cognition may be more of a problem. This
position is supported by a recent study in the occupational health literature which measured two
distinct but related forms of work-related rumination affective rumination and problem-solving
pondering in a large sample (N=719) of working adults (Querstret & Cropley, 2012). The
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32
authors suggested that affective rumination (characterised by negatively emotionally-valenced
perseverative cognitions) would potentially be more detrimental than problem-solving pondering
(characterised by perseverative cognitions without an emotional component) in the context of
recovery from work-related demands (stressors). They found that affective rumination was
significantly more predictive of both acute (short-term) and chronic (persistent; long-term) work-
related fatigue. The results of this study have been further bolstered by findings from a
longitudinal follow-up which suggested affective rumination may be part of a causal model of
work-related fatigue (Querstret & Cropley, in preparation). In line with the perseverative
cognitions hypothesis (Brosschot et al., 2006), the authors posited that affective rumination may
maintain psychophysiological arousal whereas problem-solving pondering may not. They have
speculatively suggested that these different forms of work-related rumination may operate
differentially in the brain with problem-solving pondering having a dampening effect (via the
prefrontal cortex) of the emotional response. This raises an avenue worthy of future research. If
rumination and/or worry per se are not as problematic as the individual’s emotional evaluation of
these processes, perhaps interventions designed to change emotional interpretation would be just
as effective as studies which aim to reduce rumination and/or worry.
In the studies included in this review, the majority of CBT-based interventions were
supported by trained clinicians; however, the results from Robinson et al. (2010) suggest that, in
the short-term, iCBT may reduce worry when supported by non-clinicians. However, at follow-
up those participants who had been managed by non-clinicians did not maintain gains in the
same way as those who had support from trained therapists. This seems to suggest that a model
for lasting treatment effect requires at least some training in the respective techniques for those
delivering or supporting the respective interventions. In the context of improving access to
psychological therapies, it would be advantageous to be able to develop and implement
treatments that were effective without the need for expensive therapeutic support. This is an
avenue worthy of future exploration.
There is a possibility of publication bias in this review as the articles included all came
from peer reviewed journals; and Petticrew & Roberts (2006) suggest it is more likely that the
articles published would have concluded that the intervention was effective. Also, because the
search for articles was limited to a specific time period (2002-2012), it is possible that
contradictory results have been missed which could have added to this review. However, the
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33
objective of this review was to understand the current landscape with regards to available
treatments.
5. Conclusions
This systematic review suggests that mindfulness-based and cognitive behavioural
interventions may be effective in the reduction of both rumination and worry. Irrespective of
delivery mode, both Internet-delivered and face-to-face delivered formats appear to be useful.
More broadly, treatments in which participants are encouraged to change their thinking style, or
to disengage from their emotional response to rumination and/or worry (e.g., through mindful
techniques), could be helpful.
Querstret & Cropley, Clinical Psychology Review, authors copy
34
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... When the literature is examined, it is seen that activities based on cognitive behavioral approaches have been tested and positive results have been obtained in order to reduce rumination in foreign studies (Ekkers et al., 2011;Teismann et al., 2014;Watkins et al., 2011;Wilkinson & Goodyer, 2008). Querstret and Cropley (Querstret & Cropley, 2013) reviewed 19 studies in the period 2002-2012 in a review study evaluating the treatments used to reduce rumination and anxiety. According to the results, the authors found that cognitive-behavioral interventions were more effective than other approaches in reducing both rumination and anxiety. ...
... Schmalling et al. (Schmalling et al., 2002) suggest that programs that develop thinking skills such as cognitive behavioral therapies may be effective in reducing rumination. Querstret and Cropley (Querstret & Cropley, 2013) showed that the programs prepared on the basis of cognitive and behavioral techniques were effective on the disorders associated with rumination and rumination in meta-analysis studies. The programs generally include psychoeducation, cognitive restructuring, self-monitoring, social skills and problem solving trainings, relaxation exercises, and exposure (Ciesla & Roberts, 2002;Teismann et al., 2014;Wilkinson & Goodyer, 2008). ...
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The purpose of this study is to examine the effect of group counseling program based on Cognitive-Behavioral Approach on the rumination levels of adolescents. Solomon Quadruple Model was applied in the study. Accordingly, in the study two control and two experimental groups, each consisting of 12 members, were formed. Experimental groups were provided psychological counseling with a group based on cognitive-behavioral approach for 8 weeks. No treatment was given to the control groups. The Rumination Scale Short Form (RS) was used data collection instrument. In accordance with the Solomon Quadruple Model, just one experimental and control group were pretested, while other two were not. Post-test was applied to all four groups. One months after the sessions were completed, the follow up measure was again applied to all four groups. Statistical analyzes revealed that the experimental groups had a significant decrease in the degree of brooding and reflection, rumination and sub-dimensions of rumination. It was also found that the results were independent of Maturation x Time interaction and Pretest effect. There was no statistically significant difference in the control groups. Therefore, based on the results, it can be said that the group counseling program with cognitive-behavioral approach is effective in decreasing the brooding and reflection levels of the rumination and rumination sub-dimensions of the adolescents. The findings were discussed in the light of the related literature and suggestions were made in relation to the results of the research.
... As such, while mental health professionals can play a role in reducing discrimination through research, teaching, social action, and by implementing the type of school-based interventions described above, they might also be able to help adolescents who are currently experiencing discrimination by reducing brooding, which appears to propagate the impact of PED and increases vulnerability to depression. A number of effective interventions are available to help individuals decrease ruminative thinking (Querstret & Cropley, 2013). Additionally, mental health professionals can help teach adolescents effective strategies for how to respond if they should encounter subsequent incidents of PED (Guerin, 2005;Sue et al., 2019). ...
Article
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Our study explored the relations between perceived everyday discrimination (PED), brooding rumination (dwelling on negative feelings), reflection rumination (attempting to understand a negative state), and depressive symptoms among adolescents. Previous research has identified PED as a risk factor for depressive symptoms across diverse populations, and there is evidence that brooding mediates the relation between PED and symptoms of depression in adolescents. However, we addressed a gap in the literature by examining how reflection, which is hypothesized to be a more adaptive coping response than brooding, is related to PED and depressive symptoms. Our sample of 232 adolescents (89 female) aged 13 to 16 (M = 14.18, SD = 0.54) identified as Black (46.5%), White (37.0%), Mixed Race (12.2%), Hispanic (1.7%), and Other (2.6%). Participants completed self-report measures of PED (attributable to any self-identified distinguishing characteristic), brooding and reflection, and depressive symptoms. In accordance with our hypotheses, we found that PED was positively associated with both brooding and reflection. Additionally, PED and brooding, but not reflection, were positively associated with depressive symptoms when accounting for the impact of the other variables in the model. Our results add to existing evidence that brooding is a less adaptive form of rumination than reflection. Further, our results corroborate previous findings that brooding plays a role in the association between PED and depressive symptoms. Testing the differential mediating effects of brooding and reflection in the relation between PED and adolescent depressive symptoms in a prospective study design will be an important direction for future research.
... IL-6 was used (besides psychometric tests) as a biomarker to assess its effectiveness. The cognitive-behavioral techniques chosen (psychoeducation, distraction, solving problem, behavioral activation, mindfulness, and cognitive restructure) were able to reduce rumination, IL-6, and depressive symptomatology (Querstret & Cropley, 2013;Dimidjian, et al., 2014) (Table 1). ...
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Evidence suggests that ruminative responses, or rumination, are a predictor, exacerbated, and residual symptom of psychopathologies, especially depression. A common approach is observed, researchers are not focused on previously created interventions to know how to reduce and replace rumination to prevent the development of psychopathologies. Cognitive-behavioral techniques have been demonstrated to be useful to decrease repetitive thoughts. Interleukin-6 (IL-6), a proinflammatory cytokine, is present in plasma from persons with depression so it can be used as a biomarker. The present study was conducted to decrease ruminative responses and plasma IL-6 in depressed college students. For this purpose, participants meeting the criteria for "rumination" according to "Ruminative Responses Scale" (n=3) were chosen. In general, the study of a single case with two repetitions demonstrated a decrease of ruminative responses, depressive symptomatology, and plasma IL-6. These data are consistent with previous studies. Keywords: Ruminative responses, depressive symptomatology, plasma interleukin-6, cognitive-behavioral intervention, college students. RESUMEN La evidencia sugiere que las respuestas rumiativas, o la rumiación, son un síntoma predictor, exacerbado y residual de psicopatologías, especialmente de depresión. Se observa un enfoque común, los investigadores no se centran en intervenciones creadas previamente para saber cómo reducir y reemplazar la rumiación para prevenir el desarrollo de psicopatologías. Se ha demostrado que las técnicas cognitivo-conductuales son útiles para disminuir los pensamientos repetitivos. La interleucina-6 (IL-6), una citocina proinflamatoria, está presente en el plasma de personas con depresión, por lo que puede usarse como biomarcador. El presente estudio se realizó para dis-minuir las respuestas rumiativas y la IL-6 plasmática en estudiantes universitarios deprimidos. Para ello, se eligieron los participantes que cumplían con los criterios de "rumia" según la "Escala de Respuestas Rumiantes" (n=3). En general, el estudio de un solo caso con dos repeticiones demostró una disminución de las respuestas rumiantes, la sintomatología depresiva y la IL-6 plasmática. Estos datos son consistentes con estudios previos. Palabras clave: Respuestas rumiativas, sintomatología depresiva, interleucina-6 plasmática, intervención cognitivo-conductual, estudian-tes universitarios.
... These cognitive processes relate to mood and anxiety disorders, such as depression and generalized anxiety disorder, as well as stress-related disorders, including PTSD and PGD Moulds et al., 2020;Nolen-Hoeksema et al., 2008;Olatunji et al., 2013). Systematic reviews and meta-analyses have demonstrated that treatments targeting worry and rumination are effective in reducing psychopathology (e.g., Querstret & Cropley, 2013) and pilot randomized controlled trials demonstrate that such treatments may also reduce loss-related psychopathology (e.g., Eisma et al., 2015;Wenn et al., 2019). Nevertheless, it is yet unclear what the temporal relationships are between depressive rumination, worry, and commonly observed symptoms of post-loss psychopathology. ...
Article
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Bereavement can precipitate symptoms of depression, prolonged grief disorder, and posttraumatic stress disorder. Targeting repetitive negative thought (i.e., worry, rumination) in treatment may help reduce post-loss psychopathology. Yet, evidence on longitudinal associations of depressive rumination and worry with post-loss psychopathology symptoms has been mixed and the directions of effects are still unclear. Recently bereaved adults (78% female), completed questionnaires assessing depressive rumination (brooding), worry, and depression, prolonged grief and posttraumatic stress symptoms 11 times in 1.5 month intervals. We applied random-intercept cross-lagged panel models (RICLPMs) to examine reciprocal within-person associations between worry and psychopathology symptoms, between rumination and these symptoms, and between worry and rumination. Main findings were that worry showed reciprocal relationships with psychopathology symptoms (although worry did not consistently predict prolonged grief symptoms). Depressive rumination was predicted by psychopathology symptoms, but not vice versa. Worry showed reciprocal relations with depressive rumination. Findings suggest that worry may be part of a downward spiral, enhancing psychopathology symptoms following loss, whereas depressive rumination is solely a consequence of such symptoms.
... Our findings identified two potential treatment targets, including perseverative thinking and decentering. Both cognitive and "third-wave" behavioral therapies have been shown to reduce perseverative thinking (Chambers, Lo, & Allen, 2008;Mennin et al., 2018;van Aalderen et al., 2012;Watkins et al., 2011; for a review, see Querstret & Cropley, 2013) and improve anxiety and depression (Cuijpers, Andersson, Donker, & van Straten, 2011;McCarney, Schulz, & Grey, 2012;Stewart & Chambless, 2009;Vøllestad, Nielsen, & Nielsen, 2012). The extent to which these existing interventions can prevent the development of PT and anxiety and depression remains to be established. ...
Article
While research identifies a growing list of risk factors for anxiety and depression, it is equally important to identify potential protective factors that may prevent or reduce vulnerability to developing internalizing psychopathology. We hypothesized that forms of perseverative thinking, such as rumination and worry, act as mechanisms linking negative life experiences and prospective symptoms of anxiety and depression. More specifically, we investigated whether decentering, the meta-cognitive capacity to adopt a distanced perspective toward one's thoughts and feelings, serves as a protective factor at various points along this mediational pathway. A sample of 181 undergraduate students were recruited and assessed at five time points over a 12-week period. Multilevel modeling indicated that decentering was associated with an attenuated impact of (1) negative events on prospective depressive symptoms; (2) negative events on prospective brooding, and (3) brooding, pondering and worry on prospective internalizing symptoms. Multilevel moderated mediation analyses provided partial support for the hypothesis that perseverative thinking would mediate the longitudinal associations between negative life events and internalizing symptoms, with decentering attenuating risk at several connections of the indirect pathways. The strongest support was provided for moderated mediation models in which decentering was associated with attenuated relationships between negative events, brooding, and symptoms of depression. This study is the first to elucidate the role of decentering as a protective factor against anxiety and depressive symptoms at different points in the path from stress to perseverative thought to internalizing symptoms. Decentering therefore may be a critical target for clinical intervention to promote resilience against anxiety and depression.
... From the early behavioristic stopping-technique approaches (Stern et al., 1973;Wolpe and Lazarus, 1966), which conceptualized rumination as covered ("private") verbal behavior, to rumination-focused CBT for residual depression (e.g. Cook and Watkins, 2016;Hvenegaard et al., 2020;Moeller et al., 2020;Roberts et al., 2021), psychotherapists have for decades attempted to reduce rumination, and thereby to improve the patient's condition (for a review on techniques for improving rumination (see Querstret and Cropley, 2013). Several psychological models of rumination have been introduced. ...
Article
While many clinical studies and overviews on the contribution of rumination to depression exist, relatively little information regarding the role of mind wandering (MW) in general is available. Therefore, it remains an open question whether patterns of MW are altered in depression and, if so, how these alterations are related to rumination. Here, we review and discuss studies investigating MW in cohorts, showing either a clinically significant depression or with clinically significant disorders accompanied by depressive symptoms. These studies yield first tentative insights into major issues. However, further investigations are required, specifically studies which: i) compare patients with a primary diagnosis of major depression with healthy and appropriately matched controls, ii) implement measures of both MW and rumination, iii) are based on experience sampling (in combination with other key approaches), iv) compare experience sampling during daily life, resting state and attentional tasks, v) explore possible biases in the assessment of MW, vi) acquire data not only related to the propensity and contents of MW, but also regarding meta-awareness and intentionality.
... On the other hand, it could imply that it may be worthwhile to encourage them to choose and rely more on other or new attachment figures for the support previously provided by their ex-partners. The strong association between rumination and yearning with breakup distress further suggests that treatments targeting repetitive thought may be helpful in reducing breakup distress (for a review of such treatments in other contexts : Querstret & Cropley, 2013). ...
Article
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Background and objectives Romantic relationship breakups can lead to severe emotional disturbances including major depression. Anxious attachment and desired attachment with the ex-partner are hypothesized to elicit repetitive thought about the breakup and the former partner and attempts to reunite with (i.e. approach) the ex-partner, which fuel breakup distress. Since prior research on this topic has mostly used survey methodology, the study aim was to examine the relations between above-mentioned variables employing a behavioral measure of approach of the ex-partner. Methods Automatic approach-avoidance tendencies toward the former partner were assessed with an Approach Avoidance Task (AAT). Sixty-two students (76% female) moved a manikin towards or away from stimuli pictures (ex-partner, matched stranger, landscape) as fast as possible based on the stimulus frame color (blue, yellow). Participants also completed questionnaires assessing anxious attachment, desired attachment, repetitive thought about the breakup (rumination) and the ex-partner (yearning), and breakup distress (prolonged grief symptoms). Results Anxious attachment related positively to rumination and breakup distress. Desired attachment related positively to yearning, automatic approach bias toward the ex-partner, and breakup distress. Both anxious and desired attachment, rumination, yearning, and approach bias related positively to breakup distress. Limitations The use of a student sample may limit generalizability. A correlational design precludes causal conclusions. Conclusions Together with prior work, results suggests anxious attachment hampers psychological adaptation to a breakup by increasing the use of ruminative coping. Desire to retain an attachment bond with the ex-partner, expressed in yearning and approach of the ex-partner, may also worsen breakup distress.
... This stipulates that when people are repeatedly exposed to adversity many begin to experience negative cognitions and to believe that personal control cannot be exerted on the environment and so become deactivated. It is noteworthy that depression is comorbid with many mental health difficulties and this may be indicative of a unifying cognitive or affective process present throughout mental health difficulties (Querstret & Cropley, 2013), such as negative cognition or negative affect. Positive psychotherapy may therefore be beneficial to people with a range of clinical presentations and it has a role more broadly in generally facilitating peoples' subjective wellbeing. ...
Article
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Mental health services are placing a greater emphasis on wellbeing and recovery. The current research investigated if positive psychology interventions (PPIs) increase peoples’ subjective wellbeing and reduce clinical depression. A systematic methodological review was conducted on randomized-control-trials with people attending clinical services. Five databases were searched. A hand search was then completed on the reference lists of the identified articles and the associated journals. Eleven research interventions were reviewed. PPIs were found to significantly increase wellbeing, relative to controls and there were fewer studies indicating a difference in decreasing depression. However, subsequent analysis revealed that the interventions were heterogeneous which limits the drawing of definitive systematic conclusions. A methodological evaluation also found that there were recurring issues: in delivering the interventions, measuring subjective wellbeing, and applying the design. Thus, the methodological quality of the research interventions, as measured by the current review was low. There is emerging evidence that PPIs improve peoples’ mental health. However, there is scope to standardize and to improve the quality of the research interventions.
Article
Background: Irrational beliefs, maladaptive emotions, and unhealthy lifestyle behaviors can adversely affect health status. However, limited research has examined the association between irrational beliefs and cardiovascular disease (CVD). The aim of this study was to evaluate the association between irrational beliefs and the 10-year CVD incidence among apparently healthy adults, considering the potential moderating or mediating role of particular social and lifestyle factors. Methods: The ATTICA study is a population-based, prospective cohort (2002-2012), in which 853 participants without a history of CVD [453 men (aged 45 ± 13 years) and 400 women (aged 44 ± 18 years)] underwent psychological evaluations. Among other tools, participants completed the irrational beliefs inventory (IBI, range 0-88), a self-reported measure consistent with the Ellis model of psychological disturbance. Demographic characteristics, detailed medical history, dietary, and other lifestyle habits were also evaluated. Incidence of CVD (i.e., coronary heart disease, acute coronary syndromes, stroke, or other CVD) was defined according to the International Coding Diseases (ICD)-10 criteria. Results: Mean IBI score was 53 ± 2 in men and 53 ± 3 in women (p = 0.88). IBI score was positively associated with 10-year CVD risk (hazard ratio 1.07, 95%CI 1.04, 1.13), in both men and women, and more prominently among those with less healthy dietary habits and lower education status; specifically, higher educational status leads to lower IBI score, and in conjunction they lead to lower 10-year CVD risk (HR for interaction 0.98, 95%CI 0.97, 0.99). Conclusions: The findings of this study underline the need to build new, holistic approaches in order to better understand the inter-relationships between irrational beliefs, lifestyle behaviors, social determinants, and CVD risk in individuals.
Article
The aim of the study was to determine if heart rate (HR) and skin conductance increase as a result of worrying and if the increase is greater in worriers than in non-worriers. Ten self-labelled worriers and 10 self-labelled non-worriers were individually interviewed, and a worrying event and a pleasant event were determined for each. The HR and skin resistance were then measured for all subjects when they were calm and quiet, when they imagined a worrying event, and when they imagined a pleasant event. There was no difference in the HR and skin conductance of worriers and non-worriers across the three conditions, namely, baseline, imagination of a worrying event and imagination of a pleasant event. Heart rate increased only as a result of worrying whereas the skin conductance increased both due to worrying and due to the imagination of the pleasant event. The results suggest that HR may be used as a measure of worrying.
Book
Such diverse thinkers as Lao-Tze, Confucius, and U.S. Defense Secretary Donald Rumsfeld have all pointed out that we need to be able to tell the difference between real and assumed knowledge. The systematic review is a scientific tool that can help with this difficult task. It can help, for example, with appraising, summarising, and communicating the results and implications of otherwise unmanageable quantities of data. This book, written by two highly-respected social scientists, provides an overview of systematic literature review methods: Outlining the rationale and methods of systematic reviews; Giving worked examples from social science and other fields; Applying the practice to all social science disciplines; It requires no previous knowledge, but takes the reader through the process stage by stage; Drawing on examples from such diverse fields as psychology, criminology, education, transport, social welfare, public health, and housing and urban policy, among others. Including detailed sections on assessing the quality of both quantitative, and qualitative research; searching for evidence in the social sciences; meta-analytic and other methods of evidence synthesis; publication bias; heterogeneity; and approaches to dissemination.
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Research on comorbidity among psychological disorders is relatively new. Yet, comorbidity data have fundamental significance for classification and treatment. This significance is particularly apparent in the anxiety disorders, which, prior to DSM-III-R, were subsumed under disorders considered more significant (e.g., psychotic and depressive disorders). After considering definitional, methodological, and theoretical issues of comorbidity, data on comorbidity among the anxiety disorders are reviewed as well as data on comorbidity of anxiety disorders with the depressive, personality, and substance use disorders. Treatment implications are presented with preliminary data on the effects of psychosocial treatment of panic disorder on comorbid generalized anxiety disorder. Implications of comorbidity for research on the nature of psychopathology and the ultimate integration of dimensional and categorical features in our nosology are considered.