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ORIGINAL ARTICLE
Cognitive Therapy and Research
https://doi.org/10.1007/s10608-025-10593-2
Emily Upton
e.upton@blackdog.org.au
Jill M. Newby
j.newby@unsw.edu.au
Venkatesha Venkatesha
venkatesh.bhagavath@hotmail.com
Amy E. Joubert
amy_joubert@hotmail.com
Alison E. J. Mahoney
Alison.Mahoney@svha.org.au
Michelle L. Moulds
m.moulds@unsw.edu.au
Aliza Werner-Seidler
a.werner-seidler@blackdog.org.au
1 UNSW Sydney, Sydney, Australia
2 Black Dog Institute, Sydney, Australia
3 St Vincent’s Hospital Sydney, Darlinghurst, Australia
Abstract
Background Repetitive Negative Thinking (RNT) is a key transdiagnostic mechanism underlying anxiety and depressive
disorders, and targeting RNT specically leads to improved treatment outcomes. There is a lack of research however into
mechanisms of change in RNT-focused interventions and factors that predict treatment response. The aim of this study was
to examine the mediators and predictors of outcome (RNT, depression, anxiety, and distress) in a brief online intervention
for RNT in adults.
Methods This study used secondary data from a Randomised Controlled Trial of the Managing Rumination and Worry
Program (Joubert et al. in Beh Res Therapy, 168:104378, 2023) in which N = 137 adults with elevated levels of RNT were
randomly allocated to a 3-lesson clinician-guided or self-guided version of the program delivered over 6 weeks, or a treat-
ment-as-usual (TAU) control condition. Self-report measures of depression, anxiety, distress, and RNT were administered at
baseline, post-treatment, and 3-month follow-up; RNT and distress were also measured prior to each lesson.
Results Intention-to-treat linear mixed models showed a gradual reduction in RNT and distress over treatment in both active
conditions, with the largest reductions in RNT occurring after the lessons containing the active treatment strategies (2 and
3). Structural equation modelling mediation analyses showed that reductions in transdiagnostic RNT mediated reductions
in distress between Lessons 2 and 3, and reductions in rumination specically mediated reductions in distress and depres-
sion between post-treatment and follow-up, but there was no consistent pattern of mediation by RNT throughout treatment.
Finally, higher baseline symptom severity (particularly rumination) signicantly predicted poorer post-treatment outcomes,
while higher treatment expectancy and clinician guidance signicantly predicted better post-treatment outcomes.
Conclusion This is one of the rst studies to examine mediators and predictors of change in a brief, online RNT-focused
intervention for adults with elevated RNT. Further research in larger samples is needed, examining additional possible medi-
ating and predictor variables and across more time points, to better understand how and for whom this intervention reduces
RNT, anxiety and depression.
Australian and New Zealand Clinical Trials Registration number: ACTRN 12620000959976. Date of
registration: 25/09/2020.
Keywords Rumination · Worry · Anxiety · Depression · Mediation · Predictors
Accepted: 5 March 2025
© The Author(s) 2025
Mediators and Predictors of Treatment Response in a Brief Online
Intervention for Rumination and Worry
EmilyUpton1,2· VenkateshaVenkatesha1· Amy E.Joubert1· Alison E. J.Mahoney3· Michelle L.Moulds1·
AlizaWerner-Seidler1,2· Jill M.Newby1,2
1 3
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Cognitive Therapy and Research
Introduction
Depression and anxiety disorders are among the most
prevalent mental illnesses contributing substantially to
the global burden of disease (Santomauro et al., 2021),
underscoring the key need for more accessible treatment.
Repetitive Negative Thinking (RNT) is a key causal and
maintaining process across multiple depressive and anxi-
ety disorders (Ehring & Watkins, 2008). RNT encapsu-
lates the process of perseverative and unhelpful thinking in
both rumination (repeated abstract, negative thinking about
symptoms, causes, meanings, and past events, frequently
seen in depression) and worry (repeated catastrophic think-
ing about potential negative future events, typically charac-
teristic of anxiety; Watkins, 2004). There is evidence that
RNT is frequently involved in the onset, maintenance and
severity of depressive and anxiety disorders, and the risk
of relapse (Ehring & Watkins, 2008; Wahl et al., 2019), and
that individuals with higher levels of baseline RNT respond
more poorly to cognitive behavioural therapy (CBT) inter-
ventions for depression and anxiety (Crane & Williams,
2010; Schmaling et al., 2002). RNT therefore is an impor-
tant transdiagnostic target for intervention.
Researchers have therefore developed psychological
treatments specically targeting RNT, with evidence that
targeting RNT explicitly leads to improved overall treat-
ment outcomes compared to CBT treatments for depression
and anxiety that do not specically address RNT (Spin-
hoven et al., 2018; Watkins, 2015; Watkins & Roberts,
2020; Watkins, 2022). Rumination-Focused CBT (RF-CBT;
Watkins, 2018), for example, was developed to speci-
cally target depressive rumination in the context of depres-
sion. RF-CBT signicantly reduces worry, rumination, and
depression and anxiety symptoms, compared to treatment
as usual (Hvenegaard et al., 2020; Teismann et al., 2014;
Topper et al., 2017), including in samples of patients with
chronic and/or treatment-resistant depression (Watkins et
al., 2011). Moreover, RF-CBT reduces the risk of relapse in
adolescents and adults with a history of depression (Jacobs
et al., 2016), and prevents the development of anxiety and
depressive disorders in adolescents and young adults who
are at-risk owing to high trait levels of RNT (Cook et al.,
2019; Topper et al., 2017).
While there is a growing evidence base demonstrat-
ing the eectiveness of RNT-focused interventions, more
research is needed to investigate proposed mechanisms of
change in these treatments (Ehring, 2021; Watkins, 2009).
Specically, there is a lack of research investigating how
RNT-focused treatments work, including whether they
successfully alleviate (or prevent) depression or anxiety
through changing RNT, and whether changes in RNT pre-
cede changes in symptoms (Watkins, 2009). In one trial of
RF-CBT (Watkins et al., 2011), decreases in rumination
mediated treatment eects on depression symptom sever-
ity. More research is needed to replicate these ndings, and
to extend them by studying the potential mediating eect
of changes in RNT on anxiety as well as depression symp-
toms. Another recent trial which tested whether RF-CBT
could prevent depression and Generalised Anxiety Disorder
(GAD) in high-risk adolescents (Topper et al., 2017) found
that the benets of the treatment (operationalised as lower
prevalence of depression and GAD relative to the control
condition) were mediated by changes in RNT during treat-
ment. It is important to examine whether this same pattern
of mediation found in prevention studies is observed in cur-
rently anxious or depressed individuals in treatment studies.
It is also unknown for whom RNT-focused interventions
are most eective, due to the lack of research investigating
the factors that predict treatment outcomes in these inter-
ventions. Only two identied trials of RNT-focused treat-
ments have each investigated a potential predictor variable.
The rst (Cook et al., 2019) was a trial of online RF-CBT
for the prevention of depression in undergraduate students
with high levels of RNT. As hypothesised, due to the inter-
action between rumination and stressful life events, treat-
ment was more likely to prevent the onset of depression in
participants who reported moderate or severe stressful life
events at baseline (Cook et al., 2019). The second was a
recent study of group-delivered RF-CBT (Wallsten et al.,
2023). Despite previous literature showing that patients
with higher ratings of treatment credibility and eectiveness
prior to commencement (i.e., treatment expectancy) gener-
ally experience better outcomes in various psychological
therapies (Tambling, 2012), Wallsten et al. (2023) found
participants’ ratings of treatment expectancy were not corre-
lated with changes in depression or anxiety symptoms over
treatment. To our knowledge, no other studies have investi-
gated potential predictive factors beyond baseline stressful
life events or treatment expectancy. In non-RNT-focused
CBT interventions for depression and anxiety, participants
with higher baseline depression and anxiety severity, and
higher baseline rumination and worry, show better treatment
response to non RNT-focused CBT interventions (Barrio-
Martínez et al., 2023; Karyotaki et al., 2021; Niles et al.,
2021; Reins et al., 2021). Further research is needed to
examine who is most likely to benet from RNT-focused
treatments and explore how they work, in order to target
treatments to appropriate populations, and further enhance
their ecacy.
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Cognitive Therapy and Research
The Current Intervention
There is also evidence that adapting treatments to be brief,
and delivered online, can increase their accessibility and
uptake while maintaining their eectiveness (Andersson &
Carlbring, 2017; Bisby et al., 2024; Ebert et al., 2018; Ruiz
et al., 2020). Joubert et al (2021) developed a brief, three-
lesson online intervention that specically targets RNT
(Joubert et al., 2021) using principles guided from mul-
tiple treatment frameworks including RF-CBT (Watkins,
2018), mindfulness-based cognitive therapy (MBCT; Segal,
2018) and concreteness training (Watkins et al., 2012). The
Managing Rumination and Worry Program was developed
based on the needs and treatment preferences of individuals
with high RNT (Joubert et al., 2022). It was designed to be
transdiagnostic in scope, for both clinical and sub-clinical
populations who demonstrate high trait levels of RNT, are
at risk of developing depression or anxiety, have current
symptoms, or are vulnerable to relapse.
The Managing Rumination and Worry Program has been
evaluated in a pilot trial (Joubert et al., 2021) and randomised
controlled trial (RCT) (Joubert et al., 2023) which showed
it was acceptable to participants, and ecacious in reduc-
ing the frequency of RNT, as well as symptoms of anxiety,
depression, and distress, compared to treatment as usual,
both immediately post-treatment and at 3-month follow-
up (Joubert et al., 2023). The current study extended their
research by exploring the mechanisms of change and factors
that predict benet from this brief online intervention.
Study Aims and Hypotheses
The overall aim of this study was to investigate mediators
and predictors of change in depression, anxiety and distress
outcomes in the Managing Rumination and Worry Program.
Psychological distress was included as an outcome as it is
a transdiagnostic variable highly correlated with diagnosis
and severity of anxiety and depressive disorders (Andrews
& Slade, 2001), and brief to measure (using the Kessler Psy-
chological Distress Scale–10; K-10; Kessler et al., 2002),
so it was administered at more frequent timepoints during
treatment (prior to each lesson as well as at pre, post, and
follow-up). A brief transdiagnostic measure of RNT (the
Repetitive Thinking Questionnaire 10-item; RTQ-10; McE-
voy et al., 2010) was also administered prior to each lesson,
enabling more comprehensive analysis of change in this
variable across treatment in addition to pre-to-post change.
1) Pattern of symptom change across treatment. Firstly,
we wanted to understand how RNT and distress
changed across each session of treatment, to explore
whether there were larger improvements after particular
sessions, as a rst step towards identifying the most
benecial treatment components. While there is no data
to our knowledge on patterns of symptom change in
RNT-focused interventions, studies of general CBT for
depression and anxiety show varied patterns of symp-
tom improvement in patients who respond well to treat-
ment, including sudden gains after the rst session or a
gradual improvement over time (Andrews et al., 2020;
Bisby et al., 2023; Robinson et al., 2020; Skelton et al.,
2023). Thus, these questions were exploratory.
2) Mediating eect of RNT. Secondly, we aimed to inves-
tigate whether changes in RNT mediated changes in
psychological distress, depression, and anxiety across
treatment. We explored this in two ways, given that
some measures were also administered prior to each les-
son, while others were administered only at pre, post,
and follow-up timepoints.
a) Lesson-by-lesson mediation. First, we examined
whether changes in RNT after each treatment ses-
sion mediated lower levels of distress at the next
lesson. No studies to our knowledge have exam-
ined session-by-session mechanisms of change in
RNT-focused interventions. However, Patel et al.
(2023) measured rumination and depression symp-
tom severity periodically throughout CBT treatment
for depression in an outpatient tertiary setting. They
found that lower rumination levels at each treatment
time point prospectively predicted lower symp-
toms of depression at the next time point. Based
on these ndings, and the ndings of Watkins et al.
(2011) and Topper et al. (2017) that reductions in
depression symptoms (or likelihood of developing
depression or anxiety symptoms) were mediated by
changes in RNT during treatment, we hypothesised
that changes in RNT at each time point would pre-
dict changes in distress at the following timepoint.
b) Pre- to post and follow-up mediation. Next, we
examined whether changes in RNT mediated the
eect of treatment from pre- to post-treatment and
follow-up on the key clinical outcome measures
(depression, anxiety, and distress symptoms). As
more measures were available, we examined this
using both the transdiagnostic measure of RNT
(RTQ-10) and specic measures of maladaptive
rumination (the Ruminative Response Scale—
Brooding Subscale; RRS—Brooding; Treynor et
al., 2003) and worry (the Penn State Worry Ques-
tionnaire; PSWQ; Meyer et al., 1990), to determine
whether the same pattern of mediation was observed
in both sub-types of RNT. Based on evidence that
reductions in RNT are associated with decreases in
1 3
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Cognitive Therapy and Research
[PHQ-9; Kroenke et al., 2001a] total score > 23), were
actively suicidal, self-reported diagnoses of schizophrenia,
bipolar disorder, or psychosis, commenced psychological
therapy in the preceding month, commenced or changed
dosage of depression or anxiety medication in the preceding
two months, or enrolled in an online program for depression
or anxiety in the preceding year.
Participants were recruited between August 2020 and
March 2021, via social media advertisements and email
newsletters. Eligible participants completed informed
consent, eligibility screening and demographic question-
naires online, before completing a brief telephone interview
including a structured diagnostic interview (abbreviated
Anxiety and Related Disorders Interview Schedule for
DSM-5; ADIS-5; Brown & Barlow, 2014) to assess current
and past MDD and GAD diagnoses, and a risk assessment.
They were then randomly assigned to either the 3-lesson
clinician-guided or self-guided online intervention program,
or the TAU waitlist control group. All participants were able
to continue with any current psychological or pharmacolog-
ical treatment (except those specied in the exclusion crite-
ria) but were discouraged from commencing new treatments
during the study participation period.
Participants completed online self-report measures at
pre-treatment (immediately prior to Lesson 1), post-treat-
ment (one week after completing Lesson 3), and at three-
month follow-up (12 weeks after post-treatment). They also
completed a measure of RNT (the RTQ-10) and distress (the
K-10) prior to each lesson. The ADIS-5 MDD and GAD
modules were re-administered by a Clinical Psychologist
during the 3-month follow-up telephone interview.
Measures
Repetitive Thinking Questionnaire-10 (RTQ-10; McEvoy et
al., 2010). The RTQ-10 is a transdiagnostic measure of the
extent to which an individual engages in RNT in response
to distressing situations. The scale has demonstrated excel-
lent internal consistency across both clinical and non-clin-
ical samples (α’s = 0.89–0.94; McEvoy et al., 2014, 2018),
and high convergent and divergent validity (Mahoney et al.,
2012; McEvoy et al., 2010, 2014).
Patient Health Questionnaire-9 (PHQ-9; Kroenke et
al., 2001b). The PHQ-9 is a reliable and widely validated
measure of depression symptom severity over the past two
weeks (Kroenke et al., 2001b, 2016; Titov et al., 2011). It
has good internal consistency (α = 0.86–0.89), test–retest
reliability (r = 0.84), sensitivity and specicity (both 0.88),
construct validity, and convergent validity (Kroenke et al.,
2001b, 2016).
depressive and anxiety symptoms in CBT interven-
tions (Newby et al., 2014; Spinhoven et al., 2018),
as well as the mediation ndings in the studies of
RNT-focused treatments by Watkins et al (2011)
and Topper et al (2017) above, we hypothesised that
reductions in RNT would mediate the reductions
in pre-to post-treatment and follow-up severity of
depression, anxiety, and distress.
3) Predictors of treatment response. Our nal aim was
to explore predictors of treatment response, in order
to identify which individuals benet most from this
treatment. Owing to the lack of previous research in
RNT-focused interventions, we based our hypotheses
on studies of general CBT interventions for depression
and anxiety, which show that participants with higher
baseline depression and anxiety severity, and higher
baseline rumination and worry, show better treatment
response (Barrio-Martínez et al., 2023; Karyotaki et al.,
2021; Niles et al., 2021; Reins et al., 2021). We have
also referred to the literature on treatment expectancy
as a predictor of better treatment outcome (Tambling,
2012), despite Wallsten et al.’s (2023) nding that treat-
ment expectancy was not correlated with change in
group RF-CBT. Therefore, we hypothesised that higher
baseline severity (RNT and depression and anxiety
symptom severity), and higher treatment expectations,
would predict better response to treatment.
Method
Setting, Participants and Procedure
This study used secondary data from the RCT (Joubert et al.,
2023) that compared the online Managing Rumination and
Worry program delivered with or without clinician guidance
to a treatment-as-usual (TAU) control condition in which
participants accessed the program in self-help format after
an 18-week waiting period. For a full description of the
study’s methods, including other measures assessed not pre-
sented in this paper, see (Joubert et al., 2023). The RCT was
approved by St Vincent’s Hospital Sydney Human Research
Ethics Committee (HREC/18/SVH/220) and prospectively
registered with the Australian and New Zealand Clinical
Trials Registry (ACTRN 12620000959976).
In brief, eligible participants were aged 18 years or older,
lived in Australia, were uent in English, had access to a
computer and internet, and experienced elevated levels of
rumination and/or worry (RTQ-10 total score ≥ 28). Partici-
pants were excluded if their RTQ-10 score was ≤ 27, they
had severe depression (Patient Health Questionnaire-9
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Cognitive Therapy and Research
Credibility/Expectancy Questionnaire (CEQ; Devilly &
Borkovec, 2000). This is a brief measure of participants’
perception of the credibility and perceived benet of a treat-
ment which was administered prior to completion of Lesson
1 of the program. It has high internal consistency (α = 0.85–
0.090) and test–retest reliability, and good predictive valid-
ity for treatment outcome (Devilly & Borkovec, 2000).
Description of Intervention
The Managing Rumination and Worry Program comprises
three lessons, delivered via an online research platform
(e.g., The Virtual Clinic), that participants complete over a
period of three to six weeks. Lessons are in the form of an
illustrated comic-style story following two ctional char-
acters who learn to better manage rumination and worry.
Slides follow the character’s stories, introduce treatment
skills, and show their application in the characters’ lives.
Program content1 (see Table 1) was informed by several
CBT approaches. Drawing on RF-CBT, for example, partic-
ipants learn to recognise when they are ruminating or wor-
rying, identify their individual warning signs, proactively
plan activities for high-risk times, and practice more adap-
tive alternative strategies such as structured problem-solv-
ing (Watkins, 2018). Using skills from MBCT (Segal et al.,
2018), participants learn to shift their attention away from
ruminating or worrying to focus on the present moment.
Another lesson teaches participants to recognise when they
are engaging in an unhelpful, abstract and evaluative think-
ing style characteristic of rumination, and encourages them
to shift to a more helpful thinking style that is specic and
action-oriented, or ‘concrete’ (Watkins et al., 2007, 2012).
After each lesson participants download a one-to-two
page lesson summary of key concepts and skills and an
action plan for practicing the skills over the coming week.
Optional extra resources are also accessible. A lesson is con-
sidered complete once all lesson slides have been viewed
and the lesson summary/activity plan downloaded. The pro-
gram is self-paced; one sequential lesson is made available
each week, and a ve-day lockout period between lessons
encourages participants to revise and practice the previous
lesson skills before accessing the next module. Participants
received automated email and SMS reminders from the Vir-
tual Clinic platform to complete lessons, questionnaires,
and practice activities to encourage adherence and engage-
ment. Participants in the clinician-guided group received
brief, semi-structured check-in calls from a Provisional or
Clinical Psychologist in the days following lesson comple-
tion to help summarise treatment content, answer questions,
1 Program materials can be made available by contacting the corre-
sponding author.
Generalised Anxiety Disorder 7-item Scale (GAD-
7; Spitzer et al., 2006). The GAD-7 is a brief self-report
scale that measures general anxiety symptom severity over
the past two weeks. It has strong reliability and validity in
identifying probable DSM-IV GAD (American Psychiatric
Association, 2013), hand symptom severity, in both psychi-
atric and general populations (α = 0.89–0.92; Löwe et al.,
2008; Plummer et al., 2016; Spitzer et al., 2006).
Kessler Psychological Distress Scale—10-item (K-10;
Kessler et al., 2002). The K-10 is a 10-item screening mea-
sure of psychological distress over the past two weeks. It
has strong psychometric properties across a wide range of
samples including good discriminant validity between clini-
cal and non-clinical samples (Kessler et al., 2002), conver-
gent validity (Andrews & Slade, 2001), temporal stability
(ICC = 0.86–0.89, r = 0.76–0.80; Merson et al., 2021), and
high internal consistency (α = 0.93; Kessler et al., 2002).
Ruminative Response Scale– Brooding Subscale (RRS-
Brooding; Treynor et al., 2003). This 5-item scale is a sub-
set of the original 10-item measure of rumination, the RRS,
and measures the more maladaptive form of rumination,
brooding. The scale possesses strong predictive validity for
depression (Schoofs et al., 2010), test re-test reliability and
internal consistency (α = 0.69–0.78; Schoofs et al., 2010),
convergent validity with other measures of rumination and
depression (Grith & Raes, 2014; Schoofs et al., 2010;
Valencia & Paredes-Angeles, 2022), and discriminant valid-
ity (Schoofs et al., 2010).
Penn State Worry Questionnaire (PSWQ; Meyer et al.,
1990). This 16-item questionnaire measures trait worry,
including intensity, frequency, and perceived uncontrolla-
bility. It possesses good psychometric properties (Zlomke,
2009), with high internal consistency (α = 0.86–0.95; Brown
et al., 1992), and test–retest reliability (r = 0.74—0.93;
Meyer et al., 1990), good convergent validity with other
measures of worry, anxiety and depression (Brown et al.,
1992; Van Rijsoort et al., 1999), and good discriminant
validity (Brown et al., 1992).
Table1 Brief summary of the Managing Rumination and Worry Pro-
gram content
Lesson Skills overview
1 Psychoeducation about rumination and worry
Self-monitoring of rumination/worry
Activity Planning for “high risk” times
2Three Rules of Thumb to dierentiate helpful vs
unhelpful rumination/worry
Structured Problem Solving
Worry Time
Disengaging from rumination/worry by Shifting
Attention onto present moment
3 Managing Rumination and Worry at Night
Shifting from General to Specic Thinking
Summary of program content and relapse prevention
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Cognitive Therapy and Research
b) Pre-post and follow-up mediation. Mediation analy-
ses were repeated to separately assess the mediation
eect of RNT (measured by changes in the RTQ-
10), then worry (PSWQ), and rumination (RRS-
Brooding), on longitudinal changes in depression
(PHQ-9), anxiety (GAD-7), and distress (K-10).
These analyses were conducted separately for the
pre- to post-treatment outcomes, and post-treatment
to 3-month follow-up outcomes.
3. Predictor analyses. To investigate whether the hypoth-
esised predictor variables (treatment expectancy, and
baseline depression, anxiety, RNT, worry, and rumi-
nation) predicted treatment outcomes (over and above
initial symptoms and treatment group), we conducted
separate linear mixed models with each outcome mea-
sure as the dependent variable (DV). In these models,
we included xed eects of time and treatment group
allocation (clinician-guided or self-help), as well as
each of the hypothesised predictor variables (e.g., treat-
ment expectancy, baseline depression symptoms, base-
line anxiety, baseline repetitive thinking variables).
Treatment condition was included as a variable given
the results of the original RCT; i.e., that participants
in the clinician-guided condition had better outcomes.
All models included a random intercept for each sub-
ject to account for individual dierences in treatment
response.
Results
Pattern of Symptom Change Across Treatment
Estimated marginal means and between-group comparisons
for RTQ-10 and K-10 scores across treatment (lesson-by-
lesson) and follow-up are presented in Table 2, with results
of the covariate-adjusted analyses (controlling for baseline
PHQ-9 and GAD-7, and current psychotherapy) presented
in Table 3.
a) Changes in RNT across treatment. There was a sig-
nicant eect of time (F(4, 294) = 56.99, p < 0.001), group
(F(1, 89) = 7.85, p = 0.006), and a time by group interaction
(F(4, 293) = 2.67, p = 0.032), showing that RNT reduced in
both online treatment groups, with a larger reduction on the
RTQ-10 observed in the clinician-guided group. As can be
seen in Table 2 and Fig. 1, RTQ-10 scores improved across
treatment and to follow-up, in both treatment groups. Both
treatment groups experienced small to medium reductions
in RNT after each lesson (within-group eect sizes ranging
from 0.28 to 0.57; see Table 2 for eect sizes and con-
dence intervals). In the clinician-guided group, there was
provide encouragement, and assist with implementation of
treatment skills. All participants had access to technical sup-
port throughout the treatment period. Clinical and research
sta also contacted participants by phone or email if they
had failed to log in or complete the next lesson, or to assess
their safety in response to a signicant deterioration in their
PHQ-9 or K-10 scores.
Statistical Analyses
1. Pattern of symptom change across treatment: Intention
to treat linear mixed models, with xed eects of group
(clinician-guided versus self-guided), time, and group
by time interaction eect were conducted to explore
lesson-by-lesson changes in a) RTQ-10 and b) K-10
scores. All models included a random intercept for each
subject. Pairwise comparisons, with Bonferroni cor-
rections applied for multiple comparisons, examined
whether there were statistically signicant changes in
scores between each lesson. In the original RCT study,
signicant baseline group dierences were found for
depression (PHQ-9) and anxiety (GAD-7) symptom
severity, and current psychotherapy (see (Joubert et
al., 2023) for further detail). Accordingly, we repeated
the analyses controlling for these baseline variables as
covariates. These and the predictor analyses were per-
formed in IBM SPSS Statistics v28.0.1.0.
2. Mediation analyses. Longitudinal mediation analysis of
RNT changes on outcome variables was initially planned
and conducted using a random-intercept cross-lagged
panel model (RI-CLPM). However, the goodness of
t measure of the RI-CLPM model did not achieve the
optimal convergence. Therefore, we conducted alternate
Structural Equation Modelling (SEM)-based mediation
analyses. The total eect was decomposed into direct
and indirect eects with the indirect eect accounting
for the magnitude of the mediation. An alpha of 0.05
was used to determine statistical signicance. Media-
tion analyses were performed in R, version 4.3.4, and
STATA version 18.0.
a) Lesson-by-lesson mediation. The mediating eect
of changes in RNT (RTQ-10) on changes in dis-
tress (K-10) was analysed across three intervals:
from Lesson 1 to Lesson 2, from Lesson 2 to Lesson
3, and from Lesson 3 to post-intervention. To test
whether the reverse pattern of mediation occurred,
the mediating eect of changes in distress (K-10)
on RNT (RTQ-10) was repeated across the three
intervals above (Lesson 1 to 2, 2 to 3, and 3 to
post-treatment).
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Cognitive Therapy and Research
a signicant reduction in RTQ-10 scores between Les-
son 3 and post-treatment (p = 0.003), and the reduction in
RTQ-10 between Lesson 2 and 3 approached signicance
(p = 0.052). In the self-help group, the only statistically sig-
nicant reduction was between Lesson 2 and 3 (p = 0.024).
The same pattern of results was found in the covariate-
adjusted analyses (see Table 3) with the only exception
being that in the clinician-guided group, the reduction in
RNT between Lesson 2 and 3 was statistically signicant
(p = 0.046).
b) Changes in Distress across treatment. There was a
signicant eect of time (F(4, 287) = 34.29, p < 0.001) and
group (F(1, 90) = 7.91, p = 0.006), but no time by group
interaction (F(4, 287) = 1.65, p = 0.162), showing that dis-
tress (K-10 scores) reduced in both treatment groups (see
Fig. 2, and Table 2 for results including within-group eect
sizes and condence intervals). Examining lesson-by-les-
son scores on the K-10, both groups experienced small but
mostly non-signicant improvements in distress after each
lesson, with within-group eect sizes ranging from 0.06 to
0.30. In the clinician-guided group, the only statistically sig-
nicant reduction in distress occurred between Lesson 2 and
3 (p = 0.046). In the self-help group the largest reduction in
distress occurred between Lesson 1 and 2, approaching sta-
tistical signicance (mean dierence = 2.05, p = 0.060; see
Table 2). The same pattern of ndings was observed in the
covariate-adjusted analyses (see Table 3).
Mediating Eect of RNT
Lesson-By-Lesson Mediation
Mediating Eect of RNT on Distress The mediating eect of
changes in RNT (RTQ-10) on changes in distress (K-10)
was analysed across three intervals: from Lesson 1–2, from
Lesson 2–3, and from Lesson 3 to post-intervention; see
Table 4. From Lesson 1 to Lesson 2, the overall indirect
eect was β = 0.036 (95% CI − 0.02–0.10), indicating a
non-signicant reduction in distress mediated by changes
in repetitive negative thinking (with 58.2% of this eect
attributed to the indirect pathway). Although the magni-
tude of the eect was larger in the self-help group than the
clinician-guided group (62.7% vs. 6.5% of the total eect),
both mediation eects remained non-signicant (clinician-
guided: β = 0.014, 95% CI − 0.08–0.11; self-help: β = 0.05,
95% CI − 0.01–0.12).
From Lesson 2 to Lesson 3, the results showed a signi-
cant overall indirect eect of β = 0.08 (95% CI 0.02–0.14),
indicating a signicant reduction in distress levels through
changes in repetitive negative thinking with the magnitude
of the mediated eect 1.85 times that of the total eect. In
Table2 Estimated marginal means for repetitive negative thinking (RTQ-10) and distress (K-10) by lesson and treatment group
Measure Group Baseline (Pre-
Lesson 1)
Lesson 2 Lesson 3 Post-treat-
ment
3-Month
follow-up
L1-L2 L2-L3 L3-Post Post-FU
EMM SD EMM SD EMM SD EMM SD EMM SD Hedges g (95% CI) Hedges g (95% CI) Hedges g (95% CI) Hedges g (95% CI)
RTQ-10 Clinician guided 38.67 7.30 36.57 7.65 33.04 8.11 28.39 8.03 25.48 8.47 0.28 (-0.16, 0.72) 0.44 (-0.04, 0.92) 0.57 (0.08, 1.05)* 0.35 (-0.16, 0.86)
Self-help 41.06 7.30 38.63 7.49 35.03 7.80 31.71 7.95 32.58 8.18 0.33 (-0.09, 0.75) 0.47 (0.02, 0.92)* 0.42 (-0.04, 0.88) 0.11 (-0.37, 0.58)
K-10 Clinician guided 23.93 7.45 22.71 7.63 20.35 7.85 18.25 7.81 17.15 8.02 0.16 (-0.28, 0.60) 0.30 (-0.18, 0.78) 0.27 (-0.21, 0.74) 0.14 (-0.37, 0.64)
Self-help 27.30 7.45 25.25 7.55 24.76 7.69 23.12 7.76 22.12 7.90 0.27 (-0.15, 0.69) 0.06 (-0.38, 0.51) 0.21 (-0.25, 0.67) 0.13 (-0.36, 0.61)
EMM: Estimated marginal means, SD: Standard deviation, RTQ-10: Repetitive Thinking Questionnaire – 10, K-10: Kessler Psychological Dist ress Scale – 10 item, CI: Condence Interval
*signicant at .05 level (p <.05)
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Cognitive Therapy and Research
the clinician-guided subgroup, the indirect eect was nota-
bly stronger (2.41 times that of the total eect) at β = 0.13
(95% CI 0.03–0.25), demonstrating a signicant mediating
eect of RNT on distress. However, in the self-help sub-
group, the indirect eect was non-signicant, β = 0.05 (95%
CI − 0.04–0.15).
From Lesson 3 to the post-intervention period, there was
no evidence of the mediation eect of change in RNT on dis-
tress for overall, clinician-guided, and self-help subgroups
with a relatively small proportion of total eect mediated by
RNT changes (7% for overall, 9% for clinician-led and 3%
for self-help subgroup).
Mediating eect of distress on RNT The mediating eect of
changes in distress (K-10) on RNT (RTQ-10) was repeated
across the three intervals above (Lesson 1–2, 2–3, and 3 to
post-treatment). As above, the mediating eect of change
in distress on change in RNT showed variability across dif-
ferent lessons and groups, but no eects reached statisti-
cal signicance (see Table 5). Only one indirect mediating
eect of changes in distress on changes in RNT bordered on
statistical signicance: from Lesson 3 to post-intervention,
in the clinician-guided group there was an indirect eect of
β = − 0.08 (95% CI − 0.21–0.003), with a substantial 56.9%
mediation. No other eects were statistically signicant.
Pre- to Post and Follow-Up Mediation
Mediating Eect of RNT For the overall sample, the pre- to
post-treatment change in RNT (RTQ-10) on post-treatment
depression (PHQ-9), anxiety (GAD-7), and distress (K-10)
showed small indirect mediating eects, none of which
reached statistical signicance (see Table 6), with the pro-
portion of total eect mediated ranging from 0.03 to 0.14
(3–14%). When each sub-group (clinician-guided and self-
help) was analysed separately, the indirect mediation eects
of RNT for each outcome variable were similarly small and
non-signicant.
In the post-intervention to 3-month follow-up period,
there was a signicant indirect eect of RNT on depression
overall collapsed across treatment groups (β = 0.06, 95%
CI 0.01–0.13), with 7% of the total eect being mediated.
However, when assessing clinician-led or self-help sub-
groups separately, there was no evidence of the signicant
mediation eect. There were also no signicant mediation
eects of post- to follow-up changes in RNT on post to fol-
low-up changes in anxiety or distress, either overall or for
the subgroups separately.
Table3 Estimated Marginal means for repetitive negative thinking (RTQ-10) and distress (K-10) by lesson and treatment group (covariate-adjusted analyses)
Measure Group Baseline (Pre-
Lesson 1)
Lesson 2 Lesson 3 Post-treat-
ment
3-Month
Follow-Up
L1-L2 L2-L3 L3-Post Post-FU
EMM SD EMM SD EMM SD EMM SD EMM SD Hedges g (95% CI) Hedges g (95% CI) Hedges g (95% CI) Hedges g (95% CI)
RTQ-10 Clinician guided 38.88 7.49 36.77 7.78 33.20 8.26 28.56 8.19 25.65 8.63 0.27 (-0.17, 0.71) 0.44 (-0.04, 0.92) 0.56 (0.07, 1.04)* 0.34 (-0.17, 0.85)
Self-help 40.61 6.90 38.18 7.10 34.56 7.42 31.27 7.56 32.14 7.79 0.34 (-0.08, 0.77) 0.49 (0.04, 0.94)* 0.43 (-0.03, 0.90) 0.11 (-0.36, 0.59)
K-10 Clinician guided 25.12 5.31 23.90 5.49 21.41 5.80 19.35 5.75 18.13 6.02 0.22 (-0.22, 0.66) 0.44 (-0.04, 0.92) 0.35 (-0.13, 0.83) 0.20 (-0.30, 0.71)
Self-help 26.33 4.85 24.28 4.98 23.77 5.18 22.11 5.27 21.03 5.47 0.41 (-0.01, 0.84) 0.10 (-0.34, 0.54) 0.31 (-0.14, 0.77) 0.20 (-0.28, 0.68)
EMM: Estimated marginal means, SD: Standard deviation, RTQ-10: Repetitive Thinking Questionnaire – 10, K-10: Kessler Psychological Distress Scale – 10 item
signicant at .05 level (p <.05), CI = Condence Inter val
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Cognitive Therapy and Research
on follow-up distress (K-10 scores, β = 0.07, 95% CI 0.01–
0.14, mediating 7.9%). The eects on depression and
anxiety were not signicant (depression: β = 0.07, 95% CI
− 0.002–0.13; anxiety: β = 0.02, 95% CI − 0.02–0.08).
In the clinician-led group, there were no signicant medi-
ation eects of rumination on follow-up outcome variables.
In the self-help group, there was a signicant mediation
eect of rumination on follow-up depression (β = 0.15, 95%
CI 0.05–0.29) and distress (β = 0.24 (95% CI 0.11–0.40),
but not anxiety (β = 0.15 (95% CI − 0.004–0.35), mediating
15.5%, 17.4%, and 31.3%, respectively.
Predictors of Treatment Response
Coecients and statistics for the predictor analyses are
presented in Table 9 (Depression and anxiety outcome
measures: PHQ-9 and GAD-7) and Table 10 (Repetitive
Negative Thinking outcome variables: RTQ-10, PSWQ and
RRS-Brooding). For each outcome measure (PHQ-9, GAD-
7, RTQ-10, PSWQ and RRS-Brooding), higher severity at
baseline predicted higher severity of that same measure.
Mediating Eect of Worry The mediating eect of changes
in worry on changes in depression, anxiety, and distress also
varied across periods and groups, with none of the eects
reaching statistical signicance (see Table 7). There were
no signicant mediation eects of changes in worry from
pre-to post-treatment on pre- to post-treatment changes in
depression, anxiety, or distress, either overall or for the sub-
groups separately. There were also no signicant mediation
eects of worry on the outcomes from post-treatment to
follow-up.
Mediating Eect of Rumination The mediating eect of
changes in rumination (RRS-Brooding) on changes in
depression, anxiety, and distress also varied across periods
and groups (see Table 8). From pre- to post-intervention, no
mediating eects of rumination were statistically signicant
either overall or for each subgroup.
From post-intervention to 3-month follow-up, however,
there was a signicant overall indirect eect of rumination
Fig.1 Estimated marginal means for repetitive negative thinking (RTQ-10) by lesson and treatment group
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Cognitive Therapy and Research
signicant predictors of treatment outcomes were base-
line treatment expectancy (CEQ), and baseline rumination
(RRS). Higher treatment expectancy at baseline signicantly
predicted lower scores on all measures. In addition, higher
baseline rumination on the RRS signicantly predicted
Treatment condition was also a signicant predictor of
anxiety (GAD-7) in favour of the clinician-guided group
(i.e., assignment to the clinician-guided treatment group
predicted lower scores following treatment). Over and
above baseline severity and treatment group, the principle
Table4 Lesson-wise mediation of distress levels (K-10) by changes
in RNT (RTQ-10)
Time Group Indirect eect Propor-
tion of
total eect
mediated
β (95% CI)
Lessons
1-2
Overall 0.036 (-0.02– 0.10) 0.582
Clinician-guided 0.014 (-0.08– 0.11) 0.065
Self-help 0.05 (-0.01– 0.12) 0.627
Lessons
2-3
Overall 0.08 (0.02—0.14) * 1.85
Clinician-guided 0.13 (0.03—0.25) * 2.41
Self-help 0.05 (-0.04– 0.15) 0.91
Lesson
3-Post
Overall 0.02 (-0.06– 0.10) 0.07
Clinician-guided 0.03 (-0.03– 0.13) 0.09
Self-help 0.01 (-0.14– 0.14) 0.03
CI: condence interval
*signicant at .05 level (p <.05)
Table5 Lesson-wise mediation of RNT levels (RTQ-10) by changes
in distress (K-10)
Time Group Indirect eect Propor-
tion of
total eect
mediated
β (95% CI)
Lessons
1—2
Overall 0.04 (− 0.03– 0.13) 0.137
Clinician-guided 0.07 (− 0.05– 0.23) 0.192
Self-help 0.02 (− 0.08– 0.11) 0.057
Lessons
2—3
Overall 0.02 (− 0.12– 0.16) 0.066
Clinician-guided − 0.03 (− 0.19– 0.09) 0.278
Self-help 0.13 (-0.08– 0.39) 0.291
Lesson
3—Post
Overall − 0.02 (− 0.13– 0.09) 0.084
Clinician-guided − 0.08 (− 0.21– 0.003) 0.569
Self-help 0.03 (− 0.21– 0.27) 0.104
CI: condence interval
Fig.2 Estimated marginal means for distress (K-10) by lesson and treatment group
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Table6 Mediation eect of changes in RNT (RTQ-10) on longitudinal changes in depression (PHQ-9), anxiety (GAD-7), and distress (K-10)
Time Group Depression (PHQ-9) Anxiety (GAD-7) Distress (K-10)
Indirect eect Total eect
mediated
Indirect eect Total eect
mediated
Indirect eect Total eect
mediated
β (95% CI) Proportion β (95% CI) Proportion β (95% CI) Proportion
Pre-Post Overall 0.03 (− 0.03– 0.09) 0.04 0.08 (− 0.02– 0.19) 0.14 0.02 (− 0.06– 0.09) 0.03
Clinician-guided 0.002 (− 0.08– 0.08) 0.01 0.03 (− 0.08– 0.15) 0.09 0.01 (− 0.12– 0.14) 0.01
Self-help 0.01 (− 0.07– 0.11) 0.02 0.02 (− 0.22– 0.25) 0.04 0.004
(− 0.12– 0.13)
0.01
Post-FU Overall 0.06 (0.01– 0.13)* 0.07 0.04 (− 0.03– 0.12) 0.05 0.06 (0.00– 0.13) 0.07
Clinician 0.02 (− 0.05– 0.13) 0.04 0.01 (− 0.07– 0.09) 0.02 0.04 (− 0.09– 0.24) 0.07
Self-help 0.02 (− 0.02– 0.07) 0.02 0.09 (− 0.06– 0.35) 0.12 0.04 (− 0.04– 0.18) 0.06
FU: 3-month follow-up, CI: condence interval
* signicant at .05 level (p <.05)
Table7 Mediation eect of changes in worry (PSWQ) on longitudinal changes in depression (PHQ-9), anxiety (GAD-7), and distress (K-10)
Time Group Depression (PHQ9) Anxiety (GAD7) Distress (K10)
Indirect eect Total eect
mediated
Indirect eect Total eect
mediated
Indirect eect Total eect
mediated
β (95% CI) Proportion β (95% CI) Proportion β (95% CI) Proportion
Pre-Post Overall 0.004 (− 0.04– 0.05) 0.01 0.10 (− 0.004– 0.22) 0.141 0.03 (− 0.02– 0.10) 0.04
Clinician-guided 0.01 (− 0.03– 0.06) .026 0.07 (− 0.004– 0.17) 0.169 0.04 (− 0.03– 0.12) 0.07
Self-help 0.03 (− 0.04– 0.12) .037 0.02 (− 0.13– 0.19) 0.04 0.05 (− 0.07– 0.17) 0.054
Post-FU Overall 0.04 (− 0.001– 0.09) 0.04 0.07 (− 0.001– 0.16) 0.087 0.04 (− 0.01– 0.11) 0.057
Clinician-guided 0.01 (− 0.06– 0.09) 0.01 0.01 (− 0.08– 0.11) 0.033 0.02 (− 0.07– 0.16) 0.039
Self-help 0.01 (− 0.03– 0.06) 0.01 0.01 (− 0.12– 0.15) 0.008 0.01 (− 0.06– 0.09) 0.009
FU: 3-month follow-up, CI: condence interval
*signicant at .05 level (p <.05); **signicant at .01 level (p <. 01)
Table8 Mediation eect of changes in rumination (RRS-Brooding) on longitudinal changes in depression (PHQ-9), anxiety (GAD-7), and distress
(K-10)
Time Group Depression (PHQ9) Anxiety (GAD7) Distress (K10)
Indirect eect Total eect
mediated
Indirect eect Total eect
mediated
Indirect eect Total eect
mediated
β (95% CI) Proportion β (95% CI) Proportion β (95% CI) Proportion
Pre-Post Overall 0.01 (− 0.04– 0.06) 0.015 − 0.001
(− 0.08– 0.08)
0.001 0.01
(− 0.03– 0.06)
0.012
Clinician-guided 0.04 (− 0.002– 0.10) 0.084 0.02 (− 0.06– 0.10) 0.043 0.04
(− 0.01– 0.11)
0.08
Self-help − 0.04
(− 0.17– 0.06)
0.056 − 0.11
(− 0.30– 0.02)
0.228 − 0.13
(− 0.29—0.01)
0.157
Post-FU Overall 0.07 (− 0.002– 0.13) 0.072 0.02 (− 0.02– 0.08) 0.025 0.07 (0.01– 0.14)*0.079
Clinician-guided 0.001 (− 0.04– 0.04) 0.002 − 0.01
(− 0.07– 0.04)
0.039 − 0.001
(− 0.04– 0.04)
0.001
Self-help 0.15 (0.05– 0.29)*0.155 0.15 (− 0.004– 0.35) 0.174 0.24
(0.11– 0.40)**
0.313
FU = 3-month follow-up; CI condence interval; *signicant at .05 level (p <.05); **signicant at .01 level (p <.0 1)
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Cognitive Therapy and Research
Pattern of Symptom Change Across Treatment
Studies that examine the pattern of improvement across
treatment, and identify which treatment modules produce
the greatest change, are important to further optimise eec-
tive treatments and increase our understanding of how they
work (Watkins & Newbold, 2020). In this study, we found
that both treatment groups improved throughout the pro-
gram and to follow-up, with small to moderate improve-
ments in RNT and distress after each lesson, consistent with
other studies of ecacious treatments showing a gradual
course of symptom improvement (e.g., Andrews et al.,
2020; Skelton et al., 2023). The smallest improvements
in RNT occurred after Lesson 1 (within-group Hedge’s g:
0.28–0.33), which focused on psychoeducation and moni-
toring, and between post-treatment and follow-up (within
group g’s = 0.11–0.34), whereas the largest improvements
occurred following the lessons containing the core thera-
peutic skills, from Lesson 2 to 3 (within-group g’s = 0.44–
0.49), and from Lesson 3 to post-treatment (within-group
g’s = 0.43–0.56). Distress decreased gradually in small to
moderate increments after each lesson and to follow-up. The
higher depression (PHQ-9), and approached signicance as
a predictor of higher anxiety scores (GAD-7; p = 0.052).
Discussion
This study is one of the rst to investigate mediators and
predictors of treatment outcome in a brief, online RNT-
focused intervention for adults, the Managing Rumination
and Worry Program. We found that RNT and distress gradu-
ally reduced over the course of treatment in both self-guided
and clinician-guided treatment groups, with the largest
improvements occurring after Lessons 2 and 3. While we
predicted that changes in RNT would mediate lesson-by-
lesson and pre- to post-treatment changes in outcome mea-
sures, the pattern of mediation ndings was mixed, with no
clear mediation pattern emerging. Our results also showed
that baseline severity of depression, anxiety, distress, and
RNT (particularly rumination)—and over and above these,
treatment expectancy—were signicant predictors of treat-
ment outcome.
Table9 Predictors of outcome on the PHQ-9 and GAD-7
Estimate SE df Tp95% Condence
Interval
Lower Upper
DV = PHQ-9
Intercept 0.74 2.07 90.54 0.36 0.72 − 3.37 4.85
Pre 3.82 0.41 163.15 9.39 < 0.001** 3.02 4.63
Post 0.42 0.43 155.21 1.00 0.32 − 0.42 1.27
Follow-up 0.00 0.00
Clinician-guided − 0.59 0.39 86.48 − 1.49 0.14 − 1.37 0.19
Self-guided 0.00 0.00
CEQ − 0.15 0.04 88.94 − 3.47 < 0.001** − 0.24 − 0.06
RTQ 0.02 0.04 87.90 0.50 0.62 − 0.06 0.10
PHQ-9 0.70 0.05 80.98 15.61 < 0.001** 0.61 0.79
GAD-7 − 0.03 0.05 92.76 − 0.55 0.58 − 0.14 0.08
PSWQ 0.00 0.03 99.86 0.18 0.86 − 0.05 0.06
RRS-Brooding 0.17 0.07 81.85 2.41 0.02* 0.03 0.31
DV = GAD-7
Intercept 1.62 2.18 216.00 0.74 0.46 − 2.69 5.92
Pre 4.68 0.48 216.00 9.76 < 0.001** 3.74 5.63
Post 0.39 0.50 216.00 0.78 0.43 − 0.60 1.39
Follow-up 0.00 0.00
Clinician-guided − 1.31 0.41 216.00 − 3.16 < 0.001** − 2.13 − 0.49
Self-guided 0.00 0.00
CEQ − 0.10 0.05 216.00 − 2.14 0.03* − 0.19 − 0.01
RTQ 0.02 0.04 216.00 0.57 0.57 − 0.06 0.11
PHQ-9 0.02 0.05 216.00 0.42 0.67 − 0.07 0.11
GAD-7 0.64 0.06 216.00 11.23 < 0.001** 0.52 0.75
PSWQ − 0.03 0.03 216.00 − 1.02 0.31 − 0.09 0.03
RRS-Brooding 0.14 0.07 216.00 1.95 0.05 0.00 0.29
*signicant at .05 level (p <.05); **signicant at .01 level (p <. 01)
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In a recent dismantling study, Watkins et al. (Watkins et al.,
2023) examined which CBT treatment components (includ-
ing RNT-focused strategies such as concreteness train-
ing) were most eective in reducing depression. Although
absorption training was found to be important, it was still
unclear which treatment strategies were most potent in
driving change. Absorption training teaches skills to help
patients to become immersed in positive activities (Watkins
et al., 2012, 2023), and shares similarities with the attention
shifting/disengaging from RNT skills in Lesson 2 of this
larger reductions in RNT after Lessons 2 and 3 suggest that
the active treatment strategies in these sessions (i.e., struc-
tured problem-solving, worry time, disengaging from RNT,
concreteness training) are more powerful in reducing RNT
than less specic treatment elements of psychoeducation and
monitoring in Lesson 1. It appears that these treatment com-
ponents are eective at reducing RNT and distress, despite
the brevity of the treatment, thus are important elements to
retain in future iterations of the program. It is still unclear
however which of these strategies are driving the benet.
Table10 Predictors of outcome on the RTQ-10, PSWQ and RRS
Estimate SE df TP95% Condence
Interval
Lower Upper
DV = RTQ-10
Intercept 9.89 5.26 94.55 1.88 0.06 − 0.55 20.33
Pre 10.45 0.94 165.21 11.06 < 0.001** 8.58 12.31
Post 0.87 0.99 157.28 0.88 0.38 − 1.08 2.82
Follow-up 0.00 0.00
Clinician-guided − 1.41 1.01 92.94 − 1.39 0.17 − 3.41 0.60
Self-guided 0.00 0.00
CEQ − 0.27 0.11 93.58 − 2.43 0.02* − 0.49 − 0.05
RTQ 0.59 0.10 93.97 5.78 < 0.001** 0.38 0.79
PHQ-9 0.10 0.12 87.62 0.85 0.40 − 0.13 0.33
GAD-7 − 0.05 0.14 99.03 − 0.36 0.72 − 0.32 0.22
PSWQ 0.00 0.07 104.89 − 0.02 0.99 − 0.14 0.14
RRS-Brooding 0.31 0.18 88.29 1.72 0.09 − 0.05 0.66
DV = PSWQ
Intercept 15.35 6.04 94.44 2.54 0.01* 3.36 27.34
Pre 10.70 1.10 163.95 9.72 < 0.01** 8.53 12.88
Post 2.24 1.15 155.06 1.95 0.05 − 0.02 4.51
Follow-up 0.00 0.00
Clinician-guided − 1.57 1.15 91.08 − 1.36 0.18 − 3.86 0.72
Self-guided 0.00 0.00
CEQ − 0.31 0.13 93.43 − 2.44 0.02* − 0.56 − 0.06
RTQ − 0.04 0.12 92.16 − 0.36 0.72 − 0.27 0.19
PHQ-9 − 0.05 0.13 86.30 − 0.36 0.72 − 0.31 0.22
GAD-7 0.10 0.16 97.16 0.66 0.51 − 0.21 0.41
PSWQ 0.70 0.08 103.33 8.80 < 0.001** 0.54 0.86
RRS-Brooding 0.27 0.20 86.55 1.35 0.18 − 0.13 0.68
DV = RRS-Brooding
Intercept 0.79 1.54 94.03 0.51 0.61 − 2.27 3.85
Pre 2.64 0.30 165.32 8.88 < 0.001** 2.05 3.22
Post 0.78 0.31 156.36 2.53 0.01* 0.17 1.40
Follow-up 0.00 0.00
Clinician-guided − 0.47 0.29 90.22 − 1.59 0.12 − 1.05 0.12
Self-guided 0.00 0.00
CEQ − 0.08 0.03 92.63 − 2.58 0.01* − 0.15 − 0.02
RTQ 0.00 0.03 91.54 − 0.11 0.91 − 0.06 0.06
PHQ-9 0.05 0.03 85.16 1.40 0.17 − 0.02 0.11
GAD-7 − 0.02 0.04 96.47 − 0.57 0.57 − 0.10 0.06
PSWQ 0.00 0.02 103.25 0.23 0.82 − 0.04 0.05
RRS-Brooding 0.80 0.05 85.54 15.51 < 0.001** 0.70 0.91
* signicant at .05 level (p <.05); ** signicant at .01 level (p <. 01)
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Cognitive Therapy and Research
eects may emerge when investigating the treatment in a
larger sample in future studies.
Secondly, it is possible the lack of mediation ndings
was due to the transdiagnostic measure used in the lesson-
by-lesson mediation analyses, which assessed the frequency
of RNT. There may be a delineation between the mediat-
ing eect of the dierent sub-types of RNT, rumination and
worry, as seen in the post-treatment to follow-up period
(where rumination, but not worry, mediated follow-up
depression and distress). This pattern gives support to the
strong role of rumination on depressive symptoms (e.g.,
Ehring & Watkins, 2008; Nolen-Hoeksema, 2000; Nolen-
Hoeksema et al., 2008). Interestingly, our analysis did not
nd evidence of a mediating role of reductions in RNT
(transdiagnostically or by subtype) on reductions in anxiety
symptoms across treatment, which contrasts with research
showing that RNT plays a key causal and maintaining role
in anxiety as well as depressive disorders (e.g., Ehring &
Watkins, 2008; Wahl et al., 2019). Further research is needed
investigating which factors mediate change in anxiety as
well as depressive symptoms in RNT-focused treatment.
Similarly, it is possible that other variables not measured
in this study mediated the treatment eects. Some pre-
liminary research has found improvements in behavioural
activation (Feldhaus et al., 2020), for example, may medi-
ate change in RNT-focused treatments. This program does
encourage participants to engage in behavioural activation,
and schedule in distracting activities for times when they
are at high risk of ruminating. Change in metacognitive
beliefs about RNT (e.g., ‘ruminating helps me to solve my
problems’) is a further alternative mediating variable. Some
studies of one type of RNT-focused intervention, metacog-
nitive therapy for GAD, found that reductions in negative
beliefs about worry mediated reduction in worry over treat-
ment (McEvoy et al., 2015; Wahlund et al., 2022). Another
study found that participants higher in positive metacogni-
tive beliefs about the usefulness of rumination were less
likely to have positive expectations of action-oriented treat-
ment strategies, several of which are included in the present
treatment (e.g., structured problem-solving; Ophir & Mor,
2014). Other studies of transdiagnostic CBT for depression
and anxiety, however, have found no signicant mediation
eects of either negative (Barrio-Martínez et al., 2023) or
positive metacognitive beliefs (Enrique et al., 2021), so the
impact of metacognitive beliefs warrants further investiga-
tion. Decentering, the metacognitive ability to appraise one’s
thoughts and feelings as temporary phenomena as opposed
to reality (Fresco et al., 2007), is a related variable that has
been shown to reduce the link between negative or stress-
ful events, rumination, and depressive symptoms (Feldman
et al., 2010; Wu et al., 2022). While these variables were
not measured in the current study, they could be measured
program as well as activity scheduling in Lesson 1. Further
dismantling studies of RNT-focused treatments such as the
Managing Rumination and Worry Program are important to
identify the most active ingredients of these treatments; for
example, using experimental designs that test the eects of
single ingredients.
Mediating Eects of RNT
As the current treatment was designed to reduce symptoms
of depression, anxiety and distress through reducing RNT,
we hypothesised that changes in RNT lesson-by-lesson,
and across treatment to the follow-up period, would medi-
ate the reductions in pre-to post-treatment and follow-up
clinical outcome measures. Contrary to hypotheses, there
was no clear pattern of mediating eects of RNT on clini-
cal outcomes. Some signicant mediation eects emerged:
reductions in RNT mediated reductions in distress between
Lesson 2 and 3 (overall and in the clinician-guided group
specically), and reductions in RNT from post-treatment
to follow-up signicantly mediated reductions in depres-
sion (overall). Further, in the post-treatment to follow-up
period there was a signicant mediating eect of rumina-
tion specically (Brooding subscale of the RRS) on follow-
up distress (overall), and in the self-help group a signicant
mediating eect of rumination on follow-up depression and
distress. Despite these ndings, a consistent pattern of medi-
ating eects of RNT on changes in depression, anxiety and
distress did not emerge across the analyses. Similarly, and
as expected, the reverse pattern did not reach signicance;
changes in distress did not mediate changes in RNT across
each lesson. The lack of consistent mediation eect of RNT
contrasts with the few studies that have examined mediation
in RNT-focused interventions and found that decreases in
RNT did mediate treatment outcome (Topper et al., 2017;
Watkins et al., 2011).
There are several possible explanations for these nd-
ings. Firstly, there may have been a lack of sucient power
to detect all mediation eects in this sample. While the
power calculations informing the RCT’s target sample size
were aimed at detecting a medium to large between-group
eect size (Hedge’s g = 0.7) between the treatment groups
and control group, based on (Topper et al. 2017; see Jou-
bert et al., 2023), it is possible that the sample was not large
enough to detect all mediation eects. Indeed Topper et al.
(2017) found signicant mediation eects of changes in
RNT over the course of their study with a larger sample size
(N = 251 vs. N = 137 in the current study), and it has been
recommended that sample sizes are large in studies utilis-
ing mediation analyses (e.g., Fairchild & McDaniel, 2017).
Thus it is possible that more uniform signicant mediation
1 3
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Cognitive Therapy and Research
Clinician guidance. Our results also conrm that clini-
cian guidance predicts strong outcomes in the current treat-
ment, particularly in post-treatment anxiety (GAD-7) scores.
As shown in the RCT (Joubert et al., 2023), participants in
the clinician-guided group demonstrated lower depression,
anxiety and rumination scores both at post-treatment and
follow-up, than the self-guided group; our analyses further
show this group demonstrated larger reductions in RNT and
distress lesson by lesson, and experienced reductions in
RNT earlier in treatment than the self-guided group. These
results are consistent with studies showing that therapist
guidance and alliance is associated with stronger treatment
outcomes and adherence in online treatments compared to
unguided versions (Karyotaki et al., 2021; Musiat et al.,
2022; Newby et al., 2024). Moderated mediation analysis in
future studies could help elucidate the interaction between
other predictor variables and clinician guidance, as some
research shows the importance of therapist guidance relates
particularly to patients with more severe baseline symptoms
(e.g., Karyotaki et al., 2021; Newby et al., 2024)).
Treatment expectancy. Over and above baseline sever-
ity and treatment group, and in line with our expectations,
higher treatment expectancy at baseline signicantly pre-
dicted lower post-treatment depression, anxiety, RNT,
rumination and worry. These ndings suggest that it may
be important to assess and address low treatment expectan-
cies at treatment outset, given it is associated with clinical
outcomes, and drop-out in this treatment (see Joubert et al.,
2023). These ndings are in line with a broader research
literature showing that treatment expectancies inuence
the likelihood that individuals commence treatment, put
eort into change, and obtain treatment benets (Glass et
al., 2001; Noble et al., 2001; Tambling, 2012), including
from rumination interventions (e.g., Rebstock et al., 2020).
They contrast with the recent study of group RF-CBT (Wall-
sten et al., 2023), but this may be explained by the smaller
symptom change they found compared to the present study.
Addressing negative treatment expectations may be particu-
larly challenging however given they can be dicult to shift
in depressed individuals (Everaert et al., 2018; Kube et al.,
2019; Rutherford et al., 2010). Further research is needed to
understand how to best alter negative expectations in RNT-
focused treatments (e.g., providing reputable evidence of
treatment ecacy before strategies are introduced).
Rumination. Over and above baseline severity and treat-
ment group, higher baseline rumination also emerged as a
signicant predictor of higher depression, and approached
signicance as a predictor of higher anxiety after treat-
ment. Changes in rumination across treatment also signi-
cantly mediated follow-up distress, as well as follow-up
depression in the self-help group. These ndings further
support the literature showing that pre-treatment levels of
in future studies to help elucidate alternative mediators of
treatment eects beyond changes in the frequency of RNT.
The lack of a clear overall mediation pattern in this study
suggests that further research is needed into which factors
mediate treatment change in RNT-focused treatments such
as this program. Future investigations should examine a
larger sample and measure a wider range of potential medi-
ating variables, including metacognitive beliefs about RNT
and decentering, and subtypes of RNT as well as frequency.
The use of moderated mediation analysis could also help
understand potential interaction eects between predictor
and mediating variables.
Predictors of Treatment Response
The current study is one of the rst to examine predictors
of treatment response in an RNT-focused intervention. Our
results showed some interesting predictors of improve-
ment—specically, baseline severity (particularly rumina-
tion), treatment group (as a predictor of anxiety scores), and
treatment expectancy—that provide some insight at the out-
set of the program who may benet most.
Baseline symptom severity. In line with our hypotheses,
baseline severity of outcome measures signicantly pre-
dicted treatment response. In contrast to predictions how-
ever, higher baseline severity in symptoms of depression,
anxiety, distress, RNT, worry and rumination, signicantly
predicted higher rather than lower scores in each of these
outcomes following treatment. This nding is consistent
with another study by Barrio-Martinez et al. (2023) in
which higher baseline rumination was also associated with
lower post-treatment functioning. However it contrasts with
Cook et al.’s (2019) nding that participants with higher
baseline stress levels demonstrated greater (preventative)
benet from RF-CBT, and another study by Niles et al.
(2021) in which higher frequency of baseline negative auto-
matic thoughts was associated with stronger improvement
from general CBT treatment. In a review on predictors and
moderators of treatment outcome in online psychological
treatments more broadly, Haller et al. (2023) found that,
similar to our study, higher baseline symptom severity pre-
dicted higher post-treatment scores; but overall, participants
with higher baseline scores demonstrated greater symptom
change over treatment (i.e., greater treatment benets). It is
possible that this pattern also occurred in the current inter-
vention, as participants who received treatment on average
demonstrated strong treatment benets (gs = 0.41–0.97; Jou-
bert et al., 2023). Future studies could examine this further
by analysing the magnitude of change in participants with
greater baseline severity over the course of this intervention
using moderated mediation analysis.
1 3
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Cognitive Therapy and Research
We found a gradual improvement in RNT and distress
throughout treatment, with the largest reductions in RNT
occurring after the lessons with the main active treatment
strategies. While there was some evidence of changes in
outcomes being mediated by reductions in RNT over the
course of treatment, a lack of consistent mediation pattern
was seen, suggesting that further research examining alter-
native mediating variables and across more time points is
needed to clarify the processes that mediate change. Higher
baseline severity of anxiety, depression and rumination pre-
dicted worse outcome, whereas clinician guidance predicted
better treatment outcome. In addition to these, higher treat-
ment expectations and baseline levels of rumination (rather
than transdiagnostic RNT) most strongly predicted treat-
ment response. Further research is needed to understand
the best ways to assist those identied as likely to show a
poorer response. Future studies employing larger samples
will enable more comprehensive mediation and dismantling
analyses, to further our understanding of the mechanisms by
which this ecacious RNT intervention works.
Acknowledgements We thank Dr Taylor Braund (Black Dog Institute,
UNSW) and Elliot Dovers (Stats Central, UNSW) for their input into
the statistical analyses.
Author Contributions EU, JN, AW, MM, AM and AJ contributed to
the study conception and design. The treatment design and data col-
lection were performed by JN and AJ. Data analysis was performed by
VV, EU and JN. The rst draft of the manuscript was written by EU
and all authors contributed to manuscript editing. All authors read and
approved the nal manuscript.
Funding Open Access funding enabled and organized by CAUL and
its Member Institutions
This work was supported by a University of New South Wales Austra-
lian Government Research Training Program (RTP) PhD scholarship
awarded to EU. JN is supported by an Australian Medical Research
Future Fund (MRFF) Fellowship (1145382), and National Health and
Medical Research Council Emerging Leader Fellowship (2008839).
AWS is supported by a National Health and Medical Research Coun-
cil (NHMRC) Emerging Leader Fellowship (1197074). The MRFF,
NHMRC and University of New South Wales had no role in the study
design, the collection, analysis and interpretation of the data, the writ-
ing of the manuscript or the decision to submit the paper for publica-
tion.
Data Availability Data may be made available on reasonable request
by contacting the corresponding author.
Declarations
Competing interests The authors declare no competing interests.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format,
rumination are predictive of outcomes in general CBT treat-
ments for anxiety and depression (e.g., Bredemeier et al.,
2020; Crane & Williams, 2010). It is possible that in this
transdiagnostic RNT-focused treatment, there should be an
inclusion of additional strategies, or more intensive treat-
ment, to explicitly address rumination, in order to improve
outcomes for those identied at the outset of treatment as
high in this type of RNT.
Limitations
The results above should be interpreted in the context of
several limitations. Due to the small sample size, there may
have been a lack of power to detect statistically signicant
mediation. Future research should repeat mediation and
predictor analyses in a larger sample. Mediation analyses
in this study were limited by the variables measured in the
RCT. Future studies of this and other RNT-focused inter-
ventions should measure a wider selection of potential
mediating variables, such as metacognitive beliefs about
RNT, decentering, behavioural activation and therapeu-
tic alliance, or other variables not yet identied in the lit-
erature. Conclusions about the direction of the mediation
eects seen in this study are also limited by the fact that
the mediation and outcome variables were measured con-
currently. While these results provide valuable information
about the association between changes in RNT variables
and outcome variables, in order for the temporal relation-
ship of mediation to be established, future studies should
include more time points across treatment to investigate true
mediation eects (i.e., that changes in RNT cause changes
in anxiety and depression). A further limitation relates to
the generalisability of the sample. Participants were mostly
female, employed, and well-educated. They were also self-
selected, and partly recruited from a mailing list of previous
users of the THIS WAY UP digital clinic, so may have been
more likely to engage and/or had previous experience with
online treatment. Future studies of the treatment in routine-
care community settings are warranted to explore mediators
and predictors of treatment response in more representa-
tive samples. Finally, participants were permitted to access
concurrent treatment during the trial, limiting our ability to
distinguish between mediators of the current treatment’s
eects and other potential treatments.
Conclusion
This study is one of the rst to examine the mechanisms
of how an ecacious, brief, online, RNT-focused treat-
ment works, and what factors predict treatment response.
1 3
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Cognitive Therapy and Research
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