Inflexibility as a Vulnerability to Depression: A Systematic Qualitative Review

Stange, Jonathan P.; Alloy, Lauren B.; Fresco, David M.

doi:10.1111/cpsp.12201

Cited by 179Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesResilience and Mental HealthNeural and Behavioral Psychology Studies

Inflexibility as a Vulnerability to Depression: A Systematic Qualitative Review

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Stange, Jonathan P., Alloy, Lauren B., Fresco, David M.·2017·Clinical Psychology: Science and Practice

DOI 10.1111/cpsp.12201PMC PMC5640320

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Abstract

The study of vulnerabilities to depression typically identifies factors that are thought to be universally maladaptive or adaptive. In contrast, researchers recently have theorized that the ability to flexibly engage in different thoughts and behaviors that fit situational demands may be most indicative of psychological health. We review empirical evidence from 147 studies reporting associations between five components of flexibility (set-shifting, affective set-shifting, cardiac vagal control, explanatory flexibility, and coping flexibility) and depression and classify studies according to strength of study design. Evidence from correlational and case-controlled studies suggests cross-sectional relationships, but few prospective studies have been conducted. We discuss limitations of existing studies, identify new directions for programmatic research, and discuss implications that flexibility has for the prevention and treatment of depression.

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Many flexibility researchers continue to operate within the well-established neuropsychology framework.
“Many flexibility researchers continue to operate within this well-established neuropsychology framework (e.g., Crouse et al., 2020; Stange et al., 2017).”
From Defining and measuring “psychological flexibility”: A narrative scoping review of diverse flexibility and rigidity constructs and perspectives (2021) · cites this paper as Stange et al., 2017

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“…2012; Yeh et al., 2016), with some other studies showing no impairment in CVC in MDD (Byrne et al., 2010; Garcia et al., 2016; Jiang et al., 2015; Kikuchi et al., 2009; Liang et al., 2015; Nugent et al., 2011; O’Regan et al., 2015; Voss et al., 2011), and others reporting atypical increases in…”
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Sympathetic Vasomotor Tone Is Associated With Depressive Symptoms in Young Females: A Potential Link Between Depression and Cardiovascular Disease
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High cardiac vagal control protects against future depressive symptoms under conditions of high social support
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Affective bias in internal attention shifting among depressed youth
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Integrating affective and cognitive correlates of heart rate variability: A structural equation modeling approach
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Respiratory sinus arrhythmia is reduced in adolescent major depressive disorder
Tonhajzerová, I., Ondrejka, I., Javorka, M., Adamík, P., Turianiková, Z., Kerna, V., Javorka, K., & Čalkovská, A. (2009) · European journal of medical research · doi:10.1186/2047-783x-14-s4-280 · Cited by 32 · see citing works
Maladaptive mood repair, atypical respiratory sinus arrhythmia, and risk of a recurrent major depressive episode among adolescents with prior major depression
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Adolescent Attachment Insecurity and Parasympathetic Functioning Predict Future Loss Adjustment
Fagundes, C. P., Diamond, L. M., & Allen, K. (2012) · Personality and Social Psychology Bulletin · doi:10.1177/0146167212437429 · Cited by 31 · see citing works
Sex differences in cardiac autonomic function of depressed young adults
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Stress reactivity predicts symptom improvement in children with anxiety disorders
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The Relationship of Explanatory Flexibility to Explanatory Style
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Neuropsychological functioning is compromised in binge drinking young adults with depression
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Extreme response style in recurrent and chronically depressed patients: Change with antidepressant administration and stability during continuation treatment.
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Does baseline heart rate variability reflect stable positive emotionality?
Silvia, P. J., Jackson, B. A., & Sopko, R. S. (2014) · Personality and Individual Differences · doi:10.1016/j.paid.2014.07.003 · Cited by 28 · see citing works
Heart Rate Variability Predicts Cognitive Reactivity to a Sad Mood Provocation
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Cognitive depressive symptoms associated with delayed heart rate recovery following interpersonal stress in healthy men and women
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Examining biological vulnerability in environmental context: Parenting moderates effects of low resting respiratory sinus arrhythmia on adolescent depressive symptoms
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Evaluation of the influence of ayurvedic formulation (Ayushman-15) on psychopathology, heart rate variability and stress hormonal level in major depression (Vishada)
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Extreme Attributions Predict the Course of Bipolar Depression
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Physiological and Behavioral Engagement in Social Contexts as Predictors of Adolescent Depressive Symptoms
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Sorted by citations

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Bakker, A. B., & de Vries, J. D. (2021) · Anxiety, Stress, & Coping · doi:10.1080/10615806.2020.1797695 · Cited by 1,131 · see citing works
“Coping inflexibility impairs the ability to adjust to stressors and increases vulnerability for depression (Stange et al., 2017).”
BackgroundResult
Comorbid depression in medical diseases
Gold, S. M., Köhler‐Forsberg, O., Moss-Morris, R. E., Mehnert, A., Miranda, J. J., Bullinger, M., Steptoe, A., Whooley, M. A., & Otte, C. (2020) · Nature Reviews Disease Primers · doi:10.1038/s41572-020-0200-2 · Cited by 547 · see citing works
Psilocybin therapy increases cognitive and neural flexibility in patients with major depressive disorder
Doss, M. K., Považan, M., Rosenberg, M. D., Sepeda, N. D., Davis, A. K., Finan, P. H., Smith, G. S., Pekar, J. J., Barker, P. B., Griffiths, R. R., et al. (2021) · Translational Psychiatry · doi:10.1038/s41398-021-01706-y · Cited by 356 · see citing works
Heart rate and high frequency heart rate variability during stress as biomarker for clinical depression. A systematic review
Schiweck, C., Piette, D., Berckmans, D., Claes, S. J., & Vrieze, E. (2018) · Psychological Medicine · doi:10.1017/s0033291718001988 · Cited by 293 · see citing works
Defining and measuring “psychological flexibility”: A narrative scoping review of diverse flexibility and rigidity constructs and perspectives
Cherry, K. M., Hoeven, E. V., Patterson, T. S., & Lumley, M. N. (2021) · Clinical Psychology Review · doi:10.1016/j.cpr.2021.101973 · Cited by 267 · see citing works
Distorted Cognitive Processes in Major Depression: A Predictive Processing Perspective
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van Elk, M., & Yaden, D. B. (2022) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2022.104793 · Cited by 221 · see citing works
Neural correlates of emotion-attention interactions: From perception, learning, and memory to social cognition, individual differences, and training interventions
Dolcos, F., Katsumi, Y., Moore, M., Berggren, N., de Gelder, B., Derakshan, N., Hamm, A. O., Koster, E. H. W., Ladouceur, C. D., Okon‐Singer, H., et al. (2019) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2019.08.017 · Cited by 222 · see citing works
Relations between emotion regulation strategies and affect in daily life: a systematic review and meta-analysis of studies using ecological momentary assessments
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“, 2014), and to be attenuated in participants with MDD, with inflexibility being associated with greater depression severity (Stange et al., 2017).”
Background
Looking Through Tinted Glasses: Depression and Social Anxiety Are Related to Both Interpretation Biases and Inflexible Negative Interpretations
Everaert, J., Bronstein, M. V., Cannon, T. D., & Joormann, J. (2018) · Clinical Psychological Science · doi:10.1177/2167702617747968 · Cited by 181 · see citing works
Brain-heart interaction in perseverative cognition
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Why dysfunctional expectations in depression persist – Results from two experimental studies investigating cognitive immunization
Κube, T., Rief, W., Gollwitzer, M., Gärtner, T., & Glombiewski, J. A. (2018) · Psychological Medicine · doi:10.1017/s0033291718002106 · Cited by 117 · see citing works
When negative interpretations persist, positive emotions don't! Inflexible negative interpretations encourage depression and social anxiety by dampening positive emotions
Everaert, J., Bronstein, M. V., Castro, A. A., Cannon, T. D., & Joormann, J. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2019.103510 · Cited by 119 · see citing works
Emotion context insensitivity in depression: Toward an integrated and contextualized approach
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Cognitive Control, Cognitive Biases and Emotion Regulation in Depression: A New Proposal for an Integrative Interplay Model
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Acute psilocybin enhances cognitive flexibility in rats
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Examination of the Coping Flexibility Hypothesis Using the Coping Flexibility Scale-Revised
Kato, T. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.561731 · Cited by 78 · see citing works
How to modify persisting negative expectations in major depression? An experimental study comparing three strategies to inhibit cognitive immunization against novel positive experiences
Κube, T., Glombiewski, J. A., Gall, J., Touissant, L., Gärtner, T., & Rief, W. (2019) · Journal of Affective Disorders · doi:10.1016/j.jad.2019.03.027 · Cited by 67 · see citing works
Psychological flexibility as a mechanism of change in psilocybin-assisted therapy for major depression: results from an exploratory placebo-controlled trial
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“In line with this model, global psychological inflexibility and several of its subcomponents (most notably experiential avoidance) have been linked with depression severity (for reviews, see 30,31 ) and improvement in these measures linked with clinical improvement following ACT 32–35 .”
Method
Flexible parasympathetic responses to sadness facilitate spontaneous affect regulation
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Associations between depression, anxious arousal and manifestations of psychological inflexibility
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Variability in emotion regulation strategy use is negatively associated with depressive symptoms
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How Depressive Symptoms Hinder Positive Information Processing: An Experimental Study on the Interplay of Cognitive Immunisation and Negative Mood in the Context of Expectation Adjustment
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Self-citation
Belief updating in depression is not related to increased sensitivity to unexpectedly negative information
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Using ambulatory assessment to measure dynamic risk processes in affective disorders
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Associations of depression severity with heart rate and heart rate variability in young adults across normative and clinical populations
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The use of Acceptance and Commitment Therapy (ACT) in informal caregivers of people with dementia and other long-term or chronic conditions: A systematic review and conceptual integration
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Cognitive, Affective, and Feedback-Based Flexibility – Disentangling Shared and Different Aspects of Three Facets of Psychological Flexibility
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A Lifespan Model of Interference Resolution and Inhibitory Control: Risk for Depression and Changes with Illness Progression
Bessette, K. L., Karstens, A. J., Crane, N. A., Peters, A. T., Stange, J. P., Elverman, K. H., Morimoto, S. S., Weisenbach, S. L., & Langenecker, S. A. (2020) · Neuropsychology Review · doi:10.1007/s11065-019-09424-5 · Cited by 28 · see citing works
Self-citation
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Autonomic complexity dynamically indexes affect regulation in everyday life.
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Self-citation
Who are you after psychedelics? A systematic review and a meta-analysis of the magnitude of long-term effects of serotonergic psychedelics on cognition/creativity, emotional processing and personality
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Authors: Stange, J. P., Alloy, L. B., & Fresco, D. M.
Affiliations: University of Illinois Chicago (US)
Temple University (US)
Kent State University (US)
Corresponding author: Stange, Jonathan P.
ORCID: Stange, Jonathan P.
Alloy, Lauren B.
Fresco, David M.
Venue: Clinical Psychology: Science and Practice
Publisher: American Psychological Association (APA)
Published: 2017-06-13
Volume: 24
Issue: 3
Pages: 245-276
ISSN: 0969-5893 (ISSN-L)
DOI: 10.1111/cpsp.12201
PMC: PMC5640320
OpenAlex: W2625353282
Cited by: 179
References: 223
Citations by year: 2026: 15 · 2025: 19 · 2024: 26 · 2023: 25 · 2022: 27 · 2021: 20 · 2020: 19 · 2019: 13 · 2018: 11 · 2017: 4
FWCI: 16.74
Type: journal article
Language: en
Open access: green
europepmc.org
Licence: doi.wiley.com/10.1002/tdm_license_1.1 (tdm)
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations: Clinical Psychology Science and Practice (publishedVersion)
PubMed (publishedVersion)
Europe PMC (PubMed Central) (acceptedVersion)
PubMed Central (acceptedVersion)
Funders: National Research Service Award (F31MH099761)
National Institute of Mental Health (MH79369, MH101168)
National Heart, Lung, and Blood Institute (R01HL119977)
National Institute of Nursing Research (P30NR015326)
Topics: Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Social Sciences › Psychology › Clinical Psychology › Resilience and Mental Health
Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
Keywords: inflexibility, depression vulnerability, flexibility, set-shifting, cardiac vagal control, coping flexibility, depression prevention, depression treatment, mental health

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Inflexibility as a Vulnerability to Depression: A Systematic Qualitative Review

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