Emotion Regulation in Current and Remitted Depression: A Systematic Review and Meta-Analysis

“Depression symptom checklists used Frontiers in Psychology | www.frontiersin.org 7 May 2018 | Volume 9 | Article 756 FIGURE 1 | Flow chart of study selection. were mainly Beck Depression Index (BDI-II; N = 41; Beck et al., 1996), followed by the Center for Epidemiologic Studies Depression Scale (CES-D; N = 2; Radloff,…”

“Methods followed the principles presented by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Liberati et al., 2009).”

“Reappraisal is a form of cognitive change that involves interpretation of a potentially emotion-eliciting situation in a way that changes its emotional impact (Gross and John, 2003).”

“, 1993), followed by one study reporting two trials involving the Avoidance subscale of the Need for Affect Scale (NAS-AVOIDANCE; Maio and Esses, 2001), one study reporting two trials using Avoidance subscale of the COPE (COPE-AVOIDANCE; Carver et al., 1989), one study reporting two trials using Avoidance subscale of…”

“It is often associated with anxiety disorders, involving behaviors that make it less likely that one will end up in a situation that will give rise to undesirable emotions (Gross, 1998a).”

“Total scores of questionnaires measuring general emotion regulation abilities (e.g., Gratz and Roemer, 2004) were pooled into one effect size.”

“Individual studies reported data from the subscale “Task Oriented” from the questionnaire CISS, the Planning subscale from the CERQ, and the Active Coping and Planning subscales of the Brief COPE (Carver, 1997).”

“Studies show that people with MDD report avoiding more emotional experiences than never-depressed controls (Svaldi et al., 2012; Brockmeyer et al., 2015), and that avoidance of emotional experiences is associated with symptoms of depression (Aldao et al., 2010).”

“Acceptance has been proposed as an active ingredient in the third-wave cognitive behavioral interventions of Mindfulness-Based Cognitive Therapy (Segal et al., 2013) and Acceptance and Commitment Therapy (Hayes et al., 2006).”

“Closely related to acceptance is self-compassion, which can be considered an emotion regulation strategy in which painful or distressing feelings are not avoided, but held in awareness with kindness, understanding and a sense of shared humanity (Neff, 2003).”

“Depression symptom checklists used Frontiers in Psychology | www.frontiersin.org 7 May 2018 | Volume 9 | Article 756 FIGURE 1 | Flow chart of study selection. were mainly Beck Depression Index (BDI-II; N = 41; Beck et al., 1996), followed by the Center for Epidemiologic Studies Depression Scale (CES-D; N = 2; Radloff,…”

“Eight studies reported in total 10 trials using the subscale Harm Avoidance from the Temperament and Character Inventory (TCI-HA; Cloninger et al., 1993), followed by one study reporting two trials involving the Avoidance subscale of the Need for Affect Scale (NAS-AVOIDANCE; Maio and Esses, 2001), one study reporting…”

“Rumination increases the valence and duration of depressed mood, and makes people vulnerable to onset and relapse of depressive episodes (Nolen-Hoeksema et al., 2008).”

“It is often associated with anxiety disorders, involving behaviors that make it less likely that one will end up in a situation that will give rise to undesirable emotions (Gross, 1998a).”

“Rumination is a strategy of attentional deployment, referring to focusing one’s attention toward negative emotions and on the implications of these emotions (Nolen-Hoeksema, 1991).”

“The theoretical rationale for the significance of general emotion regulation abilities has been articulated by several authors (e.g., Thompson, 1994; Gratz and Roemer, 2004; Berking and Znoj, 2008; Hofmann and Kashdan, 2010).”

“The majority of trials used BDI-II as a self-report index of depressive symptoms (n = 15), and individual studies used CES-D, PHQ, and the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR; Rush et al., 2003).”

“The majority of studies applied the Ruminative Response Scale from the Response Styles Questionnaire (RRS; N = 34; Nolen-Hoeksema and Morrow, 1991; Treynor et al., 2003).”

“Further, MDD is associated with reduced functioning, lower quality of life and increased risk of suicide (Wittchen et al., 2000; Kessler and Bromet, 2013).”

“Our finding may be seen in relation to prior reviews (Hammar and Årdal, 2009) and meta-analyses (Rock et al., 2013) showing that attentional and executive deficits continue after remission fromMDD.”

“In general, reappraisal is more effective than suppression (Augustine and Hemenover, 2009; Webb et al., 2012), and acceptance of negative emotions is a more effective strategy compared to rumination and suppression (Kohl”

“Individual studies reported data from the Avoidance subscale from the Impact of Event Scale-Revised (IES-RAVOIDANCE; Creamer et al., 2003), the Harm Avoidance subscale of the Tridimensional Personality Questionnaire (TPQHA; Otter et al.”

“, 1998), both MINI and SCID I (n = 2), the Schedules for Clinical Assessment in Neuropsychiatry (SCAN; n = 2; World Health Organization, 1998) and individual studies using the Diagnostic Interview for Mental Disorders (DIMD; Margraf and Schneider, 2006) and the Primary Care Evaluation of Mental Disorders (PRIMEMD; Spi…”

“Studies suggest that self-reported selfcompassion is negatively associated with symptoms of depression (MacBeth and Gumley, 2012), and that self-compassion may be a protective factor for the development of new episodes of MDD (Ehret et al., 2015).”

“Consequently, they have problems recovering from negative emotions, resulting in sustained depressed mood (Joormann and Gotlib, 2010).”

“It could also be that total time spent in depressive states will be a maintaining factor, in that depressogenic schemata are easily activated by sad mood (Teasdale et al., 1995).”

“Individual studies reported data from the White Bear Suppression Inventory (WBSI; Wegner and Zanakos, 1994), the subscales suppressing negative and positive emotions from the Emotion Acceptance Questionnaire (EAQ; Beblo et al.”

“Epidemiological studies show that MDD is a highly prevalent (Ferrari et al., 2013), recurrent (Mueller et al., 1999), and potentially chronic disorder (Kessing et al., 2004).”

“Early onset of MDD can be associated with the exposure of early life stress (Molnar et al., 2001).”

“Deficiencies in emotional awareness and clarity may lead to difficulties in the identification of a feeling and failure of emotion regulation (Gross, 2015).”

“, 2004), and the Avoidance subscale of Coping Inventory for Stressful Situations (CISS-AVOIDANCE; Endler and Parker, 1994).”

“Therefore, flexibility in selection and implementation of emotion regulation strategies in line with the person’s own goals and values may be more important than the use of specific strategies per se (Aldao et al., 2015).”

“Rumination has also been shown to affect executive functions such as working memory (Watkins and Brown, 2002; Joormann et al., 2011; Meiran et al., 2011) attention (Donaldson et al., 2007) and cognitive control (Koster et al., 2011).”

“…Epidemiologic Studies Depression Scale (CES-D; N = 2; Radloff, 1977), the Patient Health Questionnaire (PHQ; N = 2; Kroenke and Spitzer, 2002), and individual studies using the Internal State Scale (ISS; Bauer et al., 1991) and the Inventory of Depressive Symptomatology (IDS; Rush et al., 1986).”

“Given the high relapse rate after recovery of depression (Mueller et al., 1999), emotion regulation difficulties may be a factor that makes people recovered from depression vulnerable to later recurrent episodes.”

“(2015) utilized the subscale Reassurance from the questionnaire Forms of Self-Criticizing/Attacking and Self-Reassuring Scale (FSCRS-REASSURE; Gilbert et al., 2004).”

“However, the reviews of Liu and Thompson (2017) and Joormann and Stanton (2016) seem not to be based on systematic literature searches, as no such procedures were reported.”

“, alexithymia) is associated with symptoms of depression (Honkalampi et al., 2000).”

“Three studies applied the Reappraisal subscale from the Thought Control Questionnaire (TCQ-REAPPRAISAL; Wells and Davies, 1994).”

“, 1989), one study reporting two trials using Avoidance subscale of the Social ProblemSolving Inventory (SPSI-AVOIDANCE; D’Zurilla and Nezu, 1990) and two studies reporting three trials using the Cognitive Behavioral Avoidance Scale (CBAS; Ottenbreit and Dobson, 2004).”

“Finally, limited emotional tolerance, i.e., being easily overwhelmed by emotions, may lead to increased use of maladaptive emotion regulation strategies to avoid or suppress emotions (Naragon-Gainey et al., 2017).”

“Another maladaptive strategy that has been associated with MDD is suppression (Campbell-Sills et al., 2006).”

“, 1993), followed by one study reporting two trials involving the Avoidance subscale of the Need for Affect Scale (NAS-AVOIDANCE; Maio and Esses, 2001), one study reporting two trials using Avoidance subscale of the COPE (COPE-AVOIDANCE; Carver et al.”

“Despite rumination being associated with negative outcomes, currently and remitted MDD individuals report positive beliefs about the usefulness of the strategy (Watkins and Moulds, 2005b).”

“Rumination has also been shown to affect executive functions such as working memory (Watkins and Brown, 2002; Joormann et al., 2011; Meiran et al., 2011) attention (Donaldson et al.”

“, 1989), one study reporting two trials using Avoidance subscale of the Social ProblemSolving Inventory (SPSI-AVOIDANCE; D’Zurilla and Nezu, 1990) and two studies reporting three trials using the Cognitive Behavioral Avoidance Scale (CBAS; Ottenbreit and Dobson, 2004).”

“Previous studies have shown that treatment of depression using Mindfulness-Based Cognitive Therapy (MBCT) have better effect on individuals with an early onset in comparison to individuals with later onset (Williams et al., 2014).”

“Studies show that people with MDD report avoiding more emotional experiences than never-depressed controls (Svaldi et al., 2012; Brockmeyer et al., 2015), and that avoidance of emotional experiences is associated with symptoms of depression (Aldao et al., 2010).”

“Recently, self-compassion has been suggested as an important emotion regulation strategy that is particularly effective when coping with depressed mood (Diedrich et al., 2014).”

“Two studies reported data from the Rumination on Sadness Scale (RSS; Conway et al., 2000), and one study reported data from the subscale Rumination from Leahy Emotional Schema Scale (LESS-RUMINATION; Leahy, 2002).”

“Rumination has also been shown to affect executive functions such as working memory (Watkins and Brown, 2002; Joormann et al., 2011; Meiran et al., 2011) attention (Donaldson et al., 2007) and cognitive control (Koster et al., 2011).”

“Difficulties Recently, emotion regulation has been proposed as a transdiagnostic factor for the development of psychopathology (Fernandez et al., 2016).”

“For example, one study indicated that previously depressed individuals report limited general emotion regulation abilities compared to never-depressed individuals (Ehring et al., 2008).”

“Further, MDD is associated with reduced functioning, lower quality of life and increased risk of suicide (Wittchen et al., 2000; Kessler and Bromet, 2013).”

“However, it has been argued that the view of emotion regulation as having primarily to do with discrete strategies to modulate emotional experience is too narrow (Gratz et al., 2015).”

“The first relevant studies to be published on the topic of this metaanalysis were from 2002 (Watkins and Baracaia, 2002; Watkins and Brown, 2002).”

“Two studies reported data from the Problem Focused and Problem Solving subscales of the COPE (Thompson et al., 2010).”

“Epidemiological studies show that MDD is a highly prevalent (Ferrari et al., 2013), recurrent (Mueller et al., 1999), and potentially chronic disorder (Kessing et al., 2004).”

“In addition, emotion regulation difficulties seem to persist after individuals are remitted from MDD (Ehret et al., 2015; Halvorsen et al., 2015).”

“General emotion regulation abilities have been suggested as complementary processes that likely influence the selection and successful implementation of emotion regulation strategies (Tull and Aldao, 2015).”

“However, the reviews of Liu and Thompson (2017) and Joormann and Stanton (2016) seem not to be based on systematic literature searches, as no such procedures were reported.”

“Empirical studies indicate that general emotion regulation abilities including emotional clarity, awareness and tolerance are negatively associated with development of psychopathology (Saarijärvi et al., 2001) and use ofmaladaptive emotion regulation strategies (Jeffries et al., 2016).”

“Rumination has also been shown to affect executive functions such as working memory (Watkins and Brown, 2002; Joormann et al., 2011; Meiran et al., 2011) attention (Donaldson et al.”

“Rumination has also been shown to affect executive functions such as working memory (Watkins and Brown, 2002; Joormann et al., 2011; Meiran et al., 2011) attention (Donaldson et al.”

“The theoretical rationale for the significance of general emotion regulation abilities has been articulated by several authors (e.g., Thompson, 1994; Gratz and Roemer, 2004; Berking and Znoj, 2008; Hofmann and Kashdan, 2010).”

“Individual studies indicate that people with MDD suppress both positive (Beblo et al., 2012) and negative emotions (Campbell-Sills et al., 2006) more than healthy controls.”

“Moreover, when individuals with MDD (Millgram et al., 2015) and dysphoria (Quigley and Dobson, 2014) are instructed to use reappraisal, they have no difficulties in doing so, and gain same beneficial reductions in negative affect as healthy controls.”

“Only one study reported comorbid personality disorders (Riso et al., 2003).”

“One study reported data from eight questionnaires and subscales measuring rumination, including the RRS and the RSS (Mandell et al., 2014).”

“In the recent years, interventions have been developed specifically to enhance emotion regulation in anxiety disorders (Mennin, 2006), personality disorders (Gratz andGunderson, 2006), and inpatient treatment for MDD (Berking et al.”

“Similarly, a study by Rude and McCarthy (2003) found that individuals remitted from MDD reported lower emotional clarity compared to never-depressed individuals.”

“Further, self-reported habitual use of suppression is associated with symptoms of depression (Aldao et al., 2010), and with increased rumination (Liverant et al., 2011).”

“Despite rumination being associated with negative outcomes, currently and remitted MDD individuals report positive beliefs about the usefulness of the strategy (Watkins and Moulds, 2005b).”

“Poor general emotion regulation abilities may lead to more frequent and inflexible use of maladaptive emotion regulation strategies like avoidance, suppression and rumination (Jeffries et al., 2016; Naragon-Gainey et al., 2017).”

“Compared to healthy controls, currently depressed individuals report having limited emotional awareness (Donges et al., 2005), clarity of negative feelings (Thompson et al., 2015), and more alexithymia (Loas et al., 1998; Nandrino et al., 2012).”

“…to healthy controls, people who have recovered from depression report using more maladaptive emotion regulation strategies, including rumination (Aker et al., 2014; Halvorsen et al., 2015), suppression (Watkins and Moulds, 2009), and avoidance (Brockmeyer et al., 2012), although the findings on…”

“Compared to healthy controls, currently depressed individuals report having limited emotional awareness (Donges et al., 2005), clarity of negative feelings (Thompson et al., 2015), and more alexithymia (Loas et al., 1998; Nandrino et al., 2012).”

“…report using more maladaptive emotion regulation strategies, including rumination (Aker et al., 2014; Halvorsen et al., 2015), suppression (Watkins and Moulds, 2009), and avoidance (Brockmeyer et al., 2012), although the findings on suppression are somewhat contradictory (Joormann and…”

“Compared to healthy controls, people who have recovered from depression report using more maladaptive emotion regulation strategies, including rumination (Aker et al., 2014; Halvorsen et al., 2015), suppression (Watkins and Moulds, 2009), and avoidance (Brockmeyer et al.”

“One potential mechanism in the development and maintenance of depression is difficulties with emotion regulation (Donofry et al., 2016).”

“, 2015) and dysphoria (Quigley and Dobson, 2014) are instructed to use reappraisal, they have no difficulties in doing so, and gain same beneficial reductions in negative affect as healthy controls.”

“Compared to healthy controls, currently depressed individuals report having limited emotional awareness (Donges et al., 2005), clarity of negative feelings (Thompson et al., 2015), and more alexithymia (Loas et al., 1998; Nandrino et al., 2012).”

“, 2003), the Harm Avoidance subscale of the Tridimensional Personality Questionnaire (TPQHA; Otter et al., 1995), the Avoidance and Action Questionnaire (AAQ; Hayes et al.”

“Compared to healthy controls, currently depressed individuals report having limited emotional awareness (Donges et al., 2005), clarity of negative feelings (Thompson et al., 2015), and more alexithymia (Loas et al., 1998; Nandrino et al., 2012).”

“Studies show that people with MDD report avoiding more emotional experiences than never-depressed controls (Svaldi et al., 2012; Brockmeyer et al., 2015), and that avoidance of emotional experiences is associated with symptoms of depression (Aldao et al., 2010).”

“…emotion regulation strategies, including rumination (Aker et al., 2014; Halvorsen et al., 2015), suppression (Watkins and Moulds, 2009), and avoidance (Brockmeyer et al., 2012), although the findings on suppression are somewhat contradictory (Joormann and Stanton, 2016; Liu and Thompson, 2017).”

“A recent study with individuals with remitted MDD showed that higher general emotion regulation abilities following in-treatment predicted lower depressive symptoms at follow-up (Ebert et al., 2017).”

“Difficulties with emotion regulation are linked with increased stress [28,29], and represent an established risk factor for a range of mental health disorders such as depression [26] and bipolar disorder [30].”