ORIGINAL ARTICLE

Metacognitions and Thought Control Strategies in UnipolarMajor Depression: A Comparison of Currently Depressed,Previously Depressed, and Never-Depressed Individuals

Marianne Halvorsen • Roger Hagen • Odin Hjemdal • Marianne S. Eriksen •

Ase J. Sørli • Knut Waterloo • Martin Eisemann • Catharina E. A. Wang

� Springer Science+Business Media New York 2014

Abstract Few studies have explored the importance of

worry-related metacognitions and thought control strate-

gies in major depressive disorder. The present study

explored how metacognitions and thought control strate-

gies differentiated currently depressed (n = 37), previ-

ously depressed (n = 81) and never-depressed individuals

(n = 50). Discriminant function analysis was performed to

investigate group differences on the Metacognitions

Questionnaire-30, Thought Control Questionnaire, and

Ruminative Response Scale. The analysis revealed that

currently depressed participants scored significantly higher

than previously depressed participants and that previously

depressed participants scored higher than never-depressed

participants on negative metacognitive beliefs, rumination,

worry and the use of punishment as a thought control

strategy. The discriminant function analysis further showed

that previously depressed participants had a higher use of

the thought control strategy reappraisal, along with lower

dysfunctional metacognitions concerning the need to con-

trol their thoughts, higher confidence in their cognitive

function and lower levels about the need to worry, com-

pared to both the currently and never-depressed groups.

The results indicate that metacognitions and thought

control strategies could be promising vulnerability markers

for depression.

Keywords Major depressive disorder � Metacognition �Thought control strategies � Rumination

Introduction

Major depressive disorder (MDD) is a highly relapsing and

recurrent disorder (Andrade et al. 2003; Kessler et al. 2003).

Therefore, it is important to identify vulnerability factors for

becoming depressed to both prevent and treat the disorder.

Cognitive-behavioral therapy (CBT) has been considered to

be one of the most effective psychotherapeutic treatments

for major depression. Although CBT has been proven to be

effective, there seems to be a high relapse rate of depression

after treatment into remission; follow-up studies show

relapse rates of approximately 50 % in patients treated with

CBT (Dimidjian et al. 2006; Roth and Fonagy 2005). This

high relapse rate could indicate that a depressive episode

may result in lasting psychosocial changes in individuals

who had been depressed. This theory has often been referred

to as the ‘‘scar hypothesis’’ (Lewinsohn et al. 1981),

although recent research has failed to support this claim

(Beevers et al. 2007).

In addition to the high relapse rate at follow up, a sub-

stantial number of depressed individuals do not respond to

CBT with full remission at the termination of treatment

(Dimidjian et al. 2006; DeRubeis et al. 2005). These

findings suggest that while CBT focuses on aspects of

cognition and behavioral changes that can result in symp-

tom relief, there may be further domains that would

deserve specific attention to treat this disorder more

effectively.

M. Halvorsen (&)

Department of Pediatric Rehabilitation, University Hospital of

North Norway, 9038 Tromsø, Norway

e-mail: marianne.halvorsen@unn.no

R. Hagen � O. Hjemdal

Department of Psychology, Norwegian University of Science

and Technology, Trondheim, Norway

M. S. Eriksen � A. J. Sørli � K. Waterloo � M. Eisemann �C. E. A. Wang

Department of Psychology, Faculty of Health Sciences, UiT

The Arctic University of Norway, Tromsø, Norway

123

Cogn Ther Res

DOI 10.1007/s10608-014-9638-4

The main treatment target of CBT has been the cogni-

tive content of depressive thoughts and schemas (Beck

et al. 1979; Beck 1987; Ingram et al. 1998; Wells and

Pagageorgiou 2004). A more recent theory, Metacognitive

Therapy (MCT; Wells 2000, 2009) offers another approach

towards the understanding of depression. MCT emphasizes

the role of thinking styles and metacognitions related to

thinking—not the contents of the thoughts, but rather, how

people relate to them (Wells 2000).

MCT is based on a self-regulatory executive function

model (S-REF) of emotional disorders (Wells and Matthews

1994, 1996). The S-REF model emphasizes how the top-

down or strategic processing and regulation of responses to

negative thoughts gives rise to depression. A central tenet of

the metacognitive model is cognitive attentional syndrome

(CAS). CAS consists of perseverative thinking, such as

rumination and worry, threat monitoring, and the use of

maladaptive coping strategies. CAS is driven by metacog-

nitions, which could be conceptualized as ‘‘aspects of cog-

nition that control the way a person thinks and behaves in

response to a thought, belief or feeling’’ (Wells 2009, p. 4).

The S-REF model differentiates between positive and neg-

ative metacognitive beliefs. More specifically, internal cues,

such as dysphoric thoughts (e.g., ‘‘Why do I feel this way’’),

activate positive metacognitive beliefs about the need to

engage in extended negative processing in the form of

rumination or worry to cope with this thought. A positive

metacognitive belief about rumination could be ‘‘Ruminat-

ing will help me understand the reasons why I am depres-

sed’’. Further, the activation of negative meta-beliefs about

the uncontrollability and danger of rumination and worry

contributes to symptom maintenance and recurrent episodes

of depression. Negative metabeliefs include the following:

‘‘When I start ruminating I cannot stop’’ and ‘‘Thinking this

way is caused by an imbalance in my brain.’’ Metacognitive

theory suggests that positive metacognitive beliefs may

represent a vulnerability for developing depression through

the use of inappropriate thought control strategies (rumina-

tion, worry and suppression), and negative metacognitive

beliefs lead to and sustain emotional distress because the

individual feels that these processes are uncontrollable and

threatening (Wells 2009). It is important to explore how

these metacognitions vary across clinical and non-clinical

samples to better understand their relevance.

MCT provides a promising basis for the understanding

of the relapsing and recurrent nature of depression.

Rumination has been noted as a major contributing factor

for depressive symptoms (Nolen-Hoeksema et al. 2008).

Rumination has also been found to act both as a vulnera-

bility factor related to the onset of depression, even while

maintaining the disorder (for a review see Nolen-Hoek-

sema et al. 2008; Smith and Alloy 2009). MCT suggests

that the harmful effects of rumination (i.e., depressive

symptoms) are closely associated with metacognitive

beliefs and coping processes in initiating and perpetuating

ruminative thoughts. Indeed, Papageorgiou and Wells

(2003) found, in a cross-sectional sample of depressed

individuals (N = 200) using structural equation modelling,

that the relationship between rumination and depression

was mediated by negative metacognitive beliefs.

Despite some promising results related to positive

associations among rumination, metacognitions and

depression (Papageorgiou and Wells 2001, 2003, 2009),

the association between these constructs is scarcely

investigated in the course of MDD. Existing studies have

focused either on healthy samples or already depressed

individuals (Papageorgiou and Wells 2001, 2003; Sarisoy

et al. 2013; Spada et al. 2008; Wells and Carter 2001).

Thus, studies that include and compare both healthy and

depressed individuals are needed.

In addition, MCT suggests that worry is a component of

depression. Depressed individuals monitor themselves for

signs and symptoms of depression, which, when found, are

perceived as threatening because they signal depression. It

is plausible to assume that previously depressed individuals

could also be sensitive to mood fluctuations due to fear of

becoming depressed again. This tendency was regarded by

Wells (2009) as a sort of threat monitoring, potentially

bringing up worries among previously depressed individ-

uals and strongly suggesting that a further investigation of

metacognitions related to worry in depression is warranted.

However, very few studies have investigated worry-related

metacognitions in depression. Sarisoy et al. (2013) used the

Metacognitions Questionnaire (MCQ-30; Wells and Cart-

wright-Hatton 2004) and found that the MCQ factor

‘Negative beliefs about worry concerning uncontrollability

and danger’ was elevated both in unipolar (n = 51) and

bipolar depressed individuals (n = 45) compared to the

non-depressed control group (n = 60). Wells and Carter

(2001) also found that patients with MDD (n = 24) and

patients with panic disorder (n = 24) had similar levels of

elevated scores on MCQ ‘Negative beliefs about worry

concerning uncontrollability and danger’. In a community

sample (n = 399), Spada et al. (2008) found that MCQ

‘Negative beliefs about worry concerning uncontrollability

and danger’ predicted significant variance in both anxiety

and depression scores. Taken together, with the exception

of Sarisoy et al. (2013), the principal aims of these studies

were not to investigate metacognitions related to worry in

depression per se, but rather, to compare depressed patients

with individuals with anxiety disorders. None of the studies

investigated the presence of metacognitions in individuals

in different phases of MDD.

Furthermore, few studies have investigated a broader

range of thought control strategies in the course of

depression. Wells and Davies (1994) developed the

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Thought Control Questionnaire (TCQ) to assess individual

differences in thought control strategies when coping with

unwanted and negative thoughts. The TCQ has been mostly

used in samples suffering from anxiety disorders with

findings indicating that the TCQ Punishment factor (e.g., ‘‘I

tell myself not to be so stupid’’) and the TCQ Worry factor

(e.g., ‘‘I think about past worries instead’’) seem to be

positively associated with indices of emotional vulnera-

bility and psychopathology (Fehm and Hoyer 2004; Luci-

ano et al. 2006; Rassin and Diepstraten 2003). Reynolds

and Wells (1999) found negative correlations between

depressive symptoms and the TCQ Distraction factor (e.g.,

‘‘I occupy myself with work instead’’) and the TCQ

Reappraisal factor (e.g., ‘‘I try to reinterpret the thought’’)

among patients with MDD (n = 61). In the same study,

TCQ Distraction and TCQ Reappraisal predicted the

recovery of depressive symptoms in a mixed sample of

depressed and PTSD patients (n = 18), suggesting that

recovery was associated with the increased use of distrac-

tion and reappraisal as thought control strategies.

The principal aim of the present study was to explore the

presence of worry-related metacognitions and a broader

range of thought control strategies among patients with

current depression, those who had recovered, and never-

depressed individuals. By comparing previously depressed

with currently and never-depressed individuals in a cross-

sectional design, the present study also offers a unique

opportunity to examine the metacognitions and coping

strategies associated with MDD.

Methods

Participants

One hundred and sixty-eight participants, consisting of

currently depressed (n = 37), recovered previously depres-

sed (n = 81) and never-depressed individuals (n = 50),

took part in the study. One-hundred-and three participants

were recruited from a previous study on depression and

cognitive vulnerability (see Wang et al. 2005, 2006) and

reassessed in the present study. The participants in the ori-

ginal study consisted of a mixture of undergraduate students

and patients consulting their general practitioner (GP). Ini-

tially, we succeeded in contacting 133 of the total 149 par-

ticipants from the original study. Eighteen were unwilling to

participate, and 12 participants were excluded due to the

diagnostic criteria described below. The remaining 65 par-

ticipants were recruited through GPs and ads in a local

newspaper (Halvorsen et al. 2009, 2012).

Diagnoses were based on the Diagnostic and Statistical

Manual of Mental Disorders-IV, Text Revision, (DSM-IV-

TR; APA 2000), using the Structured Clinical Interview for

DSM-IV, Axis I (SCID-I; First et al. 1997). Based on the

information given in the clinical interview, the participants

were grouped as (a) currently depressed; (b) having pre-

viously experienced a depressive episode in the past and

fully recovered for at least the last 8 weeks or longer (i.e.,

during the past 2 months, no significant signs or symptoms

of a major depressive episode were present); or (c) having

never been clinically depressed. Participants meeting the

criteria for a major depressive episode in partial remission,

an on-going or past manic/hypomanic episode, dysthymic

disorder, or psychotic symptoms were not included in the

study. Participants with a history of known brain damage or

a major depressive episode due to a general medical con-

dition were excluded as well. Accordingly, only currently

depressed and previously depressed patients with a history

of major depression and only never-depressed without any

on-going or past Axis I disorders were included in the

study. All participants in the study were non-hospitalized.

The SCID interview was carried out by clinical psychol-

ogists or postgraduate psychology students who had been

extensively trained in its administration by a highly qualified

supervisor. All of the interviews were digitally recorded, and

30 of them, ten from each group, were subsequently ran-

domly sampled for reliability testing. The inter-rater agree-

ment (Cohen’s kappa) between two independent raters per

group (never-depressed, previously depressed and currently

depressed) was .90. When the kappa was calculated for rating

participants who had never experienced a depressive episode

(i.e., never-depressed) and those who had (i.e., previously

depressed and currently depressed), the agreement was total.

These results indicate a highly satisfactory reliability of the

group assignments. For a further description of the design

and samples, see Halvorsen et al. (2009, 2010, 2011).

The demographic and clinical characteristics of the three

groups of participants are presented in Table 1. Three

participants in the currently depressed group had a chronic

major depressive episode (i.e., the full criteria for a major

depressive episode had been continuously met for at least

2 years). The three groups did not differ significantly

concerning gender, age, or years of education. As expected,

the groups differed significantly on the Beck Depression

Inventory (Beck et al. 1996) and also on the Beck Anxiety

Inventory (Beck and Steer 1990). Few individuals were

currently on antidepressant medications.

The regional medical research ethics committee

approved this study. All participants gave written informed

consent and were paid NOK 150 (€18.80) per hour for their

participation.

Measures

The Beck Depression Inventory—Second Edition (BDI-II;

Beck et al. 1996) is a 21-item self-report inventory for

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123

assessing the presence and severity of depressive symp-

toms. Each item is rated on a four-point Likert-type scale

ranging from 0 to 3, indicating the severity of the symptom.

Beck et al. (1996) categorized BDI-II total scores as fol-

lows: 0–13 minimal, 14–19 mild, 20–28 moderate and

29–63 severe. The BDI-II proved highly internally con-

sistent (Cronbach’s alpha [.90), and its 1-week test–retest

reliability was high (r = .93) (Beck et al. 1996). For more

on the psychometric properties of the BDI-II, see Steer

et al. (1999). In the present study, the BDI-II was admin-

istered the same day as the as the diagnostic interview and

the following day, combined with other measures. The

Cronbach’s alpha for the total score on the BDI-II was .95.

The Beck Anxiety Inventory (BAI; Beck and Steer 1990) is

a 21-item self-report inventory for assessing the presence

and severity of anxiety symptoms. Each item is rated on a

four-point Likert-type scale ranging from 0 to 3, indicating

the severity of each symptom. Beck and Steer (1990) cate-

gorized the BAI total scores as follows: 0–7 minimal, 8–15

mild, 16–25 moderate, and 26–63 severe. The BAI proved

highly internally consistent (Cronbach’s alpha = .94) and

acceptably reliable over an average time lapse of 11 days

(r = .67). For further psychometric properties of the BAI,

see Steer and Ranieri (1993). In the present study, the

Cronbach’s alpha for the total score was .92.

The Metacognitions Questionnaire-30 (MCQ-30; Wells

and Cartwright-Hatton 2004) consists of 30 items in a self-

report inventory for assessing individual differences in

metacognitive beliefs. The items are scored on a four-point

Likert-type scale ranging from 1 (I do not agree) to 4 (I totally

agree), allowing a range from 30 to 120. Higher scores are

associated with higher scores on depressive symptoms

(Hjemdal et al. 2013). The 30 items are grouped within the

five subscales: Positive beliefs about worry (e.g., ‘‘Worrying

helps me to solve problems’’), Negative beliefs about worry

concerning uncontrollability and danger (e.g., ‘‘When I start

worrying I cannot stop’’), Cognitive confidence (e.g., ‘‘I do

not trust my memory’’), Need of control (e.g., ‘‘It is bad to

think certain thoughts’’), and Cognitive self-consciousness,

which is the tendency to be aware of one’s thoughts (e.g., ‘‘I

monitor my thoughts’’). The MCQ-30 proved good internal

consistency (Cronbach’s alphas from .72 to .93) and

acceptable test–retest reliability over a mean re-test interval

of 34.14 days (r from .59 to .87), (Wells and Cartwright-

Hatton 2004). For further psychometric properties of the

MCQ-30, see Spada et al. (2008). In the present study, the

Cronbach’s alphas for the various subscales ranged from .71

(Need of control) to .86 (Positive beliefs about worry).

The Thought Control Questionnaire (TCQ; Wells and

Davies 1994) is a 30-item self-report inventory for assessing

the strategies used by individuals to control unpleasant and

unwanted thoughts. Each item is rated on a four point Likert-

type scale ranging from 1 (never) to 4 (almost always) with a

range from 30 to 120. This scale measures the use of the five

coping strategies: Distraction, Punishment, Worry, Social

Control, and Reappraisal. The TCQ proved to have accept-

able internal consistency (Cronbach’s alphas from .65 to .78)

and acceptable test–retest reliability over 6 weeks

(r between .67 and .83) (Reynolds and Wells 1999; Wells and

Davies 1994). The factor structure has widely been con-

firmed in clinical and healthy samples, and the subscales

have been proven to be independent (Fehm and Hoyer 2004;

Reynolds and Wells 1999). In the present study, the Cron-

bach’s alphas for the various subscales ranged from .68

(Worry) to .81 (Reappraisal).

The Ruminative Response Scale (RRS; Nolen-Hoeksema

and Morrow 1991) is a 22-item self-report inventory for

assessing individual differences in response to sadness or a

depressed mood (e.g., ‘‘I think about how alone I feel’’). Each

item is rated on a four-point Likert-type scale ranging from 1

(almost never) to 4 (almost always), with a possible range

from 22 to 88. Higher scores indicate higher levels of

rumination. In this study, the RRS total score was used. The

RRS showed highly satisfactory internal consistency

(Cronbach’s alphas from .88 to .92), and its high test–retest

stability over 5 months (r = .80) (Luminet 2004; Nolen-

Table 1 Demographic and clinical characteristics (N = 168)

Variable 1. Currently depressed

(n = 37) M (SD)

2. Previously depressed

(n = 81) M (SD)

3. Never depressed

(n = 50) M (SD)

Significant test, p value

and post hoc

Gender (female/male) 27/10 71/10 39/11 X2(2) = 4.23, p = .12

Age 37.49 (11.98) 37.42 (9.61) 38.06 (12.66) F(2,165) = 0.06, p = .95

Education, years 13.76 (3.84) 15.12 (2.64) 15.10 (3.63) F(2,165) = 2.53, p = .08

BDI-IIa 24.00 (9.06) 6.94 (7.21) 2.71 (3.04) F(2,162) = 114.74, p \ .001, 1 [ 2 [ 3

BAIb 17.41 (9.81) 6.42 (6.30) 2.35 (2.76) F(2,164) = 58.75, p \ .001, 1 [ 2 [ 3

Antidepressant 7 6 X2 (1) = 3.43, p = .06

Single/recurrent episodes 10/27 26/55 X2 (1) = 0.31, p = .58

BAI Beck Anxiety Inventory; BDI-II Beck Depression Inventorya Data missing from two previously depressed and one never-depressed control participantb Data missing for one never-depressed control participant

Cogn Ther Res

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Hoeksema et al. 1994). For further psychometric properties

of the RRS, see Lam et al. (2003) and Luminet (2004). In the

present study, the Cronbach’s alpha for the total score was

.95.

Procedure

Participants were assessed individually over 2 days at the

University outpatient clinic at the UiT The Arctic Uni-

versity of Norway, Tromsø, Norway. The diagnostic

interview took place on the first day, and the self-report

measures were completed on the following day. The pro-

cedure was administered in the same order for all

participants.

Statistical Analyses

Analyses were conducted using the statistical package

SPSS for Windows, version 21 (IBM Corp., Armonk, NY,

USA, 2012). As the variables were approximately normally

distributed, with failures of normality being caused by

skewness rather than outliers, parametric tests were used

(Tabachnick and Fidell 2007). Differences in the demo-

graphic and clinical characteristics among the three groups

were compared by means of analysis of variance

(ANOVA) for continuous variables. Between-group com-

parisons of categorical variables were made by means of

the Chi square test (two-tailed).

A Discriminant Function Analysis was conducted to

explore which combinations of metacognitive and thought

control factors were the best indicators of discrimination

between the groups (i.e., currently depressed, previously

depressed or never clinically depressed) and to provide a plot

of the relative positions of the groups in discriminant space.

Results

Discriminant Function Analysis (DFA)

DFA allows for the identification of variables that could

correctly classify different groups. The results can be used

to visually represent the position of groups relative to each

other in a discriminant space. In this study, a DFA was

conducted using the MCQ, TCQ and RRS variables as

predictors of membership for the currently depressed,

previously depressed, and never-depressed groups. Table 2

shows the means and standard deviations of the predictor

variables as a function of group membership. Two dis-

criminant functions were calculated with a combined

v2(22) = 125.19, p \ .001, indicating a relationship

between the three groups and metacognitive and thought

control predictors that is highly unlikely to occur due to

chance alone. After removing the first function, there was

still an association between the groups and predictors,

v2(10) = 29.90, p = .001, indicating that this second

function also contributed significantly to distinguishing

between the three groups. These functions accounted for

79.9 and 20.1 %, respectively, of the variance between the

groups. The structure matrix (i.e., the loading matrix)

shows the correlations or loadings between the group

predictors (i.e., RRS-total, MCQ and TCQ variables) and

the discriminant functions (Table 3). The meaning of the

function can then be inferred from the pattern of loadings.

As observed in Table 3, the loading matrix shows that the

best predictors for distinguishing between group member-

ship (function 1) were, in descending order, rumination

(RRS-total score), MCQ ‘Negative beliefs about worry

concerning uncontrollability and danger’ (e.g., ‘‘My wor-

rying is dangerous for me’’), TCQ Worry (e.g., ‘‘I dwell on

other worries’’), TCQ Punishment (e.g., ‘‘I tell myself not

to be so stupid’’) and TCQ Distraction (e.g., ‘‘I think about

something else’’). The loading matrix further shows that

the second function, which maximally distinguished among

the groups, was correlated most highly, in descending

order, with MCQ Need of controlling thoughts (e.g., ‘‘I

should be in control of my thoughts all of the time’’), MCQ

Cognitive confidence (e.g., ‘‘I do not trust my memory’’),

TCQ Reappraisal (e.g., ‘‘I challenge the thoughts valid-

ity’’), and MCQ Positive beliefs about worry (e.g., ‘‘Wor-

rying helps me to avoid problems in the future’’). The

loadings indicate that Function 1 appears to indicate a

dimension of negative metacognitive belief as well as

suggests the use of the thought control strategies of rumi-

nation, worry and punishment at the positive end of the

continuum and the use of the thought control strategy of

distraction at the negative end of the continuum. Function 2

appears to be a dimension with high levels of beliefs about

the need for control and low cognitive confidence and high

positive beliefs about the need to worry at the positive end

of the continuum and high levels of the thought control

strategy of reappraisal at the negative end (see Fig. 1 for

further details).

Discriminant functions yield axes, and the centroids of

each group can be plotted along these axes. If there is a

large difference between the centroid of one group and the

centroid of another along a discriminant function axis, the

discriminant function separates the two groups (Tabach-

nick and Fidell 2007). Figure 1 shows a visual represen-

tation of group differences with respect to the two

discriminant functions.

The unstandardized discriminant scores for each func-

tion were used to determine which pairs of groups were

different with respect to the discriminant scores on the

discriminant functions. ANOVAs showed that there was a

significant overall main effect for Function 1,

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F (2,163) = 67.46, p \ .001, g2 = .45, and Function 2,

F (2,163) = 16.98, p \ .001, g2 = .17. Scheffe post hoc

comparisons showed that on Function 1, the currently

depressed participants had significantly higher scores than

the never-depressed participants, with the previously

depressed participants scoring in the middle (p \ .001).

With respect to Function 2, the previously depressed par-

ticipants had significantly lower scores compared to both

the currently depressed and the never-depressed partici-

pants (p \ .001). The currently depressed participants did

not differ significantly from the never-depressed partici-

pants on Function 2. In total, this analysis suggests that the

currently depressed participants score higher than the pre-

viously depressed participants, who, in turn, score higher

than the never-depressed participants on negative meta-

cognitive beliefs about uncontrollability/danger and the use

of the thought control strategies rumination, worry and

punishment (i.e., CAS). In addition, the previously

depressed participants report a higher use of the thought

control strategy reappraisal, along with lower dysfunctional

metacognitions concerning the need to control their

thoughts, higher confidence in their cognitive function and

lower levels of a need to worry (positive metacognition)

compared to currently depressed and never-depressed

participants.

Discussion

This study aimed to expand our knowledge on metacog-

nitions and coping strategies in MDD and to explore how

worry-related metacognitions and a broad range of thought

control strategies might differentiate participants with

current depression, those who are recovered, and those who

have never been depressed.

The results of the DFA showed that two significant

discriminant functions could distinguish among the three

groups. The subscale loadings on the functions suggested

that Function 1 was a dimension comprised of extended

self-referent thinking (rumination, worry, punishment) and

beliefs about the uncontrollability and dangerousness of

worry. The negative end of this construct was comprised of

the use of distraction as a mental regulation strategy. This

function is consistent with the cognitive-attentional syn-

drome (CAS) that is linked to psychological disorders in

Table 2 Means and standard deviations of predictor variables as a function of group membership (N = 168)

Predictor variable Currently depressed

(n = 37) M (SD)

Previously depressed

(n = 81) M (SD)

Never depressed

(n = 50) M (SD)

RRS-total 56.57 (11.65) 43.38 (12.31) 32.04 (7.09)

MCQ-30

Positive beliefs 9.54 (3.60) 8.14 (2.85) 8.44 (2.36)

Negative beliefs 14.54 (4.29) 10.70 (4.16) 8.34 (1.67)

Cognitive confidence 13.84 (4.98) 9.74 (3.53) 9.54 (2.74)

Need of control 11.97 (3.50) 8.80 (2.77) 8.74 (2.33)

Cognitive self-consciousness 13.19 (3.55) 12.41 (3.76) 11.84 (3.69)

TCQ

Distraction 13.83 (3.28) 14.91 (2.99) 15.94 (2.52)

Punishment 10.97 (3.90) 9.61 (2.72) 8.28 (1.62)

Reappraisal 14.19 (3.96) 15.20 (3.58) 13.18 (4.15)

Worry 12.03 (2.56) 10.14 (2.45) 9.32 (2.18)

Social control 13.25 (1.80) 12.89 (2.24) 12.60 (2.21)

MCQ Metacognitive Questionnaire, RRS Ruminative Response Scale, TCQ Thought Control Questionnaire

Table 3 Structure matrix: pooled within-groups correlations between

discriminating variables and standardized canonical discriminant

functions

Variable Function 1 Function 2

RRS-total .91* -.04

MCQ-Negative beliefs .68* .12

TCQ-Worry .44* .17

TCQ-Punishment .39* -.04

TCQ-Distraction -.29* -.05

MCQ-Cognitive self-consciousness .15* .01

TCQ-Social control .12* .03

MCQ-Need of control .45 .56*

MCQ-Cognitive confidence .47 .56*

TCQ-Reappraisal .11 -.45*

MCQ-Positive beliefs .15 .30*

MCQ Metacognitive Questionnaire; RRS Response Style Question-

naire; TCQ Thought Control Questionnaire

* Largest absolute correlation between each variable and any dis-

criminant function

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the metacognitive model (Wells 2009; Wells and Matthews

1994). Interestingly, the negative loading of distraction on

this function suggests that diverting attention away from

negative thoughts (e.g., ‘‘I keep myself busy’’) is incon-

sistent with strong beliefs about the uncontrollability and

danger of worry and the presence of an intense CAS.

Indeed, the use of distraction as a thought control strategy

may represent a greater ability to flexibly control attention,

which is considered a protective factor in Wells’ model. A

recent study confirmed that attention control moderated the

relationship between the CAS and symptoms of psycho-

pathology (Fergus et al. 2012). Function 1 discriminated

among each of the groups, suggesting that there is a con-

tinuum of strength in CAS and negative metacognition that

increases across the never-depressed, recovered and cur-

rently depressed groups. The finding that the recovered

group remained significantly elevated in this function

compared with the never-depressed group may be impor-

tant, as it suggests that the function does not entirely revert

to normative levels following a depressive episode. This

result may indicate that the CAS and negative metacog-

nitions have stable trait-like properties that distinguish

depression-prone individuals from those who are not vul-

nerable. It may also or alternatively represent a scar effect;

once depression has been experienced, the changes intro-

duced in thinking styles and metacognition do not readily

revert to normal. If the scar explanation is correct, we do

not know whether the occurrence of depression itself or the

way that depression is treated that contributes to such an

effect. It is likely, however, that the recovered group still

experiences residual depressive symptoms; if this is the

case, the CAS and metacognitions could not have fully

reverted back to ‘never-depressed’ levels.

In summary, the results relating to Function 1 may be

interpreted as the never-depressed participants using more

distraction to address negative thoughts, whereas the cur-

rently depressed participants use rumination, worry and

punishment as self-regulatory strategies and hold strong

beliefs about the uncontrollability and danger of thinking.

The second discriminant function represents strong meta-

cognitive beliefs about the need to control thoughts (e.g., ‘‘If I

could not control my thoughts, I would not be able to func-

tion’’) coupled with low cognitive confidence (e.g., ‘‘I do not

trust my memory’’) and positive beliefs about worry (e.g.,

‘‘Worrying helps me to get things sorted out in my mind’’). At

the negative end of this function sits the use of reappraisal

(e.g., ‘‘I try to reinterpret the thought’’) as a thought control

strategy. This function presents an intriguing pattern because

never-depressed and currently depressed participants did not

differ on this dimension, suggesting it is not specific to current

depression. Instead, this factor appears uniquely related with

having experienced recovery from a depressive episode. More

specifically, recovery appears to be associated with higher

levels of the use of reappraisal as a thought control strategy,

along with lower dysfunctional metacognitions concerning

the need to control thoughts, lower memory confidence

problems and lower levels of positive beliefs about the need to

worry. This function could be understood as a consequence of

Never depressed

Previously depressed

Currently depressed

-2

-1

0

1

2

-2 -1 0 1 2

Group centroid

CAS:MCQ-Negative beliefsRRS-RuminationTCQ-WorryTCQ-Punishment

MCQ-Need of controlMCQ-Low cognitive confidenceMCQ-Positive beliefs

TCQ-Distraction

TCQ-Reappraisal

Fig. 1 Perceptual map of

groups in discriminant space.

CAS Cognitive Attentional

Syndrome, MCQ Metacognitive

Questionnaire, RRS Response

Style Questionnaire, TCQ

Thought Control Questionnaire

Cogn Ther Res

123

having undergone some type of psychological treatment (e.g.,

cognitive therapy with a focus on the use of reappraisal), or it

could reflect the effects of being treated with antidepressants.

Unfortunately, we had only sparse, unsystematic retrospective

information about participants’ treatment history; therefore,

we are unable to comment on this further. However, another

factor should still be considered. The never-depressed group

did not use reappraisal, presumably because they had no need

to, whereas the currently depressed also did not use reap-

praisal, even though this strategy might help them. The

recovered group was different from the never-depressed and

the currently depressed groups, suggesting that they might be

in a chronic state of reappraising their thoughts; this very

process could contribute to maintaining their recovery status.

However, the data appear to suggest that this is not a ‘normal’

state, as this group remains different from never-depressed

individuals. Accordingly, previously depressed individuals

may still have ‘‘extended processing’’, that is, CAS, but their

content has changed. From the perspective of the S-REF

model (Wells and Matthews 1994, 1996), this shift might

suggest that fundamental processes involving the regulation of

thinking processes may not have changed following recovery

from depression and may represent a relapse marker.

The findings from the present study are consistent with the

metacognitive model and further highlight a role for meta-

cognitive beliefs and rumination in the presentation of

depression. The present results support the continued

exploration of the role of worry-related metacognitions and

thought control strategies, in addition to rumination. This

role is in accordance with the metacognitive model, which

proposes metacognition and extended thinking, such as

worry, as trans-diagnostic features of emotional disorders

(Wells 2009). Further research is required to examine the

possibility of identifying individuals at risk of developing or

re-experiencing future depressive episodes on the basis of

their metacognitive profiles. In particular, further studies

should examine if the use of reappraisal as a strategy can

generate counterproductive effects later on by keeping the

CAS (i.e., extended thinking) activated.

There are limitations within the present study. First, the

sample consisted of mainly females and mildly depressed

participants. Second, we did not assess the presence of

comorbid Axis-I disorders among the participants. How-

ever, the present study’s low mean scores on the BAI for

the previously depressed group indicate that few of the

previously depressed participants had clinical levels of

anxiety symptoms at the time of assessment. Third, the

study only contained information regarding the partici-

pants’ current antidepressant medication use. Future stud-

ies should assess exposure to other treatments. Further

research among clinical samples is needed to test the

generalizability of our findings to more severely depressed

and male groups of patients. Additionally, prospective

studies are necessary to examine the possible causal effects

of metacognitive beliefs on thinking styles in MDD.

In conclusion, negative metacognitive beliefs concern-

ing uncontrollability/danger and the use of thought control

strategies in the form of rumination, worry and punishment

can be contrasted with a self-regulated style of distraction

to effectively discriminate among groups of depressed,

recovered and never-depressed individuals. In addition, the

tendency to use reappraisal appears to be unique among

those who have recovered from depression, but this is not a

cognitive style that occurs in never-depressed individuals.

This finding raises the question of whether reappraisal is

adaptive or a risk marker that occurs as a consequence of

having been formerly depressed.

Acknowledgments This study was supported by ‘‘The National

Program for Integrated Clinical Specialist and PhD-training for Psy-

chologists’’ in Norway. This program is a joint cooperation between

the Universities of Bergen, Oslo, Tromsø, the Norwegian University

of Science and Technology (Trondheim), the Regional Health

Authorities, and the Norwegian Psychological Association. The pro-

gram is funded jointly by The Ministry of Education and Research

and The Ministry of Health and Care Services. The study was also

supported in part by the Psychiatric Research Centre of Northern

Norway. The authors would like to thank the participants and the

research assistants who contributed to the data collection. We would

also like to thank Professor Adrian Wells for commenting on an early

draft of the manuscript. Last but not least, we would like to thank the

anonymous reviewers for helpful suggestions, which contributed to

the improvement of this paper.

Conflict of Interest Marianne Halvorsen, Roger Hagen, Odin

Hjemdal, Marianne S. Eriksen, Ase J. Sørli, Knut Waterloo, Martin

Eisemann and Catharina E. A. Wang do not have any commercial

association that might pose a conflict of interest in connection with

the manuscript.

Informed Consent All of the procedures followed were in accor-

dance with the ethical standards of the responsible committee on

human experimentation (institutional and national) and with the

Helsinki Declaration of 1975, as revised in 2000. Informed consent

was obtained from all patients before entering the study.

Animal Rights No animal studies were carried out by the authors

for this article.

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