Preventing psychological disorders rather than treating them once problems are entrenched has the undoubted advantages of reducing distress for sufferers, the burden on clinical services, and their social and economic toll. The possibility of developing treatments that effectively prevent the emergence of anxiety and depression in vulnerable young people by targeting modifiable risk factors is a particularly exciting prospect.
Topper et al. (2017) propose that unhelpful Repetitive Negative Thinking (RNT) is one such modifiable risk factor. RNT is a transdiagnostic process that is observed across disorders; e.g., ruminative dwelling on the past in depression, worrisome ‘what if’ thoughts in generalised anxiety disorder (GAD) (McEvoy et al., 2010). Topper et al. make a compelling case for the value of seeking to reduce the onset of psychopathology by targeting RNT in young people with high levels of worry and rumination.
The authors compared group and online delivery of the preventive treatment (a modified version of Rumination-Focused Cognitive Behaviour Therapy; RFCBT) and hypothesised that, relative to a waitlist control condition, both modes of delivery of the preventive intervention would reduce RNT, psychological symptoms, and the prevalence of disorders one year later.
Participants were a mixed sample of adolescents in secondary school (15-18 years) and university undergraduates (18-22 years).
Participants were randomly allocated to receive the preventive intervention in either a:
- Face-to-face group format (n = 82)
- Guided Internet-based treatment (n = 84)
- Waitlist control condition (n = 85).
- Aged 15-22
- Scored above specified cut-offs for elevated worry and rumination (i.e. total score at or above 75th percentile on a self-report measure of either worry or rumination, total score at or above 66th percentile on the other screening measure) at initial screening and pre-intervention assessment
- No current self-reported diagnoses of major depression or GAD
- No current mental health treatment.
The intervention was a modified version of RFCBT, a treatment that has been shown to reduce rumination and depression in individuals with medication-refractory residual depression (Watkins et al., 2011). RFCBT is a multi-faceted treatment that adopts a functional analytic approach to identify the contingencies that prompt unhelpful RNT and the functions of this type of thinking (e.g. avoidance). Treatment includes strategies that promote alternative, concrete thinking and associated approach behaviour.
The content of the group and internet intervention was identical. The former involved 6 weekly (1.5 hour) group sessions; the web-based treatment involved 6 self-paced sessions. At the completion of each online session, therapists accessed the online platform and provided personalised feedback (following a manualised protocol). Outcomes were assessed at post-treatment, 3 and 12 month follow-up.
Therapists were experienced clinical psychology graduates who attended a 2-day training workshop by the treatment developers. Group sessions were recorded and used to provide supervision and ratings of fidelity to the protocol. Adherence was strong (average of 93% of the key elements included in each group session).
- Participants who commenced the group intervention completed significantly more sessions (4.59) relative to those who received the Internet treatment (3.96).
- There were medium to large pre- and post-treatment effects in the reduction of RNT in both the group and internet arms; effects maintained at 3 and 12 month follow-up. No difference between the active conditions. No effects to small effects in waitlist condition.
- Significant pre- and post-treatment reductions in depression, anxiety, general distress in the group and internet arms: effects maintained at 3 and 12 month follow-up. No difference between the active conditions. No significant reductions in waitlist condition.
- No differences between intervention conditions and wait-list in reduction of binge drinking, bulimia symptoms.
- Lower prevalence of self-reported depression and GAD in intervention conditions versus waitlist control condition at 12-month follow-up. No difference between rates in the group and internet arms.
- Comparable ratings of acceptability (e.g. adequacy of intervention, proficiency of trainers) for both intervention groups.
The authors conclude that their findings:
…provide the first indication of the efficacy for a preventive intervention for anxiety disorders and depression targeting excessive worry and rumination
They propose that their study:
…adds to emerging evidence for selective prevention programs targeting transdiagnostic risk factors as a promising approach to advance the field of prevention.
Strengths and limitations
These findings provide encouraging initial support for the utility of targeting RNT in preventing later psychological symptoms. The study was sufficiently powered, randomisation procedures were appropriate and intent-to-treat procedures were employed to analyse the data. Post-treatment gains were maintained at 3 and 12- month follow-up.
Nonetheless, some key issues warrant consideration:
- First, diagnostic interviews by blind assessors were not conducted; rather, responses on self-report measures (PHQ-9, GADQ-IV) were used to indicate likely diagnoses of depression and GAD at 12 months. Despite the diagnostic properties of these instruments, the possibility that participant bias may have influenced their responses cannot be ruled out.
- Second, no information was obtained about participants’ history of psychopathology or psychological treatment. Any between-condition differences on these variables may have influenced the outcomes. Further, as the authors note, the absence of this information precludes conclusions about the extent to which the self-reported prevalence of depression and GAD at 12 months reflects first onsets or the recurrence of pre-existing conditions. This is important because it has implications for how the findings can be interpreted. We can conclude that (relative to waitlist) the interventions resulted in lower rates of self-reported depression and GAD one year later, but not that they prevented the first emergence of the symptoms of these disorders. Future prevention studies with young people without a history of psychopathology will confirm whether addressing RNT effectively prevents the first onset of depression and GAD.
- Third, the analyses of respective prevalence rates at 12 months compared the combined effect of the preventive interventions to the waitlist control condition. Analyses that compared each of the preventive interventions to the waitlist condition separately demonstrated a lower prevalence of depression and GAD at 12 months in the internet versus waitlist conditions; however, no differences emerged between the group and waitlist conditions for either disorder. Future studies that compare the relative efficacy of these modes of delivery are needed to confirm that they result in comparably low prevalence rates over time.
Implications for practice
- The findings show promise for the value of prevention interventions that target problematic transdiagnostic processes such as RNT that place individuals at risk of developing psychological disorders.
- The comparable reductions in RNT and psychological symptoms observed across the group and internet-delivered versions of the intervention has key implications for dissemination.
- The relative effectiveness of these modes of delivery will need to be compared to individual one-one-one therapy to confirm their cost-effectiveness; nonetheless, these results are encouraging.
- Given recent emphasis on and initiatives to address the mental health needs of young people, more research that seeks to prevent the emergence of psychological distress in individuals at risk is needed.
Conflicts of interest
Michelle Moulds has previous and ongoing research collaborations with Ed Watkins, and was a co-author on the initial case series of RFCBT (Watkins et al., 2007). She currently collaborates with Thomas Ehring. However, she had no involvement in any aspect of this study. She conducts research on rumination and RNT in the context of depression.
Topper M, Emmelkamp PMG, Watkins E, Ehring T. (2017) Prevention of anxiety disorders and depression by targeting excessive worry and rumination in young adults: A randomized controlled trial. Behaviour Research and Therapy, 90, 123-136 [Abstract]
McEvoy PM, Mahoney AEJ, Moulds ML. (2010) Are worry, rumination, and post-event processing one and the same? Development of the repetitive thinking questionnaire. Journal of Anxiety Disorders, 24, 509-519. [PubMed abstract]
Watkins ER, Mullan E, Wingrove J, Rimes K, Steiner H, Bathurst N, Scott J. (2011) Rumination-focused cognitive-behavioural therapy for residual depression: Phase II randomized controlled trial. British Journal of Psychiatry, 199, 317-322. [PubMed abstract]