Mindfulness and emotion regulation in clinically depressed youth

Adolescence is a developmental period marked by a number of significant changes in psychological and social functioning. The demands placed upon adolescents and young adults by these changes place them at increased risk of depression, at least in part by the emergence of developmentally new stressors that can overwhelm the adolescent’s capacity for emotion regulation (ER). The adverse consequences of such early onset depression are dire, and include increased risk of suicide, increased impairment and greater risk of relapse. As such, it is vital that effective interventions are developed for addressing the putative ER deficits in youth. Designed as a thesis-by-publication, the present thesis aimed to explore and integrate two previously disparate areas of psychological research, mindfulness and ER. In addition, the present thesis aimed to explore these constructs in adolescents. The overarching aim of the present research was to inform prevention and treatment of depression, in addition to modifying associated cognitive risk markers such as rumination and dysfunctional attitudes, in a youth cohort. The thesis begins with a review of the relevant literatures. Part of this is included as a review article, published in Clinical Psychology Review. An additional section is included to provide further context for the thesis. This is then followed by an overall outline of the research aims and overall design. The published review article explores ER and mindfulness separately, highlighting similarities and distinctions between the constructs. While the term mindfulness has been used in a variety of ways, most commonly to refer to a mode of perception rooted in attention, one of the unique contributions of this thesis is to consider the relationship between mindfulness and ER. Therefore, although this is not the only way to conceive of mindfulness, we argue that it is a useful and complementary conception that allows an explicit exploration of the relationship between the established mindfulness and ER literatures. This is salient given the mounting evidence that mindfulness is associated with improved mental health, and that mindfulness interventions result in reduced symptoms of anxiety and depression, which are increasingly being conceptualised as disorders of ER. Two ER strategies are focused upon: cognitive reappraisal and expressive suppression. It is argued that mindfulness represents a conceptually distinct approach to regulating emotions, characterised by acceptance of and defusion from, rather than attempts to reduce emotional activation. This becomes possible through systematic training in both attentional control and increased acceptance of sensory and mental phenomena. It is proposed that mindful ER avoids certain problems associated emotion reduction strategies, specifically under- and over-engagement with emotions. The review then proposes the underpinnings of an integrated model of “mindful emotion regulation”, premised on development of metaawareness and consequent defusion from emotional activation. The second paper is titled “Mindfulness and Emotion Regulation in Depressed Youth: Associations with Clinical and Cognitive Features”, and has been submitted to Behavioral Research and Therapy. Using a cross-sectional design, it attempted to explore the relationship between mindfulness, reappraisal and suppression, and to contrast the relationship of each with depression, anxiety, cognitive risk markers such as rumination and dysfunctional attitudes, and quality of life (QOL). The third paper, titled “Mindfulness-Based Cognitive Therapy for Depressed Youth: Changes in Mindfulness, Emotion Regulation, and Clinical and Cognitive Features”, has been submitted to Clinical Psychology Science and Practice. Using a pre-post design, it explored the potential benefits of adding a mindfulness-based cognitive therapy (MBCT) to treatment-as-usual (TAU) for treating acute depressive symptoms and cognitive risk markers, and for improving QOL. Data for both studies one and two, respectively were collected from a larger study designed to assess the efficacy of MBCT for preventing depressive relapse in a sample of 15-25 year-olds with major depression presenting for outpatient treatment to a youth mental health service in Melbourne, Australia. A total of 107 participants (32 male, 75 female) completed a semi-structured clinical interview, a clinician-rated depression scale, and a battery of self-report measures. Study two used a subsample of participants from study one (n = 45; 13 male, 32 female), who had completed either the 8-week MBCT intervention or an equivalent amount of TAU. In both studies, mindfulness was assessed using the Mindful Attention Awareness Scale. Reappraisal and Suppression were assessed using the Emotion Regulation Questionnaire. Depression was assessed using the Centre for Epidemiological Studies Depression scale, the Hamilton Depression Rating Scale, and the Mood and Anxiety Symptoms Questionnaire. The latter questionnaire also assessed anxiety symptoms. Rumination was assessed using the Ruminative Responses Scale, drawn from the Response Styles Questionnaire. Dysfunctional attitudes were assessed using the Dysfunctional Attitudes Scale. Finally, QOL was assessed using the World Health Organization Quality of Life Scale. The results of study one indicated that mindfulness was significantly more strongly negatively associated with depression, anxiety, and cognitive risk markers, and more strongly positively associated with quality of life (QOL) than were reappraisal and suppression. The results of study two indicated that the addition of mindfulness-based cognitive therapy (MBCT) to treatment-as-usual (TAU) failed to produce any additional benefit over TAU alone. However, trait mindfulness was found to be more strongly associated with improved outcomes than reappraisal or suppression. Furthermore, higher levels of baseline mindfulness were associated with improved recovery across both the MBCT and TAU groups. Taken together, these results indicate that mindfulness is conceptually distinct from reappraisal and suppression, and is associated with better psychological and psychosocial outcomes than either ER strategy. It was concluded that despite the negative findings regarding the incremental efficacy of MBCT, it is an intervention that warrants further research in youth, given that it directly addresses problems associated with deficient and maladaptive ER strategy use in this cohort, which may represent a diathesis for depression.