Background
Depression is characterized by emotional and cognitive impairments including depressed mood, feelings of worthlessness, and diminished ability to think or concentrate [
1]. Of the 15–20% who experience depression during their lifetime [
2], 65–75% experience recurrent episodes [
3],[
4]. The National Institute for Health and Clinical Excellence [
5] has identified secondary prevention as a key goal in the long-term management of depression. High recurrence rates suggest that specific vulnerability factors increase the risk for developing repeated episodes of the disorder and these factors should be identified. One way to achieve this goal is to compare previously depressed subjects in remission, having a known vulnerability, and never depressed subjects, on relevant cognitive and emotional function dimensions.
Meta-analyses confirm that ongoing unipolar depression is reliably associated with impairments in multiple aspects of executive function [
6],[
7]. Executive functions (EF) also tend to be impaired in participants with remitted Major Depressive Disorder (MDD), and the largest impairments are found in inhibitory control [
8],[
9].
Emotional (or “hot”) cognition is also affected in depression. In particular, biased attention and perception of negative stimuli in dysphoric and clinically depressed individuals has been reported [
10]-[
12]. Importantly, biased attention to negative information has been found in both currently depressed and remitted participants [
13],[
14].
Variations in the use of emotion regulation strategies like cognitive reappraisal, expressive suppression, and rumination play an important role in depression [
12],[
15],[
16]. Individuals who have experienced depression in the past have been found to employ dysfunctional strategies more frequently (i.e. rumination, catastrophizing), and employ functional strategies less frequently (i.e. putting into perspective) [
17]. However, negative findings have also been reported [
15],[
18].
Compared to men, women have nearly twice the lifetime prevalence of depression [
19]. Women tend to ruminate more, and the gender difference in rumination precedes the gender difference in depression, indicating that rumination may contribute to the sex difference in depression [
20],[
21]. In rumination studies both trait and experimentally induced rumination are associated with impaired inhibition and switching in depressed individuals [
15],[
22]-[
25].
It has been reported that depressed patients show a specific failure to inhibit negative information, whereas formerly depressed individuals exhibited impaired inhibition of negative as well as positive information [
26]. In another study, executive control functions with emotionally valenced material, and clinical phenomena like emotion regulation and rumination, were investigated in a sample of previously depressed subjects compared to never depressed individuals [
15]. In that study a substantial proportion of participants in the clinical groups were taking medications. This is a compromising factor because antidepressant medication influences emotional processing and reduces the negative bias associated with depression [
27]. The two aforementioned studies [
15],[
26] used a negative affective priming task to assess inhibition, but negative priming is a controversial paradigm which has been criticized for low reliability [
28]. It is weakly related to latent inhibition factors derived from other inhibition tasks, and researchers have questioned whether negative priming reflects active suppression of distracting information [
29],[
30]. It is also a paradox that objectively better performance (faster reaction time to a probe) is interpreted as poorer inhibition, even though faster termination of the inhibitory effect would cause the same result. It was necessary to supplement the findings from J Joormann and IH Gotlib [
15] and E Goeleven, R De Raedt, S Baert and EH Koster [
26] with an investigation based on other measures of inhibition.
The aim of the current study was to investigate emotion regulation and executive control functions in unmedicated previously depressed and control participants. Inhibition was measured with the traditional Stroop paradigm and a modified version of the Stop-Signal task. Secondly, we also investigated the proposition that executive control in general, and in the processing of emotional material in particular, is related to depressive rumination and the emotion regulation strategy of cognitive reappraisal.
Discussion
The previously depressed participants matched never-depressed individuals on all neutral and emotional executive functions tasks. The previously depressed individuals reported that they more often respond to negative emotion with rumination and suppression and more rarely with reappraisal. A logistic regression model including all four factors of rumination and emotion regulation indicated that brooding, reflection, and suppression, but not reappraisal, predicted previous depression. The latter finding coincides with a proposition stating that the use of maladaptive strategies may be more important to psychopathology than the non-use of adaptive strategies [
51].
The absence of differences in executive performance between groups was unexpected and calls for a closer inspection. All participants in the current study were carefully assessed for current and previous depression and most other common mental health disorders, and categorized according to history of depression. Marked differences on current depressive and anxiety symptoms as reflected by Beck scales is a further indication of the clinically different characteristics of the groups. We were able to match the groups and avoid potential confounds in age, education, and general cognitive abilities. For the analyses of executive functions we also excluded individuals who were taking psychotropic medication. Whereas executive function, as indicated by the color-word interference test, is only marginally above the general population mean in both our participant groups, education is high and estimated IQ is approximately one standard deviation above the population mean. Although this prevents generalization to subgroups with low education and IQ, it is a strength of this study that the patient and control groups are highly similar in education and general cognitive abilities. Many studies of cognitive correlates of depression include severely impaired inpatients who tend to have high comorbidity, including alcohol or drug abuse, somatic health problems, and lower education. Such comorbidities complicate interpretation of results. Our results indicate that, on group level, previously depressed participants with relatively high education and IQ, and low comorbidity, are unimpaired in both neutral and emotional EF tasks. An alternative interpretation is that our groups were different in executive function, but that the tasks used in this study were not sensitive to the differences. This is an unlikely explanation for the Stroop task, which has been shown to differentiate between euthymic MDD participants and controls [
8]. In contrast, this explanation cannot be ruled out for the emotional EF tasks, which were new modifications of established EF paradigms. However, the effect sizes are similarly small for Stroop and the other executive tasks in our study. We therefore believe that the absence of significant differences between the groups on the executive tasks reflects the true state of our participants, at least in terms of non-emotional executive functioning. But the intensity of emotional stimuli in our tasks may have been too low to induce a significant effect. A comparison of stop-signal reaction time for the conditions neutral and angry suggests that the emotional effect was small.
Consistent with previous research we found more trait rumination among the previously depressed individuals [
15],[
52]. Thus, correlational data suggests that both brooding and reflection may have negative effects on mood and depression risk. Reflection was initially described as an adaptive form of rumination [
35], and this proposition gained some further support [
53], although J Joormann, DE Nee, MG Berman, J Jonides and IH Gotlib [
54] found that more reflection (but not brooding) was associated with working memory interference. Correlational data cannot rule out non-causal explanations, e.g. that reflection does not in itself confer depression risk but is an attempt to cope with the noxious effects of brooding. However, a meta-analysis indicates that both factors are related to symptoms of depression, although the association is stronger for brooding [
55]. Whether reflection leads to increased depressive symptoms depends on the interaction with other coping strategies [
56]. Importantly, in a prospective study, I Demeyer, E De Lissnyder, EH Koster and R De Raedt [
57] found that impaired cognitive control for emotional information influenced depressive symptoms one year later, and that this was fully mediated by rumination.
Contrary to some other studies we found more suppression and less reappraisal in the previously depressed group, and inclusion criteria may explain the differences. Whereas T Ehring, B Tuschen-Caffier, J Schnülle, S Fischer and JJ Gross [
18] included only participants whose BDI score was smaller than 10, and J Joormann and IH Gotlib [
15] used specified criteria to ensure full remission, we included participants who were currently not depressed according to diagnostic criteria, regardless of their current BDI scores or sub-clinical symptoms. Depending on the research question, excluding participants with negative emotions from studies of emotion regulation may imply excluding an important part of the topic. Emotion regulation tendencies are relatively stable [
58] whereas mood and symptoms of depression naturally vary with time within individuals. By definition the purpose of emotion regulation is to influence emotion, and our rationale for studying emotion regulation is that it may, over time, influence psychological well-being. Given that individual differences in emotion regulation makes some individuals more vulnerable to depression [
12],[
15] it can be expected that differences in emotion regulation may lead to differences in symptoms as reflected by BDI scores. In this context, strict inclusion criteria based on BDI or similar symptom assessments may eliminate important natural variance in the phenomena that are studied.
Executive performance did not significantly predict cognitive reappraisal or rumination. The CWI scaled scores show that executive performance is slightly above the general population average in this sample. The absence of executive dysfunction may explain why executive function was unrelated to rumination and reappraisal, and does not exclude the possibility of such correlations in samples with executive dysfunction. Another possible explanation relates to the complexity of executive processes. Inhibition is not strictly a unitary construct: inhibition of external distractors, internal distractors, and prepotent responses are partially separable components [
29],[
59]. Both Stop-Signal and Stroop have been classified as response inhibition tasks [
29],[
59]. In our understanding the involvement of inhibitory subcomponents is rather uncertain for the Stroop task, which may also rely on inhibition of cognitively prepotent irrelevant information. Different aspects of inhibition are likely to contribute differentially to the control of rumination and reappraisal, and the observed correlations will depend on the choice of tasks. J Joormann and IH Gotlib [
15] used a Negative Affective Priming tasks to show that reduced inhibition of negative material was associated with less use of reappraisal and more use of suppression in currently depressed, previously depressed, and never depressed participants. Reduced inhibition of negative material was associated with increased rumination only in currently depressed participants [
15]. However, the use of negative priming to indicate inhibitory control is controversial.
The fact that we used non-verbal material in the emotional tasks is another possible explanation, as previous studies have indicated that rumination may be associated with performance in tasks using verbal [
22], but not facial [
26], stimuli in depressed participants. It is also a reasonable assumption that rumination is primarily a verbal process [
26],[
54] and that it consequently should be closer related to performance in verbal, as opposed to non-verbal, tasks. On the other hand, the visual perception of facial expressions is deeply rooted in humans by evolution and not dependent on language or reading skills. Faces are also relevant in the current context because depression seems to be characterized by a disruption in the interpersonal domain [
60]. Furthermore, executive functions are typically defined as general high-level control mechanisms that operate on various other processes [
61],[
62]. In this perspective, the contribution from executive inhibitory mechanisms should be the same regardless of whether the task is presented with words or faces, and variance in performance between verbal and non-verbal tasks must be attributed to non-executive processes.
The majority of our previously depressed participants had received cognitively oriented psychotherapy, and we cannot rule out the possibility that this may have had some impact on our main outcome variables. Cognitive therapy for depression will typically attempt to promote antecedent-focused emotion regulation, including reappraisal, and reduce depressive rumination, and may possibly also change executive performance [
63]. However, based on the observation that our previously depressed participants are clearly different from controls on rumination and emotion regulation we find it unlikely that initial executive impairments in at-risk individuals have been eliminated by psychotherapy in the current sample.
Limitations and future directions
This study included only female participants. Participant gender has previously proven to not affect executive functions in remitted MDD compared to controls [
8], so including male participants would most likely not influence this aspect of our results. By contrast, the observed group differences in rumination and emotion regulation cannot necessarily be generalized to male populations because men and women process emotional events differently [
64]. Men and women use partially different strategies to cope with emotional distress in everyday life [
65]-[
67], and the relation between rumination and depression is stronger in women [
55]. According to Thayer and colleagues, women rely more heavily on inhibitory processes for normal social and emotional functioning, and perseverative thinking and rumination may partly be caused by deficient inhibition [
66]. Different aspects of inhibition and their relation to emotion regulation and rumination in men, both in remission from depression and in never-depressed controls, require attention in future studies.
The correlational nature of our data calls for cautious interpretation, but there is reason to trust the proposition that the differences in rumination and emotion regulation constitute vulnerability to depression in our sample. According to a meta-study, the relationship between rumination and depression is equivalent in longitudinal and cross-sectional data [
55].
Stronger neural activation may in some instances compensate for the impaired performance otherwise associated with trait rumination. In an fMRI study of healthy, never-depressed individuals, M-A Vanderhasselt, S Kuhn and R De Raedt [
68] found that brooding was associated with increased activation in right dorsolateral prefrontal cortex when successfully disengaging from negative material. This indicates that healthy high-brooders need more attentional control to disengage from negative information [
68]. BCY Lo, S Lau, S-h Cheung and NB Allen [
69] found increased late positive potential on medial scalp sites (Fz, Cz and Pz electrodes) among high ruminators when shifting between emotional material while in an induced sad mood state. An interesting continuation of the current research would be to use ERP data to investigate whether increased activation may explain why the previously depressed perform similar to control participants on executive tasks.
Competing interests
Author MA: Declares no competing interest.
Author CH: Consultancy fees received from Lundbeck, p1vital and Servier. Directorship and shareholder of Oxford Psychologists Ltd.
Author NIL: Declares no competing interest.
Authors’ contributions
MA participated in study design, collected the data, performed the analyses, and drafted the manuscript. CH participated in data interpretation and manuscript preparation. NIL participated in study design, data interpretation and manuscript preparation. All authors read and approved the final manuscript.