There is a growing body of research supporting the potential therapeutic value of the Cognitive Control Training (CCT) for depression, even though more research including a control condition is necessary to investigate its working mechanisms.
The aim of this randomized, double-blind, placebo-controlled trial was to investigate the adjunctive effects of CCT to treatment-as-usual, compared to a sham-training, in patients with Major Depressive Disorder. Hundred-and-fifteen inpatients were randomly assigned to complete ten sessions of either an active working-memory based CCT (n = 56) or a comparable sham-training (n = 59). Changes in depressive symptoms and rumination were assessed from baseline to post-training, and at 1 year follow-up. Secondary outcome measures included alternative indices of maladaptive emotion regulation strategies, state-rumination in response to a worry induction, a cognitive transfer task and self-reports of work-status and well-being at 1 year follow-up.
Our results show no evidence for short-term beneficial effects of CCT in depressed inpatients when added to TAU.
Although other studies suggest that CCT may hold potential as an add-on intervention for depression, our findings point to the importance of investigating individual differences and conditions predicting training response.
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It should be noted that the pre-registration wrongly mentioned BDI < 11 as an inclusion criterium. Moreover, we have added the BDI as a primary outcome measure, even though it was listed as a secondary outcome measure in the pre-registration. Based on new insights in the field of cognitive remediation, we also consider depressive symptoms and emotion regulation as primary outcome variables, and changes in rumination as a potential mediator. Finally, after an initial pilot test, it became clear that the burden of the pre-registered original protocol was too high for the patients. Therefore, the Internal Shift Task was replaced by the Random Number Generation task.
Results of the analyses on the RSQ subscale Distraction may be affected by the significant baseline between-group difference on this scale.
We had planned to use both self-judgments and rater-judgments of the intrusions. However, the inter-rater reliability was so low (none to slight or fair agreement for the different phases of the task) that only the self-judgments could be used.
Due to missing data on single items of both subscales, the n of the two subscales differs slightly (Expectancy: Active-Trainingn = 47, Sham-Trainingn = 57, Credibility: Active-Trainingn = 50, Sham-Trainingn = 57).
Due to the small sample-size the analysis of the BDI-II follow-up data was based on, this analysis is not considered reliable.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Bauer, M., Bschor, T., Pfennig, A., Whybrow, P. C., Angst, J., Versiani, M., et al. (2007). World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders in primary care. The World Journal of Biological Psychiatry, 8(2), 67–104. https://doi.org/10.1080/15622970701227829.
Baxter, L. R., Schwartz, J. M., Phelps, M. E., Mazziotta, J. C., Guze, B. H., Selin, C. E., et al. (1989). Reduction of prefrontal cortex glucose metabolism common to three types of depression. Archives of General Psychiatry, 46(3), 243–250. https://doi.org/10.1001/archpsyc.1989.01810030049007.
Boot, W. R., Simons, D. J., Stothart, C., & Stutts, C. (2013). The pervasive problem with placebos in psychology: Why active control groups are not sufficient to rule out placebo effects. Perspectives on Psychological Science, 8(4), 445–454. https://doi.org/10.1177/1745691613491271.
Borkovec, T. D., Robinson, E., Pruzinsky, T., & DePree, J. A. (1983). Preliminary exploration of worry: Some characteristics and processes. Behaviour Research and Therapy, 21(1), 9–16. https://doi.org/10.1016/0005-7967(83)90121-3.
Brunoni, A. R., Boggio, P. S., De Raedt, R., Bensenor, I. M., Lotufo, P. A., Namur, V., et al. (2014). Cognitive control therapy and transcranial direct current stimulation for depression: A randomized, double-blinded, controlled trial. Journal of Affective Disorders, 162, 43–49. https://doi.org/10.1016/j.jad.2014.03.026.
Bürger, C., & Kühner, C. (2007). Copingstile im Umgang mit depressiverStimmung. Zeitschrift fürKlinischePsychologie und Psychotherapie, 36, 36–45. https://doi.org/10.1026/1616-34220.127.116.11.
Calkins, A. W., McMorran, K. E., Siegle, G. J., & Otto, M. W. (2015). The effects of computerized Cognitive Control Training on community adults with depressed mood. Behavioural and Cognitive Psychotherapy, 43(5), 578–589. https://doi.org/10.1017/s1352465814000046.
Carvalho, A. F., Cavalcante, J. L., Castelo, M. S., & Lima, M. C. O. (2007). Augmentation strategies for treatment-resistant depression: A literature review. Journal of Clinical Pharmacy and Therapeutics, 32(5), 415–428. https://doi.org/10.1111/j.1365-2710.2007.00846.x.
Cuijpers, P., Karyotaki, E., Weitz, E., Andersson, G., Hollon, S. D., & van Straten, A. (2014). The effects of psychotherapies for major depression in adults on remission, recovery and improvement: A meta-analysis. Journal of Affective Disorders, 159, 118–126. https://doi.org/10.1016/j.jad.2014.02.026.
Davidson, R. J., Putnam, K. M., & Larson, C. L. (2000). Dysfunction in the neural circuitry of emotion regulation: A possible prelude to violence. Science, 289, 591–594. https://doi.org/10.1126/science.289.5479.591.
De Raedt, R., & Koster, E. H. (2010). Understanding vulnerability for depression from a cognitive neuroscience perspective: A reappraisal of attentional factors and a new conceptual framework. Cognitive, Affective and Behavioral Neuroscience, 10(1), 50–70. https://doi.org/10.3758/CABN.10.1.50.
De Raedt, R., Vanderhasselt, M. A., & Baeken, C. (2015). Neurostimulation as an intervention for treatment resistant depression: From research on mechanisms towards targeted neurocognitive strategies. Clinical Psychology Review, 41, 61–69. https://doi.org/10.1016/j.cpr.2014.10.006.
Demeyer, I., De Lissnyder, E., Koster, E. H. W., & De Raedt, R. (2012). Rumination mediates the relationship between impaired cognitive control for emotional information and depressive symptoms: A prospective study in remitted depressed adults. Behaviour Research and Therapy, 50(5), 292–297. https://doi.org/10.1016/j.brat.2012.02.012.
Devilly, G. J., & Borkovec, T. D. (2000). Psychometric properties of the credibility/expectancy questionnaire. Journal of Behavior Therapy and Experimental Psychiatry, 31, 73–86. https://doi.org/10.1016/S0005-7916(00)00012-4.
Fales, C. L., Barch, D. M., Rundle, M. M., Mintun, M. A., Snyder, A. Z., Cohen, J. D., et al. (2008). Altered emotional interference processing in affective and cognitive-control brain circuitry in major depression. Biological Psychiatry, 63(4), 377–384. https://doi.org/10.1016/j.biopsych.2007.06.012.
Garnefski, N., & Kraaij, V. (2007). The Cognitive Emotion Regulation Questionnaire—Psychometric features and prospective relationships. European Journal of Psychological Assessment, 23, 141–149. https://doi.org/10.1027/1015-5718.104.22.168.
Goeleven, E., De Raedt, R., Baert, S., & Koster, E. H. W. (2006). Deficient inhibition of emotional information in depression. Journal of Affective Disorders, 93(1–3), 149–157. https://doi.org/10.1016/j.jad.2006.03.007.
Gotlib, I. H., & Joormann, J. (2010). Cognition and depression: Current status and future directions. Annual Review of Clinical Psychology, 6, 285–312. https://doi.org/10.1146/annurev.clinpsy.121208.131305.
Gronwall, D. M. A. (1977). Paced Auditory Serial-Addition Task: A measure of recovery from concussion. Perceptual and Motor Skills, 44(2), 367–373. https://doi.org/10.2466/pms.1922.214.171.1247.
Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85(2), 348–362. https://doi.org/10.1037/0022-35126.96.36.1998.
Hardeveld, F., Spijker, J., de Graaf, R., Nolen, W. A., & Beekman, A. T. (2010). Prevalence and predictors of recurrence of major depressive disorder in the adult population. Acta PsychiatricaScandinavica, 122(3), 184–191. https://doi.org/10.1111/j.1600-0447.2009.01519.x.
Hautzinger, M., Keller, F., Kühner, C. (2006). Beck Depressions-Inventar (BDI-II). Revision. Frankfurt am Main: Harcourt Assessment Inc.
Hirsch, C. R., Hayes, S., & Mathews, A. (2009). Looking on the bright side: Accessing benign meanings reduces worry. Journal of Abnormal Psychology, 118(1), 44–54. https://doi.org/10.1037/a0013473.
Hoorelbeke, K., & Koster, E. H. W. (2017). Internet-delivered cognitive control training as a preventive intervention for remitted depressed patients: Evidence from a double-blind randomized controlled trial study. Journal of Consulting and Clinical Psychology, 85(2), 135–146. https://doi.org/10.1037/ccp0000128.
Hoorelbeke, K., Koster, E. H. W., Demeyer, I., Loeys, T., & Vanderhasselt, M. A. (2016). Effects of cognitive control training on the dynamics of (mal)adaptive emotion regulation in daily life. Emotion, 16(7), 945–956. https://doi.org/10.1037/emo0000169.
Hoorelbeke, K., Koster, E. H. W., Vanderhasselt, M. A., Callewaert, S., & Demeyer, I. (2015). The influence of cognitive control training on stress reactivity and rumination in response to a lab stressor and naturalistic stress. Behaviour Research and Therapy, 69, 1–10. https://doi.org/10.1016/j.brat.2015.03.010.
Joormann, J., & D’Avanzato, C. (2010). Emotion regulation in depression: Examining the role of cognitive processes. Cognition and Emotion, 24(6), 913–939. https://doi.org/10.1080/02699931003784939.
Keller, M. B., Lavori, P. W., Lewis, C. E., & Klerman, G. L. (1983). Predictors of relapse in major depressive disorder. The Journal of the American Medical Association, 250(24), 3299–3304. https://doi.org/10.1001/jama.1983.03340240025024.
Koster, E. H. W., Hoorelbeke, K., Onraedt, T., Owens, M., & Derakshan, N. (2017). Cognitive control interventions for depression: A systematic review of findings from training studies. Clinical Psychology Review, 53, 79–92. https://doi.org/10.1016/j.cpr.2017.02.002.
Loch, N., Hiller, W., & Witthöft, M. (2011). The Cognitive Emotion Regulation Questionnaire (CERQ). Psychometric evaluation of a German adaptation. Zeitschrift FürKlinischePsychologie und Psychotherapie, 40(2), 94–106. https://doi.org/10.1026/1616-3443/a000079.
Marchetti, I., Mor, N., Chiorri, C., & Koster, E. H. W. (2018). The Brief State Rumination Inventory (BSRI): Validation and psychometric evaluation. Cognitive Therapy and Research, 42(4), 447–460. https://doi.org/10.1007/s10608-018-9901-1.
Miyake, A., Friedman, N. P., Emerson, M. J., Witzki, A. H., Howerter, A., & Wager, T. D. (2000). The unity and diversity of executive functions and their contributions to complex “frontal lobe” tasks: A latent variable analysis. Cognitive Psychology, 41(1), 49–100. https://doi.org/10.1006/cogp.1999.0734.
Moshier, S. J., & Otto, M. W. (2017). Behavioral activation treatment for major depression: A randomized trial of the efficacy of augmentation with cognitive control training. Journal of Affective Disorders, 210, 265–268. https://doi.org/10.1016/j.jad.2017.01.003.
Motter, J. N., Pimontel, M. A., Rindskopf, D., Devanand, D. P., Doraiswamy, P. M., & Sneed, J. R. (2016). Computerized cognitive training and functional recovery in major depressive disorder: A meta-analysis. Journal of Affective Disorders, 189, 184–191. https://doi.org/10.1016/j.jad.2015.09.022.
National Collaborating Centre for Mental Health. (2010). Depression: The Nice Guideline on the treatment and management of depression in adults (Updated). Leicester: British Psychological Society.
Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100(4), 569–582. https://doi.org/10.1037/0021-843X.100.4.569.
Nolen-Hoeksema, S., Morrow, J., & Fredrickson, B. L. (1993). Response styles and the duration of episodes of depressed mood. Journal of Abnormal Psychology, 102(1), 20–28. https://doi.org/10.1037/0021-843X.102.1.20.
Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on Psychological Science, 3(5), 400–424. https://doi.org/10.1111/j.1745-6924.2008.00088.x.
Ochsner, K. N., & Gross, J. J. (2005). The cognitive control of emotion. Trends in Cognitive Sciences, 9(5), 242–249. https://doi.org/10.1016/j.tics.2005.03.010.
Ochsner, K. N., Ray, R. D., Cooper, J. C., Robertson, E. R., Chopra, S., Gabrieli, J. D. E., & Gross, J. J. (2004). For better or for worse: Neural systems supporting the cognitive down- and up-regulation of negative emotion. NeuroImage, 23(2), 483–499. https://doi.org/10.1016/j.neuroimage.2004.06.030.
Paelecke-Habermann, Y., Pohl, J., & Leplow, B. (2005). Attention and executive functions in remitted major depression patients. Journal of Affective Disorders, 89(1–3), 125–135.
Papageorgiou, C., & Wells, A. (2000). Treatment of recurrent major depression with attention training. Cognitive & Behavioral Practice, 7(4), 407–413. https://doi.org/10.1016/S1077-7229(00)80051-6.
Peters, M., Giesbrecht, T., Jelicic, M., & Merckelbach, H. (2007). The random number generation task: Psychometric properties and normative data of an executive function task in a mixed sample. Journal of the International Neuropsychological Society, 13(4), 626–634. https://doi.org/10.1017/S1355617707070786.
Ruscio, A. M., & Borkovec, T. D. (2004). Experience and appraisal of worry among high worriers with and without generalized anxiety disorder. Behaviour Research and Therapy, 42(12), 1469–1482. https://doi.org/10.1016/j.brat.2003.10.007.
Segrave, R. A., Arnold, S., Hoy, K., & Fitzgerald, P. B. (2014). Concurrent cognitive control training augments the antidepressant efficacy of tDCS: A pilot study. Brain Stimulation, 7(2), 325–331. https://doi.org/10.1016/j.brs.2013.12.008.
Siegle, G. J., Ghinassi, F., & Thase, M. E. (2007a). Neurobehavioral therapies in the 21st century: Summary of an emerging field and an extended example of cognitive control training for depression. Cognitive Therapy and Research, 31(2), 235–262. https://doi.org/10.1007/s10608-006-9118-6.
Siegle, G. J., Price, R. B., Jones, N. P., Ghinassi, F., Painter, T., & Thase, M. E. (2014). You gotta work at it. Clinical Psychological Science, 2(4), 455–471. https://doi.org/10.1177/2167702614536160.
Siegle, G. J., Thompson, W., Carter, C. S., Steinhauer, S. R., & Thase, M. E. (2007b). Increased amygdala and decreased dorsolateral prefrontal BOLD responses in unipolar depression: Related and independent features. Biological Psychiatry, 61(2), 198–209. https://doi.org/10.1016/j.biopsych.2006.05.048.
Solomon, D. A., Keller, M. B., Leon, A. C., Mueller, T. I., Lavori, P. W., Shea, M. T., et al. (2000). Multiple recurrences of major depressive disorder. American Journal of Psychiatry, 157(2), 229–233. https://doi.org/10.1176/appi.ajp.157.2.229.
Steer, R. A., Beck, A. T., Brown, G. K., & Beck, J. S. (1993). Classification of suicidal and nonsuicidal outpatients: A cluster-analytic approach. Psychodynamics and Psychopathology, 49(5), 603–614.
Thase, M., Entsuah, A., & Rudolph, R. (2001). Remission rates during treatment with venlaxafine or selective seretonin reuptake inhibitors. British Journal of Psychiatry, 178, 234–241. https://doi.org/10.1192/bjp.178.3.234.
Tombaugh, T. N. (2006). A comprehensive review of the Paced Auditory Serial Addition Test (PASAT). Archives of Clinical Neuropsychology, 21, 53–76. https://doi.org/10.1016/j.acn.2005.07.006.
Vanderhasselt, M. A., & De Raedt, R. (2009). Impairments in cognitive control persist during remission from depression and are related to the number of past episodes: An event related potentials study. Biological Psychology, 81(3), 169–176. https://doi.org/10.1016/j.biopsycho.2009.03.009.
Vanderhasselt, M. A., De Raedt, R., Namur, V., Lotufo, P. A., Bensenor, I. M., Boggio, P. S., & Brunoni, A. R. (2015). Transcranial electric stimulation and neurocognitive training in clinically depressed patients: A pilot study of the effects on rumination. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 57, 93–99. https://doi.org/10.1016/j.pnpbp.2014.09.015.
Vanderhasselt, M. A., Koster, E. H. W., Onraedt, T., Bruyneel, L., Goubert, L., & Raedt, R. D. (2014). Adaptive cognitive emotion regulation moderates the relationship between dysfunctional attitudes and depressive symptoms during a stressful life period: A prospective study. Journal of Behavior Therapy and Experimental Psychiatry, 45(2), 291–296.
World Health Organization (WHO). (2015). Depression Fact sheet N°369. Retrieved April 8, 2016, from http://www.who.int/mediacentre/factsheets/fs369/en/.
Zhong, M., Wang, X., Xiao, J., Yi, J., Zhu, X., Liao, J., et al. (2011). Amygdala hyperactivation and prefrontal hypoactivation in subjects with cognitive vulnerability to depression. Biological Psychology, 88(2–3), 233–242. https://doi.org/10.1016/j.biopsycho.2011.08.007.
The study was funded by the Behavioural Science Institute of Radboud University. The Salus Clinic Lindow provided the rooms and facilities for conducting the study. Neither funding source had any influence on the design or results of the study.
Conflict of Interest
Gina R. A. Ferrari, Marie-Anne Vanderhasselt, Mike Rinck, Ineke Demeyer, Rudi De Raedt, Silvia Beisel, Johannes Lindenmeyer and Eni S. Becker declare that they have no conflict of interest.
This RCT was pre-registered at the Nederlands Trial Register (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5030). The study received ethical approval from the Ethics Committee of the University of Chemnitz, Germany. All procedures performed in the study involving human participants were in accordance with the ethical standards of the ethics committee, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
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Ferrari, G.R.A., Vanderhasselt, MA., Rinck, M. et al. A Cognitive Control Training as Add-On Treatment to Usual Care for Depressed Inpatients. Cogn Ther Res 45, 929–943 (2021). https://doi.org/10.1007/s10608-020-10197-y
- Major depression
- Cognitive control training