ReviewSelection and implementation of emotion regulation strategies in major depressive disorder: An integrative review
Introduction
Major depressive disorder (MDD) is one of the most prevalent, disabling, and burdensome mental disorders (Eaton et al., 2012, Kessler and Bromet, 2013). The 12-month prevalence for experiencing a major depressive episode (MDE) for adults in the United States (US) is approximately 6.7% (National Institute of Mental Health, 2015). MDD is associated with impairments in various domains of functioning, including low education completion rate, unemployment, poor marital quality, and early mortality in part due to elevated risk for physical disorders and suicide (Kessler & Bromet, 2013). The economic burden associated with MDD in the US is estimated to be $210.5 billion in 2010, representing a 21.5% increase from 2005 (Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2015).
MDD is a mood disorder, and the two cardinal symptoms involve aberrations in affect (American Psychiatric Association, 2013): elevated negative affect and diminished positive affect. Additionally, compared to healthy controls, people with MDD are characterized by greater instability of negative affect (Houben, Van Den Noortgate, & Kuppens, 2015) and blunted reactivity to positive and negative laboratory stimuli (Bylsma, Morris, & Rottenberg, 2008). Considering these affective aberrations associated with MDD, some recent theoretical approaches aim to understand MDD from the perspective of emotion dysregulation (Campbell-Sills and Barlow, 2007, Gross and Muñoz, 1995, Kring and Werner, 2004). In fact, researchers speculate that those who are unable to successfully down-regulate negative affect are vulnerable to MDD (e.g., Gotlib and Joormann, 2010, Gross and Muñoz, 1995). Hence, difficulties with emotion regulation are likely risk and maintaining factors for MDD.
Emotion regulation (ER) refers to a set of processes that influence how people experience and express emotions (Gross & Thompson, 2007). Emotion regulatory processes can alter various aspects of emotion, including frequency, intensity, duration, and stability of positive and negative emotions. Two factors that determine the success of ER are (a) skillful selection of ER strategies and (b) effective implementation of selected strategies to achieve ER goals (Gross & Jazaieri, 2014). As such, unsuccessful ER in those with MDD could be due to inappropriate choice of ER strategies based on the situational demands and/or lack of abilities to effectively implement the selected strategies.
In the current paper, we review peer-reviewed research examining eight ER strategies in adults with MDD. We focus on rumination, distraction, cognitive reappraisal, and suppression because they have been strategies examined most frequently in the MDD literature. Further, the habitual use of these strategies has been significantly associated with more (for rumination and suppression) or less (for cognitive reappraisal) depressive symptomatology (Aldao et al., 2010, Nolen-Hoeksema et al., 2008). Additionally, considering the effectiveness of mindfulness-based treatment for MDD, of which acceptance is a central component (Piet & Hougaard, 2011), we review research on the ER strategy of acceptance. Lastly, given recent interest in regulation of positive emotions (i.e., positive ER; Carl, Soskin, Kerns, & Barlow, 2013), we review the literature on three main positive ER strategies—savoring, positive rumination, and dampening.
For each ER strategy, we organize the review based on four types of study designs. First, we describe literature examining global self-report measures (i.e., trait ER). Self-report measures reflect individuals' habitual use of, or dispositional tendency to adopt, an ER strategy.
Second, we review laboratory studies that measure spontaneous use of each strategy (i.e., spontaneous ER). These types of studies usually involve a mood induction task aimed to induce certain emotions (e.g., sadness) in participants. During or following the mood induction, participants are typically instructed to freely regulate their emotions. Then they are asked to report the extent to which they have used different ER strategies during the regulation phase by completing a self-report measure assessing distinct ER strategies.
Third, we review laboratory studies focused on the effects of experimentally instructed ER strategies on mood. In these studies, participants report their mood states before and after an experimentally instructed ER task that focuses on a particular ER strategy. Researchers assess mood changes to indicate the effects of the strategy on mood. When the ER task is preceded by or conducted during a mood induction, we note it. For strategies that are intended to improve mood (i.e., increase positive affect and/or decrease negative affect), this mood change can be viewed as an index of how effectively one uses the strategy. For this reason, these studies provide information about participants' abilities to implement different ER strategies when instructed to do so. For example, people with MDD may experience difficulties with ER due to inappropriate selection of ER strategies but can implement these strategies as successfully as healthy controls when instructed.
Finally, we review studies that examined ER strategies in everyday settings (naturalistic ER) using the experience sampling method (ESM; Csikszentmihalyi & Larson, 1987). ESM can increase ecological validity and reduce the recall biases inherent to retrospective self-report measures and daily diary studies (Stone et al., 1998). To date, there are only two studies that met our criteria to be included in the review (see details below), and both involved rumination. Consequently, only the Rumination section includes a review of naturalistic ER.
There are two recent review papers examining multiple ER strategies in relation to depression, broadly defined (i.e., Aldao et al., 2010, Joormann and Stanton, 2016), and we do not duplicate their efforts. The breadth of Aldao et al. (2010) focused on a broader range of psychopathology, which included depressive symptomatology. In contrast, we focus our review on the ER of people with diagnosed MDD. Like Aldao et al., we review research examining self-reported ER strategies, but we also review three additional types of study designs, including two that are laboratory-based and one that is naturalistic. Of note, the current review does not include neuroimaging research (see Joormann & Stanton, 2016 and Rive et al., 2013, for reviews of neural correlates of ER in depressive psychopathology). Although Joormann and Stanton (2016) included studies using various designs, they did not include naturalistic studies or always explicitly note the study designs. In fact, no reviews to date have systematically differentiated and compared these methodologies of measuring ER in MDD. By doing so, we aim to clarify whether results provide similar conclusions across methodologies.
The current review only includes studies that had at least one MDD group (current or remitted) and one nondepressed control group, which allowed for between-group comparisons. All group differences we describe in this review—unless otherwise noted—always refer to differences between groups that were statistically significant in the original studies. We focus our review on studies that assessed psychiatric disorders using well-validated diagnostic interviews (e.g., SCID-IV; First, Spitzer, Gibbon, & Williams, 1996). We exclude research assessing psychiatric disorders using self-report measures and applying clinical cutoffs because doing so can lead to a greater number of false positives and false negatives of MDD than do diagnostic interviews (see Bredemeier et al., 2010, for a discussion). To provide a thorough background of each ER strategy, however, we briefly describe their associations with depressive symptoms when we introduce each strategy. Finally, we use specific terms throughout the paper to describe the MDD and control group samples; these are detailed in Table 1.
Section snippets
Rumination
Rumination has received the most attention compared to other ER strategies; it refers to repetitively focusing on the nature and the consequences of one's feelings (Gross & Thompson, 2007). Rumination was first proposed in Nolen-Hoeksema, 1987, Nolen-Hoeksema, 1991 response styles theory as a dispositional tendency (i.e., trait) to “repetitively [focus] on the fact that one is depressed; on one's symptoms of depression; and on the causes, meaning, and consequences of depressive symptoms” (
Distraction
Distraction involves shifting one's attention away from the emotion-evocating aspect of the situation to other aspects of the situation or a completely different situation (Gross & Thompson, 2007). Like rumination, distraction was initially examined as a style by which individuals respond to their depressed mood and symptoms (Nolen-Hoeksema, 1991). In fact, Nolen-Hoeksema (1991) defined distracting responses as “purposeful turning one's attention away from one's symptoms of depression and its
Cognitive reappraisal
Cognitive reappraisal involves reinterpreting the meaning or self-relevance of an emotion-eliciting situation to modify its potential emotional significance before emotion is fully developed (Gross and Thompson, 2007, John and Gross, 2004). For example, one may view a bad test result as a reflection of an area of growth (reinterpret meaning) or perceive a sad movie ending as unrelated to one's life (reappraise self-relevance). Laboratory studies have shown that instructed cognitive reappraisal
Suppression
Suppression refers to effortful attempts to inhibit physiological, behavioral, and/or experiential aspects of emotional responses (Gross & Thompson, 2007). Like trait rumination, trait suppression is positively associated with depressive symptoms (Aldao et al., 2010). Researchers have studied various forms of suppression by focusing on different aspects of emotion that are suppressed. Expressive suppression, a continuing effort to inhibit explicit behavioral expressions in response to an
Acceptance
Acceptance can be conceptualized in two ways—acceptance of emotion and acceptance of situation. Acceptance of emotion involves letting one's emotions unfold without intervention and embracing their existence without judgment or avoidance. Acceptance of situation refers to accepting and resigning to one's past experiences (e.g., a stressful event) and current situations (Garnefski et al., 2001, Hayes et al., 1999). Acceptance is a crucial component of mindfulness-based therapies (Hayes,
Positive ER: savoring, positive rumination, and dampening
The ER literature has predominantly focused on regulation of negative emotion—the mood-repair effects of ER; there is a dearth of research on regulation of positive emotion. Given that diminished positive affect is a cardinal symptom of MDD, positive emotion regulation is particularly relevant to MDD. Recently, researchers have started to examine positive ER and identified several strategies that people employ to either upregulate (e.g., savoring, positive rumination) or downregulate positive
General summary
This review is the first that systematically examines studies on the use—both selection and implementation—of ER strategies as a function of MDD status and research methodology. We focused on eight strategies: rumination, distraction, cognitive reappraisal, suppression, acceptance, savoring, positive rumination, and dampening. For each ER strategy, we reviewed self-reports of habitual use of the strategy (i.e., trait ER), laboratory studies assessing spontaneous use of the strategy (i.e.,
Current limitations and future directions of ER in MDD
The field has made much progress in understanding ER and MDD. In particular, research attention has been given to self-reported habitual use of ER strategies and the effectiveness of implementing experimentally instructed ER strategies. Below, we highlight five burgeoning areas of research that are critical to further elucidating the role of emotion dysregulation in MDD.
Conclusion
MDD is characterized by elevated negative affect and diminished positive affect, and these emotional aberrations may be attributed in part to emotion dysregulation. Researchers over the past few decades have made significant progress in understanding ER and MDD, including the ability to appropriately select and effectively implement ER strategies. Given these research advances, we review empirical studies on eight ER strategies and four types of research designs. Findings suggest that emotion
Role of funding sources
This research was supported in part by the Mr. and Mrs. Spencer T. Olin Fellowships for Women in Graduate Study, Washington University in St. Louis, to Daphne Y. Liu. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Contributors
Daphne Y. Liu conducted literature searches and provided summaries of relevant research studies. Daphne Y. Liu and Renee J. Thompson collectively wrote this manuscript and both have approved the final manuscript.
Conflict of interest
Both authors declare that they have no conflicts of interest.
Acknowledgements
The authors wish to thank Kirsten Gilbert, Natasha Haradhvala, and Haijing Wu for their feedback on an initial draft of this manuscript. The authors also wish to thank Jenna Borenstein, Annie Castelluccio, Morgan Hartman, Hee Yeon Hwang, Lauren Mackay, Tori Metheny, and Remy Schlossberg for their assistance in project management.
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