Thinking in circles: reducing rumination-related depression in adolescents

Rumination, or overthinking, is a process of recurrent negative thinking and dwelling on feelings of emotional distress like anxiety, sadness, fear, anger, guilt, and shame. It’s a major factor in the vulnerability to, and onset, severity, and duration of, depression.

A new study has found that an intervention, called Rumination-focused Cognitive Behavioural Therapy (RF-CBT), is effective at reducing negative overthinking in adolescents.

By using “functional magnetic resonance imaging”, or fMRI, technology researchers observed shifts in brain connectivity associated with overthinking.

“We know adolescent development is pivotal. Their brains are maturing, and habits are forming. Interventions like RF-CBT can be game-changers, steering them towards a mentally healthy adulthood,” says Dr Scott Langenecker of the department of psychiatry and behavioural health at Ohio State University in the US.

“We were particularly excited that the treatment seemed developmentally appropriate and was acceptable and accessible via telehealth during the early pandemic.”

Cognitive behavioural therapy (CBT) is a treatment approach for a range of mental and emotional health issues. CBT is based on the idea that how you think and act affects how you feel, and it aims to help the patient identify and change unhealthy patterns of thinking and behaviour.

Rumination-focused Cognitive Behavioural Therapy (RF-CBT) is an approach pioneered by Ed Watkins, professor of experimental and applied clinical psychology at the University of Exeter, UK, that specifically targets ruminative thinking. It has been shown to be an effective approach among adults with depression.

“We wanted to see if we could adapt it for a younger population to prevent the ongoing burden of depressive relapse,” says Rachel Jacobs, adjunct assistant professor of psychiatry and behavioural sciences at Northwestern University, US, who conducted the pilot study in 2016.

“As a clinician, I continued to observe that standard CBT tools such as cognitive restructuring didn’t give young people the tools to break out of the painful mental loops that contribute to experiencing depression again.

“If we could find a way to do that, maybe we could help young people stay well as they transition to adulthood, which has become even more important since we’ve observed the mental health impact of COVID-19.”

In this trial 76 teenagers aged 14-17 years old and with a history of depression were randomly assigned to 10-14 sessions of RF-CBT or were encouraged to receive any standard treatment (control).

Teens who received RF-CBT reported ruminating significantly less than the control, but the study also found shifts in brain activity associated with RF-CBT

FMRI measures the small changes in blood flow that occur with brain activity. They found that there was a reduction in the connection between the left posterior cingulate cortex and two other regions: the right inferior frontal gyrus and right inferior temporal gyrus. These zones are involved in self-referential thinking and emotional stimuli processing, respectively.

The findings, which replicate the same effects of a smaller 2016 pilot study, suggest that RF-CBT can be used to enhance the brain’s ability to shift out of the rumination habit in adolescents.

“For the first time, this paper shows that the version of rumination-focused CBT we have developed at the University of Exeter leads to changes in connectivity in brain regions in adolescents with a history of depression relative to treatment as usual,” says Watkins.

“This is exciting, as it suggests the CBT either helps patients to gain more effortless control over rumination or makes it less habitual. We urgently need new ways to reduce rumination in this group in order to improve the mental health of our young people.

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