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Rumination-focused cognitive–behavioural therapy for residual depression: phase II randomised controlled trial

  • Edward R. Watkins (a1), Eugene Mullan (a1), Janet Wingrove (a2), Katharine Rimes (a2), Herbert Steiner (a2), Neil Bathurst (a3), Rachel Eastman (a4) and Jan Scott (a4)...



About 20% of major depressive episodes become chronic and medication-refractory and also appear to be less responsive to standard cognitive–behavioural therapy (CBT).


To test whether CBT developed from behavioural activation principles that explicitly and exclusively targets depressive rumination enhances treatment as usual (TAU) in reducing residual depression.


Forty-two consecutively recruited participants meeting criteria for medication-refractory residual depression were randomly allocated to TAU v. TAU plus up to 12 sessions of individual rumination-focused CBT. The trial has been registered (ISRCTN22782150).


Adding rumination-focused CBT to TAU significantly improved residual symptoms and remission rates. Treatment effects were mediated by change in rumination.


This is the first randomised controlled trial providing evidence of benefits of rumination-focused CBT in persistent depression. Although suggesting the internal validity of rumination-focused CBT for residual depression, the trial lacked an attentional control group so cannot test whether the effects were as a result of the specific content of rumination-focused CBT v. non-specific therapy effects.

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Corresponding author

Edward R. Watkins, Mood Disorders Centre, School of Psychology, University of Exeter, Exeter EX4 4QG, UK. Email:


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This trial was funded by a Young Investigators Grant to E.R.W. from the National Alliance for Research into Schizophrenia and Depression (NARSAD), with J.S. as mentor.

Declaration of interest




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1 Hollon, SD, Munoz, RF, Barlow, DH, Beardslee, WR, Bell, CC, Bernal, G, et al. Psychosocial intervention development for the prevention and treatment of depression: promoting innovation and increasing access. Biol Psychiatry 2002; 52: 610–30.
2 Judd, LL. The clinical course of unipolar major depressive disorders. Arch Gen Psychiatry 1997; 54: 989–91.
3 Scott, J. Depression should be managed like a chronic disease. BMJ 2006; 332: 985–6.
4 Fava, GA. Subclinical symptoms in mood disorders: pathophysiological and therapeutic implications. Psychol Med 1999; 29: 4761.
5 Judd, LL, Paulus, MP, Zeller, P, Fava, GA, Rafanelli, C, Grandi, S, et al. The role of residual subthreshold depressive symptoms in early episode relapse in unipolar depressive disorder. Arch Gen Psychiatry 1999; 56: 764–5.
6 Paykel, ES, Ramana, R, Cooper, Z, Hayhurst, H, Kerr, J, Barocka, A. Residual symptoms after partial remission – an important outcome in depression. Psychol Med 1995; 25: 1171–80.
7 Cornwall, PL Scott, J. Partial remission in depressive disorders. Acta Psychiatr Scand 1997; 95: 265–71.
8 Fava, GA, Grandi, S, Zielezny, M, Canestrari, R, Morphy, MA. Cognitive-behavioral treatment of residual symptoms in primary major depressive disorder. Am J Psychiatry 1994; 151: 1295–9.
9 Fava, GA, Rafanelli, C, Grandi, S, Canestrari, R, Morphy, MA. Six-year outcome for cognitive behavioral treatment of residual symptoms in major depression. Am J Psychiatry 1998; 155: 1443–5.
10 Paykel, ES, Scott, J, Teasdale, JD, Johnson, AL, Garland, A, Moore, R, et al. Prevention of relapse in residual depression by cognitive therapy – a controlled trial. Arch Gen Psychiatry 1999; 56: 829–35.
11 Paykel, ES, Scott, J, Cornwall, PL, Abbott, R, Crane, C, Pope, M, et al. Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial. Psychol Med 2005; 35: 5968.
12 Kocsis, JH, Gelenberg, AJ, Rothbaum, BO, Klein, DN, Trivedi, MH, Manber, R, et al. Cognitive behavioral analysis system of psychotherapy and brief supportive psychotherapy for augmentation of antidepressant nonresponse in chronic depression. Arch Gen Psychiatry 2009; 66: 1178–88.
13 Watkins, ER, Scott, J, Wingrove, J, Rimes, KA, Bathurst, N, Steiner, H, et al. Rumination-focused cognitive behaviour therapy for residual depression: a case series. Behav Res Ther 2007; 45: 2144–54.
14 Watkins, ER. Depressive rumination: investigating mechanisms to improve cognitive-behavioral treatments. Cogn Behav Ther 2009; 38: 814.
15 Nolen-Hoeksema, S. Responses to depression and their effects on the duration of depressive episodes. J Abnorm Psychol 1991; 100: 569–82.
16 Watkins, ER. Constructive and unconstructive repetitive thought. Psychol Bull 2008; 134: 163206.
17 Riso, LP, du Toit, PL, Blandino, JA, Penna, S, Dacey, S, Duin, JS, et al. Cognitive aspects of chronic depression. J Abnorm Psychol 2003; 112: 7280.
18 Roberts, JE, Gilboa, E, Gotlib, IH. Ruminative response style and vulnerability to episodes of dysphoria: gender, neuroticism, and episode duration. Cognit Ther Res 1998; 22: 401–23.
19 Ciesla, JA, Roberts, JE. Self-directed thought and response to treatment for depression: a preliminary investigation. J Cogn Psychother 2002; 16: 435–53.
20 Schmaling, KB, Dimidjian, S, Katon, W, Sullivan, M. Response styles among patients with minor depression and dysthymia in primary care. J Abnorm Psychol 2002; 111: 350–6.
21 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). APA, 1994.
22 Hamilton, M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 12: 5262.
23 Beck, AT, Steer, RA, Brown, GK. The Beck Depression Inventory (2nd edn). The Psychological Corporation, 1996.
24 British Medical Association, Royal Pharmaceutical Society of Great Britain. British National Formulary (issue 60). BMJ Group and Pharm Press, 2010.
25 Williams, JBW. A structured clinical interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry 1998; 45: 742–7.
26 Spitzer, RL, Williams, JBW, Gibbon, M, First, MB. Structured Clinical Interview for DSM-IV (SCID). American Psychiatric Association, 1996.
27 Nolen-Hoeksema, S, Morrow, J. A prospective-study of depression and posttraumatic stress symptoms after a natural disaster – the 1989 Loma-Prieta Earthquake. J Pers Soc Psychol 1991; 61: 115–21.
28 Jacobson, NS, Martell, CR, Dimidjian, S. Behavioral activation treatment for depression: returning to contextual roots. Clin Psychol 2001; 8: 255–70.
29 Schulz, K, Altman, DG, Moher, D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med 2010; 152: 16.
30 Baron, RM, Kenny, DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic and statistical considerations. J Pers Soc Psychol 1996; 51: 1173–82.
31 Dimidjian, S, Hollon, SD, Dobson, KS, Schmaling, KB, Kohlenberg, RJ, Addis, ME, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. J Consult Clin Psychol 2006; 74: 658–70.
32 Ehring, T, Watkins, ER. Repetitive negative thinking as a transdiagnostic process. Int J Cogn Ther 2008; 1: 192205.
33 Harvey, AG, Watkins, E, Mansell, W, Shafran, R. Cognitive Behavioural Processes Across Psychological Disorders. Oxford University Press, 2004.
34 Kraemer, HC, Wilson, GT, Fairburn, CG, Agras, WS. Mediators and moderators of treatment effects in randomized clinical trials. Arch Gen Psychiatry 2002; 59: 877–83.
35 Emsley, R, Dunn, G, White, I. Mediation and moderation of treatment effects in randomised controlled trials of complex interventions. Stat Methods Med Res 2010; 19: 237–70.

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Rumination-focused cognitive–behavioural therapy for residual depression: phase II randomised controlled trial

  • Edward R. Watkins (a1), Eugene Mullan (a1), Janet Wingrove (a2), Katharine Rimes (a2), Herbert Steiner (a2), Neil Bathurst (a3), Rachel Eastman (a4) and Jan Scott (a4)...


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Rumination-focused cognitive–behavioural therapy for residual depression: phase II randomised controlled trial

  • Edward R. Watkins (a1), Eugene Mullan (a1), Janet Wingrove (a2), Katharine Rimes (a2), Herbert Steiner (a2), Neil Bathurst (a3), Rachel Eastman (a4) and Jan Scott (a4)...
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Hope for Management of Residual Depression

Abu-Bakarr Collier, Core Trainee (CT1), Tees, Esk & Wear Valley NHS Trust
Itoro Udo, Speciality Registrar, Darlington Memorial Hospital
Baxi Sinha, Consultant Psychiatrist, Stockton Community Affective Disorders Team, Tees, Esk, Wear Valleys NHS Foundation Trust
29 February 2012

Dear Editor,

We read this article with interest. (1) This paper has obvious strengths, it employs a robust method of case identification through the triangulation of self rated Beck's and observer rated Hamilton's tools to correctly identify persons level of depression. It offers hope for a new form of CBT for refractory patients. However, we feel that if some of the confounding variables (which have a bearing on the treatment outcomes of refractory depression) were better addressed, this study would have been even more valuable.

1. Information about the medication history and adherence with treatment is an important consideration. This may have included overview of previous and current medication use and adherence; previous antidepressant use and any changes in medications during the study. Also, whether medication changes occurred more in any particular group (TAU Vs RFCBT); whether augmentation strategies were required more in one group as compared to the other. Further, in the clinical identification of refractoriness, it is important to discuss and identify medication non adherence. (2) From the study design, we do not have clear information about how this was determined or assumed in the study. We know that patients presenting to psychiatrists are generally thought to have already received at least two antidepressant medications hence it becomes important to elucidate medication side effects and non-adherence which could have contributed to failure of previous treatment(s).(3,4)

2. For the study, therapists in the RFCBT received intensive supervision and training. There is no description of the training, qualifications and supervision arrangements of the therapists involved with the TAU group, if any. The provision of which would have helped us to evaluate for the influence of performance bias in this study. Studies now show that results from CBT can be associated with the competence and adherence of the therapists. (5,6)

3. While we are informed about the length of current depressive episode and the number of past episodes, we do not know about the mean duration of past episodes (and its comparison between the groups) which could have a bearing on refractoriness of current episode.

4. The study would have been enhanced by the provision of information such as any past history of CBT or any other form of psychotherapy; medical co-morbidities such as hypothyroidism, chronic pain; presence or exclusion of personality disorder and life events. These may have contributed to the chronic nature of the depression.

5. Meta-analysis of controlled trials show that absence of double blinding yield exaggerated estimates of treatment effect. (7) We wonder whether this may have been the case in this study, which appears to be single blind, given that the 95% Confidence Intervals appear wide in this study. Awareness by participants of group allocation, if this occurred, may have contributed to a reporting basis in either group.

6. In discussing the implications of the results presented, information on importance and the prevalence of ruminative thinking in depressive illness has not been adequately discussed for the benefit of readers who may not be fully aware of its nature and implications. (1) This information may form the basis for which RFCBT may be effective hence making a case for the introduction of RFCBT into routine clinical practice.

In spite of the above, this paper is of strategic importance because it offers hope of reduced waiting and treatment times for persons experiencing chronic depression. It also paves the way for further studies in this area, in due course; this could potentially offer value for commissioners and hope for better treatment to service users.


1. Watkins ER, Mullan E, Wingrove J, Rimes K, Steiner H, Bathurst N, Eastman R, Scott J. Rumination - focused Cognitive Behavioural Therapy for Residual Depression: Phase 11 Randomised Controlled Trial. British Journal of Psychiatry 2011; 199: 317-322.

2. National Institute for Health and Clinical Excellence. Depression: The Treatment and Management of Depression in Adults. Partial Update of NICE Clinical Update 23). London: National Institute of Health and Clinical Excellence; 2009. (accessed 23 Nov 2011).

3. Cowen PJ. Pharmacological Management of Treatment-resistant Depression. Advances in Psychiatric Treatment 1998; 4: 320-327.

4. Cowen PJ. New Drugs, Old Problems. Revisiting...Pharmacological Management of Treatment Resistant Depression. Advances in Psychiatric Treatment 2005; 11: 19-27.

5. Barber JP, Crits-Christoph P, Luborsky L. Effects of Therapist Adherence and Competence on Patient Outcome in Brief Dynamic Therapy. Journal of Consulting and Clinical Psychology. 1996; 64(3): 619-622.

6. Kazantzis N. Therapist Competence in Cognitive-behavioural Therapies: Review of the Contemporary Empirical Evidence. Behaviour Change 2003; 20(1): 1-12.

7. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical Evidence of Bias. The Journal of the American Medical Association 1995; 273(5): 408- 412.

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Conflict of interest: None declared

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Supervised self-help for primary care.

Alastair Edward Dobbin, GP and Director
18 January 2012

Dear Sir,

Congratulations to Professor Watkins for a promising piece of research. As followers for many years of his innovative research output we have been using his concept of the benefits of switching 'thinking styles', essentially moving from 'abstract' to 'concrete' processing when under stress, as part of our neurobiological explanation for the anti-depressive effect of our supervised self-help programme 'Positive Mental Training'. This programme has been in use in Scotland and England since 2006 and has been available on the NHS in Edinburgh since 2006, Halton & St Helens since 2010, and over 50,000 patients have been safely treated for emotional distress by their GP/primary care clinician in the past 5 years. Positive Mental Training is a complex intervention of modular recorded material which was tested in association with Edinburgh University department of General Practice in 2004/5, and the results are outlined in our paper (1). We have shown that this approach of promoting the switch from analytical to experiential processing can be automated andcombined with positive priming and re-appraisal, and 'mindful relaxation' to provide a safe popular and effective treatment for emotional distress. Because we approach this from a 'promoting skills' rather than a 'correcting dysfunction' (as Dr Watkins correctly points out there is little evidence justifying the logico-rational socratic dialogue correction of dysfunction from Aaron Becks original model) there is no stigma involved in this approach, many GPs use the programme personally for their own benefit, indeed the programme was partly derived from an olympic sports programme.

Given that 2 recent studies have shown that only 1/3 of all patients with emotional distress receive any treatment at all (2) (3), we see one of the key messages to be 'get your treatment frontline' (4) as we believethe main obstacle is lack of effective frontline clinician supervised psychological treatment, and our approach is currently being independentlyevaluated by the Centre for the Economics of Mental and Physical Health (CEMPH) at the Institute of Psychiatry to determine cost effectiveness.

Yours Sincerely Alastair Dobbin

1.Dobbin, Alastair, Maxwell, Margaret and Elton, Robert (2009) 'A Benchmarked Feasibility Study of a Self-Hypnosis Treatment for Depression in Primary Care' International Journal of Clinical and Experimental Hypnosis 57:293-3182.Wittchen H, Jacobi F, Rehm J, Gustavsson A, Svensson M, J?nsson B, Olesen J, Allgulander C, Alonso J, Faravelli C, Fratiglioni L, Jennum P, Lieb R, Maercker A, van Os J, Preisig M, Salvador-Carulla L, Simon R, Steinhausen H (2011) The size and burden of mental disorders and other disorders of the brain in Europe 2010 European Neuropsychopharmacology 21:655-6793.Jorm A (2011) The population impact of improvements in mental health services: the case of Australia British Journal of Psychiatry 199:443-4444. accces checked 13/01/2012

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Conflict of interest: Managing Director of the Foundation for Positive Mental Health (Scottish Charity no SC041132) Director of Positive Rewards Ltd

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