Developing more accessible evidence-based psychological treatments for pathological worry and rumination in generalised anxiety and depressive disorders.

Michelle Moulds is a Professor at the University of New South Wales interested in a type of repetitive thinking called rumination. Her innovative work has the potential to develop effective new ways to treat people affected by mental health conditions like depression and anxiety. We spoke to her to find out more about this promising area of research.

What is rumination and why is it important for people with depression and other mental health conditions?

Rumination refers to the tendency to get lost in our thoughts, to think over and over very repetitively on one particular theme.

We know that rumination is a very important cognitive characteristic of people with depression, who often might think back on past events, past perceived failures, things they’d wished they’d done differently – and really analyse those kinds of things… again, again and again.

One of the interesting things about rumination is that we know that it’s a predictor. So people who engage in rumination are more likely to become depressed, and stay depressed for longer.

Something else that’s interesting is that when people who have been depressed recover, their symptoms improve to the point where they recover, so they’re no longer meeting diagnostic criteria for depression, they still tell mental health professionals they engage in levels of rumination that are elevated – and in fact are the same as people who are currently depressed.

This makes us wonder whether that elevated rumination might have been a precursor to their depression in the first place, or maybe it’s what we call a ‘scar’ of their previous depression. So, once someone has learnt this pattern of thinking it stays with them even though their symptoms might improve. Or – perhaps it’s both.

What other mental health conditions is rumination associated with?

We know that if we look across our diagnostic criteria that rumination and repetitive thinking comes up across a number of disorders.

So for example, in social anxiety, we know that clients tell us that they spend a lot of time stewing over social events afterwards and going through a kind of post-mortem – of what they did, what they said, how it came across to other people. They may also engage in repetitive thinking in advance of walking into a social situation – will I know anyone? Will I be interesting? Will people want to talk to me.

We also know that in PTSD, post-traumatic stress disorder, that it’s a very common style of thinking. So people with PTSD will often ruminate after their trauma about the circumstances leading to their trauma: ‘If only I’d left five minutes earlier, then maybe I wouldn’t have been there and had that accident’ or, ‘if only I had behaved differently and not put myself in a situation where there was danger’. So we know there are other examples of disorders in which our clients get stuck in a stream of negative thinking.

It sounds like rumination is a bit like worry, but it isn’t is it? What are the differences between the two?

I think that’s a really good question, I would say there’s certainly been a push in the last fifteen years to be thinking in this way that we call ‘transdiagnostic’. So to be thinking about the types of cognitive and behavioural processes – like repetitive thinking or rumination – that run across categories that we use to diagnose people.

We think of rumination as dwelling on the past, and worry is more about things which could happen in the future. Despite that temporal difference, this way of thinking might actually be similar in process.

Traditionally, that distinction has been about what has happened and what could happen – but nonetheless, I think more and more people are thinking transdiagnostically – and that these processes might be more similar than different.

And what can we do to intervene in terms of treatment?

There is some really exciting new data in a treatment study that’s just come out this year, conducted by Maurice Topper and colleagues. It shows that if you take children and young adults with high levels of rumination and worry – and actually teach them strategies and more adaptive ways of thinking, it can actually reduce that tendency to engage in rumination, reduce anxiety and depression – but most importantly, seems to stave off the onset of psychological conditions.

So by catching people who might be at high risk because they’ve already shown this cognitive habit that we know is unhelpful, and teaching them alternative ways of thinking, it might be a really useful way of preventing mental illness in the long term.

Listen to our podcast interview with Michelle from our Mental Health Science Meeting