Clinical Psychology Review 69 (2019) 51–66

Contents lists available at ScienceDirect

Clinical Psychology Review

journal homepage: www.elsevier.com/locate/clinpsychrev

Review

Depression: A cognitive perspective☆ T

a,⁎ b
Joelle LeMoult , Ian H. Gotlib
a
University of British Columbia, Canada
b
Stanford University, United States

H I GH L IG H T S

• Depression is characterized by negative cognitive biases and maladaptive emotion regulation strategies
• Depression-related deficits in cognitive control over mood-congruent material may underlie other cognitive processes
• Cognitive control deficits relate to maladaptive emotion regulation strategies, and negative biases in attention and memory
• We discuss empirical evidence and implications for theory, practice, and future research

A R T I C LE I N FO A B S T R A C T

Keywords: Cognitive science has been instrumental in advancing our understanding of the onset, maintenance, and treat-
Depression ment of depression. Research conducted over the last 50 years supports the proposition that depression and risk
Cognition for depression are characterized by the operation of negative biases, and often by a lack of positive biases, in self-
Information-processing biases referential processing, interpretation, attention, and memory, as well as the use of maladaptive cognitive
Emotion regulation strategies
emotion regulation strategies. There is also evidence to suggest that deficits in cognitive control over mood-
Cognitive control
congruent material underlie these cognitive processes. Specifically, research indicates that difficulty inhibiting
and disengaging from negative material in working memory: (1) increases the use of maladaptive emotion
regulation strategies (e.g., rumination), decreases the use of adaptive emotion regulation strategies (e.g., re-
appraisal), and potentially impedes flexible selection and implementation of emotion regulation strategies; (2) is
associated with negative biases in attention; and (3) contributes to negative biases in long-term memory.
Moreover, studies suggest that these cognitive processes exacerbate and sustain the negative mood that typifies
depressive episodes. In this review, we present evidence in support of this conceptualization of depression and
discuss implications of research findings for theory and practice. Finally, we advance directions for future re-
search.

1. Introduction worldwide (World Health Organization, 2017), accounting for almost

half of disability-adjusted life years (World Health Organization, 2012).
Major Depressive Disorder (MDD) is one of the most prevalent and Finally, in addition to documented adverse effects of depression on
debilitating forms of psychopathology (Kessler et al., 2005). Epide- interpersonal relationships, educational attainment, and financial se-
miological surveys indicate that the lifetime prevalence of MDD is curity (Kessler & Wang, 2009), MDD has been associated both con-
16.6%, with estimates as high as 21.3% in women (Kessler, Berglund, currently and prospectively with poor physical health, cardiac pro-
et al., 2005; Kessler & Bromet, 2013); indeed, more than 30 million U.S. blems, and cancer (Knol et al., 2006; Luppino et al., 2010).
adults have met criteria for MDD in their lifetime (Haro et al., 2006). Given the high prevalence and substantial burden of depression, it is
Importantly, MDD is a highly recurrent disorder; moreover, each de- not surprising that investigators have conducted a great deal of research
pressive episode increases the likelihood that individuals will develop a with the goal of increasing our understanding of the onset, main-
subsequent episode of MDD (Solomon et al., 2000). Depression is also tenance, and treatment of depressive episodes. In this review, we will
associated with enormous costs at both the individual and societal level; examine how cognitive science, in particular, has promoted our un-
in fact, depression continues to be the leading cause of disability derstanding of depression. The current review advances our

☆
Preparation of this paper was facilitated by Brain & Behavior Research Foundation Young Investigator Award 22337 to JL, SSHRC Grant 430-2017-00408 to JL, and NIMH Grants
MH101495 and MH111978 to IHG.
⁎
Corresponding author at: Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver BC V6T1Z4, Canada.
E-mail address: [email protected] (J. LeMoult).

https://doi.org/10.1016/j.cpr.2018.06.008
Received 31 August 2017; Received in revised form 17 June 2018; Accepted 17 June 2018
Available online 18 June 2018
0272-7358/ © 2018 Elsevier Ltd. All rights reserved.
J. LeMoult, I.H. Gotlib Clinical Psychology Review 69 (2019) 51–66

present, albeit ‘latent,’ even after recovery from the depressive episode,
and trigger negative automatic thoughts and moods when they are
activated by negative events, thereby explaining the onset of both first
and subsequent depressive episodes.
Beck's original model was the impetus for decades of research and
theory on cognition and depression. One major advance in this area
came from Bower's (1981) seminal work on mood and memory. Bower
postulated that cognition is influenced by an interconnected network of
nodes, each of which contains semantic representations that can be
activated by external stimuli. Activation of any single node partially
activates adjacent nodes, resulting in an automatic spreading of acti-
vation. As a result, the schematic representations in the adjacent nodes
require less environmental activation for them to be accessed, leading
to a processing advantage for stimuli that are related to these primed
representations. Like Beck, Bower argued for the persistence of biased
cognition and posited that associative networks are stable constructs
that endure beyond the depressive episode. In fact, building on Bower's
Fig. 1. Depression is associated with (1) cognitive biases in self-referential work, Ingram (1984) and Teasdale (1988) argued that the onset,
processing, attention, interpretation, and memory; (2) the use of maladaptive maintenance, and recurrence of depressive disorders is a result of
versus adaptive cognitive emotion regulation strategies; and (3) deficits in biased processing of emotional information, evidenced by mood-con-
cognitive control over mood-congruent material, which in turn, contributes to gruent biases in self-referential processing, attention, memory, and in-
cognitive biases and the use of maladaptive emotion regulation strategies, all of terpretation. This formulation has led to a wealth of research examining
which exacerbate and sustain symptoms of depression. the nature and role of cognitive biases in depression.

understanding of cognition and depression by including recent research 3. Empirical findings

that capitalizes on methodological developments (e.g., eye tracking
technology) and techniques (cognitive bias modification paradigms), by Over the past several decades a significant methodological shift has
offering a theoretical model (Fig. 1) that depicts the relations among taken place in the measurement of cognition, and in particular, cogni-
cognitive factors and depression, and by discussing in detail the clinical tive biases. The field moved away from an exclusive reliance on self-
implications of this work. We begin by providing an historical overview report measures of cognition toward emphasizing objective indices and
of cognitive theories of depression. We then review major advances in experimental manipulations. This methodological shift reflects in-
our understanding of cognition and depression, focusing specifically on vestigators' increased awareness of the drawbacks of self-report mea-
cognitive deficits in executive functioning, working memory, and pro- sures, which, for example, are limited by individuals' introspective
cessing speed; cognitive biases in self-referential processing, attention, ability and are subject to recall, demand, and reference biases
interpretation, and memory; deficits in cognitive control over stimuli or (Althubaiti, 2016). Given the consistent evidence of biased cognition
information that is congruent with one's emotional state (i.e., mood- associated with depression (Mathews & MacLeod, 2005), these biases
congruent material); and the cognitive emotion regulation strategies of are especially problematic in studies of participants who are currently
rumination, distraction, and reappraisal. Fig. 1 depicts the relations depressed or who are at risk for developing depression, as we review
among cognitive factors that are most strongly supported by empirical below. Thus, by having relied primarily on self-report measures, the
evidence. Next, we discuss the implications of empirical findings for validity of researchers' assessments of cognitive functioning in depres-
theory and practice. Finally, we offer our perspective on what we think sion was almost certainly limited by the very construct they were
lies ahead for researchers in this area. Certainly, researchers have stu- purporting to examine. The relatively recent utilization of computer-
died other aspects of cognition, including goal selection, response se- based information-processing tasks and eye-tracking technology has
lection, performance monitoring, and language; however, because these helped to overcome the limitations of self-report measures. That being
are relatively less studied in relation to depression, they are outside the said, it is also important to acknowledge that the psychometric prop-
scope of this review. erties of some information-processing tasks have been insufficiently
tested or found to be poor (Brown et al., 2014; Schmukle, 2005).
Variable scoring methods (e.g., Starzomska, 2017) can further compli-
2. Historical overview of cognitive theories of depression cate interpretation of results and can obfuscate true findings. Thus,
while we are enthusiastic about the move toward more objective as-
Researchers and clinicians have long acknowledged that cognition sessments of cognition, we also encourage researchers to take into ac-
plays a critical role in the onset and maintenance of depressive dis- count the limitations of existing measures when interpreting results
orders. Fifty years ago, Beck (1967) posited that biased acquisition and presented below. A second methodological advancement involves the
processing of information influence the etiology and course of depres- development of cognitive bias modification (CBM) methods (Hallion &
sive episodes. Beck argued that internal mental representations, or Ruscio, 2011; Hertel & Mathews, 2011). Specifically, by experimentally
schemas, affect how depressed individuals perceive themselves and the manipulating the presence or intensity of information-processing
world around them. He contended that individuals with depression biases, researchers are able to examine the effects of these alterations
have mood-congruent schemas that are characterized by themes of loss, on mood, behavior, and other cognitive processes. Whenever possible,
failure, worthlessness, and rejection that lead depressed individuals to in this review of the literature we weigh more heavily studies that have
have negative perceptions of themselves, the world, and the future (the used these stronger methodological approaches.
cognitive triad) and to exhibit negative information-processing biases.
These characteristics, in turn, contribute to negative mood states in 3.1. Cognitive deficits
depressed persons. Importantly, Beck posited that early life adversity
confers vulnerability to MDD by promoting the development of de- Before we discuss the substantial literature examining cognitive
pressive schemas that could be activated by internal or external nega- biases in the context of depression, we briefly review the evidence for
tive events. Beck posited further that these negative schemas remain general cognitive deficits in this disorder. Investigators have posited

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that depression is associated with broad deficits in cognitive func- closer examination of the literature suggests that the link between de-
tioning, evidenced by difficulties in executive functioning, working pression and impairments in working memory is observed almost ex-
memory, and processing speed (Ahern & Semkovska, 2017; clusively when attention is not constrained by the task (e.g., Hertel &
Chakrabarty, Hadjipavlou, & Lam, 2016). Indeed, some cognitive def- Rude, 1991) and, instead, could be allocated to personal concerns and
icits are reflected in depressive symptoms listed in the Diagnostic and task-irrelevant thoughts (e.g., Ellis & Ashbrook, 1989). In fact, pro-
Statistical Manual of Mental Disorders (American Psychiatric viding depressed individuals with instructions that focused their
Association, 2013). Therefore, it is not surprising that almost 40% of thoughts on the task at hand eliminated depression-related deficits in
currently or formerly depressed participants have been found to ex- working memory (Hertel, 1998). Hertel (2004) concluded that de-
perience impairment in at least one cognitive domain (Gualtieri & pressed individuals have the ability to perform at the level of healthy
Morgan, 2008). We briefly review evidence documenting depression- control participants in structured situations but have difficulty doing so
related impairment in the three cognitive deficits that have received the when situations are unconstrained or when they are left to their own
most consistent empirical support in the literature: executive func- initiative. She argued that in these unconstrained situations, it is likely
tioning, working memory, and processing speed. For additional detail, that the opportunity to ruminate will impair working memory perfor-
we direct readers to recent reviews and meta-analyses of this literature mance in depressed individuals. Moreover, a recent meta-analysis re-
(Ahern & Semkovska, 2017; Chakrabarty et al., 2016; McIntyre et al., ported that both visuospatial and auditory working memory perfor-
2013). mance did not differ between formerly depressed participants and
Executive functioning refers to the ability to plan, problem solve, healthy control participants (Ahern & Semkovska, 2017).
and inhibit the processing of information. Researchers have postulated Processing speed deficits are among the most frequently replicated
that executive functioning is impaired in depression (e.g., Levin, Heller, findings related to cognitive deficits in depression (McIntyre et al.,
Mohanty, Herrington, & Miller, 2007; Nitschke, Heller, Imig, 2013), and Mohn and Rund (2016) found that depressed participants
McDonald, & Miller, 2001); empirical evidence, however, has been exhibited larger deficits in processing speed than in working memory.
mixed. Whereas some studies report significant deficits across multiple Yet, studies of this construct, too, have yielded mixed results. For ex-
domains of executive functioning (e.g., Porter, Gallagher, Thompson, & ample, evidence from a recent meta-analysis suggested that impair-
Young, 2003), other investigators have found no significant differences ments in processing speed were inconsistent and task-dependent (Ahern
between individuals with and without depression (Grant, Thase, & & Semkovska, 2017). Specifically, depression-related deficits in pro-
Sweeney, 2001). Moreover, evidence from several reviews yields only cessing speed ranged from nonsignificant to large; tasks involving word
partial support for deficits in executive functioning in depression reading were associated with the largest source of impairment. Im-
(DeBattista, 2005; Ottowitz, Dougherty, & Savage, 2002; Rogers et al., portantly, deficits in processing speed have been found to improve
2004; Veiel, 1997; Zakzanis, Leach, & Kaplan, 1998). In contrast, during periods of remission and following effective treatment (Herrera-
however, a more recent – and more comprehensive – meta-analysis Guzmán et al., 2010); moreover, meta-analytic evidence suggests that
concluded that compared to healthy control participants, depressed processing speed does not differentiate formerly depressed participants
participants show deficits across numerous aspects of executive func- from healthy control participants (Ahern & Semkovska, 2017). Thus, to
tioning, including updating, shifting, and inhibition (Snyder, 2013). the extent that deficits in processing speed are found in depressed in-
Importantly, however, data suggest that aspects of executive func- dividuals, they are more likely to be observed during a current de-
tioning (e.g., shifting) return to baseline after remission (see systematic pressive episode than during a period of episode remission.
review and meta-analysis by Ahern & Semkovska, 2017), suggesting
that executive functioning deficits are concurrent, rather than stable 3.1.1. Summary of cognitive deficits
and residual, characteristics of depression. To the extent that depressed Taken together, the presence of pervasive deficits in cognitive
individuals do exhibit deficits in executive functioning, there is at least functioning remains a topic of considerable debate, with evidence to
preliminary experimental evidence to indicate that these deficits un- support both the presence and the absence of cognitive impairment in
derlie depression-related difficulties in other domains of cognitive depression. Clearly, more data are needed before strong conclusions can
functioning, including deficits in the domains of memory, attention, be made regarding the extent of general cognitive deficits in depression.
and rumination (e.g., Hertel, 1997; Levin et al., 2007; Nitschke, Heller, When cognitive deficits are present, however, they are likely to cause
Etienne, & Miller, 2004; Whitmer & Gotlib, 2013). For example, Siegle, considerable interference and functional impairment in individuals'
Ghinassi, and Thase (2007) experimentally tested the relations among everyday life. For example, cognitive deficits may mediate the asso-
executive functioning, rumination, and depressive symptoms in a group ciation between depression and psychosocial dysfunction (notably
of severely depressed participants using a novel cognitive bias mod- workforce performance; McIntyre et al., 2013). Cognitive deficits are
ification (CBM) protocol aimed at improving executive functioning, also relevant in the context of cognitive biases in depression. For ex-
specifically cognitive control. Participants were assigned to receive six ample, as we discuss in greater detail below, researchers have posited
sessions of cognitive control training, which consisted of participants that deficits in processing speed are relevant when interpreting results
completing Wells (2000) Attention Control Training intervention and of studies based on reaction times. Importantly, evidence from recent
Gronwall's (1977) Paced Auditory Serial Attention Task. They docu- reviews and meta-analyses suggests that cognitive deficits (e.g.,
mented that depressed participants who received cognitive control shifting) ameliorate during episode remission and cognitive functioning
training exhibited significant improvement in behavioral indices of does not differ between formerly depressed participants and healthy
executive functioning and reported significant decreases in depressive control participants (Ahern & Semkovska, 2017). Thus, cognitive defi-
symptoms and levels of rumination. Similarly, Hoorelbeke and Koster cits are more likely to be observed during current depressive episodes
(2017) reported that 10 sessions of Siegle et al.'s (2007) cognitive than during periods of episode remission.
control training procedure reduced levels of rumination, other mala-
daptive cognitive emotion regulation strategies, and depressive symp- 3.2. Cognitive biases
toms in formerly depressed participants.
Working memory is defined as the ability to maintain or manipulate There is now consistent evidence that individuals with depression or
information across a short delay (Baddeley, 1992, 1996). Several re- who are at risk for depression exhibit preferential processing of mood-
views suggest that depression is associated with deficits in working congruent material across multiple forms of cognition. Findings have
memory (e.g., Zakzanis et al., 1998), a conclusion that has been sup- largely supported theoretical models of depression in which negative
ported by the results of meta-analyses (Christensen, Griffiths, schemas are posited to influence perceptions of the self, as well as
MacKinnon, & Jacomb, 1997; Snyder, 2013). Importantly, however, a biases in attention, memory, and interpretation. Based on these models,

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J. LeMoult, I.H. Gotlib Clinical Psychology Review 69 (2019) 51–66

we would expect to observe mood-congruent cognitive biases in de- negatively biased self-referential processing predicts the onset of new
pressed individuals, as well as in individuals at risk for depression or in depressive episodes (LeMoult, Kircanski, et al., 2017), and initial
individuals with a history of depression when they are in a dysphoric evidence suggests that biased self-referential processing is associated
mood state. As we describe below, empirical evidence obtained over the with attentional biases (Disner et al., 2017).
last several decades has also helped to refine and extend the original
cognitive models of depression in several important ways. In the fol- 3.2.2. Attentional biases
lowing sections we review findings from studies of biases in self-refer- Whether depressed individuals are characterized by negative biases
ential processing, attention, interpretation, and memory. in attention has been a topic of considerable debate. Historically, re-
searchers examining attentional biases in depression have generally
3.2.1. Biased self-referential processing used the emotional Stroop task or the dot-probe task. In the emotional
Self-referential processing is posited to reflect individuals' under- Stroop task, participants are asked to name the color of an emotionally
lying negative cognitive schemas (Beck, 1967), and is often measured valenced word; a negative attentional bias is inferred if participants
using the self-referential encoding task (SRET). In the SRET, partici- take longer to name the color of negative versus neutral words. Overall,
pants are asked to judge whether or not emotional adjectives describe studies using the emotional Stroop task to assess attentional biases in
them. Participants' memory of those adjectives is then tested in an in- depression have yielded equivocal results; indeed, a meta-analysis by
cidental recall paradigm. A meta-analysis concluded that negative Peckham and colleagues found only marginally significant differences
schemas, as measured with the SRET, were associated with depression between depressed and control participants' performance on this task
more strongly than were any other cognitive processes that were as- (Peckham, McHugh, & Otto, 2010). These mixed results may be due to
sessed (Phillips, Hine, & Thorsteinsson, 2010). Findings from adult, the limitations of the emotional Stroop task. For example, researchers
adolescent, and child samples indicate that depressed participants ex- have argued that this task yields an ambiguous measure of attention
hibit more negative self-referential biases than do healthy control because longer response latencies could reflect biases either in initial
participants; more specifically, they endorse more negative and fewer attention or in subsequent response selection (Mogg, Millar, & Bradley,
positive adjectives as self-descriptive, endorse negative adjectives and 2000).
reject positive adjectives more quickly, and recall more negative and An alternative measure of attentional bias is the dot-probe task. In
fewer positive adjectives, regardless of whether or not they were en- this task participants are asked to detect the location of a dot that has
dorsed (Auerbach, Stanton, Proudfit, & Pizzagalli, 2015; Connolly, been presented behind either a neutral or an emotional (e.g., happy,
Abramson, & Alloy, 2016; Derry & Kuiper, 1981; Gilboa, Roberts, & sad) stimulus; in most studies, words or faces are used as stimuli.
Gotlib, 1997; Gotlib, Kasch, Traill, Joormann, & Arnow, Johnson, 2004; Attentional allocation is determined based on participants' reaction
Joormann & Siemer, 2004; Kuiper & Derry, 1982). Taken together, this time to detect the location of the dot once the stimuli have been re-
pattern of negatively biased self-referential processing has been inter- moved from the display. Based on cognitive models of depression, one
preted to reflect the presence of negative self-schemas in depression would expect that depressed individuals would exhibit negative atten-
(Davis & Unruh, 1981; Derry & Kuiper, 1981; Dobson & Shaw, 1987). tional biases, operationalized as shorter response latencies to detect the
Moreover, prospective studies show that more negatively biased self- dot when it appears behind sad versus happy stimuli. Findings from
referential processing predicts a more pernicious course of depression, empirical studies, however, suggest that delineating the nature of at-
evidenced by longer-lasting (Davis & Unruh, 1981) and more severe tentional biases in depression is more complicated than was originally
(Disner, Shumake, & Beevers, 2017) symptoms. thought. On one hand, depressed individuals have been found to show
Although the literature examining self-referential processing in at- the expected pattern of negative attentional bias that is specific to sad
risk and formerly depressed individuals is less established than is re- versus angry or happy stimuli (e.g., Gotlib, Krasnoperova, Yue, &
search assessing self-referential processing in currently depressed per- Joormann, 2004). On the other hand, results differ as a function of the
sons, this area of research is growing. For example, several investigators duration for which stimuli are presented. When stimuli are presented
have found that children at risk for depression exhibit negative self- for short or subliminal durations, researchers have failed to find evi-
referential biases following a negative mood induction, suggesting that dence of a negative attentional bias in depression (Mogg, Bradley, &
cognitive biases are evident before the onset of the disorder and can be Williams, 1995). In contrast, when stimuli are presented for longer
primed by a negative mood state (Hammen et al., 1987; Hayden et al., durations (i.e., > 1000 ms), the predicted negative attentional bias is
2013; Taylor & Ingram, 1999). Moreover, euthymic individuals with a observed (e.g., Donaldson & Lam, 2004; Gotlib, Krasnoperova, et al.,
history of depression exhibit negatively biased self-referential proces- 2004; Joormann & Gotlib, 2007; see meta-analysis by Peckham et al.,
sing after experiencing a negative mood induction (Fritzsche et al., 2010) and further, predicts the onset of depression in at-risk youth
2010; Kircanski, Mazur, & Gotlib, 2013; LeMoult, Kircanski, Prasad, & (Jenness, Young, & Hankin, 2017). Moreover, more consistent evidence
Gotlib, 2017), which has been found to prospectively predict episode of negative attentional bias is obtained when faces rather than words
relapse (LeMoult, Kircanski, et al., 2017). are used as stimuli (see Armstrong & Olatunji, 2012, for a review). This
Interestingly, consistent with cognitive models of depression (Beck, pattern of results has led researchers to conclude that depression is
1967), researchers have posited that negative self-referential schemas characterized not by biases in the initial orienting toward negative
are related to other cognitive biases. Initial evidence supports this stimuli, as is often observed in anxiety disorders, but rather, by diffi-
formulation. For example, Disner et al. (2017) found that a more ne- culty disengaging from negative stimuli that has captured depressed
gative self-referential processing bias associated with a more negative individuals' attention (Mathews & MacLeod, 2005).
attentional bias. As we discuss in more detail below, however, few in- In this context, researchers have recently pointed out that a lim-
vestigators have examined the nature of the relations among different itation of the dot-probe task is its lack of precision in being able to
cognitive processes; thus, this is an important area for future research. differentiate initial orienting from subsequent disengagement (Grafton
& MacLeod, 2014; Grafton, Watkins, & MacLeod, 2012). This limitation
3.2.1.1. Summary of biased self-referential processing. As depicted in is due to the fact that the dot-probe task typically assesses attention at
Fig. 1, negative self-referential biases are one of the cognitive biases only one point in time on each trial: at the time the dot is displayed.
reported in at-risk, currently, and formerly depressed individuals Prior to the dot being displayed, participants may shift their attention
(Auerbach et al., 2015; Hayden et al., 2013; Kircanski et al., 2013); between the two stimuli any number of times, which reduces the sen-
these findings have been interpreted as reflecting the presence of sitivity and validity of the task to assess different components of at-
negative self-schemas in these populations (Davis & Unruh, 1981; tention. Although alternative computer-based tasks have been used to
Derry & Kuiper, 1981). In addition, prospective studies indicate address this limitation of the dot-probe task (e.g., Grafton, Southworth,

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J. LeMoult, I.H. Gotlib Clinical Psychology Review 69 (2019) 51–66

Watkins, & MacLeod, 2016; Koster, De Raedt, Goeleven, Franck, & biases to negative stimuli have been found to predict the subsequent
Crombez, 2005; Rinck & Becker, 2005), a particularly promising ap- onset of depressive symptoms (Beevers & Carver, 2003). Finally, there
proach to overcoming this limitation of the task comes from the use of is now evidence from CBM studies that six sessions of dot-probe based
eye-tracking technology, which continuously monitors the focus of vi- attention bias training can modify attentional biases in youth at familial
sual attention and, thus, provides measures of attention the entire time risk for depression and, further, that doing so modulates the heightened
stimuli are displayed. Using this information, researchers can extract emotional and physiological responses to stress that are otherwise ob-
data concerning initial gaze location (i.e., initial engagement) and the served in high-risk youth (LeMoult, Joormann, Kircanski, & Gotlib,
speed with which participants shift their attention away from a stimulus 2016).
following fixation (which has been used as a marker of subsequent
disengagement). Findings of studies using tasks that have been carefully 3.2.2.1. Summary of attentional biases. Evidence of biased attention in
designed for assessment of eye tracking support the conclusion that depression has been equivocal; however, data from a growing number
depressed individuals have difficulty disengaging their attention from of studies support the proposition that at-risk, currently, and formerly
negative material (Caseras, Garner, Bradley, & Mogg, 2007; Eizenman depressed individuals experience difficulty disengaging attention from
et al., 2003) and, further, that this difficulty is associated with more negative stimuli that has captured their attention, which is depicted in
maladaptive responses to stress (Sanchez, Vazquez, Marker, LeMoult, & the theoretical model that we present in Fig. 1. It is important to note
Joormann, 2013). Research conducted using eye trackers (Kellough, that the majority of past studies have assessed attentional biases using
Beevers, Ellis, & Wells, 2008) also add to a growing body of evidence the dot-probe task, which has been found to have poor psychometric
(Deveney & Deldin, 2004; LeMoult, Joormann, Sherdell, Wright, & properties (Schmukle, 2005) that may contribute to the equivocal
Gotlib, 2009; Surguladze et al., 2004) that depressed participants differ findings in this area. With this in mind, we encourage researchers to
from healthy control participants in the way they process positive in- develop and use alternative tasks to measure attentional biases;
formation. For example, Kellough et al. (2008) found that compared to creating emotional modifications of existing tasks from cognitive
healthy control participants, depressed participants not only spent more psychology may be a promising path toward this goal. CBM studies
time viewing dysphoric images, but also spent less time viewing posi- aimed at modifying attentional biases have been found to be most
tive images. effective when multiple training sessions are administered using dot-
Several studies have used CBM paradigms to conduct causal tests of probe tasks and when targeting either individuals with less severe
effects of attentional biases on symptoms and on other cognitive biases depressive symptoms (Baert et al., 2010) or adolescents at risk for
in depression. These studies, too, however, have yielded equivocal depression (LeMoult, Joormann, et al., 2016). Even when attention
findings. For example, using a CBM version of the dot-probe task, in- biases are modified, however, evidence of transfer of training has been
vestigators have reported that multiple (between four and eight) ses- inconsistent. It is possible that these inconsistencies will be resolved
sions of attention bias training reduce attention to negative stimuli and through the use of more effective CBM paradigms (Vazquez, Blanco,
increases attention to neutral stimuli in depressed college students Sanchez, & McNally, 2016).
(Wells & Beevers, 2010; Yang, Ding, Dai, Peng, & Zhang, 2015) and
depressed youth (Yang, Zhang, Ding, & Xiao, 2016). In addition, 3.2.3. Interpretation bias
Beevers, Clasen, Enock, and Schnyer (2015) examined depressed adults' One of the core tenets of cognitive models of depression is that
pre- to post-training change in attentional bias following eight sessions depressed individuals interpret ambiguous information in a negative
of a CBM version of the dot-probe task. Not only did Beevers et al. find manner. Historically, evidence of negatively biased interpretation in
the expected changes in attentional biases, but they also found that depression has been equivocal. In recent years, however, increasing
greater improvement in negative biases from pre- to post-training was evidence suggests that people with depression do, in fact, tend to make
correlated with greater reduction in depressive symptoms, suggesting negative interpretations of ambiguous information (Lee, Mathews,
that negative attentional biases play a causal role in the maintenance of Shergill, & Yiend, 2016; Orchard, Pass, & Reynolds, 2016). For ex-
depressive episodes. Moreover, Browning, Holmes, Charles, Cowen, and ample, compared to their nondepressed peers, depressed individuals
Harmer (2012) found that 28 sessions of a dot-probe-based attention exhibit more negative interpretations on homophone tasks (Mogg,
bias training benefited currently euthymic individuals with a history of Bradbury, & Bradley, 2006), questionnaires (Voncken, Bögels, Peeters,
depression by reducing the magnitude of predictors of risk for recur- Bogels, & Peeters, 2007), ambiguous scenarios tasks (Butler & Mathews,
rence, specifically depressive symptoms and cortisol responses to stress. 1983), and eye-blink tests (Lawson, MacLeod, & Hammond, 2002).
Other researchers, however, have failed to replicate these results. For Researchers have found negative interpretation biases in both adult and
example, Kruijt, Putman, and Van Der Does (2013) found that one adolescent depressed samples (Orchard et al., 2016), and in both social
session of the visual-search CBM paradigm had no effect on attentional and non-social situations (Voncken et al., 2007). Moreover, negative
biases or mood in a group of dysphoric adults. Similarly, Baert, De interpretation biases have been shown to vary as a function of symptom
Raedt, Schacht, and Koster (2010; experiment 2) found no effects of 10 severity (Lee et al., 2016), with severely depressed individuals inter-
sessions of attention training using a CBM version of the spatial cueing preting emotionally ambiguous information more negatively than do
task with word stimuli in a sample of depressed in- and out-patients. their mildly or moderately depressed counterparts.
Moreover, even with successful training, the benefits have not trans- Evidence of negative interpretation bias has also been reported
ferred consistently to other domains of functioning (see Hallion & outside of a depressive episode. For example, Dearing and Gotlib (2009)
Ruscio, 2011). There is evidence that studies using multiple sessions of documented a negative interpretation bias in never-depressed girls at
CBM training are more likely to find changes in attentional biases (al- risk for depression. In addition, Wenzlaff and Bates (1998) reported
though see Baert et al., 2010, for an exception); however, the type of that, under high cognitive load, euthymic individuals with a history of
training task might also influence training effectiveness, with dot-probe depression demonstrate negative interpretation biases; moreover, re-
tasks being superior to spatial-cueing or visual-search tasks. Moreover, sults from prospective studies indicate that negative interpretation
attentional biases might be more easily modified in individuals with biases predict the onset of a depressive episode 18-28 months later
less severe depressive symptoms (Baert et al., 2010). (Rude, Valdez, Odom, & Ebrahimi, 2003). These findings provide sup-
Importantly, depressed children and adolescents have also been port for the formulation that interpretation biases are risk factors for
found to exhibit attentional biases to negative stimuli (see Jacobs, the onset of future depressive episodes.
Reinecke, Gollan, & Kane, 2008, for a review), as have youth at familial It is important to note, however, that there have been several no-
risk for depression following a negative mood induction (Joormann, table exceptions to the results described above. For example, Lawson
Talbot, & Gotlib, 2007; Kujawa et al., 2012). Moreover, attentional and MacLeod (1999) examined depressed participants' response

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latencies to target words that were presented after ambiguous sentences hinder effective interpersonal interactions and, thereby, impair social
and found no interpretation bias. Bisson and Sears (2007) used a similar support. Individuals use facial expressions to monitor emotional reac-
task and also failed to find evidence of an interpretation bias in de- tions, to determine others' opinions and to adjust their behavior to
pression, even following a negative mood induction. Lawson et al. avoid conflict (e.g., Hess, Kappas, & Scherer, 1988). Thus, the ability to
(2002) argued that the lack of consistent evidence for interpretation accurately and quickly identify others' emotional facial expressions is
biases in depression may stem from a reliance on response latencies as important in social interactions. Results of a growing number of studies
the dependent variable. Although negative interpretation biases have suggest that deficits in social skills and interpersonal interactions play
been found using reaction-time based tasks (Hindash & Amir, 2012), an important role in risk for depression (Joiner & Timmons, 2009), and
depression is associated both with slowed reaction time to execute it is possible that biased processing of social cues, evidenced via ne-
voluntary responses and with increased variability of such response gative biases in the identification of facial expressions of emotion,
latencies (Azorin, Benhaïm, Hasbroucq, & Possamaï, 1995; Byrne, contributes to these impairments.
1976); thus, reaction-time based assessments may yield insensitive and
inconsistent indices of cognitive processing in this disorder (Moretti 3.2.3.1. Summary of interpretation biases. Although evidence of
et al., 1996). negative interpretation biases in depression has been mixed,
Interestingly, findings from other researchers suggest that depressed researchers have documented the presence of negative interpretation
participants are more accurate in their interpretations and judgments biases in depression (Mogg et al., 2006), especially when using non-
than are healthy control participants, who may be more likely to see the reaction-time-based tasks (Lawson et al., 2002), as we have depicted in
world through “rose-colored glasses” (McKendree-Smith & Scogin, Fig. 1. Moreover, depressed individuals may also differ from healthy
2000). These findings are consistent with a growing literature doc- control participants in their lack of a positive interpretation bias (Alloy
umenting that depressed participants fail to show the positive cognitive & Abramson, 1979; McKendree-Smith & Scogin, 2000) and in their
biases that are exhibited by healthy control participants (Alloy & ability to identify subtle happy emotional expressions (Joormann &
Abramson, 1979; Canli et al., 2004; Gotlib, Jonides, Buschkuehl, & Gotlib, 2006; LeMoult et al., 2009). CBM studies designed to alter
Joormann, 2011). For example, Alloy and Abramson (1979) concluded interpretation biases have shown that interpretation biases can be
that, at times, depressed individuals are “sadder but wiser” than are modified in depressed adolescents and adults (Joormann et al., 2015;
individuals without a history of psychopathology. They observed that LeMoult, Colich, et al., 2017); evidence of transfer of training, however,
nondepressed individuals exhibited cognitive biases that facilitated has been inconsistent (Joormann et al., 2015; Yiend et al., 2014).
positive interpretations of themselves and the world, whereas depressed
persons maintained a realistic, albeit negative, perspective that likely 3.2.4. Memory bias
contributed to their negative mood. One of the most robust findings in the depression literature is that
Studies using CBM to alter interpretation biases have been useful in depressed individuals exhibit mood-congruent biases in memory, evi-
testing the proposed link between interpretation biases and depressed denced by preferential recall for negative information (Mathews &
mood. Several studies have documented that positive interpretation MacLeod, 2005). Memory biases are found most consistently when in-
biases can be trained through one or two training sessions and lead to vestigators are assessing explicit memory – i.e., overtly asking partici-
more positive interpretations of novel ambiguous information pants to recall previously encoded information. Not only do depressed
(Joormann, Waugh, & Gotlib, 2015; Möbius, Tendolkar, Lohner, individuals preferentially recall negative versus neutral stimuli, but
Baltussen, & Becker, 2015; Yiend et al., 2014). Importantly, after one or they also fail to show the pattern of preferential recall of positive versus
two CBM training sessions, corresponding changes have also been ob- neutral stimuli exhibited by individuals without a history of psycho-
served in depressed mood (Blackwell & Holmes, 2010; Holmes, Lang, & pathology (see Gotlib, Roberts, & Gilboa, 1996, for a review; or Matt,
Shah, 2009), memory biases, and responses to stress (Joormann et al., Vázquez, & Campbell, 1992 for a meta-analysis). Moreover, explicit
2015); evidence of transfer to other tasks, however, has been incon- memory biases in depression appear to be specific to depression-re-
sistent (Möbius et al., 2015; Yiend et al., 2014), even when multiple levant stimuli, rather than to negative stimuli more generally (Gotlib
sessions of training have been administered (LeMoult, Colich, et al., et al., 1996). Interestingly, emerging evidence suggests that, at least for
2017). For example, Yiend et al. (2014) found that one session of po- positive stimuli, memory biases might be related to how the informa-
sitive interpretation bias training had little effect on mood or responses tion was initially encoded. Specifically, whereas healthy control parti-
to stress in a sample of depressed adults. Similarly, LeMoult, Colich, cipants preferentially encode positive information, depressed in-
et al. (2017) found that six interpretation bias training sessions led to dividuals fail to show this bias (Gotlib et al., 2011). These findings
more positive interpretation biases in depressed adolescents, but the underscore the need to separate biases in encoding from biases in
benefits of did not transfer to other tests of interpretation bias or in- memory, and highlight an important area for future research.
fluence reactivity to stress. Although less consistent, researchers have also provided evidence of
Related to biases in interpretation are biases in the identification of implicit memory biases in depression. Implicit memory is a form of
emotion, and like biases in interpretation, mood-congruent biases in the long-term memory that is not influenced by conscious thought or in-
identification of facial expressions of emotion have been documented in tentional effort (Graf & Schacter, 1985). Biases in implicit memory are
depressed individuals (Surguladze et al., 2004). For example, Joormann defined as the preferential recall or recognition of emotional informa-
and Gotlib (2006) examined depressed individuals' ability to identify tion that occurs in the absence of any intention to remember the in-
the emotional expression displayed in a series of faces as they pro- formation or its emotional content. Thus, examinations of implicit
gressed from neutral to 100% emotional intensity. Depressed partici- biases provide an important, and arguably more accurate, representa-
pants required significantly greater intensity of emotion than did par- tion of memory biases in that they are not influenced exclusively by
ticipants with social anxiety disorder and healthy control participants intentional recall. Consistent with cognitive theories of depression,
to correctly identify happy expressions, and less intensity to identify sad depressed individuals exhibit preferential implicit memory for negative
than angry expressions. Moreover, biases in the identification of facial versus positive information (Bradley, Mogg, & Millar, 1996; Ruiz-
expressions of emotion have been found to remain even after in- Caballero & González, 1997; Taylor & John, 2004; Watkins, Martin, &
dividuals recovered from a depressive episode (LeMoult et al., 2009). Stern, 2000; Watkins, Vache, Verney, & Mathews, 1996). Moreover,
Specifically, formerly depressed participants in whom a negative mood Vrijsen et al. (2014) found better memory for negative versus positive
was induced required significantly greater emotional intensity to stimuli on an incidental recall task in individuals with a history of de-
identify happy expressions. pression. There is also inconsistent evidence, however, particularly
Difficulty accurately identifying subtle expression of emotion may when memory is assessed through recall rather than through

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recognition tasks. For example, Tarsia, Power, and Sanavio (2003) decreased both depressive symptoms and their frequency of rumina-
failed to find implicit memory biases in a sample of depressed adults. In tion. Interestingly, evidence suggests that the relation between rumi-
addition, evidence from a recent meta-analysis (Gaddy & Ingram, 2014) nation and memory is bidirectional; specifically, following a one-time
suggests that inconsistencies in mood-congruent memory biases are due rumination induction depressed participants exhibited increased over-
to the different types of stimuli used. Gaddy and Ingram (2014) found general autobiographical memories (Watkins & Teasdale, 2001) and
that mood-congruent memory biases were especially strong when the improved memory for negative self-referential material (Moulds,
stimuli were self-relevant. Kandris, & Williams, 2007).
Depressed individuals also differ from healthy control participants
in their recall of autobiographical memories, which has been observed 3.2.4.1. Summary of memory biases. Evidence of negatively biased
across cultural groups (Dritschel, Kao, Astell, Neufeind, & Lai, 2011). memory may be related to how information was initially encoded
Specifically, when asked to recall autobiographical memories, de- (Gotlib et al., 2011) and is more commonly observed when explicit
pressed individuals exhibit more generic memories than do healthy versus implicit memory is assessed and when stimuli are self-relevant
control participants. Autobiographical memory is most frequently as- (Gaddy & Ingram, 2014). Depressed individuals also differ from healthy
sessed via the autobiographical memory test (AMT), in which partici- control participants in their recall of autobiographical memories:
pants are asked to provide a specific memory triggered by positive and depressed individuals tend to recall more overgeneral positive
negative cue words. Compared to individuals without a history of autobiographical memories, which may underlie the difficulties in
psychopathology, depressed individuals provide memories that sum- emotion regulation that have been documented in MDD, as we
marize a category of similar events (e.g., taking vacations with my fa- depicted in Fig. 1 (Joormann & Siemer, 2004; Joormann, Siemer, &
mily) rather than a specific event (e.g., the time my brother and I Gotlib, 2007). CBM-memory studies are in relatively early stages, but
kayaked on the lake). Raes et al. (2005) documented that overgeneral initial evidence suggests that training depressed participants to hold
memories are associated with difficulties in problem solving, deficits in less overgeneral memories decreases levels of both depressive
imagining specific future events, and longer duration of depressive symptoms and rumination.
episodes. Biases in autobiographical memory have also been observed
during periods of episode remission, and have been found to predict the 3.3. Cognitive control
subsequent onset of depressive episodes in the context of postpartum
depression (Mackinger, Pachinger, Leibetseder, & Fartacek, 2000). As depicted in Fig. 1, difficulty controlling the content of negative
Importantly, mood-incongruent processing has been identified as an information in working memory is posited to underlie many of the
adaptive mood regulation strategy, and difficulties in mood-incon- cognitive biases described earlier as well as the cognitive emotion
gruent memory recall are posited to impair depressed individuals' regulation strategies that we discuss later in this paper (Everaert,
ability to use positive memories to improve negative mood states Koster, & Derakshan, 2012; Joormann, 2006; Joormann & Gotlib, 2010;
(Joormann & Siemer, 2004; Joormann, Siemer, & Gotlib, 2007). Joormann & Tanovic, 2016). Cognitive control plays a central role in
Moreover, recent evidence suggests that mood-incongruent processing determining the contents of working memory, the part of short-term
– measured by the proportion of positive emotion words used to de- memory that reflects current cognitions and awareness. Importantly,
scribe a sad memory – predicted fewer symptoms of depression six working memory is a limited-capacity system; therefore, efficient
months later and a shorter time to recover from a depressive episode working memory functioning requires flexible control over the contents
(Brockmeyer, Kulessa, Hautzinger, Bents, & Backenstrass, 2015). Biased of working memory by limiting the initial access of information into
memory has also been linked to the onset of depressive symptoms. For working memory (inhibiting) and expelling information that is no
example, overgeneral autobiographical memory was found to moderate longer relevant (updating).
the effect of daily hassles in predicting increased depressive symptoms Depressed individuals have been found to have difficulty inhibiting
over time in a college-age sample. Further, Rawal and Rice (2012) negative information from entering working memory. In order to assess
documented that overgeneral autobiographical memory increased risk inhibition in the processing of emotional information, Joormann (2004)
for depression in adolescents. These findings are consistent with the designed the negative affective priming task, which examines partici-
formulation that depressed individuals' overgeneral autobiographical pants' ability to intentionally ignore (i.e., inhibit from working
memories limit their ability to use these memories to repair negative memory) positive and negative material. Using the negative affective
mood (Chen, Takahashi, & Yang, 2015; Joormann, Siemer, & Gotlib, priming task, researchers have found that dysphoric, currently de-
2007). pressed, and formerly depressed participants experience difficulty in-
More recently, several investigators have attempted to modify ne- hibiting negative, but not positive, information from working memory
gative memory biases through the use of CBM methods (Arditte Hall, De (Goeleven, De Raedt, Baert, & Koster, 2006; Joormann, 2004;
Raedt, Timpano, & Joormann, 2018; Eigenhuis, Seldenrijk, van Schaik, Joormann & Gotlib, 2010). Further, difficulty inhibiting negative in-
Raes, & van Oppen, 2017; Vrijsen et al., 2014). For example, Arditte formation from working memory was associated with the use of more
et al. (2018) examined the impact of one session of positive memory maladaptive emotion regulation strategies (i.e., rumination; Joormann
enhancement training (PMET) on the memories and subjective experi- & Gotlib, 2010) which has also been found by De Lissnyder, Derakshan,
ences of individuals with MDD, and found that participants assigned to De Raedt, and Koster (2011). Bootstrapping analysis also documented
PMET showed improved memory specificity, increased ability to that difficulty inhibiting negative information in working memory was
“relive” positive memories, and enhanced emotion regulation. In ad- associated with negative attentional biases, which in turn was asso-
dition, Raes, Williams, and Hermans (2009) developed MEmory Spe- ciated with negative interpretation biases and symptoms of depression
cificity Training (MEST) to reduce overgeneral memory. These in- (Everaert, Grahek, & Koster, 2017).
vestigators administered MEST on a weekly basis for 4 consecutive Updating, a second component of cognitive control, involves effec-
weeks to 10 inpatients with depressive symptoms. Whereas other in- tively revising the contents of working memory by discarding no-
vestigators have found that memory specificity does not improve with longer-relevant information. Using an affective version of the Sternberg
treatment as usual in depression, Raes and colleagues documented that task, Joormann and Gotlib (2008) examined whether depressed in-
participants' retrieval style became significantly more specific following dividuals had difficulty removing emotionally valenced material from
MEST. Watkins, Baeyens, and Read (2009) also targeted overgeneral working memory. Compared to individuals without a history of psy-
memory, but did so using eight sessions of a concreteness training chopathology, depressed individuals had difficulty removing negative,
paradigm. They demonstrated that training dysphoric participants to but not positive, words from working memory. Moreover, greater dif-
hold more concrete and less overgeneral memories significantly ficulty discarding negative information was related to higher levels of

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rumination. Researchers have also assessed individuals' ability to up- Gotlib, 2010; Meiran, Diamond, Toder, & Nemets, 2011; Nolen-
date the contents of working memory using a directed forgetting task, Hoeksema, Wisco, & Lyubomirsky, 2008). Unlike the research pre-
in which participants are asked to intentionally forget a subset of in- sented earlier in this paper examining cognitive biases, the majority of
formation that they recently learned (Bjork, 1972). Consistent with work examining emotion regulation in depression continues to rely on
findings obtained using the affective Sternberg task, depressed in- self-report measures. Nevertheless, researchers have benefited by ex-
dividuals show greater facilitation, or less successful updating, for ne- perimentally inducing various emotion regulation strategies and ex-
gative than for positive words learned in a self-relevant manner (Power, amining the results on cognition, mood, and/or behavior. Numerous
Dalgleish, Claudio, Tata, & Kentish, 2000); further, they have been emotion regulation strategies have been implicated in psychopathology
found to incorrectly recall negative words that had never been pre- (see Aldao, Nolen-Hoeksema, & Schweizer, 2010, and Schäfer et al.,
sented in the task (Joormann, Teachman, & Gotlib, 2009). Interestingly, 2017, for recent meta-analytic reviews). In this review, we focus on
similar results were found in individuals who scored high on a trait three cognitive emotion regulation strategies that have received parti-
measure of rumination; high trait-ruminators exhibited reduced for- cular attention in depression: rumination, distraction, and reappraisal.
getting of negative material (Joormann & Tran, 2009). Further evidence
of reduced cognitive disengagement from negative material comes from 3.4.1. Rumination
a series of studies using Anderson and Green's (2001) think-no-think Rumination is traditionally considered a maladaptive emotion reg-
task. Researchers found that depressed individuals had difficulty dis- ulation strategy defined as thinking repetitively and passively about
carding from working memory recently learned negative, but not po- negative mood states or about the causes and consequences of negative
sitive, nouns (Joormann, Hertel, Brozovich, & Gotlib, 2005), which has mood (Nolen-Hoeksema et al., 2008). Led by the theoretical and em-
been related to increased reactivity to stress (LeMoult, Hertel, & pirical contributions of Susan Nolen-Hoeksema, a number of re-
Joormann, 2010). Moreover, Everaert and colleagues provided cross- searchers have examined the association between rumination and de-
sectional evidence that the relation between difficulty updating nega- pressive symptoms. Taken together, the findings of this body of
tive information in working memory and depressive symptoms was research suggest that higher levels of rumination are associated with
mediated by negative interpretation biases (Everaert, Grahek, Duyck higher levels of depressive symptoms both concurrently and pro-
et al., 2017). spectively (see reviews by Lyubomirsky, Layous, Chancellor, and
Building on this work, several researchers have begun to examine Nelson (2015) and Nolen-Hoeksema et al. (2008); although note con-
the potential benefits of cognitive control training over emotional in- flicting evidence regarding the effect of rumination on the maintenance
formation. For example, using a training version of Anderson and of depressive episodes (Lyubomirsky et al., 2015; Nolen-Hoeksema
Green's (2001) think-no-think task, Joormann et al. (Joormann, Hertel, et al., 2008)). Nonetheless, consistent evidence documents that rumi-
Lemoult, & Gotlib, 2009) showed that depressed participants could be nation both predicts the onset of depressive episodes and mediates the
trained in one session to forget negative material. In addition, de- sex differences in depression prevalence (Nolen-Hoeksema, 2000;
pressed participants performed particularly well when they were given Nolen-Hoeksema, Stice, Wade, & Bohon, 2007). Several studies have
a strategy of how to remove no-longer-relevant material from working found that, across ages, females are more likely to ruminate than are
memory (i.e., by using thought substitutes). Moreover, training using males (Grant et al., 2004; Nolen-Hoeksema, Larson, & Grayson, 1999).
an emotional working memory training task improved performance on In addition, data from longitudinal studies indicate that this sex dif-
the affective Stroop task (Schweizer, Hampshire, & Dalgleish, 2011) ference in the prevalence rate of rumination contributes to females
and improved emotion regulation after multiple training sessions being more vulnerable to depressive symptoms than males (e.g., Nolen-
(Schweizer, Grahn, Hampshire, Mobbs, & Dalgleish, 2013). Additional Hoeksema et al., 1999).
evidence for the association between cognitive control and cognitive Some researchers have posited that the association between rumi-
emotion regulation strategies can be found in the Relation Between nation and depression is driven by the fact that the most commonly
Cognitive Emotion Regulation Strategies and Other Cognitive Processes used measure to assess rumination, the Ruminative Response Scale
section below. (RRS) of the Response Styles Questionnaire (Nolen-Hoeksema &
Morrow, 1991), contains overlapping content about both depression
3.3.1. Summary of cognitive control and rumination (Treynor, Gonzalez, & Nolen-Hoeksema, 2003). In re-
As depicted in Fig. 1, compared to healthy control participants, sponse to these concerns, Treynor et al. (Treynor et al., 2003) examined
depressed individuals have difficulty both inhibiting and updating ne- the distinct components of the RRS and isolated two unique compo-
gative information in working memory. Importantly, this has been nents of rumination – brooding and reflection. Researchers examining
linked to rumination and is associated with increased reactivity to these subcomponents have found that brooding is particularly elevated
stress. Findings from CBM studies are consistent with the proposition among currently (e.g., Joormann, Dkane, & Gotlib, 2006) and formerly
that depressed individuals can compensate for cognitive control biases depressed individuals (e.g., D'Avanzato, Joormann, Siemer, & Gotlib,
when given explicit strategies, which may have promising implications 2013).
for interventions. Moreover, experimentally induced rumination is associated with
prolonged emotional and biological response to stress, particularly for
3.4. Cognitive emotion regulation strategies depressed individuals (Donaldson & Lam, 2004; Lavender & Watkins,
2004; LeMoult & Joormann, 2014; LeMoult, Yoon, & Joormann, 2015;
Cognitive emotion regulation strategies describe what people think Rimes & Watkins, 2005; Watkins & Brown, 2002). Rumination has also
about following an emotion-eliciting event in order to consciously or been shown to impede individuals' use of adaptive emotion regulation
unconsciously cope with the event or influence the experience, mag- strategies; specifically, rumination interferes with effective problem
nitude, or duration of the resulting emotional response (Campbell-Sills solving and engagement in instrumental behavior (Lyubomirsky &
& Barlow, 2007; Rottenberg & Gross, 2003; Thompson, 1994; Williams, Nolen-Hoeksema, 1995; Lyubomirsky, Tucker, Caldwell, & Berg, 1999).
Bargh, Nocera, & Gray, 2009). Research examining cognitive emotion In addition, rumination may be linked with poor mood recovery be-
regulation strategies has been instrumental in helping us gain a better cause of its association with isolation; correlational evidence indicates
understanding of depression and has been increasingly integrated into that, although individuals who ruminate reach out for social support
recent cognitive models of depression (Everaert et al., 2012; Joormann, more often than do nonruminators, they are less likely to receive
2010; Joormann & Vanderlind, 2014) given evidence that cognitive emotional support (Nolen-Hoeksema & Davis, 1999) and are more
emotion regulation strategies are associated both with symptoms of likely to experience higher levels of social exclusion and victimization
depression and with the cognitive biases described earlier (Joormann & (McLaughlin & Nolen-Hoeksema, 2012).

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3.4.2. Distraction strategies may offer valuable avenues for intervention. The majority of
In contrast to rumination, distraction is typically considered an work in this area has focused on understanding the association between
adaptive emotion regulation strategy. Researchers have found that de- rumination and cognitive biases – particularly difficulties in cognitive
pressed participants are less likely to use distraction than are their control. Increasing correlational evidence supports the proposition that
nondepressed peers, even though they report it would likely help alle- rumination is associated with biases across multiple aspects of cognitive
viate their negative mood (Lyubomirsky & Nolen-Hoeksema, 1993). control, including difficulties inhibiting negative information from en-
Lyubomirsky and Nolen-Hoeksema (Lyubomirsky & Nolen-Hoeksema, tering working memory (Joormann, 2006; Joormann & Gotlib, 2010)
1993) argue that depressed individuals avoid distraction because it and updating information in working memory (Meiran et al., 2011),
interferes with their attempts to gain insight into their problems. including removing irrelevant negative material from working memory
Nevertheless, depressed and dysphoric individuals are able to success- (Joormann & Gotlib, 2008). In addition, individuals' ability to update
fully use distraction when instructed to do so and, further, compared to information in working memory was found to moderate the effects of
rumination inductions, distraction inductions reduce subjective and reappraisal and rumination on high-arousal negative emotions (Pe,
objective markers of distress in depressed and dysphoric samples Raes, & Kuppens, 2013). Specifically, whereas reappraisal was asso-
(Joormann, Siemer, et al., 2007; LeMoult et al., 2015; Lyubomirsky & ciated with decreased experience of these emotions for those with high,
Tkach, 2008). Specifically, adults and adolescents who distract them- but not with low, updating ability, rumination was associated with
selves by completing an emotionally neutral task or thinking about greater experience of negative emotions for those with low, but not
externally focused items report lower levels of sad mood. with high, updating ability. Difficulty flexibly shifting between different
Despite these positive results, researchers have questioned the tasks has also been associated with higher levels of rumination, parti-
benefits of distraction. For example, Kross and Ayduk (2008) found cularly brooding, in both depressed (De Lissnyder et al., 2012) and
that, compared to participants in a control condition, participants in a nonclinical samples (Beckwé, Deroost, Koster, De Lissnyder, & De
distraction condition reported lower depressed mood immediately after Raedt, 2014; Koster, De Lissnyder, & De Raedt, 2013; Owens &
the mood induction, but higher depressed mood one day and seven days Derakshan, 2013). Tentative evidence that cognitive control might
later. The authors concluded that distraction does not change in- underlie ruminative responses to stress comes from work by Demeyer,
dividuals' ability to cope with future situations, and that the utility of De Lissnyder, Koster, and De Raedt (2012). These investigators found
distraction is limited to the short term (Kross & Ayduk, 2008). This that, in formerly depressed individuals, the prospective association
interpretation is consistent with Campbell-Sills' perspective that dis- between shifting impairments and depressive symptoms was fully
traction is no more than a short-term “band-aid,” and not a long-term mediated by rumination (Demeyer et al., 2012). The association be-
solution to symptoms of psychopathology (Campbell-Sills & Barlow, tween cognitive control and rumination was further investigated by
2007). Other researchers go further to suggest that distraction is actu- Cohen, Mor, and Henik (2015). These researchers examined the ex-
ally maladaptive in the long run; consistent with this possibility, perimental effects of one session of cognitive control training on ru-
avoidance-related coping strategies such as distraction are associated mination in a nonclinical sample and found that participants who were
with adult and adolescent depression (Aldao et al., 2010; Schäfer et al., trained to control the content of negative information in working
2017). In order to reconcile these discrepant views of distraction, it will memory reported less rumination following training than did partici-
be important to also consider the timing and context of its use. In fact, pants who were trained to control neutral information in working
more recent conceptualizations of emotion regulation argue that the memory. Interestingly the relation between cognition and rumination
ability to flexibly select and implement emotion regulation strategies may be bidirectional; for example, Whitmer and Gotlib (2012) found
may be more adaptive than is the use of any single strategy (Aldao & that depressed individuals who completed a rumination induction
Nolen-Hoeksema, 2013; Bonanno & Burton, 2013). Indeed, depression performed more poorly on a switching task than did depressed and
has been associated with “stereotyped and inflexible responses” to healthy control participants who completed a distraction induction.
emotional contexts (Rottenberg, Kasch, Gross, & Gotlib, 2002, p. 136). Rumination has also been associated with other cognitive biases.
Everaert et al. (2017) for example, found that the relation between
3.4.3. Reappraisal cognitive biases (particularly biases in interpretation) and depressive
Reappraisal is an antecedent-focused strategy consisting of re- symptoms was mediated by brooding and reappraisal. In addition,
interpreting the meaning or interpretation of an emotion-eliciting si- higher levels of rumination have been associated with more negative
tuation in order to modify the emotional experience. Individuals with autobiographical memories (e.g., Lyubomirsky & Tucker, 1998) and
depression report using reappraisal less frequently than do formerly with greater difficulty using positive autobiographical memories to
depressed individuals and those without a history of psychopathology repair a negative mood state (Joormann & Siemer, 2004; Joormann
(D'Avanzato et al., 2013). Importantly, however, when depressed par- et al., 2007). Moreover, trait rumination has been associated with an
ticipants are induced to reappraise in the laboratory, their negative attentional bias for negative words (Donaldson, Lam, & Mathews, 2007)
mood is improved and, further, the amount of improvement does not that is specific to biases in attentional disengagement (Grafton et al.,
differ from the improvement reported by healthy control participants 2016); similarly, state ruminative (i.e., ruminative response to a la-
(Ellis, Vanderlind, & Beevers, 2013; Millgram, Joormann, Huppert, & boratory stressor) has been associated with difficulty disengaging from
Tamir, 2015; Smoski, LaBar, & Steffens, 2014). Given this, it is sur- emotional expressions (LeMoult, Arditte, D'Avanzato, & Joormann,
prising that researchers have found that levels of cognitive reappraisal 2013).
do not predict recovery from a depressive episode (Arditte & Joormann, Although the association between cognitive biases and reappraisal
2011) or improvement in depressive symptoms (Chambers et al., 2015). has not been examined extensively, initial evidence suggests that dif-
Additional research is needed to examine more explicitly the dis- ficulty shifting and updating negative information in working memory
crepancy between findings obtained in the laboratory versus natur- undermines participants' use of reappraisal and its effectiveness.
alistic settings. Malooly, Genet, and Siemer (2013) found that difficulty shifting be-
tween different sorting rules during an affective switching task was
3.4.4. The relation between cognitive emotion regulation strategies and associated with poorer down-regulation of negative affect through the
other cognitive processes use of reappraisal. Moreover, Joormann and Gotlib (2010) documented
Researchers have now begun to examine the association between that difficulty inhibiting negative information from working memory
cognitive emotion regulation strategies and the cognitive biases de- was associated with less frequent use of reappraisal.
scribed earlier. This is an important area of research as the ability to
identify cognitive mechanisms underlying cognitive emotion regulation

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3.4.5. Summary of emotion regulation disengaging attention from negative information. In turn, negative
Considerable evidence suggests that depression is associated with content is preferentially stored in long-term memory, explaining the
more frequent use of rumination and less frequent use of reappraisal negative memory biases that typify depression.
(D'Avanzato et al., 2013; Nolen-Hoeksema et al., 2008), as is depicted Koester and colleagues (Koster et al., 2011) formulated the ‘im-
in the Cognitive Emotion Regulation box of Fig. 1. Although depression paired disengagement’ hypothesis to explain the persistence of negative
might also be associated with less frequent use of distraction, re- thoughts in depression. Koester et al. argue that prolonged cognition of
searchers have questioned the benefits of distraction as an adaptive self-referent material stems from impaired attentional disengagement
long-term emotion regulation strategy (Aldao et al., 2010; Campbell- from negative self-referent information. In fact, they posit that diffi-
Sills & Barlow, 2007; Kross & Ayduk, 2008; Schäfer et al., 2017). In culties in attentional disengagement also underlie the decreased use of
more recent conceptualizations of emotion regulation, the ability to adaptive emotion regulation strategies, including reappraisal and dis-
flexibly select and implement emotion regulation strategies is posited to traction.
be a more important determinant of wellbeing then is the use of any Finally, in addition to the cognitive models of depression presented
single strategy (Aldao & Nolen-Hoeksema, 2013; Bonanno & Burton, here, we suggest that researchers attend closely to recent integrative
2013). Importantly, researchers are beginning to examine the relations models of depression that are aimed at understanding how cognitive-
among cognitive emotion regulation strategies and cognitive biases. biological interactions contribute to the pathophysiology and course of
Findings from this work are incorporated in the theoretical model de- depression. Although a detailed summary of these models is outside of
picted in Fig. 1 and support the formulation that difficulties disenga- the scope of this review, interested readers are referred to Beck and
ging attention from negative stimuli and controlling negative in- Bredemeier (2016) and Disner, Beevers, Haigh, and Beck (2011).
formation in working memory are associated with higher levels of
rumination and, possibly, with lower levels of reappraisal and distrac- 5. Clinical implications
tion (Joormann, 2010; Koster, De Lissnyder, Derakshan, & De Raedt,
2011). At present, fewer than 40% of individuals who are treated for MDD
achieve symptom remission with initial treatment (Gaynes et al., 2009;
4. Implications for theory Holtzheimer & Mayberg, 2011). Given evidence that cognitive biases
and emotion regulation strategies influence the onset, maintenance,
Findings over the last several decades have largely supported the and recurrence of depressive symptoms, cognition is an important
cognitive models of depression formulated by Beck, Bower, and target for intervention. Both theoretical models of depression and em-
Teasdale by providing evidence of the role of cognitive biases in the pirical findings suggest that ameliorating maladaptive cognition can
onset, maintenance, and recurrence of depressive episodes. reduce depressive symptomatology. Consistent with this possibility,
Importantly, however, empirical findings have also served to expand Cognitive Behavior Therapy (CBT) has been shown to have beneficial
and refine those early cognitive theories of depression in several im- effects on cognitive biases and emotion regulation strategies. For ex-
portant ways that are depicted in Fig. 1. For example, studies have ample, several studies have examined the effects of CBT on cognitive
highlighted the important role that cognitive emotion regulation stra- biases and have found significant reductions in biases in attention (e.g.,
tegies play in depression; whereas rumination contributes to the onset Davis et al., 2016; Lazarov et al., 2018), interpretation (e.g., Williams
and maintenance of depressive episodes, reappraisal, and to a lesser et al., 2015), and perceived control (Pereira et al., 2017). Moreover,
extent distraction, are more adaptive alternatives that facilitate stress reappraisal is a fundamental component of cognitive restructuring,
recovery. In addition, research suggests that cognitive models of de- which is a central therapeutic technique in CBT (Beck, Rush, Shaw, &
pression should take into account the consistent finding that depression Emery, 1979; Beck, 2011). CBT has been associated with increased use
is associated with particular difficulty disengaging from negative ma- of reappraisal (Goldin et al., 2014; Moscovitch et al., 2012), and in turn,
terial that has been captured by attention or has entered working self-efficacy of reappraisal has been shown to mediate the effect of CBT
memory. Moreover, experimental evidence supports the importance of on symptoms, such that increases in reappraisal self-efficacy predicted
cognitive control biases as a mechanism underlying other cognitive decreases in symptoms one year post CBT (Goldin et al., 2012). In ad-
biases and maladaptive emotion regulation strategies (Cohen et al., dition, several treatment-outcome studies have demonstrated that CBT
2015; Joormann, Hertel, et al., 2009; Schweizer et al., 2013, 2011). reduces rumination (e.g., Price & Anderson, 2011).
Below we describe other more recent cognitive models of depression In addition, several investigators have begun to apply recent cog-
that have incorporated the evidence presented above. nitive science theories and findings to create alternatives or extensions
The response styles theory of rumination (Nolen-Hoeksema et al., to CBT. Indeed, results of CBM studies indicate that reducing negative
2008; Nolen-Hoeksema & Morrow, 1991) posits that individuals differ cognitive biases improves depressive symptoms and attenuates emo-
in their response to negative mood states and that certain response tional and biological responses to stress (for a review see Hallion &
styles – in particular, rumination – exacerbate depressed mood and Ruscio, 2011; Hertel & Mathews, 2011). Although the effectiveness of
negative cognition. The harmful effects of rumination are posited to be CBM has been called into question, it is possible that researchers will be
due not to the increased attention to distress or the negative content of able to refine CBM methods for improved therapeutic effect. For ex-
individuals' thoughts, but rather to the passive and repetitive “re- ample, by targeting the core cognitive biases underlying other cognitive
cycling” of these thoughts. The response styles theory predicts that risk factors or by improving our implementation of CBM training
rumination will be associated with higher levels of depressive symp- methods, CBM tasks may serve as an adjunct or alternative to existing
toms and increased onset of depressive episodes. It also attributes sex treatments.
differences in the prevalence of depression to sex differences in the use Increasing evidence documents the benefits of mindfulness-based
of rumination. cognitive therapy (MBCT) for depression (Dimidjian, Kleiber, & Segal,
Building on Nolen-Hoeksema's response styles theory and on cog- 2009; Segal, Williams, Teasdale, & Gemar, 2002). MBCT uses a com-
nitive models of depression (Beck, 1978; Bower, 1981; Ingram, 1984; bination of psychoeducation about depression, mindfulness meditation
Teasdale, 1988), Joormann (2010) posited a model of depression in practices, and cognitive-behavioral strategies. Several large randomized
which deficits in cognitive control are central to both cognitive biases trials documented reductions in depressive symptoms and relapse rates
and cognitive emotion regulation strategies. Specifically, Joormann following MBCT (Ma & Teasdale, 2004; Teasdale et al., 2000). Although
argued that difficulty inhibiting access of negative information into the literature examining the effects of MBCT for depression on changes
working memory and removing no-longer-relevant negative content in cognitive processes is small, initial evidence suggests that MBCT is
from working memory underlie both rumination and problems associated with reduced overgeneral autobiographical memory,

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negative attentional biases, and rates of rumination (Dimidjian et al., (RDoC) will continue to shape the way we define and study psycho-
2009; Teasdale, Segal, & Soulsby, 2000; van Vugt, Hitchcock, Shahar, & pathology. RDoC, a system for classifying mental disorders based lar-
Britton, 2012). gely on a dimensional framework encompassing biology and behavior,
Another promising therapeutic development is emotion regulation posits that mechanisms that underlie problematic behaviors and
therapy (ERT). ERT is a recently developed treatment that integrates symptoms are transdiagnostic. RDoC was formulated to identify and
components of CBT, acceptance, mindfulness, and experiential, emo- utilize biomarkers that can reliably predict the onset, course, and out-
tion-focused therapeutic techniques (Mennin, Fresco, Ritter, & come of mental illness. Importantly, the RDoC approach has the po-
Heimberg, 2015; Renna, Quintero, Fresco, & Mennin, 2017). It was tential to improve methods and systems used in the prevention and
designed originally for Generalized Anxiety Disorder (GAD) but has treatment of psychiatric disorders. The Cognitive Systems domain,
been applied to individuals with GAD and comorbid depression. ERT which includes constructs such as attention, memory, and cognitive
focuses on training three emotion regulation skills: allowance, distan- control, is particularly relevant to consider in attempting to understand
cing, and reframing. Despite its relatively recent development, re- the nature of the association between cognition and depression.
searchers have documented the efficacy of ERT (Mennin et al., 2015; Moreover, two of the major domains of the RDoC approach, the Positive
Renna et al., 2017). Specifically, patients receiving ERT showed im- Valence System and the Negative Valence System, most strongly cap-
provement in symptom severity, impairment, quality of life, mindful ture the aberrant processing that may be common to depression and
attending/acceptance, and cognitive reappraisal (Mennin et al., 2015). related disorders; studying these domains is a promising avenue for
Work by Watkins and colleagues provides another example of re- future investigation.
searchers applying recent cognitive science theories and findings to Fourth, there is currently a relative gap in our understanding of
improve clinical practice. These researchers adapted CBT to specifically individual-difference factors (e.g., ethnicity, race, sex) that interact
target rumination via a rumination-focused CBT protocol, and docu- with cognitive processes to affect depressive symptomatology. This gap
mented significant reductions in symptoms and remission rates that is particularly surprising given evidence that prevalence rates of de-
were mediated by reductions in rumination (Watkins et al., 2007, pression differ across ethnicity, race, and sex (Kessler, 2003; Kessler
2011). Over the next decade, we envision researchers will continue to et al., 2003; Kessler et al., 2005) and that perceived discrimination is
develop and refine therapeutic approaches that target other cognitive associated with negative mental health outcomes, such as depression
processes that are related to depression. (Chou, Asnaani, & Hofmann, 2012). Initial work in this area suggests
As we consider the current state of the treatment outcome literature, that ethnic and racial factors and sex differences can influence the as-
we would like to make two additional points. First, we believe that the sociation between cognitive factors and depression. For example, there
field can now move toward targeted and person-specific interventions is considerable evidence that women are more likely to ruminate than
that are informed by cognitive and biological markers. At present, are men, and some studies find that sex differences in rumination
person-centered variables are rarely used to inform intervention ap- mediate sex differences in the prevalence of depression (Nolen-
proaches, and we know little about which interventions work best for Hoeksema et al., 2008). In addition, Kwon, Yoon, Joormann, and Kwon
which individuals and why. Second, we urge investigators to move (2013), found that the association between reappraisal and depressive
toward early identification of risk for depression so that we can make symptoms was stronger in a Korean than in a US sample, but that,
the transition from a reactive- to a proactive-based approach to treat- across both countries, women were more likely to ruminate than were
ment. Although we have made progress in identifying individuals at men. In contrast, however, Dritschel and colleagues (Dritschel et al.,
greatest risk for depression on the basis of demographic, environ- 2011) documented similar autobiographical memory biases in de-
mental, and developmental risk factors (e.g., sex, family history of the pressed individuals from Britain and Taiwan. This finding suggests that
disorder, early life stress, and/or the onset of puberty), we still need there are circumstances when culture does not influence cognitive
preventive interventions that reduce the rates of the onset of depression processes, and it highlights the importance of identifying when and for
in these at-risk populations. whom individual-difference factors influence the role of cognition in
depression.
6. Future directions Fifth, we think initial findings regarding the role of mental imagery
biases in depression are promising. Mental imagery, or the ability to
Over the past several decades we have made exciting progress in our imagine a past, current, or future event, is a central feature of cognition.
understanding of depression. What should we work towards and expect Although its role in depression has been largely overlooked, researchers
over the next several years? First and foremost, despite considerable have documented that, compared with healthy control participants,
progress in the measurement of cognition in depression, the psycho- depressed participants have more intrusive negative mental images, less
metric properties of many information-processing tasks are still un- vivid positive images, and overgeneral images of past events (for a re-
known or poor (Brown et al., 2014; Schmukle, 2005). It is critical that view see Holmes, Blackwell, Burnett Heyes, Renner, & Raes, 2016). For
researchers use experimental methods and tasks with strong psycho- example, Holmes, Crane, Fennell, and Williams (2007) reported that
metric properties. Therefore, we encourage researchers to evaluate and intrusive mental images of suicide (termed flash-forwards) are asso-
report the psychometric properties of the tasks that they are using so ciated with depression and suicidal ideation. Moreover, several in-
that other researchers can select tasks with the strongest psychometrics, vestigators have found reduced vividness for positive future events in
can interpret inconsistencies in the literature in light of potential dysphoric than in non-dysphoric participants (Anderson & Evans, 2015;
variability in task psychometrics, and can identify when new tasks with Holmes, Lang, Moulds, & Steele, 2008; Szollosi, Pajkossy, & Racsmány,
stronger psychometric properties should be developed. 2015) and in formerly depressed participants compared to healthy
Second, there has been a trend toward the development of more control participants (Werner-Seidler & Moulds, 2011); this reduced
integrative models of depression that aim to describe how biological, vividness may limit individuals' ability to imagine future positive events
emotional, and cognitive components interact to precipitate and ex- and increase negatively biased affective forecasts. Less vivid processing
acerbate depressive symptoms (e.g., Disner, Beevers, Haigh, & Beck, of positive memories may also hinder individuals' ability to use positive
2011). We think that it is critical that researchers continue to pursue memories to repair or protect against negative mood states. Consistent
this line of inquiry in order to move the field forward. Specifically, the with this possibility, researchers have shown that experimentally in-
integration of cognitive science with biology will allow us to identify ducing concrete, imagery-focused processing when currently or for-
the biological factors that influence and are influenced by negative merly depressed individuals recall a positive memory leads to greater
cognitive biases and maladaptive emotion regulation strategies. improvement in mood than does an abstract, verbal processing style
Third, we anticipate that the NIMH's Research Domain Criteria (Werner-Seidler & Moulds, 2012). Thus, although the role of mental

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imagery biases in depression has been understudied, initial evidence Contributors

suggests that this is a promising approach for future research.
Finally, it is increasingly apparent that any single form of cognition JL and IHG discussed the focus of the current review. JL wrote the
does not operate in isolation. Although investigators have begun to first draft of the manuscript, and IHG contributed to and approved the
examine the relations among cognitive biases and emotion regulation final manuscript.
strategies (these initial findings inform the theoretical model depicted
in Fig. 1), additional research is needed to understand how different Conflict of interest
components of cognition interact and influence one another. Similarly,
by including multiple forms of cognition together in the same model, All authors declare that they have no conflicts of interest.
researchers are able to test the relative and differential contribution of
different cognitive factors in the onset and maintenance of depression. References
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