Journal of Affective Disorders 331 (2023) 130–138

Contents lists available at ScienceDirect

Journal of Affective Disorders

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

Research paper

The influence of childhood maltreatment on trait depression in patients

with major depressive disorder: A moderated mediation model of
rumination and mindful attention awareness
Lingyun Mao, Yunhong Wu, Xin Hong, Pan Li, Xin Yuan, Maorong Hu *
Department of Psychosomatic Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China

A R T I C L E I N F O A B S T R A C T

Keywords: Major depressive disorder (MDD) is one of the most prevalent psychiatric disorders. Individuals who were
Childhood trauma exposed to childhood maltreatment might be an especially vulnerable group and were more likely to meet the
Ruminative thinking diagnostic criteria for depression than those who were not. Trait depression refers to a personality trait pre­
Trait depression
disposition to depression, expressed as the frequency of symptoms rather than a transient depressive mood state.
Mindfulness
Clarifying the relationship between childhood maltreatment and trait depression in patients with MDD has
MDD
Moderated mediation model therefore become an important field of research. Childhood Trauma Questionnaire-Short Form (CTQ-SF),
Ruminative Responses Scale (RRS), State-Trait Depression Scale (ST-DEP), and Mindful Attention Awareness
Scale (MAAS) were used as research instruments. SPSS 23.0 statistical software was used for statistical analysis
and examined the moderated mediation models. A total of 288 patients with MDD were included in this study.
After standardization of the variables, the model revealed childhood maltreatment was positively associated with
trait depression (β = 0.215, p < 0.001) and that rumination partially mediated the effect between childhood
trauma and trait depression. Mindfulness moderated the association between rumination and trait depression in
depressed patients (β = 0.171, p < 0.001). Simple slope tests showed that rumination significantly predicted trait
depression in patients with high levels of mindfulness (bsimple = 0.460, p < 0.001, 95%CI = [0.339, 0.581]),
while this predictive effect was not significant in patients with low levels (bsimple = 0.119, p = 0.097, 95%CI =
[− 0.022, 0.261]). After adding mediating variables, we found that the negative impact of childhood maltreat­
ment on trait depression was both directly and indirectly through the patients’ own ruminative levels. However,
mindfulness performed a critical moderating role in the overall mediating model, aggravating the negative
impact of childhood maltreatment on trait depression. There are several limitations in this study: the history of
childhood maltreatment was reviewed and reported; the MAAS was a single-dimensional questionnaire that fails
to measure the content of other mindfulness factors; cross-sectional data could not be used to infer the causal
relationship between variables.

1. Introduction et al., 2009). A recent study revealed that almost three-quarters of

persistently depressive adults recalled traumatic childhood events
Major depressive disorder (MDD) is one of the most common psy­ (Negele et al., 2015), and those with a history of childhood neglect or
chiatric disorders, characterized by persistent and pervasive depressed abuse were also more likely to suffer from depression(Taillieu et al.,
mood, diminished interests, and impaired cognitive function(Otte et al., 2016). Specifically, maltreated children were nearly twice as likely to
2016). A cross-sectional epidemiological study reveals that the lifetime develop recurrent and persistent depression as those without a history of
prevalence of MDD in China has reached 3.4 %, making it the most childhood maltreatment, and were associated with an earlier onset,
dangerous psychological disorder threatening the public’s physical and higher severity of symptoms, and a greater likelihood of not responding
mental health(Huang et al., 2019). Childhood maltreatment, including to common treatments(Nanni et al., 2012; Nelson et al., 2017). It has
emotional, physical, and sexual abuse, and emotional and physical been suggested that depression can be divided into two types: state
neglect, has been demonstrated as a pivotal antecedent of MDD(Gilbert depression and trait depression(Spielberger et al., 2002). State

* Corresponding author.
E-mail address: [email protected] (M. Hu).

https://doi.org/10.1016/j.jad.2023.03.052
Received 11 February 2023; Received in revised form 6 March 2023; Accepted 18 March 2023
Available online 22 March 2023
0165-0327/© 2023 Published by Elsevier B.V.
L. Mao et al. Journal of Affective Disorders 331 (2023) 130–138

depression typically refers to a transient depressive mood state that is ruminative thinking and depressive symptoms(Belleau et al., 2022;
characterized by the severity and intensity of symptoms (e.g., how you Kaiser et al., 2019). Accordingly, the present study hypothesized that
feel at the moment), whereas trait depression refers to a personality trait ruminative thinking mediates the correlation between childhood
predisposition to depression, expressed as the frequency of symptoms (e. maltreatment experiences and trait depression in patients with MDD
g., how you regularly feel)(Spielberger et al., 2002), i.e., individuals (H2).
with high levels of trait depression will objectively demonstrate more Although childhood maltreatment has been regarded as a risk factor
frequent depressive reactions. Childhood maltreatment contributes to for psychopathology, there is no one-to-one correlation between
the progressive development of Early Maladaptive Schemas, a firm maltreatment and psychiatric disorders, as not everyone exposed to
maladaptive perception that predisposes susceptibility to psychological early-life stress develops mental health problems(Belsky and Pluess,
and personality problems, resulting in a propensity to react to negative 2009; Kalia and Knauft, 2020). Mindfulness meditation is generally
information with stable depression(Young et al., 2003). Despite the fact defined as the observation and awareness of thoughts, sensations, and
that Early Maladaptive Schemas no longer apply to current reality, in­ feelings from moment to moment in a particular nonjudgmental or
dividuals continue to employ this diffuse cognitive concept to under­ accepting way(Bishop et al., 2004). Mindfulness has also been concep­
stand the external world due to the need for cognitive coherence, which tualized as a trait-like disposition, referring to a person’s tendency to
eventually reinforces maladaptive schemas(Castille et al., 2007). invoke a state of mindfulness in daily life outside of meditation practice
Recurrence of Early Maladaptive Schemas might increase the frequency (Baer et al., 2006). Several randomized controlled studies have
of depressed reactions and ultimately become a trait-like depression. We demonstrated that mindfulness-based interventions show effective re­
therefore hypothesized that there is a positive association between sults in improving psychological outcomes in patients with depression
childhood maltreatment and trait depression in patients with MDD. (Cladder-Micus et al., 2018; Winnebeck et al., 2017). It has been sug­
(H1). gested that the ability to control one’s attention enhanced by mindful­
Childhood is considered to be an essential period for the cultivation ness meditation could be used to treat the negative effects of childhood
of emotion regulation skills(Eisenberg et al., 2010). The emotionally maltreatment(Ortiz and Sibinga, 2017). By shifting attention from
stressful, unpredictable, and uncontrollable nature of abuse and neglect ruminative thinking to the present moment, which helps individuals
hinders the development of appropriate behavior in children and may become aware that they are in a dysfunctional thought pattern,
promote inadequate emotional regulation strategies(Briere and Jordan, mindfulness-based interventions could reduce the possibility of
2009). Particularly, individuals who have encountered childhood ad­ depression recurrence by moderately reducing rumination(Perestelo-
versities may engage in repetitive negative thinking as a regulation Perez et al., 2017). Multiple mediation analysis studies have shown that
strategy to improve or modify their negative emotions(Sarin and Nolen- rumination significantly mediates the association between dispositional
Hoeksema, 2010). Rumination refers to a state in which an individual mindfulness and depressive symptoms in healthy or clinical samples
passively and repeatedly focuses their attention on negative events and (Desrosiers et al., 2013; Mamede et al., 2022; Yu et al., 2021). Mind­
their possible causes, meanings, and implications(Nolen-Hoeksema fulness meditation advocates directing attention to the present moment
et al., 2008). Individuals who are involved in rumination might be with conscious awareness and nonjudgmental acceptance, as opposed to
striving to comprehend the possible reasons and outcomes of negative ruminative response style that repeatedly focuses on past negative ex­
events so as to alleviate them(Mao et al., 2023). When confronted with periences and information(Li et al., 2022; Webb et al., 2021). Mindful­
parental abuse and neglect, for instance, children might devote a ness affects at least three components of self-regulatory processing:
tremendous amount of time to evaluating and interpreting the motives anterior cingulate cortex, striatum, and lateral prefrontal cortex asso­
and signals of violent behaviors in order to anticipate maltreatment and ciated with attentional control, prefrontal cortex and limbic area asso­
effectively avoid being punished again(Spasojević and Alloy, 2002). ciated with emotion regulation, and insula, medial prefrontal cortex,
However, ruminative thinking typically over-concentrates on one’s posterior cingulate cortex, and precuneus cortex involved in self-
emotions and unsettled problems, producing and deteriorating negative referential processing(Tang and Leve, 2016). These areas interact
impacts rather than seeking constructive solutions(Nolen-Hoeksema closely to constitute an enhanced self-regulatory and alleviate depres­
et al., 2008). A meta-analysis indicated that excessive rumination was a sive symptoms. We therefore hypothesized that an individual’s own
more detrimental and dysfunctional emotion regulation adjustment mindful disposition might be able to moderate and weaken the associ­
than other strategies such as acceptance, reappraisal, avoidance, prob­ ation between ruminative thinking and trait depression in patients with
lem solving, or inhibition(Aldao et al., 2010). According to response MDD (H3).
style theory, the severity and duration of symptoms are determined by
how individuals respond to symptoms(Nolen-Hoeksema et al., 2008). 2. Method
That is, rumination is likely to have a positive predictive effect on the
evolution, maintenance, and recurrence of depressive symptoms(Li 2.1. Participants and procedures
et al., 2022). In addition, rumination may also be a factor that mediates
childhood maltreatment and depression(Kim et al., 2017). For instance, Patients with major depressive disorder (MDD) who had been
a longitudinal study revealed that childhood experiences of emotional referred for assessment and treatment in the Department of Psychoso­
abuse by parents serve as a prerequisite for the development of negative matic Medicine of the First Affiliated Hospital of Nanchang University
cognitive styles, and this vulnerability, once developed, could in turn were recruited from July to September 2022. The inclusion criteria were
become a risk factor for the increase of depressive symptoms in as follows: (i) MDD diagnosed by an experienced psychiatrist according
adolescence(Padilla Paredes and Calvete, 2014). O’Mahen et al. found to the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edi­
that rumination was a partial mediator between childhood emotional tion; (ii) volunteering to participate in this study; (iii) a certain level of
abuse and depressive symptoms in a clinical women’s sample(O’Mahen education and the ability to understand the meaning of the scales. The
et al., 2015). Moreover, attempts to explain the cognitive impact of Exclusion criteria were: (i) presence of organic injury; (ii) drug or
trauma suggest that persistent stress responses in early life result in alcohol dependence; (iii) mental retardation; (iv) serious physical
dysfunction of the hypothalamic-pituitary-adrenal axis, which has been illness.
associated with developmental abnormalities in cognitive processing All participants were informed of the significance of their answers
and emotion regulation related to the brain(Cross et al., 2017). Neuro­ being authentic and comprehensive. Prior to data collection, the confi­
biological evidence suggests that, for example, abnormalities in the dentiality of the study was emphasized. The researcher assisted the
function of posterior cingulate cortex, medial prefrontal cortex, dorso­ patients in answering the questions and clarified any unclear items. If
lateral prefrontal cortex, insular cortex, and amygdala contribute to patients become fatigued or unwell, they could withdraw from the

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study. A total of 295 patients were recruited, of which 7 were excluded database, and the obtained questionnaire data were entered for statis­
for invalid answers, and 288 patients with MDD were finally included in tical analysis. To prevent probable common method bias, Harman’s one-
this study. The final sample included 95 males (32.99 %) and 193 fe­ way test was initially applied to the sample data(Podsakoff et al., 2003).
males (67.01 %), aged from 12 to 64 years old (mean = 23.69, standard Descriptive analyses were used to examine the data for concentration
deviation[SD] = 9.37). and dispersion trends. The degree of linear correlation between the in­
We used G*Power 3.1 to perform post hoc tests(Faul et al., 2009). dependent, mediating, moderating, and dependent variables was then
Based on our original hypothesis, we entered 0.05 alpha error proba­ evaluated by calculating the Pearson product moment correlation
bility, a sample size of 288, and 4 number of predictors (childhood coefficients.
maltreatment, rumination, mindfulness, and the interaction of mind­ The moderated mediation models for childhood trauma and trait
fulness and rumination). The results showed that the power of test (1-β) depression were examined using the SPSS macro PROCESS (version 3.3),
was one, indicating that the sample size of this study provided an which was developed by Hayes (2013)(Hayes, 2013). Bootstrapping
acceptable statistical power to test our hypothesis. based on 5000 samples with 95 % confidence intervals (CI) was used to
estimate standard errors (SE) of conditional direct and indirect effects,
2.2. Measures and the effects were significant when the CI did not contain zero
(Holland et al., 2016).
2.2.1. Childhood maltreatment
Childhood Trauma Questionnaire-Short Form (CTQ-SF) has 28 3. Result
items, including five types of childhood maltreatment: physical abuse
(PA), emotional abuse (EA), sexual abuse (SA), physical neglect (PN), 3.1. Test of common method Bias
and emotional neglect (EN)(Bernstein et al., 2003). The questionnaire
was scored on a 5-point Likert scale, from “Never” (score = 1) to “Al­ This study collected data through self-assessment, which was sus­
ways” (score = 5). The total score ranges from 25 to 125 points, and ceptible to common method bias. The results of the Harman one-way
higher scores indicate more severe experiences of childhood abuse or test revealed that 13 factors had eigenvalues >1, accounting for
neglect. In the present study, Cronbach’s alpha for the total CTQ-SF was 64.79 % of the total variance, whereas the first factor accounted 28.24 %
0.91, and the five subscales were EA = 0.84, PA = 0.83, SA = 0.76, EN = of the variance, which fell short of the 40 % criterion(Xu et al., 2022). As
0.87, and PN = 0.70, respectively. a consequence, there was no serious common method bias in this study.

2.2.2. Rumination 3.2. Descriptive statistics and correlation analysis

Ruminative Responses Scale (RRS) is a 22-item scale that measures
ruminative tendencies. The 12 items of the rumination scale that The means, standard deviations, and Pearson correlations between
correlate with depression have been regrouped into one dimension, the study variables are shown in Table 1. Childhood maltreatment was
depression-related rumination, while the remaining 10 items have been positively associated with trait depression (r = 0.486, p < 0.001) and
reorganized into two dimensions, reflective and brooding rumination rumination (r = 0.393, p < 0.001). The relationship between rumination
(Treynor et al., 2003). To prevent the overlap and substantial correlation and trait depression was positive (r = 0.614, p < 0.001). There were
between ruminative thinking and depression, (Treynor et al., 2003) a negative associations between mindfulness and rumination (r = − 0.661,
two-dimensional rumination scale was utilized in this study. The RRS p < 0.001) and trait depression (r = − 0.628, p < 0.001).
was scored on a 4-point Likert scale, from “almost never” (score = 1) to
“almost always” (score = 4). Reflective and brooding rumination were 3.3. Analysis of mediators of rumination
scored independently, with higher scores representing a greater pro­
pensity for rumination. The Cronbach’s α for the RRS in the present Multiple regression analysis was performed using SPSS process
sample was 0.89; brooding rumination was 0.83; and reflective rumi­ component model 4 with childhood maltreatment as the independent
nation was 0.79. variable, trait depression as the dependent variable, and rumination as
the mediating variable. As shown in Table 2, childhood maltreatment
2.2.3. Trait depression was positively associated with trait depression (β = 0.290, p < 0.001)
State-Trait Depression Scale (ST-DEP) contains a total of 32 items and significantly predicted trait depression. Childhood maltreatment
and 2 subscales: State-Depression Subscale (S-DEP) (16 items) and Trait- was a positive predictor of rumination (β = 0.393, p < 0.001), and
Depression Subscale (T-DEP) (16 items)(Spielberger et al., 2002). Each rumination positively predicted trait depression (β = 0.500, p < 0.001).
subscale comprised of two 8-item factors: euthymia and dysthymia. The We tested CI estimates using the bootstrap method and showed that
S-DEP measures the most recent experience of loss and helplessness at a the 95 % CI for the direct effect (effect size = 0.290, SE = 0.048, 95%CI
particular time, whereas the T-DEP measures the frequency of emotional = [0.196, 0.384]) and indirect effect (effect size = 0.197, SE = 0.036,
events. Trait depression was measured using the T-DEP in this study. The 95%CI = [0.128, 0.268]) of childhood maltreatment on trait depression
T-DEP was scored on a 4-point Likert scale, from “almost never” (score did not include zero. Total effect size was 0.486 (SE = 0.052, 95%CI =
= 1) to “almost always” (score = 4), with higher scores indicating [0.385, 0.588]). Therefore, the partial mediating effects equation model
greater levels of trait depression. Cronbach’s α for the T-DEP in the holds true, and rumination was the mediating variable between child­
present sample was 0.92. hood maltreatment and trait depression. The direct and indirect effects
accounted for 59.60 % and 40.42 % of the total effect, respectively.
2.2.4. Mindfulness
Mindful Attention Awareness Scale (MAAS) is a self-reported ques­ 3.4. Moderated mediation effect
tionnaire to assess trait mindfulness(Brown and Ryan, 2003). The MAAS
included 15 items rated on a 6-point Likert scale, from “almost always” In this study, the moderating variable mindfulness was introduced to
(score = 1) to “almost never” (score = 6). Higher scores indicate higher the second half of the mediation model, and an analysis of the moder­
levels of mindfulness. The Cronbach’s α for the MAAS was 0.91. ated mediation model was conducted using SPSS process model 14. After
standardization of the variables, the model revealed childhood
2.3. Statistical analysis maltreatment positively predicted rumination (β = 0.393, p < 0.001),
and that rumination significantly predicted trait depression (β = 0.290,
For this study, SPSS 23.0 statistical software was used to establish a p < 0.001), see Fig. 1 and Table 3. The pathway of childhood

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Table 1
Descriptive statistics and correlations among variables.
Variables*,** Mean SD Childhood maltreatment Rumination Trait depression

Childhood maltreatment 50.71 15.99 –

Rumination 26.92 6.97 0.393*** –
Trait depression 45.65 10.28 0.486*** 0.614*** –
Mindfulness 52.80 15.00 − 0.503*** − 0.661*** − 0.628***

Note. Means (M), standard deviations (SD), and Pearson correlation (n = 288).
*
p < 0.050.
**
p < 0.010.
***
p < 0.001.

Table 2
Testing the mediation effect of childhood trauma on trait depression.
Predictors*,** Rumination Trait depression

β SE t β SE t

Childhood maltreatment 0.393 0.054 7.232*** 0.290 0.048 6.056***

Rumination 0.500 0.048 10.446***
R2 0.155 0.448
F 52.295*** 115.638***

Analyses conducted using PROCESS model 4.

*
p < 0.050.
**
p < 0.010.
***
p < 0.001.

Fig. 1. Standardized path coefficients of the moderated mediation model. *p < 0.05, **p < 0.01, ***p < 0.001.

Table 3
Moderated mediation test.
Predictors*,** Rumination Trait depression

β SE t β SE t

Childhood maltreatment 0.393 0.054 7.232*** 0.215 0.048 4.534***

Rumination 0.290 0.055 5.234***
Mindfulness − 0.312 0.058 − 5.372***
Mindfulness * Rumination 0.171 0.037 4.565***
R2 0.155 0.529
F 52.295*** 79.482***

Analyses conducted using PROCESS model 14.

*
p < 0.050.
**
p < 0.010.
***
p < 0.001.

maltreatment affecting trait depression remained significant (β = 0.215, and performed simple slope analysis. The mediating effects were 0.047
p < 0.001) after adding mindfulness as a moderating variable, i.e., (SE = 0.030, 95%CI = [− 0.009, 0.109]), 0.114 (SE = 0.029, 95%CI =
rumination partially mediated the effect between childhood trauma and [0.061, 0.180]), and 0.181 (SE = 0.039, 95%CI = [0.113, 0.265]) for
trait depression. To further analyze the moderating effect, mindfulness mindfulness took different values of − 1Z, 0, and +1Z, respectively.
was divided into three groups: high (+1Z), medium (0), and low (− 1Z), The interaction between rumination and mindfulness was

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significantly positively related to trait depression (β = 0.171, p < 0.001), maltreatment leads to detectable alterations in a variety of neuro­
implying that mindfulness moderated the association between rumina­ cognitive systems(McCrory et al., 2017a; McCrory and Viding, 2015).
tion and trait depression in depressed patients. Simple slope tests Compared to depressed patients without a history of childhood
showed that rumination significantly predicted trait depression in pa­ maltreatment, patients with such a history mainly display widely
tients with high levels of mindfulness (bsimple = 0.460, p < 0.001, 95% impaired functional connectivity within the prefrontal-limbic-thalamic-
CI = [0.339, 0.581]), while this predictive effect was not significant in cerebellar circuitry(Wang et al., 2014).
patients with low levels of mindfulness (bsimple = 0.119, p = 0.097, Neurobiological evidence suggests that negative experiences during
95%CI = [− 0.022, 0.261]), see Fig. 2. The Johnson-Neyman inspection early development can have a debilitating impact on specific prefrontal
revealed that, when the moderating variable mindfulness was greater cortex structures and functions, such as a reduction in medial and
than − 0.899, the relationship between rumination and trait depression dorsolateral prefrontal cortex gray matter and volume, detrimentally
grew more positive with the increase of the impact of mindfulness affecting cognitive control and problem-solving thinking(Andersen
(Fig. 3). When mindfulness smaller than − 0.899, the correlation be­ et al., 2008; Underwood et al., 2019). The limbic-medial temporal lobe
tween rumination and trait depression was nonsignificant. regions, including the hippocampus and amygdala, which play an
essential role in emotion regulation, memory, and stress responses, are
4. Discussion also sensitized by childhood maltreatment(McCrory et al., 2011; Nem­
eroff, 2016). For example, MDD patients with a history of childhood
Childhood experiences of maltreatment are frequently disregarded trauma showed smaller hippocampal volumes and enhanced amygdala
due to the unconscious character of behavioral purpose and the implicit responses to negative stimuli compared to patients without a history of
nature of behavioral consequences, while the effects of this abuse or childhood trauma(Grant et al., 2011; Vythilingam et al., 2002). In
neglect might persist into adulthood. Individuals who were exposed to addition, functional magnetic resonance imaging studies have found
early life stress might be an especially vulnerable group and were more that adults exposed to early life stress had a higher negative resting-state
likely to meet the diagnostic criteria for depression than those who were functional connectivity between dorsolateral prefrontal cortex and
not(LeMoult et al., 2020). Previously, depression in individuals was amygdala(Kaiser et al., 2018). Childhood maltreatment is largely char­
investigated using state scales that measured the severity of depression acterized by a lack of appropriate stimulation or interaction required by
within a certain time period. However, the depressive state might be the brain during development, leading to significant abnormalities in
sensitive to the influences of time and external stimuli. Spielberger et al. the organization and connection of brain networks, particularly in
designed the T-DEP scale, which measures the intensity and frequency of stress-sensitive regions. Abnormalities in the neurodevelopment of
depression(Spielberger et al., 2002). Trait depression, as opposed to certain brain regions inhibit the successful acquisition of cognitive,
state depression, characterizes an individual’s recurrent emotional emotional, and behavioral functions, which in turn improve the risk of
experience and reflects a generally steady personality propensity to developing depression(Fadel et al., 2021; Wang et al., 2014).
become depressed readily. This study therefore investigated the asso­ It has been argued that depression is not determined by the negative
ciation between childhood maltreatment and trait depression in patients emotional state itself, but rather by a greater propensity to enter into it
with MDD, constructed a moderated mediation model, and confirmed and an inability to disengage from it(Holtzheimer and Mayberg, 2011).
for the first time the mediating function of rumination and the moder­ Rumination inevitably repeatedly evokes emotional experiences(Nolen-
ating effect of mindfulness. Hoeksema et al., 2008), and may serve as a mediator to prolong and
As hypothesized, the present study found that patients with higher exacerbate existing depressive symptoms. Consistent with the findings
levels of childhood maltreatment demonstrate more severe trait of several studies exploring depressive symptoms(Fang et al., 2022; Kim
depression, which is in line with recent meta-analytic results(Nanni et al., 2017; O’Mahen et al., 2015), the present study revealed that
et al., 2012; Nelson et al., 2017). Childhood maltreatment was sub­ ruminative thinking partially mediated the relationship between child­
stantially associated with an enhanced risk of developing MDD(Danese hood maltreatment and trait depression, which represents a stable ten­
et al., 2009). According to the theory of latent vulnerability, dency to be depression, and that in addition to this mediating pathway,

Fig. 2. The moderating effect of mindfulness on the association between rumination and trait depression. The result of 0 ± 1Z.

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Fig. 3. Significance region of the moderating effect of mindfulness on the association between rumination and trait depression based on Johnson-Neyman output.
Variables are standardized. Significance region is situated for mindfulness >0.899. Dashed line indicates 95%CI.

there was also a significant direct effect of childhood maltreatment on to link internal states with external inputs and allocates resources ac­
trait depression. cording to the salience of events to regulate attention to the internal or
It has been suggested that early maltreatment constitutes an out-of- external environment(Yu et al., 2022). Nevertheless, a study using
control environment prone to experiencing high levels of despair and resting-state co-activation pattern analysis found that spending more
psychological symptoms(Padilla Paredes and Calvete, 2014). According time in co-activation patterns involving the DMN, FPN, and SN regions,
to response style theory(Nolen-Hoeksema et al., 2008), when faced with as well as transitioned more frequently between these networks, was
stressful or adverse life events, individuals who tend to think in the related to a strong propensity to ruminate(Kaiser et al., 2019). In addi­
cognitive style of ruminative thinking typically regard problems more tion, a review study on MDD revealed enhanced functional connectivity
negatively and persistently dwell on emotions and negative thoughts, between the DMN and SN, as well as reduced connectivity between the
resulting in their inability to find positive strategies to solve problems, DMN and FPN(Mulders et al., 2015).
which ultimately increases the risk of depression. In the theory of latent Dysfunction between the DMN, FPN, and SN might be important
vulnerability(McCrory et al., 2017a; McCrory and Viding, 2015), spe­ biomarkers of MDD and repetitive introspection, resulting in attentional
cific neurobiological alterations occur in response to maltreatment, bias toward negative and self-referential information, and cognitive and
enabling children to initially adapt to harmful rearing conditions. In the emotional deficits(Belleau et al., 2022; Kaiser et al., 2019). This ab­
long term, however, these alterations might lead to maladaptive be­ normality in network transitions activated by the insular cortex within
haviors in other settings, creating a potential vulnerability to the the SN may be strongly associated with childhood maltreatment(Goul­
development of psychiatric disorders. den et al., 2014; Marusak et al., 2015). Early life maltreatment was also
Recently, it has been proposed that childhood maltreatment causes related to altered neural responses to autobiographical memories,
particular alterations in several resting state networks(Fadel et al., including enhanced activation of the amygdala and connectivity with
2021). The Default Mode Network (DMN), Frontoparietal Network the SN during negative memory recovery, and this alteration leads to the
(FPN), and Salience Network (SN) represent the brain’s functions in internalization of negative self-referential patterns, such as difficulties
introspective and autobiographical thinking, cognitive, and emotional switching from the default state of internal attention to the executive
processes, all of which are important processes that are altered in state of external stimuli, which is a feature of rumination(Hoffmann
depression and ruminative thinking(Belleau et al., 2022; Kaiser et al., et al., 2018; McCrory et al., 2017b). Consequently, childhood
2019; Mulders et al., 2015). Overactivation of the DMN, which includes maltreatment may affect cognitive and emotional processes by dis­
the medial prefrontal cortex, posterior cingulate cortex, and precuneus rupting the maturation of underlying brain networks, such as difficulties
cortex and involves evaluative self-referential processing and emotional in emotion regulation represented by ruminative thinking, ultimately
value judgments, is closely associated with ruminative thinking leading to increased vulnerability to the development of depression. The
(Andrews-Hanna, 2012; Zhou et al., 2020). In contrast to the DMN, the preliminary findings of this study have some potential clinical implica­
FPN, which includes the lateral prefrontal and posterior parietal regions, tions. In terms of assessment, information about ruminative thinking can
is most active during cognitive tasks including attention and working be gathered from the memories of adults who have experienced child­
memory(Mulders et al., 2015; Zanto and Gazzaley, 2013). The SN, hood adversities and considered as a potential therapeutic target to
mainly composed of the insular cortex, dorsal anterior cingulate cortex, reduce their depression.
and amygdala, plays a central role in emotion control and is also asso­ It was previously mentioned that the DMN, FPN, and SN exhibited
ciated with the switch between the DMN and the FPN(Fadel et al., functional abnormalities in psychiatric disorders and that the activity of
2021). The SN activated in response to various salient stimuli (including these regions was likewise massively modulated by mindfulness(Sezer
acute stress) typically coordinates the transition between DMN and FPN et al., 2022). Mindfulness meditation could help practitioners more

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effectively recruit SN that engage in stimulus identification and guide 2008): observation, description, acting with awareness, nonjudgement
behavior based on their evaluations, thereby improving the individual’s of inner experience, and nonreactivity to inner experience. However, the
ability to switch more flexibly between DMN and FPN activities and MAAS used in this study only focused on one aspect, attentional
related tasks(Barnhofer et al., 2015). For example, a meta-analysis based awareness of the present, and lacked measures of attitudinal factors,
on the activation likelihood estimation approach found increased acti­ which made it impossible to explore the positive role of attitudinal
vation in the prefrontal cortex and insula during mindfulness meditation factors. Further research is needed to better understand the moderating
compared to neural activation baseline control condition(Falcone and role of mindfulness between childhood maltreatment, ruminative
Jerram, 2018). thinking, and trait depression by using other multi-faceted question­
In fact, rapid switching is considered important in mindfulness, naires such as the five-facet mindfulness questionnaire. There are
refocusing attention on present-moment awareness rather than mind- several limitations in this study that need to be improved in the subse­
wandering or dwelling on self-reflection(Sezer et al., 2022). In­ quent investigation. First, the history of childhood maltreatment was
dividuals with a greater capacity for mindfulness may commit cognitive reviewed and reported, creating the possibility of retrospective bias and
resources to maintain attention, exhibiting reduced functional connec­ might exaggerate the relationship between maltreatment and symptom.
tivity between the SN and DMN and enhanced functional connectivity In addition, the MAAS used in this study was a single-dimensional
within the SN and between the posterior cingulate cortex within the questionnaire that fails to measure the content of mindfulness atti­
DMN and the dorsolateral prefrontal cortex within the FPN(Bilevicius tudes; hence, it is impossible to determine which aspects of mindfulness
et al., 2018; Sezer et al., 2022). This suggests that mindfulness medita­ could have a more significant impact. Finally, the data that only
tion enhanced the self-monitoring and cognitive control associated with collected the first response of the participants to the questionnaires were
the FPN and also reduced the self-referential DMN-related processes cross-sectional and could not be used to infer the causal relationship
(Brewer et al., 2011; Tang et al., 2015). Recent meta-analysis results between variables.
indicate that mindfulness-based therapies have a beneficial impact on
ruminative thinking in depressed patients(Mao et al., 2023). In Funding
depressed individuals, rumination is associated with greater depressive
symptoms, unless the individual has high levels of mindfulness and the This study was financially supported by the National Natural Science
ability to process autobiographical content, in which case rumination is Foundation of China (81960261) and the Research and Cultivation Fund
significantly connected with adaptive regulation(Brennan et al., 2015). for Young Talents of the First Affiliated Hospital of Nanchang University
Mindfulness meditation can theoretically improve the brain networks of (PRJ-20211018180007878).
patients with MDD and moderate the effects of ruminative thinking on
depression caused by childhood maltreatment. However, the moder­
CRediT authorship contribution statement
ating effect of mindfulness was statistically significant in the present
study, but contrary to hypothesis H3, the association between rumina­
All authors contributed to the article and approved the submitted
tive thinking and trait depression was stronger with increasing levels of
version.
mindfulness in patients with MDD, which is partially different from
previous studies. A cross-sectional study, for instance, revealed that
mindfulness moderated the relationship between rumination and Conflict of interest
depression, with the relationship being significantly higher among ad­
olescents with low levels of mindfulness(Li et al., 2022). The authors declare that the research was conducted in the absence
It has been argued that while mindfulness meditation can play a of any commercial or financial relationships that could be construed as a
protective role in the negative experiences of individuals, there is vari­ potential conflict of interest.
ability in the effectiveness of mindfulness(Farias and Wikholm, 2016).
Monitoring acceptance theory suggests that attentional monitoring in Data availability
the process of mindfulness interventions is effective in improving
cognitive functioning, but it can enhance emotional reactions, whereas The data used to support the findings of this study are available from
keeping an accepting attitude toward the monitored experience weakens the corresponding author upon request.
emotional reactions(Lindsay and Creswell, 2017). Individuals who
responded immediately to their observations were probably observing
Acknowledgments
emotional states such as sadness or worry and then began to think about
what caused the emotions and fell into rumination, thus exacerbating
None.
depressive symptoms(Desrosiers et al., 2014). Instead, observing inner
experiences with an acceptance attitude rather than attempting to
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