Introduction

Metacognitive therapy (MCT) is a relatively new therapy for treating depression. It compares favorably to the best current treatments, which are cognitive behavioral therapy (CBT) and antidepressant medication.

Efficacy

From the introduction to the article “Metacognitive Therapy for Depression in Adults: A Waiting List Randomized Controlled Trial with Six Months Follow-Up“:

Depression has been described as one of the most common psychiatric disorders, with a high degree of comorbidity (Kessler et al., 2003). By 2030, depression is predicted to be the second-leading cause of disease burden worldwide after HIV/AIDS (Mathers and Loncar, 2006). It is therefore essential to develop effective treatments for depression. Cognitive-behavioral therapy (CBT) is the recommended treatment for depression, with a large number of clinical trials supporting its efficacy (Butler et al., 2006). However, only 40–58% of patients receiving CBT are recovered at post-treatment (Dimidjian et al., 2006). Relapse rates are between 40 to 60% within a period of 2 years (Hollon et al., 2006; Vittengl et al., 2007). Antidepressant medication has a similar efficacy in treating depression (Parker et al., 2008). It is therefore necessary to develop new treatments that have greater short-term and long-term efficacy.

A new treatment approach to depression that has produced encouraging results is metacognitive therapy (MCT; Wells, 2009). This approach is based on the metacognitive model where psychological disorder results from an inflexible and maladaptive response pattern to cognitive events labeled the Cognitive Attentional Syndrome (CAS; Wells, 2000; Wells and Matthews, 1994, 1996). The CAS consists of persistent worry and rumination, threat monitoring and ineffective coping strategies that contribute to the maintenance of emotional disorder. Rumination in depression is seen as a coping strategy which follows an initial negative thought labeled a ‘trigger thought’. The depressed individual engages in rumination consisting of repeatedly analyzing negative feelings, past failures and mistakes. Depression is therefore understood as an extension of low mood resulting from a problem of overthinking (e.g., worry and rumination) and withdrawal of active coping. (e.g., social withdrawal and reduction in activity). According to the metacognitive model of depression, rumination and worry is maintained by metacognitions and not by changes in mood or events. Further, this response to triggers extends negative thinking, leads to reduced attentional flexibility and involves a failure to exercise appropriate control over negative affective experiences (Wells, 2009).

According to the metacognitive model metacognitive beliefs control, monitor and appraise the CAS (Wells, 2009). There are both positive and negative metacognitive beliefs. Positive metacognitions are concerned with the benefits of worry and rumination, while negative metacognitions are concerned with the uncontrollability and danger of thoughts. Positive metacognitions related to depression may be exemplified by statements like: “Analyzing the causes of my sadness will give me an answer to the problem”, and “Thinking the worst will make me snap out of it”. Such positive metacognitive beliefs lead to repeated and/or prolonged engagement in ruminative thinking. Negative metacognitions are activated as the rumination process leads to distress and/or as a result of what the individual learns about depression. Examples of negative metacognitions are: “I can’t control my thinking”, “My thoughts are caused by my defective brain”, “Sleeping more will sort out my mind”. and “Thinking like this means I could have a mental breakdown”. Negative metacognitions lead to more distress and to unhelpful behaviors that reduce effective coping.

Metacognitive therapy aims to eliminate the CAS and to modify erroneous metacognitive beliefs to enable the development of greater flexible reactions to negative internal events. It does so by using behavioral experiments and verbal reattribution (Wells and Matthews, 1996; Wells, 2009), targeted at metacognitive change and specific techniques such as the attention training technique, detached mindfulness and postponement of rumination. According to metacogntive therapy this will enhance flexible executive control, and through the process of therapy the patient learns new and more beneficial ways of relating to thoughts that act as triggers for rumination (Wells, 2009). To clarify the differences between CBT and MCT; CBT focus on the content of thoughts and invites the patient to reality test this content, while in MCT thinking processes are addressed (for further descriptions of differences and similarities confer Fisher and Wells, 2009).

A recent meta-analysis of MCT for anxiety and depression concluded that MCT is effective and superior to waiting list and possibly CBT (Normann et al., 2014). The review by Normann et al. (2014) included two treatment studies on depression (Nordahl, 2009; Wells et al., 2012), one postpartum depression study (Bevan et al., 2013) as well as results from an unpublished study. Within-group effect size for depression trials in the review was 2.18 (Hedges g) at post-treatment. However, only the Nordahl (2009) study was a randomized trial and the primary problem was not exclusively depression. A previous study on MCT for depression was not included in the review: Wells et al. (2009) described MCT for four depressed patients of which three were recovered at 6 months follow-up. Recovery in the Wells study (2009) was defined using Frank et al.’s (1991) criteria, consisting of no longer having a diagnosis of depression and a Beck Depression Inventory (BDI) score of 8 or less. Since the publication of the review of Normann et al. (2014), several studies on MCT for depression have been published (Jordan et al., 2014; Callesen et al., 2015; Dammen et al., 2015; Papageorgiou and Wells, 2015). These studies also used Frank et al.’s (1991) criteria. The study by Callesen et al. (2015) described the treatment of four depressed patients of which three of them were recovered. The group-MCT study by Dammen et al. (2015) reported that 91% of the patients recovered at follow-up. Another group-MCT study (Papageorgiou and Wells, 2015) included 10 antidepressant and CBT resistant depression patients, and found that 70% were recovered at post-treatment and follow-up. The reported effect size reported with Hedge’s g was 2.88 at end treatment and 2.50 et 6 months’ follow-up. However, the small sample size of all these studies limits the generalizability of these results.

In the only controlled study of MCT in depression, 23 depressed patients were treated with MCT and compared with 25 patients treated with CBT (Jordan et al., 2014). Jordan et al. (2014) found that MCT and CBT produced similar positive results on symptom measures, but MCT produced superior effects on improved executive control (Groves et al., 2015). The reported effect sizes using Cohen’s d for intention to treat were 1.12 for MCT at end treatment. However, there were limitations in this study including low power, greater comorbidity in the MCT condition, and a lack of formal therapist training in MCT.

In summary, current recommended approaches for depression are CBT and antidepressant medication which produce moderate success rates and are often associated with significant relapse or recurrence. The metacognitive approach offers promising opportunities for addressing these limitations of treatment by directly targeting rumination and its underlying mechanisms that are seen as essential in the development and maintenance of depression (Wells, 2009). The present randomized controlled trial includes a larger sample of patients treated with MCT, and metacognitive therapist competency was ensured through training and supervision. We compared MCT with a waiting list control, since treatment studies do not take into account spontaneous remission in depression, as demonstrated by a mean decrease of 10–15% in depressive symptoms for waiting list control groups (Posternak and Miller, 2001). Furthermore, a WL condition can provide control over the effects of repeated assessment, regression to the mean and the expectancy of receiving treatment (e.g., optimism). Our prediction was that MCT would lead to greater improvement in depressive symptoms than a waiting period of 10 weeks.

Introduction to Metacognitive Therapy

The definitive reference to metacognitive therapy is “Metacognitive Therapy for Anxiety and Depression” by Adrian Wells.