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Depression is common psychological disorders with around 15% of people suffering form it during a lifetime. Depression can present with a variety of symptoms, such as marked low mood, a deep feeling of sadness, and a noticeable loss of interest or pleasure in favourite activities. Other symptoms may include loss of appetite and/or weight loss, or conversely overeating and weight gain, insomnia, early-morning awakening, or oversleeping, restlessness, feelings of worthlessness or guilt, hopelessness, rumination, difficulty thinking or concentrating or making decisions.

Often depression manifests clinically as persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain. In more severe cases of depression thoughts of death or suicide or attempts at suicide may occur. Depression in children is often difficult to diagnose having more somatic symptoms, which are easily missed as depression and thus go untreated.

The severity of symptoms varies widely among individuals and not everyone presents every symptom. The symptoms must persist for at least two weeks before being considered clinical depression, with the exception of suicidal thoughts or attempts, where you instantly should get treatment. There are a lot of subtypes of depression, a common one is Major Depressive Disorder that can be divided into mild, moderate or severe forms depending on disability and number of criteria fulfilled in the diagnosis.

In diagnosing depression, a complete medical examination should first be conducted, to rule out any possible physical causes for the depressive symptoms. If no such cause is found, a psychological evaluation should be done including a complete history of symptoms, assessment of alcohol and drug abuse, and the patient’s level of suicidal thoughts or wishes about ending his or her life. The evaluation should include a family medical history to see if other family members suffer from any form of depression or similar mood disorder.


There are several forms of treatments that may be used for depression. In most cases drug therapy is used with Selective Serotonin Re-uptake Inhibitors (SSRI's) or Tricyclic antidepressants (TCA). The most effective psychological treatments are Cognitive Behaviour therapy and Interpersonal therapy. Promising results have also been obtained with Behavioural Activation Therapy. These are highly structured psychological treatments that can be applied to most depressive disorders. In addition there are some new forms of treatment, such as Mindfulness-Based Cognitive Therapy and Metacognitive therapy that look promising and may offer some advantages over other treatments.

Metacognitive therapy

Metacognitive therapy for depression is based on the idea that depression is maintained by unhelpful and difficult to control thinking patterns dominated by rumination and excessive self-focused attention on thoughts and feelings.

The person has learned positive assumptions (positive metacognitive beliefs) about the need to ruminate as a means of overcoming depressed feelings and finding answers to problems, but over time develops negative beliefs (negative metacognitive beliefs) about the uncontrollability or danger of rumination. Eventually the person is no longer aware of the quantity and role of rumination and the significance of rumination for sustaining depressive symptoms. An example of positive metacognitive beliefs is “Thinking about the causes of depression will help me to prevent it•, a belief which sustain rumination.

Thus, depression is maintained and intensified by activation of rumination and patterns of attention. However, dysfunctional behaviour in response to thoughts and feelings of sadness also play an important role in keeping depression going. In particular sufferers tend to reduce their activities and may spend more time withdrawing from people and from work. This gives more space for rumination and for unhelpful dwelling on thoughts and feelings.

Eventually negative metacognitive beliefs about thinking and depression develop and these make it more difficult to switch out of unhelpful patterns of rumination and behaviour. Examples of negative metacognitions are “There’s nothing I can do about my thoughts•, “My depression is beyond my control•. Other negative beliefs about rumination concern the idea that it is an indication that there is a biological problem in one’s brain, especially when patients are unable to find a reason for feeling depressed.

Treatment incorporates Attention Training (ATT) as a means of increasing awareness of thinking and regaining flexible control over it. The programmed practice of ATT also serves to counteract depressive inertia by providing a discreet set of daily exercises. To find out more check out our ATT fact-sheet. MCT also focuses on reducing rumination and unhelpful coping behaviours. It modifies positive and negative metacognitive beliefs about rumination. Treatment typically ranges from 5-12 sessions. Uncontrolled preliminary studies suggest that the treatment may be effective in up to 70% of patients with clinical depression, but further studies are required.

MCT References

Papageorgiou C & Wells A (2000). Treatment of recurrent major depression with Attention Trianing. Cognitive and Behavioral practise, 7, 407-413.

Wells A & Papageorgiou C (2004). Metacognitive therapy for depressive rumination: In C Papageorgiou & A Wells (eds). Depressive Rumination: Nature, Theory and Treatment. Chichester, UK: Wiley.

Wells A, Fisher P.L., Myers, S., Wheatley, J., Patel, T. & Brewin C.R. (2008). Metacognitive therapy in recurrent and persistent depression: A multiple-baseline study of a new treatment. Cognitive Therapy and Research (DOI: 10.1007/s10608-007-9178-2).

Wells A (2008). Metacognitive Therapy for Anxiety and Depression: New York: Guilford Press.