Emotion Regulation In Depression Research Articles

Shared and distinct prefrontal cortex alterations of implicit emotion regulation in depression and anxiety: An fNIRS investigation

BackgroundEmotion regulation deficits, particularly in cognitive reappraisal, are crucial in depression and anxiety. However, research on the neural mechanisms of implicit emotion regulation is lacking, and it remains unclear whether these mechanisms are shared or distinct between the two disorders. MethodsWe investigated the neural mechanisms of implicit cognitive reappraisal in 28 individuals with major depressive disorder (MDD), 25 with generalized anxiety disorder (GAD), and 30 healthy controls (HC) using functional near-infrared spectroscopy (fNIRS). Participants completed an implicit cognitive reappraisal task and underwent neuropsychological and clinical assessments. ResultsWe found that MDD patients reported higher levels of rumination and lower utilization of cognitive reappraisal, while GAD patients reported reduced use of perspective-taking. Notably, both MDD and GAD patients exhibited decreased activation in the dorsolateral prefrontal cortex (DLPFC) and orbitofrontal cortex (OFC) compared to HC participants during implicit cognitive reappraisal. Specifically, inadequate OFC activation was observed in MDD patients, while GAD patients demonstrated OFC deactivation during the task. Furthermore, DLPFC activation showed a negative correlation with depression severity in MDD patients, while OFC activation was positively correlated with perspective-taking in GAD patients. LimitationsfNIRS has limited depth and spatial resolution. ConclusionOur fNIRS study is the first to reveal shared and distinct neurobiological profiles of depression and anxiety in implicit emotion regulation. These findings underscore the significance of reduced DLPFC/OFC activation in emotion regulation impairment and highlight unique OFC activation patterns in these disorders. These insights have potential implications for developing cognitive-behavioral therapy and transcranial magnetic stimulation as treatment approaches.

Emotion Regulation in Depression of Physical Achievement Based on Machine Learning

Depression is a clinical disease, mainly accompanied by mood or emotional abnormalities, mainly depression, slow thinking, often accompanied by emotional abnormalities, cognitive behavior, psychophysiological and interpersonal changes or disorders. Here, using static and task-state MRI data, we present a comprehensive study of abnormal neural activity in patients with depression through spatiotemporal, static, and dynamic measures, demonstrating its validity as an underlying biological trait. In order to effectively study the role of emotion regulation in depression, a brain dynamic network synthesis method based on support vector machine model and community detection algorithm was established. We selected data on the mental state of 45 patients from a hospital’s psychiatric disease control center. They had no history of hearing impairment and normal (or corrected) vision. All procedures are agreed in writing by each participant. The results show that this method can effectively reduce the depression degree of the subjects, and the multi-level features of the integration of task activation and task regulation connection reach 81% ( < 0.0010, surrogate test) and 83% (<0.0016, surrogate test), respectively. The recovery of its depressive psychological state has a significant impact. Numerous studies have used various forms of emotional stimuli to reveal abnormal behaviors and neural responses in multi-channel emotional processing in patients with depression, providing valuable insights into the mechanism of multi-channel emotion regulation in depression.

Desired sadness, happiness, fear and calmness in depression: The potential roles of valence and arousal.

Prior research has shown that clinically depressed individuals are somewhat more motivated to feel sadness and less motivated to feel happiness than nondepressed individuals are. However, what underlies these patterns is not yet clear, as people may be motivated to experience positive (vs. negative) valence, high (vs. low) arousal, or discrete emotions. To test these possibilities, we assessed the motivation to experience emotions that capture different combinations of positive and negative valence and high and low arousal (i.e., sadness, happiness, fear and calmness) in 36 clinically depressed and 36 nondepressed college students (76% females, Mage = 24.5). We measured desired emotions by selections of emotional music clips and by the self-reported desirability of emotions. We found that both depressed and nondepressed individuals desired calmness the most across measures, and this desire was stronger among depressed individuals. We replicated prior findings, such that across measures, depressed individuals were relatively more motivated to feel sadness than nondepressed individuals were. Furthermore, whereas nondepressed individuals were motivated to listen to music clips and experience emotions that were positive (vs. negative) in valence, this was not necessarily the case among depressed individuals. Compared to nondepressed individuals, depressed individuals desired music that was relatively lower (vs. higher) in arousal, but reported a relatively stronger desire for negative (vs. positive) emotions. We discuss the implications of these findings for understanding motivated emotion regulation in depression. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Understanding the benefits of extrinsic emotion regulation in depression.

Depression is a serious psychiatric illness that negatively affects people's feelings, thoughts, and actions. Providing emotion regulation support to others, also termed Extrinsic Emotion Regulation (EER), reduces depressive symptoms such as perseverative thinking and negative mood. In this conceptual review paper, we argue that EER may be especially beneficial for individuals with depression because it enhances the cognitive and affective processes known to be impaired in depression. Behavioral studies have shown that EER recruits processes related to cognitive empathy, intrinsic emotion regulation (IER), and reward, all impaired in depression. Neuroimaging data support these findings by showing that EER recruits brain regions related to these three processes, such as the ventrolateral prefrontal cortex which is associated with IER, the ventral striatum, which is associated with reward-related processes, and medial frontal regions related to cognitive empathy. This conceptual review paper sheds light on the mechanisms underlying the effectiveness of EER for individuals with depression and therefore offers novel avenues for treatment.

Effects of depressive symptoms on regulating emotional goals: Preferences for distinct facial emotions

BackgroundAlthough many studies of emotion regulation in depression have focused on regulatory strategies, few have explored the goals of regulation. Regulatory strategies refer to methods of adjusting emotions, while regulatory goals refer to the desired states of emotion. According to situational selection strategy, individuals choose situations to regulate their emotions, and also selectively approach or avoid certain people. MethodsWe used the Beck Depression Inventory-II scale to classify healthy individuals into two groups: those with either high or low levels of depressive symptoms. We then explored the influence of these symptoms on individual goals for emotion regulation. Event-related potentials in the brain were recorded as participants viewed and selected images of happy, neutral, sad, and fearful faces. Participants also provided subjective emotional preferences. ResultsLate positive potential (LPP) amplitudes for all faces were smaller in the high depressive-symptom group than those in the low depressive-symptom group. Additionally, participants in the high depressive-symptom group chose to look at sad and fearful faces more often than they chose to view happy or neutral faces, and showed a stronger preference for sad and fearful emotions and a weaker preference for happy emotions. ConclusionThe results suggest that the more individuals exhibit depressive symptoms, the less likely that they will be motivated to approach happy faces and avoid sad and fearful faces. The result of this emotional regulation goal is an increase in the experience of negative emotions, which likely contributes to their depressive state.

Improved emotion regulation in depression following cognitive remediation: A randomized controlled trial

ObjectiveExecutive functions (EFs) play a key role in emotion regulation and, related to this, depression. Cognitive remediation (CR) targeting EFs, such as Goal Management Training (GMT) and computerized cognitive training (CCT), may reduce maladaptive emotion regulation. However, the clinical potential of GMT in the context of depression and emotion regulation remains to be tested. Hence, the primary aim of the present study was to compare effects of GMT with CCT on symptoms of emotion dysregulation. MethodThe paper reports the effects of a preregistered randomized controlled trial. Sixty-three participants (18–60yrs) with active or remitted depression and EF complaints were randomized to nine sessions of GMT (n = 35) or CCT (n = 28). All were assessed at baseline, post-intervention, and at 6-month follow-up. The Ruminative Response Scale and the Difficulties in Emotion Regulation Scale were employed to assess emotion regulation. ResultsBoth groups improved following the intervention on emotion regulation domains after controlling for intention-to-treat, including brooding rumination and on items reflecting non-accepting reactions to distress. Relative to CCT, the GMT-group demonstrated increased clarity of emotional responses in the per protocol analysis. ConclusionsOur findings demonstrate the potential of GMT and CCT in reducing maladaptive emotion regulation in depression.

Differential effects of faces and words in cognitive control in older adults with and without major depressive disorder: An emotional Stroop task study

Aging and major depressive disorders have been associated with impaired cognitive control. These deficits are also influenced by the affective valence and by the type of stimulus processed. Using an emotional Stroop task, the current study aims to examine cognitive control deficits and their association with emotion regulation in depression and the influence of the type of stimulus (words and faces) in this association. A total of 26 older patients with a major depressive disorder (MDD) (19 women; age range: 65–84 years) and 26 older healthy controls (18 women; age range: 65–80 years) participated in the study. The results showed that MDD individuals presented greater Stroop effects than their healthy controls and an absence of the conflict adaptation effect defined as a reduction of the influence of irrelevant stimulus dimensions after incongruent trials. Additionally, our results also showed that the processing of emotional words in depressed participants is more automatic than the processing of emotional faces. These findings suggest that older depressed individuals have greater difficulty in recognizing affective facial expressions than older healthy controls, while the over-learned behavior of word reading greatly reduces differences in the performance of the emotional Stroop task between groups (MDD and healthy controls).

Cognitive Control, Cognitive Biases and Emotion Regulation in Depression: A New Proposal for an Integrative Interplay Model.

Research traditions on cognition and depression focus on relatively unconnected aspects of cognitive functioning. On one hand, the neuropsychological perspective has concentrated on cognitive control difficulties as a prominent feature of this condition. On the other hand, the clinical psychology perspective has focused on cognitive biases and repetitive negative patterns of thinking (i.e., rumination) for emotional information. A review of the literature from both fields reveals that difficulties are more evident for mood-congruent materials, suggesting that cognitive control difficulties interact with cognitive biases to hinder cognitive switching, working memory updating, and inhibition of irrelevant information. Connecting research from these two traditions, we propose a novel integrative cognitive model of depression in which the interplay between mood-congruent cognitive control difficulties, cognitive biases, and rumination may ultimately lead to ineffective emotion-regulation strategies to downregulate negative mood and upregulate positive mood.

Effects of unilateral tDCS over left prefrontal cortex on emotion regulation in depression: Evidence from concurrent functional magnetic resonance imaging.

Major depressive disorder (MDD) is the most common mood disorder and a primary cause of disability worldwide. MDD symptomatology entails disturbances in emotion regulation, namely one's ability to modify the intensity and duration of emotional reactions towards affective events. Transcranial direct current stimulation (tDCS) has emerged as a promising treatment for MDD. Yet, positive tDCS outcomes vary across studies, while the precise effects of the procedure for cortical excitability in MDD during emotion regulation remain largely unexplored. Here, we leveraged functional magnetic resonance imaging (fMRI)-compatible tDCS technology to examine the functional consequences of a unilateral anodal tDCS montage at 1.5 mA over left PFC (area F3; with the reference electrode over an extracephalic location) for brain activity during an emotion-regulation task in MDD patients and age-matched healthy control subjects. Our results revealed down-regulation of negative emotions in the right amygdala and visual cortex of healthy controls but not MDD patients prior to stimulation, the degree of which correlated with the magnitude of the participants' reappraisal scores. TDCS did not elicit significant changes in neural activation patterns for either group. These findings contribute to the literature on the pathophysiology of MDD by showing that a key disturbance in the disorder entails the ineffective down-regulation of activity not only within the amygdala, but also within visual cortical areas in response to negative information. Further, these results suggest that relative to bifrontal tDCS montages, unilateral stimulation of moderate intensity over left PFC may not be sufficient to elicit therapeutic effects for MDD.

抑郁症中的情绪目标研究述评

情绪调节缺陷是抑郁症的特征之一。在相关领域的研究中，研究者主要聚焦于情绪调节策略的研究。基于情绪调节的动机取向，有研究者认为，为了理解抑郁症中的情绪调节，关注情绪目标也是有必要的。情绪目标是指人们想要达到的感觉，它决定了人们是否、何时以及如何调节情绪。因此，抑郁症中的情绪调节缺陷可能受到了所追求的情绪目标的影响。已有研究表明，抑郁症个体与非抑郁症个体对某些情绪的渴望程度有所不同，而且这种差异影响了情绪调节和心理健康。本文主要回顾了这些实验证据，对抑郁症个体的情绪目标相关研究进行了梳理并展望了未来的研究方向。 A defect in emotion regulation is one of the hallmarks of depression. In the research of related fields, researchers mainly focus on the study of emotion regulation strategies. Based on the motivational approach of emotion regulation, some researchers believe that it is necessary to focus on emotional goals in order to understand emotion regulation in depression. Emotional goals are feelings that people want to achieve and determine if, when, and how they regulate their emotions. Thus, deficiencies in emotion regulation in depression may be influenced by the emotional goals which are pursued. Studies have shown that depressed individuals and non-depressed individuals have different levels of desire for certain emotions, and this difference affects emotion regulation and mental health. This paper mainly reviews the experimental evidence, sorts out the relevant researches on emotional goals of depressed individuals, and looks forward to the future research direction.

Emotion Regulation in Context: Social Connectedness Moderates Concurrent and Prospective Associations With Depressive Symptoms

Introduction: Emotion regulation in healthy functioning and in depression is typically examined as an intrapersonal phenomenon, but growing evidence suggests social factors affect individuals' strategy use and effectiveness. We examined whether the role of emotion regulation in depression—concurrently and over four weeks—depends on social connectedness, predicting that higher social connectedness would dilute effects of one's own strategy use regardless of specific strategy. Methods: Young adult participants (n = 187) completed measures of perceived social connectedness, depressive symptoms, two avoidant emotion regulation strategies (ruminative brooding and experiential avoidance), and two approach-oriented strategies (positive reappraisal and planning), and depressive symptoms again four weeks later (n = 166). Results: Cross-sectional associations of emotion regulation with symptoms were moderated by social connectedness: effects of both avoidant and approach strategies were weaker among more connected individuals. Prospectively, social connectedness moderated effects of approach strategies, but not avoidant strategies. Among more socially connected individuals, using approach strategies—which are typically adaptive—was associated with higher symptoms over time. Discussion: Results partially replicate previous research and support the role of social factors as important contexts of intraper-sonal emotion regulation and dysregulation in depression. Findings suggest that social resources can dilute intrapersonal effects regardless of strategy type—more in the shorter term than in the longer term—and can even lead seemingly adaptive strategies to backfire over time. Implications for research integrating emotion regulation, relationships, and depressive psychopathology are discussed.

Attention control and its emotion-specific association with cognitive emotion regulation in depression.

Individuals with major depression show impaired control of attention and emotions. Both processes are conceptually similar and might share common mechanisms. The current study aims to examine attention control and its association with cognitive emotion regulation in depression. 26 patients with a history of major depression (14 females) and 26 healthy controls (14 females) performed an emotional face-word Stroop task and a cognitive emotion regulation task while undergoing fMRI. Patients and controls showed a similar behavioral performance in both tasks. Across groups, participants who were less distracted from happy faces by the incongruent word "sadness" (Stroop task) were better at regulating their happiness (emotion regulation task). Notably, both the Stroop and emotion regulation task recruited the left supramarginal gyrus. Additionally, only patients showed a relative attentional disengagement from positive compared to negative stimuli in the Stroop task. Attention control and cognitive emotion regulation capabilities appear to be linked at both the behavioral and neural level. Shared mechanisms suggest that emotional disturbances in depression may be improved by interventions that target attention control, particularly regarding the processing of positive stimuli.

Motivations to Experience Happiness or Sadness in Depression: Temporal Stability and Implications for Coping With Stress

Difficulties with emotion regulation in depression may be linked not only to emotion regulation strategies but also to the motivation to experience certain emotions. We assessed the degree of motivation to experience happiness or sadness in major depressive disorders outside the laboratory and prospective links to clinical outcomes over time. Depressed individuals were consistently less motivated to experience happiness and more motivated to experience sadness than nondepressed individuals. The less motivated participants were to experience happiness, the less they tried to upregulate happiness in an emotion regulation task and downregulate negative emotions during real-life stress. Importantly, the less motivated depressed participants were to experience happiness, the more clinical symptoms they exhibited months later during a stressful period, even after controlling for initial levels of symptoms. These findings demonstrate that individual differences in the degree of motivation to experience happiness in depression may carry clinical implications.

Clinical pilot study of transcranial direct current stimulation combined with Cognitive Emotional Training for medication resistant depression

BackgroundWhile the clinical results from transcranial direct current stimulation (tDCS) for the treatment of depression have been promising, antidepressant effects in patients with medication resistance have been suboptimal. There is therefore a need to further optimise tDCS for medication resistant patients. In this clinical pilot study we examined the feasibility, safety, and clinical efficacy of combining tDCS with a psychological intervention which targets dysfunctional circuitry related to emotion regulation in depression, Cognitive Emotional Training (CET). MethodstDCS was administered during CET three times a week for a total of 18 sessions over 6 weeks. Mood, cognition and emotion processing outcomes were examined at baseline and after 3 and 6 weeks of treatment. ResultsTwenty patients with medication resistant depression participated, of whom 17 were study completers. tDCS combined with CET was found to be feasible, safe, and associated with significant antidepressant efficacy at 6 weeks, with 41% of study completers showing treatment response (≥ 50% improvement in depression score). There were no significant cognitive enhancing effects with the exception of improved emotion recognition. Responders demonstrated superior recognition for the emotions fear and surprise at pre-treatment compared to non-responders, suggesting that better pre-treatment emotion recognition may be associated with antidepressant efficacy. LimitationsThis was an open label study. ConclusionstDCS combined with CET has potential as a novel method for optimising the antidepressant efficacy of tDCS in medication resistant patients. Future controlled studies are required to determine whether tDCS combined with CET has greater antidepressant efficacy compared to either intervention alone.

Cognition and Emotion: The Cognitive Regulation of Emotions : A Review

One of life’s great challenges is successfully regulating emotions (Gross, 2002). The topic of emotion regulation has been of interest since Freud (1923) began to examine the relationship between the control of affective impulses and psychic health ( Krohne et al., 2002) . The emerging field of emotion regulation studies how individuals influence which emotions they have, when they have them, and how they experience and express them. Emotion regulation is defined and distinguished from coping, mood regulation, defense, and affect regulation (Gross, 1998). Many studies have been conducted in the field of cognition and emotion; e.g., emotion regulation: Past, present, future (Gross, 1999), the cognitive regulation of emotions: The role of success versus failure experience and coping dispositions (Krohne et al., 2002), the cognitive control of emotion (Ochsner and Gross, 2005), relationships between cognitive emotion regulation strategies and depressive symptoms: A comparative study of five specific samples, (Garnefski and Kraaij, 2002), incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders (Campbell-Sills et al., 2007), healthy and unhealthy emotion regulation: Personality processes, individual differences, and life span development (John and Gross, 2004), emotion regulation in adulthood: Timing is everything (Gross, 2001 ),emotional states, attention, and working memory. Emotion regulation in depression: Relation to cognitive inhibition (Joormann and Gotlib, 2010), individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being (Gross and John, 2003), mindfulness and emotion regulation: The development and initial validation of the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R)(Laurenceau, 2007), regulation of distress and negative emotions: A developmental view (Kopp, 1989), basic emotions, relations among emotions, and emotion-cognition relations (Izard, 1992), emotional reactivity and cognitive regulation in anxious children, (Carthy, 2010)

Quadratic Associations Between Empathy and Depression as Moderated by Emotion Dysregulation

ABSTRACTEmpathic tendencies have been associated with interpersonal and psychological benefits, but empathy at extreme levels or in combination with certain personal characteristics may contribute to risk for depression. This study tested the moderating role of cognitive emotion regulation in depression's association with empathy using nonlinear models. Young adults (N = 304; 77% female; M = 19 years) completed measures of cognitive emotion regulation strategies, depression, and affective and cognitive empathy. Individuals with good regulation had low levels of depression overall and their depression symptoms were lowest when levels of affective empathy were average. Individuals with poor regulation had high levels of depression overall, particularly when levels of empathy were moderate to high. Extremely high and low levels of cognitive empathy were associated with elevated depression, and this association was not moderated by regulation. These findings suggest tendencies to respond empathically to others’ needs is neither an adaptive nor maladaptive characteristic but rather moderate empathy, particularly in the context of good regulation, may offer the greatest protection against depression.

Resting-state functional connectivity modulation and sustained changes after real-time functional magnetic resonance imaging neurofeedback training in depression.

Amygdala hemodynamic responses to positive stimuli are attenuated in major depressive disorder (MDD) and normalize with remission. Real-time functional magnetic resonance imaging neurofeedback (rtfMRI-nf) training with the goal of upregulating amygdala activity during recall of happy autobiographical memories (AMs) has been suggested, and recently explored, as a novel therapeutic approach that resulted in improvement in self-reported mood in depressed subjects. In this study, we assessed the possibility of sustained brain changes as well as the neuromodulatory effects of rtfMRI-nf training of the amygdala during recall of positive AMs in MDD and matched healthy subjects. MDD and healthy subjects went through one visit of rtfMRI-nf training. Subjects were assigned to receive active neurofeedback from the left amygdale (LA) or from a control region putatively not modulated by AM recall or emotion regulation, that is, the left horizontal segment of the intraparietal sulcus. To assess lasting effects of neurofeedback in MDD, the resting-state functional connectivity before and after rtfMRI-nf in 27 depressed subjects, as well as in 27 matched healthy subjects before rtfMRI-nf was measured. Results show that abnormal hypo-connectivity with LA in MDD is reversed after rtfMRI-nf training by recalling positive AMs. Although such neuromodulatory changes are observed in both MDD groups receiving feedback from respective active and control brain regions, only in the active group are larger decreases of depression severity associated with larger increases of amygdala connectivity and a significant, positive correlation is found between the connectivity changes and the days after neurofeedback. In addition, active neurofeedback training of the amygdala enhances connectivity with temporal cortical regions, including the hippocampus. These results demonstrate lasting brain changes induced by amygdala rtfMRI-nf training and suggest the importance of reinforcement learning in rehabilitating emotion regulation in depression.

Emotion Regulation in Depression

Sustained negative affect and difficulties experiencing positive affect are hallmark features of major depressive disorder. Recent research has suggested that difficulties in emotion regulation are at the core of these cardinal symptoms of major depressive disorder; depressed patients exhibit more frequent use of maladaptive emotion regulation and difficulties effectively implementing adaptive strategies. It remains unclear, however, what underlies these difficulties in emotion regulation. Cognitive theories of depression have a long tradition of focusing on cognitive factors that increase depression risk and maintain depressive episodes, but the link between cognitive and affective aspects of major depressive disorder remains to be explored. We propose that cognitive biases and deficits in cognitive control putatively associated with depression affect emotion regulation in critical ways, thereby setting the stage for maintained negative affect and diminished levels of positive affect. We close with a discussion of implications for treatment and future directions for research in this area.

Emotion Regulation in Depression and Anxiety: Examining Diagnostic Specificity and Stability of Strategy Use

Many psychological disorders are characterized by difficulties in emotion regulation. It is unclear, however, whether different disorders are associated with the use of specific emotion regulation strategies, and whether these difficulties are stable characteristics that are evident even after recovery. It is also unclear whether the use of specific strategies is problematic across all disorders or whether disorders differ in how strongly strategy use is associated with symptom severity. This study investigated (1) the specificity of use of emotion regulation strategies in individuals diagnosed with current major depressive disorder (MDD), with social anxiety disorder (SAD), and in never-disordered controls (CTL); and (2) the stability of strategy use in formerly depressed participants (i.e., remitted; RMD). Path analysis was conducted to examine the relation between strategy use and symptom severity across diagnostic groups. Compared to the CTL group, participants in both clinical groups endorsed more frequent use of rumination and expressive suppression, and less frequent use of reappraisal. Specific to SAD were even higher levels of expressive suppression relative to MDD, as well as a stronger relation between rumination and anxiety levels. In contrast, specific to MDD were even higher levels of rumination and lower levels of reappraisal. Interestingly, elevated rumination, but not decreased reappraisal, was found to be a stable feature characterizing remitted depressed individuals. These results may provide insight into ways in which emotion regulation strategy use maintains psychological disorders.

Emotion Regulation in Depression: Reflection Predicts Recovery from a Major Depressive Episode

Little is known about the relation between individual differences in emotion regulation (ER) and the maintenance of clinical depression. This study examined whether frequency of use of four ER strategies (i.e., cognitive reappraisal, expressive suppression, reflection, and brooding) predicts recovery from a major depressive episode. At an initial appointment (Time 1), participants diagnosed with current major depressive disorder completed measures assessing symptom severity and use of ER strategies. Six months later (Time 2), participants were reassessed to determine diagnostic status (i.e., recovered or non-recovered). Results demonstrated that, after controlling for symptom severity, use of ER strategies predicted recovery status at Time 2. Specifically, use of reflection at Time 1 was a unique and significant predictor of greater chance for recovery. Results indicate that ER strategies may be utilized to predict long-term symptom maintenance and provide support for the proposition that reflection may be used adaptively among individuals diagnosed with depression.