Managing rumination and worry: A pilot study of an internet intervention targeting repetitive negative thinking in Australian adults

Highlights

• Pilot trial of brief unguided internet intervention for rumination and worry.

• Large and significant reductions in rumination, worry, anxiety, and depression.

• Treatment effects maintained at 1-month follow-up.

• Online treatment program acceptable to participants (69.2% completion rate).

Abstract

Background

Rumination and worry, both forms of repetitive negative thinking (RNT), have been implicated in the onset, maintenance, severity, and relapse risk of depression and anxiety disorders. Despite promising initial findings for internet-delivered interventions targeting both rumination and worry simultaneously, no studies have investigated treatment effects in an adult population or when delivered in a brief, unguided format. We developed a 3-lesson unguided online treatment program targeting both rumination and worry and evaluated the adherence and effectiveness in Australian adults using an open pilot trial.

Methods

Adult participants (N=26) experiencing elevated levels of RNT completed the online program over 6-weeks. Outcomes were assessed at baseline, post-treatment, and 1-month follow-up. Intention-to-treat linear mixed models were used to examine effects on RNT, anxiety, depression, and general psychological distress.

Results

Of the 26 participants who started the program, 18 completed all three lessons (69.2% completion rate). Large within-subject effect sizes were found between pre- and post-treatment for RNT (Hedges’ g= 2.26) and symptoms of depression (g = 1.04), generalised anxiety (g = 1.82) and distress (g = 0.93). Treatment effects were maintained at 1-month follow-up.

Limitations

No long-term follow-up, exclusion of severely depressed individuals.

Conclusions

This is the first study to evaluate a brief, unguided internet intervention targeting both rumination and worry in adults. The results provide promising preliminary evidence for the feasibility and acceptability of the online program. Randomised controlled trials are needed to evaluate treatment efficacy compared to a control group and to investigate long-term outcomes.

Introduction

Rumination and worry are both forms of repetitive negative thinking (RNT), defined as repeatedly dwelling on negative feelings, situations, and events (Ehring and Watkins, 2008). Rumination refers to a repetitive, evaluative, and analytic cognitive style that generally focuses on the causes, meanings, and consequences of depressive symptoms and mood (Nolen-Hoeksema, 1998) while worry is typically defined as a “chain” of uncontrollable thoughts focused on possible or imagined future risks, uncertainties, and catastrophes as well as questioning how one would cope if these feared events did occur (Borkovec, 1994). Both have been implicated in the onset, maintenance, and severity of depression and anxiety disorders and shown to increase the likelihood of relapse following psychological treatment (e.g., Ehring and Watkins, 2008; Watkins and Roberts, 2020). Rumination and worry are transdiagnostic processes that often co-occur in the same individual (e.g., Watkins et al., 2005) and are associated with symptoms of both depression and anxiety (e.g., Segerstrom et al., 2000). Rumination and worry are highly correlated and share more similarities than differences. Indeed, the only consistently replicated variation between rumination and worry is thought content and temporal orientation; rumination is typically focused on the past and losses whereas worry is typically focused on the future and possible threats (e.g., Watkins, 2004; Watkins et al., 2005). Despite this, rumination and worry have generally been studied separately and within the context of depression and anxiety disorders, respectively.

A number of Cognitive Behaviour Therapy (CBT) based treatments specifically targeting RNT have been developed to reduce and prevent psychopathology, such as Rumination-focused Cognitive Behavioural Therapy (RFCBT; Watkins et al., 2007; Hvengaard et al., 2020; Cook et al., 2019), Metacognitive Therapy (Wells, 2009), and Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2002). Treatments for depression specifically targeting one form of RNT (e.g., RFCBT) have demonstrated significantly better treatment outcomes than those that do not target RNT (e.g., antidepressants, light therapy) (Spinhoven et al., 2018). However, existing RNT interventions targeted either rumination or worry rather than both RNT variants simultaneously, leaving room for improvement.

In the first study to target and measure both RNT variants, 251 Dutch adolescents and young adults (aged 15-22) with elevated levels of rumination and worry (but no current diagnoses of depression and/or generalised anxiety disorder) were randomly allocated to receive 6-weeks of RFCBT delivered in a face-to-face group format or individually via the internet with clinician support (i-RFCBT), or to a waitlist control condition (Topper et al., 2017). Relative to the waitlist control, both group-delivered and i-RFCBT significantly reduced RNT (between-group d = .53 to .89) and symptoms of depression and anxiety (d = .36 to .72), with treatment effects maintained at 12-month follow-up. There was no significant difference between the two active treatment conditions.

Similarly, Cook et al. (2019) randomly allocated 235 UK university students (aged 18-24) with elevated levels of rumination and worry but no current diagnoses of depression and/or generalised anxiety disorder to receive guided i-RFCBT or treatment as usual (TAU) control. Compared to TAU, guided i-RFCBT was significantly more effective at reducing rumination, worry, and symptoms of depression at 3 and 6 months, however, treatment gains were not maintained at 15-month follow-up. Interestingly, as a secondary objective, participants were also randomly allocated to an unguided i-RFCBT group to evaluate the feasibility and acceptability of that alternate format. Although, the authors did not make any direct comparison between the guided and unguided i-RFCBT groups, compliance rates were similar between the two groups, and the authors proposed preliminary proof of principle of the use of unguided i-RFCBT. Nevertheless, the absence of a direct comparison between the guided and unguided groups prevents any firm conclusions about their relative efficacy or adherence.

Together, this evidence suggests that interventions can simultaneously target both variants of RNT with corresponding reductions in depression and anxiety. These studies also demonstrate that RNT interventions may be effectively delivered via the internet. This is important as delivering treatment online overcomes a number of the well-documented social, logistical, economic, and geographical barriers to accessing face-to-face mental health treatment and has been shown to be as effective as face-to-face therapy, and more cost effective (Andrews et al., 2010; 2018; Spek et al., 2007; Andersson and Titov, 2014).

Despite the encouraging initial findings for internet-delivered RFCBT, the limited research to date has been conducted with adolescent and young-adult populations, and focused on evaluating preventative RNT interventions. No studies have evaluated programs targeting both rumination and worry in adults older than 25, including those currently experiencing depression and/or anxiety. Further, to our knowledge, no study has investigated the effectiveness of an internet-delivered intervention targeting both rumination and worry delivered in a brief, unguided (i.e., no therapist support) format for an adult sample. Whereas the scalability, accessibility, and cost-effectiveness of internet-interventions are reduced when delivered with clinician support, unguided internet interventions do not have these constraints and offer almost limitless scalability for wide-scale dissemination. It is thus important to evaluate whether unguided internet interventions targeting rumination and worry are associated with comparable treatment benefits. Mean completion rates in the Topper et al. (2017) and Cook et al. (2019) studies were also relatively low, with participants in the guided i-RFCBT conditions completing an average of 3.96 (SD = 1.65) and 3.46 (SD = 2.25) out of 6 sessions, respectively, and 2.66 sessions (SD = 2.35) in the unguided i-RFCBT condition. The evaluation of brief (i.e., < 6 sessions) interventions is thus also important as shorter programs may be more appealing to potential users and reduce treatment drop out.

To address these gaps, we developed a brief, unguided internet-delivered intervention specifically targeting both rumination and worry. This pilot study aimed to evaluate the acceptability and impact of the intervention program in reducing rumination and worry in Australian adults. Secondary aims were to evaluate changes anxiety, depression, general psychological distress, metacognitive beliefs about rumination and worry, program adherence, and to gain participant feedback to identify any refinements needed to the intervention prior to commencing a randomized controlled trial. We hypothesised that the program would significantly reduce participants’ self-reported levels of rumination, worry, general psychological distress, depression and generalised anxiety symptoms. We also hypothesised that the program would be acceptable to participants, as measured by completion rate, treatment satisfaction, and qualitative reports. To our knowledge, this is the first study to investigate the effects of a brief unguided, internet-delivered intervention targeting both rumination and worry in adults.