Background: Deficits in emotion regulation skills are possible factors maintaining major depressive disorder (MDD). Therefore, the aim of the study was to test whether integrating a systematic emotion regulation training (ERT) enhances the efficacy of routine inpatient cognitive behavioral therapy (CBT) for MDD. Methods: In a prospective randomized controlled trial, 432 inpatients meeting criteria for MDD were assigned to receive either routine CBT or CBT enriched with an intense emotion regulation skills training (CBT-ERT). Results: Participants in the CBT-ERT condition demonstrated a significantly greater reduction in depression (response rates - CBT: 75.5%, CBT-ERT: 84.9%; remission rates - CBT: 51.1%, CBT-ERT: 65.1%). Moreover, CBT-ERT participants demonstrated a significantly greater reduction of negative affect, as well as a greater increase of well-being and emotion regulation skills particularly relevant for mental health. Conclusions: Integrating strategies that target emotion regulation skills improves the efficacy of CBT for MDD.

1.
Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR: The epidemiology of major depressive disorder. Results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095-3105.
2.
Kupfer DJ: Long-term treatment of depression. J Clin Psychiatry 1991;52(suppl):28-42.
3.
Eaton WW, Shao H, Nestadt G, Lee HB, Bienvenu OJ, Zandi P: Population-based study of first onset and chronicity in major depressive disorder. Arch Gen Psychiatry 2008;65:513-520.
4.
Üstün TB, Ayuso-Mateos JL, Chatterji S, Mathers C, Murray CJ: Global burden of depressive disorders in the year 2000. Br J Psychiatry 2004;184:386-392.
5.
Kelley JM, Kaptchuk TJ, Cusin C, Lipkin S, Fava M: Open-label placebo for major depressive disorder: a pilot randomized controlled trial. Psychother Psychosom 2012;81:312-314.
6.
Smits JJ, Minhajuddin A, Thase ME, Jarrett RB: Outcomes of acute phase cognitive therapy in outpatients with anxious versus nonanxious depression. Psychother Psychosom 2012;81:153-160.
7.
Hofmann SG, Asnaani A, Vonk JJ, Sawyer AT, Fang A: The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res 2012;36:427-440.
8.
Cuijpers P, van Straten A, Andersson G, van Oppen P: Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J Consult Clin Psychol 2008;76:909-922.
9.
Casacalenda N, Perry JC, Looper K: Remission in major depressive disorder: a comparison of pharmacotherapy, psychotherapy, and control conditions. Am J Psychiatry 2002;159:1354-1360.
10.
Härter M, Sitta P, Keller F, Metzger R, Wiegand W, Schell G: Stationäre psychiatrisch-psychotherapeutische Depressionsbehandlung: Prozess- und Ergebnisqualität anhand eines Modellprojekts in Baden-Württemberg. Nervenarzt 2004;11:1083-1091.
11.
Paykel ES, Ramana R, Cooper Z, Hayhurst H, Kerr J, Barock A: Residual symptoms after partial remission: an important outcome in depression. Psychol Med 1995;25:1171-1180.
12.
Thase ME, Simons AD, McGeary J: Relapse after cognitive behavior therapy of depression: potential implications for longer courses of treatment. J Psychiatr Res 1992;149:1046-1052.
13.
Vittengl JR, Clark LA, Dunn TW, Jarrett RB: Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects. J Consult Clin Psychol 2007;75:475-488.
14.
Andrews G, Issakidis C, Sanderson K, Corry J, Lapsley H: Utilizing survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders. Br J Psychiatry 2004;184:526-533.
15.
Gross JJ, Muñoz RF: Emotion regulation and mental health. Clin Psychol Sci Prac 1995;2:151-164.
16.
Hofmann SG, Sawyer AT, Fang A, Asnaani A: Emotion dysregulation model of mood and anxiety disorders. Depress Anxiety 2012;29:409-412.
17.
Hollon SD, Thase ME, Markowitz JC: Treatment and prevention of depression. Psychol Sci Public Interest 2002;3:1-39.
18.
Thompson RA: Emotion regulation: a theme in search of definition. Monogr Soc Res Child 1994;59:25-52.
19.
Berking M: Training Emotionaler Kompetenzen. Heidelberg, Springer, 2010 (English translation: The Affect Regulation Training. New York, Springer, in press).
20.
Honkalampi K, Saarinen P, Hintikka J, Virtanen V, Viinamäki H: Factors associated with alexithymia in patients suffering from depression. Psychother Psychosom 1999;68:270-275.
21.
Rude S, McCarthy C: Emotional functioning in depressed and depression-vulnerable college students. Cogn Emot 2003;17:799-806.
22.
Brody CL, Haag DAF, Kirk L, Solomon A: Experiences of anger in people who have recovered from depression and never-depressed people. J Nerv Ment Dis 1999;187:400-405.
23.
Campbell-Sills L, Barlow DH, Brown TA, Hofmann SG: Effects of suppression and acceptance on emotional responses of individuals with anxiety and mood disorders. Behav Res Ther 2006;44:1251-1263.
24.
Conway M, Csank PA, Holm SL, Blake CK: On assessing individual differences in rumination on sadness. J Pers Assess 2000;75:404-425.
25.
Hayes SC, Strohsal KD, Wilson KG, Bissett RT, Pistorello J, Toarmino D: Measuring experiential avoidance: a preliminary test of a working model. Psychol Rec 2004;54:553-578.
26.
Gilbert P, Baldwin M, Irons C, Baccus J, Clark M: Self-criticism and self-warmth: an imagery study exploring their relation to depression. J Cogn Psychother 2006;20:183-200.
27.
Hofmann SG, Grossman P, Hinton DE: Loving-kindness and compassion meditation: potential for psychological interventions. Clin Psychol Rev 2011;31:1126-1132.
28.
Catanzaro SJ, Wasch HH, Kirsch I, Mearns J: Coping-related expectancies and dispositions as prospective predictors of coping responses and symptoms. J Pers 2000;68:757-788.
29.
Ehring T, Fischer S, Schnuelle J, Boesterling A, Tuschen-Caffier B: Characteristics of emotion regulation in recovered depressed versus never depressed individuals. Pers Individ Dif 2008;44:1574-1584.
30.
Kassel JD, Bornovalova M, Mehta N: Generalized expectancies for negative mood regulation predict change in anxiety and depression among college students. Behav Res Ther 2007;45:939-950.
31.
Aldao A, Nolen-Hoeksema S, Schweizer S: Emotion-regulation strategies across psychopathology. A meta-analytic review. Clin Psychol Rev 2010;30:217-237.
32.
Garnefski N, Kraaij V: Relationships between cognitive emotion regulation strategies and depressive symptoms: a comparative study of five specific samples. Pers Individ Dif 2006;40:1659-1669.
33.
Berking M, Wupperman P: Emotion regulation and health: state of the art. Curr Opin Psychiatry 2012;25:128-134.
34.
Moulds ML, Kandris E, Starr S, Wong AC: The relationship between rumination, avoidance and depression in a non-clinical sample. Behav Res Ther 2007;45:251-261.
35.
Aldao A, Nolen-Hoeksema S: When are adaptive strategies most predictive of psychopathology? J Abnorm Psychol 2012;121:276-281.
36.
Kraaij V, Pruymboom E, Garnefski N: Cognitive coping and depressive symptoms in the elderly: a longitudinal study. Aging Ment Health 2002;6:275-281.
37.
Seiffge-Krenke I: Causal links between stressful events, coping style, and adolescent symptomatology. J Adolesc 2000;23:675-691.
38.
McLaughlin KA, Hatzenbuehler ML, Mennin DS, Nolen-Hoeksema S: Behaviour research and therapy emotion dysregulation and adolescent psychopathology: a prospective study. Behav Res Ther 2011;49:544-554.
39.
Peeters F, Nicolson NA, Berkhof J, Delespaul P, deVries M: Effects of daily events on mood states in major depressive disorder. J Abnorm Psychol 2003;112:203-211.
40.
O'Neill SC, Cohen LH, Tolpin LH, Gunthert KC: Affective reactivity to daily interpersonal stressors as a prospective predictor of depressive symptoms. J Soc Clin Psychol 2004;23:172-194.
41.
Cohen LH, Gunthert KC, Butler AC, O'Neill SC, Tolpin LH: Daily affective reactivity as a prospective predictor of depressive symptoms. J Pers 2005;73:1687-1714.
42.
Backenstrass M, Schwarz T, Fiedler P, Joest K, Reck C, Mundt C: Negative mood regulation expectancies, self-efficacy beliefs, and locus of control orientation: moderators or mediators of change in the treatment of depression? Psychother Res 2006;16:250-258.
43.
Ehring T, Tuschen-Caffier B, Schnuelle J, Fischer S, Gross JJ: Emotion regulation and vulnerability to depression: spontaneous versus instructed use of emotion suppression and reappraisal. Emotion 2010;10:563-572.
44.
Liverant GI, Brown TA, Barlow DH, Roemer L: Emotion regulation in unipolar depression: the effects of acceptance and suppression of subjective emotional experience on the intensity and duration of sadness and negative affect. Behav Res Ther 2008;46:1201-1209.
45.
Morrow J, Nolen-Hoeksema S: Effects of responses to depression on the remediation of depressive affect. Pers Soc Psychol 1990;58:519-527.
46.
Greenberg LS, Watson JC: Emotion-focused therapy for depression. Washington, American Psychological Association, 2006.
47.
Linehan MM: Cognitive-behavioral treatment of borderline personality disorder. New York, Guilford, 1993.
48.
Grosse Holtforth M, Hayes AM, Sutter M, Wilm K, Schmied E, Laurenceau J-P, Caspar F: Fostering cognitive-emotional processing in the treatment of depression: a preliminary investigation in exposure-based cognitive therapy. Psychother Psychosom 2012;81:259-260.
49.
Ellison JA, Greenberg LS, Goldman RN, Angus L: Maintenance of gains following experiential therapies for depression. J Consult Clin Psychol 2009;77:103-112.
50.
Greenberg LS, Watson JC: Experiential therapy for depression: differential effects of client-centered relationship conditions and process experiential interventions. Psychother Res 1998;8:210-224.
51.
Goldman RN, Greenberg LS, Angus L: The effects of adding specific emotion-focused interventions to the therapeutic relationship in the treatment of depression. Psychother Res 2006;16:536-546.
52.
Harley R, Sprich S, Safren S, Jacobo M, Fava M: Adaptation of dialectical behavior therapy skills training group for treatment-resistant depression. J Nerv Ment Dis 2008;196:136-143.
53.
Lynch TR, Morse JQ, Mendelson T, Robins CJ: Dialectical behavior therapy for depressed older adults: a randomized pilot study. Am J Geriatr Psychiatry 2003;11:33-45.
54.
Watson JC, Gordon LB, Stermac L, Kalogerakos F, Steckley P: Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression. J Consult Clin Psychol 2003;71:773-781.
55.
Berking M, Wupperman P, Reichardt A, Pejic T, Dippel A, Znoj H: General emotion-regulation skills as a treatment target in psychotherapy. Behav Res Ther 2008;46:1230-1237.
56.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4, rev. Washington, APA, 2000.
57.
Wittchen HU, Zaudig M, Fydrich T: SKID-I/II Strukturiertes Klinisches Interview für DSM-IV. Göttingen, Hogrefe, 1997.
58.
Beck AT, Rush AJ, Shaw BF, Hautzinger M: Kognitive Therapie der Depression, ed 2. Weinheim, Beltz, 2001.
59.
Barlow DH, Farchione TJ, Fairholme CP, Ellard KK, Boisseau CL, Allen LB, Ehrenreich- May J: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide. New York, Oxford University Press, 2011.
60.
Lewinsohn PM: A behavioral approach to depression; in Friedman RJ, Katz MM (eds): Innovative Treatment Methods of Psychopathology. New York, Wiley, 1974, pp 88-102.
61.
Nezu AM, Nezu CM, Perri MG: Problem-Solving Therapy for Depression: Therapy, Research, and Clinical Guidelines. New York, Wiley, 1989.
62.
Barlow DH: Clinical Handbook of Psychological Disorders: A Step-By-Step Treatment Manual, ed 4. New York, Guilford Press, 2008.
63.
Bogdan R, Pizzagalli D: Acute stress reduces reward responsiveness: implications for depression. Biol Psychiatry 2006;60:1147-1154.
64.
Berking M, Schwarz J: The affect regulation training; in Gross JJ (ed): Handbook of Emotion Regulation. New York, Guilford, in press.
65.
Berking M, Meier C, Wupperman P: Enhancing emotion-regulation skills in police officers - results of a controlled study. Behav Ther 2010;41:329-339.
66.
Kabat-Zinn J: Mindfulness-based intervention in context: past, present and future. Clin Psychol Sci Prac 2003;10:144-156.
67.
Nezu A, D'Zurilla T, Zwick M, Nezu C: Problem-solving therapy for adults; in Chang E, D'Zurilla T, Lawrence S (eds): Social Problem Solving: Theory, Research, and Training. Washington, American Psychological Association, 2004, pp 171-191.
68.
Hautzinger M, Bailer M, Worall H, Keller F: BDI. Beck-Depressions-Inventar von A. T. Beck. Göttingen, Hogrefe, 1995.
69.
Brown C, Herbert C, Madonia MJ: Assessment depression in primary care practice with the Beck Depression Inventory and the Hamilton Rating Scale for Depression. Psychol Assess 1995;7:59-65.
70.
Herrmann C, Buss U: Vorstellung und Validierung einer deutschen Version der Hospital Anxiety and Depression Scale (HAD-Skala). Diagnostica 1994;40:143-154.
71.
Rabung S, Harfst T, Koch U, Wittchen HU, Schulz H: Hamburger Module zur Erfassung allgemeiner Aspekte psychosozialer Gesundheit für die therapeutische Praxis (HEALTH) - psychometrische Überprüfung eines neuen Selbstbeurteilungsinstruments zur multidimensionalen Erfassung psychosozialer Gesundheit. Phys Med Rehab Kuror 2007;17:133-140.
72.
Rabung S, Harfst T, Kawski S, Koch U, Wittchen HU, Schulz H: Psychometrische Überprüfung einer verkürzten Version der ‘Hamburger Module zur Erfassung allgemeiner Aspekte psychosozialer Gesundheit für die therapeutische Praxis (HEALTH-49)' . Z Psychosom Med 2009;55:162-179.
73.
Gross JJ: The emerging field of emotion regulation: an integrative review. Rev Gen Psychol 1998;2:271-299.
74.
Larsen RJ: Toward a science of mood regulation. Psychol Inq 2000;11:129-140.
75.
Mayer JD, Salovey P: Emotional intelligence and the construction and regulation of feelings. Appl Prev Psychol 1995;4:197-208.
76.
Saarni C: The Development of Emotional Competence. New York, Guilford, 1999.
77.
Berking M, Margraf M, Ebert D, Wuppermann P, Hofmann S, Junghanns K: Emotion regulation skills as a predictor of relapse during and after treatment of alcohol dependence. J Consult Clin Psychol 2011;79:307-318.
78.
Berking M, Poppe C, Wuppermann P, Luhmann M, Ebert D, Seifritz E: Emotion-regulation skills and psychopathology: is the ability to modify one's negative emotions the ultimate pathway by which all other skills affect symptoms of mental disorders? J Behav Ther Exp 2012;43:931-937.
79.
Berking M, Orth U, Wupperman P, Meier L, Caspar F: Prospective effects of emotion regulation on emotional adjustment. J Couns Psychol 2008;55:485-494.
80.
Berking M, Znoj H: Entwicklung und Validierung eines Fragebogens zur standardisierten Selbsteinschatzung emotionaler Kompetenzen (SEK-27). Z Psychiatr Psychol Psychother 2008;56:141-152.
81.
Ebert D, Christ O, Berking M: Entwicklung und Validierung eines Fragebogens zur emotionsspezifischen Selbsteinschätzung emotionaler Kompetenzen (SEK-ES). Diagnostica, in press.
82.
Krohne HW, Egloff B, Kohlmann CW, Tausch A: Untersuchungen mit einer deutschen Version der ‘Positive and Negative Affect Schedule' (PANAS). Diagnostica 1996;42:139-156.
83.
Raudenbush SW, Bryk AS: Hierarchical Linear Models: Applications and Data Analysis Methods, ed 2. Newbury Park, Sage Publication, 2002.
84.
Jacobson NS, Truax P: Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 1991;59:12-19.
85.
Riedel M, Moller HJ, Obermeier M, Schennach-Wolff R, Bauer M, Adli M: Response and remission criteria in major depression - a validation of current practice. J Psychiatr Res 2010;44:1063-1068.
86.
Tomba E: Nowhere patients. Psychother Psychosom 2012;81:69-72.
87.
Cohen J: Statistical Power Analysis for the Behavioral Sciences, ed 2. Hillsdale, Erlbaum, 1988.
88.
Gilbert P: Compassion Focused Therapy: The Distinctive Features. London, Routledge, 2011.
89.
Hayes SC, Strohsal KD, Wilson KG: Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York, Guilford Press, 1999.
90.
Leyro TM, Zvolensky MJ, Bernstein A: Distress tolerance and psychopathological symptoms and disorders: a review of the empirical literature among adults. Psychol Bull 2010;136:576-600.
91.
Sotsky SM, Glass DR, Shea MT, Pilkonis PA, Collins JF, Elkin I, Watkins JT, Imber S, Leber WR, Moyer J, Oliveri ME: Patient predictors of response to psychotherapy and pharmacotherapy: findings in the NIMH Treatment of Depression Collaborative Research Program. Am J Psychiatry 1991;148:997-1008.
92.
Grawe K: Psychological Therapy. Cambridge, Hogrefe and Huber, 2002.
93.
Unützer J, Katon W, Callahan CM, et al: Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002;288:2836-2845.
94.
Zwarenstein M, Treweek S, Gagnier JJ, Altman DG, Tunis S, Haynes B, Oxman AD, Moher D, CONSORT Group, Pragmatic Trials in Healthcare Group: Improving the reporting of pragmatic trials: an extension of the CONSORT statement. BMJ 2008;11:337.
95.
van der Lem R, van der Wee NJ, van Veen T, Zitman FG: Efficacy versus effectiveness: a direct comparison of the outcome of treatment for mild to moderate depression in randomized controlled trials and daily practice. Psychother Psychosom 2012;81:226-234.
96.
Fava GA, Rafanelli C, Tomba E, Guidi J, Grandi S: The sequential combination of cognitive behavioral treatment and well-being therapy in cyclothymic disorder. Psychother Psychosom 2011;80:136-143.
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