Emotional Regulation Skills Can Make or Break MDD Relapse


Researchers accumulated information on self-reported emotion regulation in patients with current and remitted MDD. Then, they crunched the data.




Challenges in emotion regulation are known to plague patients actively enduring major depressive disorder (MDD) as well as persons with remitted MDD. Regulating emotions may be a central factor in preventing relapse, according to a meta-analysis conducted by a team from the University of Bergen in Bergen, Norway.1 Noting that no meta-analytic information on self-reported emotion regulation in patients with current and remitted MDD yet exists, the authors accumulated information via a systematic literature review. Then, they crunched the data.

Seventy-two relevant studies involving 91 trials were included in the meta-analysis. Sixty-nine of those trials involved 2415 participants with MDD and 3536 health controls, and 22 involved 956 participants with remitted MDD and 1558 healthy controls. Meta-regression analysis was used to investigate potential modifying effects on emotion regulation difficulties. Effect size was measured using Hedges’ g, a variation of Cohen’s d that corrects for biases due to small sample sizes.

Emotion regulation refers to the modulation, experience, and expression of emotion.2 It is a sequence that involves situation selection (avoidance or confrontation); acting in ways to modify the emotional impact; making choices about where to direct one’s attention (attentional deployment); making cognitive judgements about the situation; and then reacting (response modification). This sequence can occur before the onset of an emotional reaction (antecedent-focused) or after (response-focused).

Antecedent-focused emotion regulation strategies include the generally more maladaptive traits of avoidance and rumination and the more constructive ones of problem solving and reappraisal. Response-focused emotion regulation strategies include the more maladaptive response of suppression and more constructive of acceptance and self-compassion.

Not surprisingly, the research team found that, compared with healthy controls, patients with current MDD had higher maladaptive emotion regulation strategies regarding avoidance (g = 1.3); rumination (g = 2.1); and suppression (g = 1.1). The patients had lower adaptive emotion regulation strategies concerning acceptance (g = −1.0); problem solving (g = −1.0); and reappraisal (g = −0.7). Similar effect sizes in regard to maladaptive emotion regulation strategies were seen in patients with remitted MDD but adaptive strategies among this group were on par with that of healthy controls. The authors suggested that the higher tendency toward maladaptive strategies among remitters underlies relapse.

The research team cited several studies to make the point that maladaptive emotion regulation corresponds with deficits in emotional clarity and awareness (alexithymia). Indeed, higher alexithymia (g = 1.45) and lower emotional awareness (g = −0.95), emotional clarity (g = −1.50), and emotional tolerance (g = −1.89) were observed in patients with MDD compared with controls. No studies of patients with remitted MDD measured these parameters.

Factors that influence emotion regulation and MDD relapse were found to be age of illness onset, comorbid anxiety, and duration of remission. The authors also noted that, although maladaptive emotion regulation strategies have been well-studied in patients with active and remitted MDD, adaptive emotion regulation strategies in these population groups need further elucidation as does the degree to which alexithymia impacts patients with remitted MDD. Enhanced knowledge in this regard has the potential to pave the way for psychotherapeutic strategies that cultivate the adaptive and attenuate the maladaptive and also provide insight into risk of MDD relapse.


1. Visted E, Vøllestad J, Nielsen MB, Schanche E. Emotion regulation in current and remitted depression: a systematic review and meta-analysis. Front Psychol. 2018;9:756.

2. Gross JJ. The emerging field of emotion regulation: an integrative review. Rev Gen Psychol. 1998;2:271–299.

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