Australian and Newhttp://anp.sagepub.

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Zealand Journal of Psychiatry

Metacognitive therapy versus cognitive behavioural therapy for depression: a randomized pilot study
Jennifer Jordan, Janet D Carter, Virginia VW McIntosh, Kumari Fernando, Christopher MA Frampton, Richard J Porter, Roger T
Mulder, Cameron Lacey and Peter R Joyce
Aust N Z J Psychiatry published online 8 May 2014
DOI: 10.1177/0004867414533015

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research-article2014
ANP0010.1177/0004867414533015ANZJP ArticlesJordan et al.

Research

Australian & New Zealand Journal of Psychiatry

Metacognitive therapy versus cognitive 1­–12

DOI: 10.1177/0004867414533015

behavioural therapy for depression: a © The Royal Australian and

New Zealand College of Psychiatrists 2014

randomized pilot study Reprints and permissions:

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Jennifer Jordan1,2, Janet D Carter3, Virginia VW McIntosh1,2,

Kumari Fernando1, Christopher MA Frampton1, Richard J
Porter1, Roger T Mulder1, Cameron Lacey1,4 and Peter R Joyce1

Abstract
Objective: Metacognitive therapy (MCT) is one of the newer developments within cognitive therapy. This randomized
controlled pilot study compared independently applied MCT with cognitive behavioural therapy (CBT) in outpatients
with depression to explore the relative speed and efficacy of MCT, ahead of a planned randomized controlled trial.
Method: A total of 48 participants referred for outpatient therapy were randomized to up to 12 weeks of MCT or
CBT. Key outcomes were reduction in depressive symptoms at week 4 and week 12, measured using the independent-
clinician-rated Quick Inventory of Depressive Symptomatology16. Intention-to-treat and completer analyses as well as
additional methods of reporting outcome of depression are presented.
Results: Both therapies were effective in producing clinically significant change in depressive symptoms, with moderate-
to-large effect sizes obtained. No differences were detected between therapies in overall outcome or early change on
clinician-rated or self-reported measures. Post-hoc analyses suggest that MCT may have been adversely affected by
greater comorbidity.
Conclusions: In this large pilot study conducted independently of MCT’s developers, MCT was an effective treatment
for outpatients with depression, with similar results overall to CBT. Insufficient power and imbalanced comorbidity limit
conclusions regarding comparative efficacy so further studies of MCT and CBT are required.

Keywords
Cognitive behavioural therapy, depression, metacognitive, randomized pilot study

Introduction
Depression is a common and debilitating condition and is a
leading contributor to disease burden (World Health
Organization, 2004). As the best evaluated psychotherapy
for unipolar depression, cognitive behavioural therapy
(CBT) is recommended in treatment guidelines for depres-
sion of mild-to-moderate severity (Goldberg, 2006; Royal
Australian and New Zealand College of Psychiatrists
Clinical Practice Guidelines Team for Depression, 2004).
Despite consistently demonstrated efficacy, only around
half of those receiving CBT achieve remission, and relapse
challenging the content of thoughts, as is the focus of CBT,
MCT addresses factors maintaining psychological distress:
metacognitions (thoughts about cognitive processes) and
1Department of Psychological Medicine, University of Otago,
Christchurch, New Zealand.
2Clinical Research Unit, Canterbury District Health Board,
Christchurch, New Zealand.
3Psychology Department, University of Canterbury, Christchurch,
New Zealand.
4Maori Indigenous Health Institute, University of Otago, Christchurch,

is common (Butler et al., 2006). New Zealand.

Metacognitive therapy (MCT) is one of the newer devel-
opments within CBT attempting to improve acute treatment
outcomes by focussing on a different approach to cognitive
processes contributing to depression. Rather than
Corresponding author:
Jennifer Jordan, Department of Psychological Medicine, University of
Otago, Christchurch, PO Box 4345, Christchurch 8140, New Zealand.
Email: jenny.jordan@otago.ac.nz

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 2 ANZJP Articles
specific unhelpful cognitive processes called the cognitive
attentional syndrome. This includes rumination, worry,
threat monitoring, thought suppression, and the use of
problematic affect regulation strategies such as behavioural
avoidance, substance use, or binge eating.
Wells and colleagues have outlined the theory and prin-
ciples of MCT (Wells, 2008b, 2009). Empirical evaluation
of key theoretical elements underpinning MCT provides
evidence of the importance of a ruminative thinking style in
depression (Nolen-Hoeksema and Morrow, 1991;
Papageorgiou, 2009; Papageorgiou and Wells, 2003;
Watkins et al., 2007), the importance of positive and nega-
tive metacognitive beliefs in predicting both state and trait
depression (Papageorgiou and Wells, 2001, 2003, 2009),
and that an inability to take a metacognitive perspective is
associated with relapse (Fresco et al., 2007; Teasdale et al.,
2002).
The research evidence for efficacy of MCT for depres-
sion is promising but more studies are required to fully
establish the relative effectiveness of MCT (Churchill et al.,
2013). In a recent study, Wells and colleagues reported an
open trial/multiple baseline study of MCT for 12 partici-
pants with recurrent depression (Wells et al., 2012). MCT
achieved large effect sizes, and change was well main-
tained. A previous multiple baseline study (n=4) also
reported that MCT was effective in treating severe and
recurrent depression (Wells et al., 2009). A recent case
series of four Danish patients with depression also reported
clinically significant changes, maintained at follow up
(Callesen et al., 2013).
Nordahl (2009) compared MCT (n=15) with CBT
(n=13) in an outpatient sample with mixed psychiatric
diagnoses (primarily anxiety and depression). Both thera-
pies were effective with no difference in reduction of
depressive severity scores although MCT had a superior
effect in reducing anxiety symptoms and rumination.
Papageorgiou and Wells (2000) reported a single case
series using their attention training technique, a key com-
ponent of MCT, for four participants with moderate-to-
severe depression. All were in the “not-depressed” range
after very brief treatment.
Siegle et al. (2007) published a randomized controlled
trial of cognitive control training (n=19) compared to treat-
ment as usual (n=10). Cognitive control training included
computerized versions of Wells and colleagues’ attention
training technique as well as another cognitive strategy
(Adaptive PASAT). After only six 35-min sessions over 2
weeks, participants achieved clinically significant change
in depressive symptoms, greater than that achieved in the
comprehensive treatment-as-usual arm over 6 weeks.
Increasingly, clinicians are using MCT after attending
workshops and utilizing published treatment resources
(Wells, 2009) but to date, published studies of MCT for
depression include the originators or key collaborators
within the research teams. This pilot study compared the
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ANP533015.indd 2
speed and efficacy of independently applied MCT and CBT
in outpatients with depression to inform power calculations
and determine potential effect sizes for a proposed rand-
omized controlled trial. Exploratory questions were: (1) Is
MCT more effective than CBT in reducing depressive
symptoms at end of treatment (12 weeks); and (2) does
MCT work more quickly than CBT (change by 4 weeks)?
Methods
Recruitment was primarily through referrals from health
professionals although included some self-referrals. No
advertising for patients was involved. Recruitment took
place between September 2009 and January 2011. This
study was conducted in the Clinical Research Unit,
Department of Psychological Medicine, University of
Otago, Christchurch, in collaboration with the Canterbury
District Health Board. This pilot study received ethical
approval from the Upper South B Regional Ethics
Committee, New Zealand and was registered with the
Australian and New Zealand Clinical Trials Registry
(ACTRN12611000804987).
Participants
Participants were 48 men and women aged 18–65 years
with a current primary DSM-IV diagnosis of major depres-
sive disorder, bipolar II, or bipolar not-otherwise-specified-
depressed who were able to converse and answer
questionnaires in the English language and provide
informed consent. Exclusion criteria included bipolar I dis-
order, schizophrenia, current severe substance abuse, use of
psychotropic medication (other than the occasional hyp-
notic), severe physical illness, or an adequate course of
CBT or MCT in the past year.
A research nurse screened referrals for inclusion/exclu-
sion criteria and, if potentially eligible, the participant was
contacted by the next available therapist and booked for a
clinical interview. If eligible, informed consent was
obtained.
Assessment
A comprehensive pretreatment assessment included demo-
graphic information, clinician-rated diagnostic assess-
ments; Diagnostic and Statistical Manual of Mental
Disorders-IV mood, anxiety, substance use diagnoses, and
Global Assessment of Functioning (American Psychiatric
Association, 2000). Clinician ratings of mood severity were
made using the 16-item Quick Inventory of Depressive
Symptomatology (QIDS16-C; Rush et al., 2003). QIDS16
assesses symptom domains for DSM-IV major depressive
disorder. Both clinician-rated and self-report versions of
QIDS16 (QIDS16-SR) were used at key time points. The
Montgomery Asberg Depression Rating Scale (MADRS;
02/05/2014 12:30:51 PM
 Jordan et al. 3
Montgomery and Asberg, 1979) is a more widely used
measure of depressive severity and was included for com-
parability with other samples. Key assessment points
reported were week 0 (pretreatment), week 4, and week 12
(end of treatment). Six-month follow-up data are also
reported. The final 2-year follow up is underway. Pre- and
post-treatment Penn State Worry Questionnaire scores are
reported to provide a measure of anxiety.
Randomization
This is a parallel trial design with equal allocation to each
therapy. Computerized permuted block randomization to
determine therapy allocation was undertaken by the team’s
biostatistician (CF) prior to the commencement of the pilot
study. Sequentially numbered envelopes were stored in a
locked cabinet by an independent research coordinator and
given to therapists after the pretreatment assessment was
completed.
Therapy phase
The therapy was 12 sessions (permitted range 8–15) over
12 weeks. Eight sessions was set as the minimum adequate
dose of therapy. Sessions were conducted twice weekly for
2 weeks, to achieve six sessions within 4 weeks to maxi-
mize early change. All four therapists (clinical psycholo-
gists) delivered both therapies. Mood and risk status were
monitored weekly. If a patient deteriorated in mood or risk
status or failed to improve, he or she was referred for other
treatment, usually antidepressant medication, and was
removed from the assessment protocol.
Therapy content
CBT was based on the manuals of Aaron T Beck (Beck
et al., 1978) and Judith Beck (Beck, 1995). The key target
in CBT was the specific content of negative thoughts lead-
ing to depressed feelings and to unhelpful behaviours seen
in depression such as social or behavioural avoidance. Key
components included orientation to the CBT model, behav-
ioural activation (activity scheduling, pleasant event sched-
uling), training in the identification, self-monitoring, and
challenging of negative automatic thoughts with behav-
ioural experiments to test the validity of thoughts and pro-
vide evidence for alternative appraisals. Other skills such
as problem solving were taught if necessary.
MCT followed treatment manuals by Wells (2008a,
2009) and Papageorgiou and Wells (2004). The key target
in MCT was unhelpful cognitive patterns. Strategies
included case conceptualization and socialization to the
MCT model using key questions to explore a recent dip in
mood; use of Socratic questions and behavioural experi-
ments to challenge positive metacognitive beliefs driving
selection of cognitive strategies (e.g. rumination) to serve a
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ANP533015.indd 3
particular function (e.g. I need to keep focussing on my
thoughts so I can understand what is wrong with me); and
negative metacognitions regarding dangerousness or
uncontrollability of specific thinking processes (e.g. I have
lost control of my thoughts); addressing the cognitive atten-
tional syndrome (extended conceptual processing through
worry and rumination, threat monitoring, all types of avoid-
ance – cognitive, emotional, and behavioural, including
unhelpful coping behaviours e.g. substance use); the atten-
tion training task to enhance flexible control of attention;
attentional refocussing away from threat monitoring
(excessive scanning of mood symptoms to determine cop-
ing ability), detached mindfulness (being aware of thoughts
as internal events, without engaging with them by judging,
trying to control, suppress, or avoid), behavioural experi-
ments (e.g. rumination modulation experiments, rumina-
tion postponement); and the therapy blueprint (an
individualized summary contrasting old patterns of
responses to triggers, with new adaptive processing plans
(e.g. new metacognitive beliefs, thinking style, behaviours,
attentional focus). Residual symptoms were targeted.
Therapist competence
Supervisors rated complete sets of audiotaped CBT ses-
sions, and therapists were required to exceed the compe-
tence threshold on the Cognitive Therapy Scale for at least
two cases prior to commencing protocol therapy. Although
there was no competence rating scale available for MCT
during the pilot study, the MCT supervisor (JC) applied a
similar level of scrutiny to complete sets of audiotaped
MCT sessions until a satisfactory level of competent deliv-
ery was achieved for at least two cases per therapist. During
the pilot study, therapist competence and treatment integ-
rity were addressed by weekly group supervision and
monthly supervisor reviews of randomly selected audio-
taped sessions for each therapist for each modality.
Treatment fidelity ratings
Independent ratings of fidelity were conducted after the
pilot study was completed. Raters were two clinical psy-
chologists and an honours year psychology student. Raters
were trained using didactic lectures and read key treatment
resources for both therapies. They were trained on use of an
observer rating scale and rating manuals and co-rated audi-
otapes with the supervisor until a satisfactory level of
agreement was reached (routinely scoring within 2 points
on each item). The Collaborative Study Psychotherapy
Rating Scale (CSPRS) was adapted by adding an MCT sub-
scale to capture key MCT strategies and the metacognitive
focus of cognitive challenges. Preliminary data were avail-
able for 115/184 tapes (63%). The therapies were able to be
distinguished by trained raters blind to therapy modality.
The MCT subscale was higher for those randomized to
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 4 ANZJP Articles
MCT (MCT 48.6±10.8 vs. CBT 22.6±1.4, t=13.6, p<0.001)
and the CBT subscale was higher for those randomized to
CBT (CBT 66.3±16.0 vs. MCT 34.6±4.4, t=−14.7,
p<0.001).
Statistical analysis
All data were analysed using Statistical Package for the
Social Sciences version 19 for Windows. Student’s t-tests
were used to compare normally distributed continuous vari-
ables. For dichotomous variables, the chi-squared test was
used or Fisher’s exact test where expected cell numbers
were small. Paired t-tests were used to calculate pre–post
effect sizes within each therapy. A general linear model was
utilized to establish the effect size for the between-therapy
comparisons at 4 weeks and end of treatment (week 12).
Effect sizes are Cohen’s d. Outcome data are reported for
intention-to-treat (ITT) using last observation carried for-
ward (LOCF), and completer analyses. ITT analyses are
based on numbers in the originally assigned groups. For
completer analyses, effect sizes were based on paired t-tests
so included only those with data at both respective time
points. Power calculations were not made for this pilot
study which was intended to establish effect sizes for the
planned larger study.
The QIDS16-C was completed weekly for 4 weeks, then
fortnightly. The QIDS16-SR was completed weekly. The
LOCF data point came from the last available assessment
completed before the participant discontinued treatment.
The primary outcome variable was reduction in depres-
sive symptoms measured by change in QIDS16-C. Where
blind ratings were unavailable, independent (nontreating
clinician) ratings were used. In two cases, at end of treat-
ment, two therapist (nonblind) ratings were used as no
other raters were available. At week 0, all ratings were
blind ratings and at week 12, blind ratings were available
for 35/37 participants. At week 4, 12/48 ratings were blind
and 32 were independent ratings.
Reliability of clinician ratings
To establish reliability for the primary outcome measure,
the QIDS16, both blind rater and treating therapists sepa-
rately conducted QIDS16-C interviews with each patient at
baseline and at week 12. An intraclass correlation (ICC)
analysis was calculated to provide an index of the reliabil-
ity of the blind rater in relation to the nonblind raters. The
ICC indicated a high level of agreement between raters
(ICC 0.86 (95% CI 0.78 to 0.91, F 13.9, df 81, p<.001). A
paired t-test indicated a consistent difference between the
blind and nonblind raters of around one QIDS16 point with
the blind rater scoring higher (i.e. worse depression) at both
week 0 and week 12. Interrater reliability for SCID I diag-
noses were not undertaken for this study; however, a previ-
ous study by this group demonstrated satisfactory reliability,
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ANP533015.indd 4
with an overall kappa for lifetime Axis I diagnoses of 0.85
(overall concordance 93%, range 83–100%; Jordan et al.,
2008).
Other outcome analyses
Different methods of reporting outcome status are presented
to allow comparison with other studies. These include remit-
ted status (in the nondepressed range) using the QIDS16-C
and responder status using the MADRS, defined as greater
than 60% reduction in severity from pre- to post-treatment.
The 60% reduction threshold has previously been found to
offer an optimum balance of specificity and sensitivity in
defining responder status (Mulder et al., 2003).
Results
Patient flow
Patient flow is presented in Figure 1. The final sample
included 48 participants (MCT n=23, CBT n=25). Dropout
rate did not differ between therapies; two participants
within each therapy withdrew before the minimum eight
sessions (completer status threshold). A total of 37 partici-
pants (MCT n=18, CBT n=19) completed at least part of the
week-12 end assessment. Between session eight and the
end assessment at week 12, seven participants dropped out
or were withdrawn for the following reasons; started anti-
depressants (n=2), psychiatric admission after a suicide
attempt (n=1), unilateral withdrawal (n=2), and earthquake
disruption (n=2). The median number of sessions was 11.5
(range 3–15) and did not differ between therapies. Six-
month follow-up assessments were completed by 19 in the
MCT group (83%) and 21 in the CBT group (84%).
Table 1 presents pretreatment characteristics of the sam-
ple. The age of the sample was (mean±SD) 36±12.8 years
(range 18–68 years) and the gender ratio was almost equal
(males 52%, females 48%). Ethnicity was predominantly
New Zealand Caucasian (67%), with 10% New Zealand
Maori. A significant minority of participants were born out-
side New Zealand (23%), including participants from
Australia, Europe, North and South America, and Africa,
and 48% were married or in a stable de facto relationship,
44% had never married, 6% were separated, and 2%
divorced. The number of education years was 14.5±2.6
years, and 71% were employed, 18% received a social wel-
fare benefit, 8% were students, and one person (2%) self-
identified as a housewife. There were no statistically or
clinically significant differences between groups for any
demographic variables. The sample was moderately
depressed at the initial assessment, had on average three
prior depressive episodes, and most participants reported
chronic symptoms over the past 5 years.
Table 2 presents comorbid psychiatric diagnoses.
Comorbidity was highly prevalent in both groups. Although
02/05/2014 12:30:51 PM
 Jordan et al. 5

Figure 1.  Patient flow in the pilot study for depression.

Enrolment

Assessed for eligibility (n=64)

Excluded (n=15)
- Not meeting inclusion criteria (n=8)
- Declined to participate (n=6)
- Other reason
- Insufficient English language (n=1)

Excluded (n=1)
Randomized (n=49) Withdrew before randomisation
was revealed

Metacognitive therapy (n= 23)

Allocation Cognitive Behaviour Therapy (n=25)

Completed week 4 assessment n=23 (100%) Completed week 4 assessment n= 23 (92%)

Completer
Received allocated intervention Received allocated intervention
8 or more sessions n=21 (91%) 8 or more sessions n=23 (92%)
Discontinued intervention (n=2) Discontinued intervention (n=2)
- Started antidepressants n=1 - Started antidepressants n=1
- Withdrew n=1 - Withdrew n=1

12 weeks
End treatment End treatment
Completed week 12 assessment n=18 Completed week 12 assessment n=19
- Retention rate: 78 % - Retention rate 76 %
Reasons for “completers” not participating in Reasons for “completers” not participating in
the end assessment (n=3) the end assessment (n=4)
- Started on antidepressants n=1 - Started on antidepressants n=1
- Kumari Fernando
Withdrew n=1 - Withdrew n=1
- Earthquake interruption n=1 - Psychiatric admission n=1
- Earthquake interruption n=1

Follow-up
Completed 6 month follow-up n=19 (83%) Completed 6 month follow-up n=21 (84%)

the MCT prevalence for social phobia was much higher
(48%) than for CBT (28%), there were no statistically sig-
nificant differences between groups for this or any current
or lifetime comorbid disorder.
Changes in depressive scores over treatment are illus-
trated for both blind clinician-rated (Figure 2) and self-
report (Figure 3) depression scores (ITT analyses). Outcome
data are reported in Table 3 for ITT and completer analyses
for both clinician-rated and self-report versions of the
QIDS16. Using ITT, participants in both therapies
demonstrated clinically significant improvements on the
primary outcome variable, QIDS16-C, at week 4 (MCT
d=0.74, 95% CI 0.30 to 1.17; CBT d=0.73, 95% CI 0.31 to
1.14) and at end of treatment (MCT d=1.03, 95% CI 0.60 to
1.46; CBT d=1.03, 95% CI 0.61 to 1.44). There were no
significant differences between therapies for the ITT analy-
ses at either week 4 (d=0.06, 95% CI −0.65 to 0.52) or end
of treatment (d=0.04, 95% CI −0.62 to 0.54) (Table 3).
The same pattern of results of clinically significant
changes within each treatment but negligible differences

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 6 ANZJP Articles

Table 1.  Pretreatment functioning and psychiatric comorbidity in metacognitive therapy and cognitive behavioural therapy groups.

MCT (n=23) CBT (n=25) Statistic p

Demographic  
  Age (years) 37.2±12.7 35.0±13.0  0.6 0.55
  Gender (male:female) 52:48 52:48  

Psychiatric history  
  Age at onset depression (years) 22.5±16.2 17.4±9.1  1.3 0.19
  No. of episodes  4.2±3.7  3.4±2.7  0.8 0.43
  Prior suicide attempt 30 36  0.2 0.68
  Prior self-harm 35 28  0.3 0.61

Current functioning  
  Global Assessment of Functioning 54.4±8.8 55.7±6.8 –0.6 0.56
 MADRS 24.7±7.7 22.6±7.2  1.0 0.34

Values are mean±SD or %. t-tests were used for continuous variables and chi-squared tests were used for dichotomous variables.
CBT, cognitive behavioural therapy; MADRS, Montgomery and Asberg Depression Rating Scale; MCT, metacognitive therapy.

Table 2.  Psychiatric comorbidity in metacognitive therapy and cognitive behavioural therapy groups.

Psychiatric diagnosis MCT (n=23) CBT (n=25) Statistic p

ANY anxiety disorder  

 Lifetime 78 64 1.2 0.29
 Current 74 60 1.0 0.31

Obsessive compulsive disorder  

 Lifetime 17  4 0.18
 Current  9  4 0.60

Panic dis- and/or agoraphobia  

 Lifetime 44 32 0.7 0.41
 Current 17 16 1.00

Social phobia  
 Lifetime 48 28 2.0 0.16
 Current 48 28 2.0 0.16

Specific phobia  
 Lifetime 17 12 0.70
 Current 13  8 0.66

Post-traumatic stress disorder  

 Lifetime 30 36 0.2 0.68
 Current 26 24 0.0 0.87

ANY SUD abuse/dependence  

 Lifetime 48 48 0.0 0.99
 Current  9 16 0.67

Alcohol abuse/dependence  
 Lifetime 20 18 1.00
 Current  9  8 1.00

Cannabis abuse/dependence  
 Lifetime 39 24 1.3 0.26
 Current  0  8 0.49

Values are %.
aChi-square test, unless there is no entry in the statistic column, indicating Fisher’s exact test was used.

CBT, cognitive behavioural therapy; MCT, metacognitive therapy; SUD, substance use disorder.

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 Jordan et al. 7
Figure 2.  Clinician-rated QIDS16 depression severity scores
over treatment and at 6-month follow up.
18
16
14
12
10 MCT
QIDS-C
8 CBT
6
4 6
2
0
0 1 2 3 4 6 8 10 12 6mth
Weeks
Intention-to-treat (last observation carried forward) analysis. CBT, cog-
nitive behaviour therapy; MCT, metacognitive therapy; QIDS-C, Quick
Inventory of Depressive Symptomatology – 16 item clinician version.
between treatments at each time point was found for com-
pleter analyses for QIDS16-C scores and for each set of
analyses for QIDS16-SR scores (Table 3). Effect sizes for
completer analyses for QIDS16-C at week 4 were MCT
d=0.80 (95% CI 0.34 to 1.25) and CBT d=0.88 (95% CI
0.45 to 1.31) and at end of treatment were MCT d=1.12
(95% CI 0.62 to 1.61) and CBT d=1.44 (95% CI 0.96 to
1.93). Effect sizes for ITT analyses for QIDS16-SR at
week 4 were MCT d=0.96 (95% CI 0.52 to 1.39) and CBT
d=0.60 (95% CI 0.18 to 1.00) and at end of treatment were
MCT d=1.12 (95% CI 0.69 to 1.55) and CBT d=0.96 (95%
CI 0.54 to 1.37). Effect sizes for completer analyses for
QIDS16-SR at week 4 were MCT d=0.96 (95% CI 0.52 to
1.39) and CBT d=0.63 (95% CI 0.20 to 1.07) and at end of
treatment were MCT d=1.33 (95% CI 0.84 to 1.83) and
CBT d=1.09 (95% CI 0.57 to 1.60) (Table 3).
At end of treatment, there were no significant differ-
ences between therapy groups using the additional methods
of examining outcome. Similar numbers of participants
were in the nondepressed range on the QIDS16-C (MCT
43.5%, CBT 44%, chi-squared 0.001, p=0.97). A further
measure of treatment response was a greater than 60%
reduction on the MADRS. Those meeting this response cri-
terion for each therapy were MCT (52%) and CBT (44%)
(chi-squared 0.32, p=0.57).
Six-month follow-up data indicated that changes were
maintained but again there were no statistically significant
differences between therapies for any of the analyses.
Pre–post results for anxiety measured by the Penn State
Worry Questionnaire are presented in Table 3. Anxiety lev-
els reduced in both therapies over treatment but there were
no statistical differences between therapies at any time
point. Within-treatment effect sizes indicated large effect
sizes for MCT, especially for the completer analyses (ITT
d=0.96, completer analysis d=1.26).
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ANP533015.indd 7
Figure 3.  Self-rated QIDS16 depressive severity scores over
treatment and at 6-month follow up.
14
12
10
8
QIDS-SR
MCT
CBT
4
2
0
Intention-to-treat (last observation carried forward) analysis. CBT, cog-
nitive behaviour therapy; MCT, metacognitive therapy; QIDS-SR, Quick
Inventory of Depressive Symptomatology – 16 item self-report version.
Post-hoc subgroup analyses
Exploratory post-hoc analyses were undertaken to better
understand the sizable difference in within-therapy effect
sizes (MCT d=0.96, CBT d=0.60) at week 4 for the
QIDS16-SR, despite the lack of significant differences
between treatments at pretreatment or week 4. This was
explained by greater variability in the change scores within
the CBT group by week 4: 32% in the CBT group had
worse scores (any change in the wrong direction) on the
QIDS16-SR (ITT) compared with 4% in the MCT group
(Fisher’s exact test, p<0.02).
The three participants with a bipolar diagnosis (two with
bipolar II and one with bipolar not-otherwise-specified were
all in the MCT group. The primary outcome analyses were
re-run with those participants excluded. There were small
positive changes in the MCT means, but there were still no
statistically significant differences between therapy modali-
ties on any of the primary outcome analyses at any time
point. For example, for the primary outcome, the ITT
QIDS16-C analyses, the data (mean±SD) with bipolar II/not-
otherwise-specified excluded were as follows: week 0:
MCT 15.6±4.1 vs. CBT 15.0±4.5 (t=0.49, p=0.83); week 4
MCT 10.7±5.8 vs. CBT 10.1±5.5 (t=0.31, p=0.76); week 12
MCT 7.2±5.9 vs. CBT 7.5±5.9 (t=−0.16, p=0.88). The pre–
post percentage change was MCT 51% vs. CBT 47%. This
difference was not statistically significant (t=0.13, p=0.90).
The disproportionate prevalence of social phobia in the
MCT group (48% vs. CBT 28%) was a potential con-
founder. Key analyses were rerun with all those with cur-
rent social phobia excluded from both groups. This
substantially reduced the power to detect differences as the
groups (particularly MCT) were much smaller (MCT
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 8 ANZJP Articles

Table 3. Treatment outcome for metacognitive therapy and cognitive behavioural therapy groups.

Outcome MCT CBT df t p Effect size

QIDS16-C: clinician-rated depression  

  Intention-to-treat (LOCF) n=23 n=25  
  Week 0 15.3±4.1 15.0±4.5 46 0.24 0.81 0.07
  Week 4 10.8±6.0 10.1±5.5 46 0.43 0.67 0.12
    Change from week 0 to 4 4.4±6.0 4.8±6.7 46 –0.22 0.83 0.06
    % change from week 0 to 4 29 32  
   Within-therapy effect size from 0.74 (p<0.01) 0.73 (p<0.01)  
week 0 to 4
  Week 12 8.1±6.6 7.5±5.9 46 0.34 0.74 0.14
    Change from week 0 to 12 7.2±7.0 7.5±7.3 46 –0.15 0.88 0.04
    % change from week 0 to 12 47 50 46 –0.15 0.89  
   Within-therapy effect size from 1.03 (p<0.001) 1.03 (p<0.001)  
week 0 to 12
  n=18 n=20  
   Six-month follow up (LOCF) 7.2±4.9 6.7±5.6 46 0.32 0.75 0.09
   Within-therapy effect size from 1.31 (p<0.001) 1.16 (p<0.001)  
week 0 to 6 months

  Completer analysis n=21 n=23  

  Week 0 15.0±4.1 15.3±4.6 42 –0.271 0.79 0.07
  Week 4 10.1±5.8 9.7±5.4 42 0.24 0.81 0.07
    Change from week 0 to 4 4.8±6.0 5.6±6.3 42 –0.41 0.69 0.13
    % change from week 0 to 4 32 37  
   Within-therapy effect size from 0.80 (p<0.01) 0.88 (p<0.001)  
week 0 to 4
  n=18 n=19  
  Week 0 14.9±4.2 14.9±4.5 35 –0.004 0.98 0
  Week 12 7.2±5.9 5.5±4.9 35 0.95 0.35 0.3
    Change from week 0 to 12 7.7±6.9 9.4±6.5 35 –0.77 0.45 0.25
    % change from week 0 to12 52 63  
   Within-therapy effect size from 1.12 (p<001) 1.44 (p<.001)  
week 0 to 12
  n=19 n=21  
  Week 0 15.1±4.1 15.7±5.5  
   6-month follow upa 6.8±4.2 5.5±4.9 38 0.91 0.37 0.28
   Within-therapy effect size from 1.30 (p<0.001) 1.73 (p<0.001)  
week 0 to 6 months

QIDS16-SR: self-rated depression  

  Intention-to-treat (LOCF) n=23 n=25  
  Week 0 13.1±4.3 12.8±4.7 0.251 0.80 0.7  
  Week 4 9.0±4.7 9.3±5.6 –0.21 0.83 0.06  
    Change from week 0 to 4 4.1±4.3 3.4±5.8 0.44 0.66 0.1  
    % change from week 0 to 4 (all) 31 27  
   Within-therapy effect size from 0.96 (p<0.001) 0.60 (p<0.01)  
week 0 to 4
  Week 12 7.7±4.8 6.5±5.3 0.83 0.41 0.2  
    Change from week 0–12 5.4±4.8 6.3±6.6 0.2  
    % change from week 0–12 41 49  
   Within-therapy effect size from 1.12 (p<0.001) 0.96 (p<0.001)  
week 0 to 12
   6-month follow up (LOCF)b 8.1±5.5 6.4±4.9 1.15 0.26 0.3  
   Within-therapy effect size from 0.86 (p<0.001) 1.10 (p<0.001)  
week 0 to 6 months

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 Jordan et al. 9

Table 3. (Continued)

Outcome MCT CBT df t p Effect size

  Completer analysis n=23 n=23  

  Week 0 13.1±4.3 13.0±4.8 0.101 0.92 0.02  
  Week 4 9.0±4.7 9.2±5.8 –0.14 0.89 0.04  
    Change from week 0 to 4 4.1±4.3 3.7±5.9 0.23 0.82 0.1  
    % change from week 0 to 4 (all) 31 29  
   Within-therapy effect size from 0.96 (p<0.001) 0.63 (p<0.01)  
week 0 to 4
  n=18 n=17  
  Week 0 12.8±4.1 13.2±5.3 –0.22 0.83 0.08  
  Week 12 6.8±4.4 5.4±5.6 0.81 0.42 0.3  
    Change from week 0 to 12 6.1±4.5 7.8±7.2 –0.85 0.40 0.3  
    % change from week 0 to 12 48 59  
   Within-therapy effect size from 1.33 (p<0.001) 1.09 (p<0.001)  
week 0 to 12
  n=18 n=20  
  Week 0 13.2±4.1 12.7±4.7  
   6-month follow upc 7.3±5.5 6.1±5.0 36 0.76 0.46 0.2
   Within-therapy effect size from 1.01 (p<0.001) 1.38 (p<0.001)  
week 0 to 6 months

Penn State Worry Questionnaire  

  Intention-to-treat (LOCF) n=23 n=25
  Week 0 62.3±10.8 60.4±13.6 46 0.5 0.60 0.2
  Week 12 49.7±16.9 52.1±16.8 46 –0.5 0.63 0.1
    Change from week 0 to 12 12.6±13.1 8.3±12.5 46 1.2 0.25 0.3
    % change from week 0 to 12 20 14  
   Within-therapy effect size from 0.96 (p<0.001) 0.71 (p<0.01)  
week 0 to 12
  Completer analysis n=18 n=17  
  Week 0 60.4±11.1 57.9±15.1 46 –0.2 0.86 0.2
  Week 12 44.3±14.7 45.8±16.2 33 –0.27 0.79 0.1
    Change from week 0 to 12 16.1±12.8 12.2±13.5 33 0.6 0.56c 0.3
    % change from week 0 to 12 27 21  
   Within-therapy effect size from 1.26 (p<0.001) 0.90 (p<0.01)  
week 0 to 12

Independent t-tests compared MCT with CBT at each time point.

aFor completer analyses, paired t-tests were used to calculate effect sizes within each therapy from pretreatment (week 0) to each time point

(weeks 4 or 12 or 6-month follow up).

bSelf-report data were unavailable for two of these participants.
cNumbers attending the 6-month follow-up were: MCT n=19 (83%) and CBT n=21 (84%).
dEffect sizes are Cohen’s d.

CBT: cognitive behaviour therapy; LOCF: last observation carried forward; MCT: metacognitive therapy; QIDS: Quick Inventory of Depressive
Symptomatology; QIDS-C: QIDS-clinician rated; QIDS-SR: QIDS self-report.

n=12/23, CBT n=18/25). There were no significant differ-
ences for the QIDS16 clinician-rated or self-report measures
at weeks 0, 4, or 12; however, the outcomes were better in
both therapies. Using the MADRS responder outcome
measure (>60% improvement), the percentage classified as
responding in MCT improved from 52% in the original
analyses to 83% in analyses excluding those with social
phobia, while the CBT group did not change (44%). This
result was statistically significant (chi-squared 4.54,
p=0.03). A similar pattern was observed on the other
outcome measure, nondepressed status on the QIDS16: the
MCT group changed to 66.7% remitted and the CBT to
44.4%; however, this was not statistically significant (chi-
squared 1.43, p=0.23).
Discussion
The aim of this pilot study was to compare MCT with CBT
for outpatients with depression to establish effect sizes for
power calculations for a proposed randomized controlled

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 10 ANZJP Articles
trial. Exploratory research questions concerned speed and
efficacy of MCT in relation to CBT. Large effect sizes were
achieved for both therapies. On the primary analyses, MCT
was not more effective than CBT at end of treatment on any
clinician-rated or self-report depression outcome measure
and was not faster in reducing depression severity by week
4. However, the pilot study was underpowered to detect dif-
ferences, and the disproportionate prevalence of social pho-
bia in the MCT group is likely to have impacted on these
results.
Notwithstanding the power issue noted above, the fail-
ure to find a difference in effectiveness between MCT and
CBT for depression is consistent with results of one previ-
ous study of those with mixed diagnoses (Nordahl, 2009).
In that study, both therapies were effective in reducing
depression severity, although MCT was better at reducing
anxiety in those with comorbid anxiety symptoms.
Although the impact on anxiety levels was not significantly
different between therapies in the present study due to
insufficient power, the pattern of results was similar, sug-
gesting that MCT may have added benefit for those with
anxiety.
The large pre–post effect sizes achieved in the current
study for CBT (clinician-rated d=1.03; self-report d=0.96)
fall within the ranges reported in other published studies of
CBT for depression (Beck and Dozois, 2011; Butler et al.,
2006; Cuijpers et al., 2008; Dobson, 1989; Lambert and
Ogles, 2004). Effect sizes reported for MCT for depression
by Wells and colleagues are larger (1.83; Wells et al., 2012)
than the effect sizes reported here (1.03 for clinician-rated,
1.12 for self-report). It has been suggested that therapy
developers achieve larger effect sizes than independent
investigators typically achieve in effectiveness studies
(Cuijpers et al., 2010; Kliem et al., 2010). Failure to repli-
cate those large effects in MCT here may relate to therapist
competence and/or allegiance, as well as sample
composition.
Participants in the current study were similar in age and
extent of comorbidity to previous outpatient samples
treated in our clinical research unit (e.g. Luty et al., 2007)
although there was a higher prevalence of post-traumatic
stress disorder in the current study. The latter finding was
almost certainly related to the Christchurch earthquakes of
2010–2011 which occurred during this study. Participants
in previous MCT studies for depression have had chronic,
usually moderate, depressive symptoms and were taking
antidepressants and/or other psychotropic medications
(Nordahl, 2009; Siegle et al., 2007; Wells et al., 2009, 2012)
whereas participants in the current study were medication
free. Previous studies of MCT (Nordahl, 2009; Wells et al.,
2009, 2012) excluded those with substance addiction,
whereas participants were included in the current study
provided the substance use disorder was not severe or the
primary diagnosis. These factors may have contributed to
the relatively smaller effect sizes.
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ANP533015.indd 10
Limitations
The current study has a number of limitations. This pilot
study was not expected to have sufficient power to detect
statistically significant differences for the therapy compari-
son but was intended to provide valuable data regarding
treatment effect sizes for power calculations of the sample
size needed for a larger randomized controlled trial. Failure
to find a significant difference is not evidence of equal effi-
cacy, which can only be determined by an equivalence
design with typically a very large sample size.
Although therapists and supervisors involved in this
pilot study attended at least one training workshop by
Wells, were closely supervised, and followed the MCT
therapy manual, these therapists did not have the opportu-
nity to attend intensive training such as that now offered by
the Metacognitive Institute, and the therapy was not super-
vised by Wells, Papageorgiou, or their colleagues. As such,
MCT in this pilot study may not have been exactly as the
originators would deliver. It is likely, however, to represent
the way that clinicians across the world would implement a
therapy such as MCT after attending training courses
offered by therapy originators. Independent application of a
therapy is an important step in establishing real-world
effectiveness.
Formal competence ratings were not made during the
pilot study and no competence measures for MCT were
available. However, competence ratings in other trials by
this group indicate that our therapists (some of whom over-
lap with this study) maintained scores above the compe-
tence threshold for CBT throughout those trials (Carter
et al., 2013; McIntosh et al., 2013).
All therapists delivered both therapies. Although this
controls to some extent for nonspecific therapist factors,
there is also potential for reduced fidelity. Therapists had
been trained originally in CBT and had learned MCT subse-
quently. As such, it could be argued that they may have had
a greater therapeutic allegiance to and competence in CBT
relative to MCT; however, these results do not support that
argument. It has been suggested the mechanism of change in
CBT might be due to adopting a metacognitive stance after
having challenged common negative automatic thoughts,
rather than thought challenging per se being the primary
mechanism of change (Teasdale et al., 2002). It is also pos-
sible that delivery of MCT might have primed therapists to
assist CBT patients in adopting a metacognitive approach. A
more in-depth analysis of therapist fidelity and competence,
as well as other therapy process factors, is underway.
MCT is reported to work rapidly, with the number of
sessions in MCT for depression being typically 5–7 ses-
sions. No difference between therapies was detected here
for speed of change or the number of sessions attended;
however, presetting minimum and maximum treatment
parameters to match our standard treatment length for CBT
may have influenced the number of sessions in MCT.
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 Jordan et al. 11
The sample was not stratified for variables such as
comorbidity or prior depressive history at baseline.
Although most variables did not differ between groups, the
disproportionate burden of comorbidity in the MCT group,
particularly for social phobia may have adversely affected
the MCT results, posing a methodological issue.
The current study has a number of strengths. With a
sample size of 48, this is a large pilot study collecting com-
prehensive pretreatment data using standardized well-vali-
dated measures, with reliability data reported for the
primary outcome measure and fidelity data indicating ther-
apy distinctiveness. ITT and completer analyses are
reported along with several alternative outcome measures
(responder and nondepressed status). Reporting multiple
measures of outcome allows comparison with existing
studies (Hiller et al., 2011).
Conclusions
This is the largest study of MCT for depression and, to our
knowledge, the only randomized pilot study to date of MCT
with CBT for those with depression as the primary present-
ing problem. Both therapies were effective in reducing
depressive (and anxiety) symptoms by end of treatment.
This finding is noteworthy as MCT was applied here inde-
pendently of the originators, and the MCT group suffered
from a greater burden of comorbidity. These preliminary
data suggest that MCT may offer another useful therapy
option. Further comparative studies of MCT and CBT are
required with sufficiently large sample sizes to answer
questions of relative efficacy and to allow for stratification
of potentially confounding variables associated with sever-
ity. Future research should also examine possible differen-
tial predictors of response in MCT and CBT such as the
level of rumination, specific anxiety symptoms, treatment
acceptability, therapy process, and mechanisms of change.
Acknowledgements
We thank Amanda Baird and Joanna Vallance, therapists on this
study, and Julia Martin, Robyn Abbott, Andrea Bartram, Yolanda
Broerson, Barbara Malthus, Bridget Kimber, and Megan Tucker
for their invaluable assistance.
Funding
This work was supported by the New Zealand Lottery Board
Health Fund (grant no. 279032) and the University of Otago
Research Fund (grant no. ORG0109-0310).
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
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