DEPRESSION AND ANXIETY 31:308–315 (2014)

2013 ADAA Scientific Symposium

COGNITIVE PROCESSES AND EMOTION REGULATION
IN DEPRESSION
Jutta Joormann, Ph.D.∗ and Meghan E. Quinn, M.S.

Sustained negative affect and diminished positive affect are hallmark features of
Major Depressive Disorder (MDD). Difficulties in emotion regulation have been
proposed to be at the core of these cardinal symptoms of MDD. It remains un-
clear, however, what underlies emotion regulation difficulties. Cognitive theories
of depression have focused on cognitive processes and recent studies suggest that
cognitive biases and deficits in cognitive control may help explain affective symp-
toms of this disorder. Specifically, it is proposed that cognitive biases and deficits
affect emotion regulation ability thereby setting the stage for maintained nega-
tive affect and diminished levels of positive affect. The article reviews empirical
studies that speak to these links and closes with a discussion of novel treatment
approaches that are inspired by these ideas. Depression and Anxiety 31:308–315,
2014. 
C 2014 Wiley Periodicals, Inc.

Key words: Cognition; Coping; Depression; Mood disorders; Stress

INTRODUCTION in their initial responses to negative events but in their

M ajor Depressive Disorder (MDD) is among the most
prevalent of all psychiatric disorders, affecting almost
20% of the US population at some point in their lives.[1]
Given the high prevalence and the substantial personal
and societal costs of MDD, efforts to identify risk factors
and underlying mechanisms as well as effective inter-
vention strategies are particularly pressing. Disordered
affect is the hallmark feature of depression, specifically
sustained negative affect and difficulties experiencing
positive affect.[2] Individual differences in responses to
negative events and, most importantly, in the regula-
tion of emotion have been linked to heightened risk for
the onset of MDD.[3] Indeed, it has been proposed that
individuals who experience episodes of depression dif-
fer from their nondepressed counterparts not so much
Department of Psychology, Northwestern University,
Evanston, Illinois
responses to the ensuing affect, resulting in prolonged
episodes of sadness and depressed mood.[4, 5] It remains
unclear, however, what underlies these differences in re-
sponding to negative, and perhaps also positive, affect
that may be associated with a heightened depression
risk. Research on depression has identified cognitive pro-
cesses that play a critical role in the onset and mainte-
nance of depression such as cognitive biases and deficits
in cognitive control. These cognitive processes may af-
fect the responding to emotion-eliciting situations by
interfering with effective emotion regulation. This ar-
ticle briefly reviews research on cognitive processes in
depression that may help or hinder emotion regulation
and will then turn to a discussion of novel approaches
to treatment that result from this perspective. The focus
will be on studies that have used clinically diagnosed sam-
ples but studies with analog samples are also reviewed if
they are particularly informative or if clinical studies are
missing.

∗ Correspondence
COGNITIVE BIASES AND
to: Jutta Joormann, Ph.D., Department of Psy-
chology, Northwestern University, 2029 Sheridan Road, Evanston,
DEFICITS IN EXECUTIVE
IL 60208. E-mail: jutta.joormann@northwestern.edu CONTROL: LINK TO EMOTION
Received for publication 01 January 2014; Revised 14 February REGULATION
2014; Accepted 21 February 2014
PERCEPTION AND ATTENTION
DOI 10.1002/da.22264
Published online 25 March 2014 in Wiley Online Library Individual differences in early perception of emo-
(wileyonlinelibrary.com). tional material and in the tendency to orient

C 2014 Wiley Periodicals, Inc.
 2013 ADAA Scientific Symposium: Cognitive Processes in Depression
toward these stimuli, as well as a person’s ability to dis-
engage from emotional stimuli, are important factors
that affect emotion regulation when confronted with an
emotion-eliciting situation. The question of whether de-
pression is associated with enhanced and maybe even
automatic perception of emotional stimuli has been
investigated in studies using either subliminal mate-
rial, material with low degrees of emotional intensity
or very fast presentation times. Strikingly, few studies
to date have found biases in clinically depressed par-
ticipants when depression-relevant (or other) stimuli
have been masked in order to investigate unconscious
processing.[6, 7]
The evidence for attention biases in depression is also
mixed. In the emotional Stroop task, individuals with de-
pression should take longer to respond to the color of the
negative words compared to neutral words suggesting
that their attention was “grabbed” by the content of the
words. Whereas anxious participants exhibited slower
color naming of all negative words at both subliminal and
supraliminal exposure durations, depressed participants
did not differ from control participants in the sublimi-
nal condition.[8, 9] In the dot probe task, a pair of stimuli
(words or faces) is presented simultaneously: one stim-
ulus is neutral and the other is emotional. Participants
are asked to respond to a probe that replaces the neu-
tral or the emotional stimulus. Allocation of attention
to the spatial position of the stimuli is determined from
response latencies to the probes. Here, too, the results
have not been encouraging when words were presented
briefly and masked.[8, 10]
Taken together, empirical findings that depression
is associated with the easy identification of mood-
congruent material or a fast orienting toward negative
stimuli are rather mixed. There is evidence, however,
that depressed persons are characterized by attentional
biases in later stages of processing. Studies using the dot
probe task, for example, have reported selective atten-
tion in depression but only under conditions of long
stimuli exposures.[10–12] In two studies,[12, 13] these find-
ings were replicated in samples of remitted depressed
adults and nondisordered girls at high risk for depression
due to their mothers’ psychopathology. These results
suggest that attentional biases are not simply a symp-
tom of depression or a scar of a previous depressive
episode but may play an important role in vulnerability to
depression.
Whereas the dot probe task has been criticized as a
measure of disengagement, similar difficulties in dis-
engaging attention from negative material have now
been demonstrated in various attention tasks.[14] Im-
portantly, these results have been replicated using eye
tracking technology to continuously monitor point of
gaze. Depressed individuals spent significantly more
time looking at pictures featuring sadness and loss and
had significantly longer average glance durations for
these pictures than did nondepressed controls.[15] Sim-
ilarly, Caseras et al.[16] found that depressed individuals
were no more likely than controls to shift their attention
309
toward negative stimuli, but once their attention was fo-
cused on negative stimuli they spent significantly more
time looking at these stimuli than nondepressed controls.
These findings have been replicated across dysphoric and
clinical samples and across a variety of cognitive
tasks.[17, 18] In a recent study, Sanchez et al.[18] used an
eye tracking task that allowed for the separate assess-
ment of orienting and disengagement and showed that
clinically depressed participants had specific difficulties
to disengage their attention from sad stimuli. No group
differences were obtained for initial orientation to nega-
tive material. Importantly, difficulties disengaging atten-
tion were related to increased reactivity in a subsequent
stress task.
Difficulties disengaging from negative stimuli may
preclude depressed people from using effective emotion
regulation strategies such as distraction when confronted
with stressful events and may result in the sustained pro-
cessing of emotion-eliciting stimuli leading to prolonged
negative affect. Being “stuck” in attending to negative as-
pects of the situation may make it more difficult to shift
attention to more positive aspects thus hindering a more
balanced appraisal of the emotion-eliciting event.
INTERPRETATION
Most situations that evoke emotions are ambiguous.
Negative interpretation biases could result in rigid, au-
tomatic mood-congruent interpretations of emotion-
eliciting events and may make it difficult to see the situ-
ation from a different perspective. Results, however, are
mixed with regard to whether depression is character-
ized by automatic interpretation biases.[19] Butler and
Mathews,[20] for example, presented clinically depressed
participants with ambiguous scenarios and found that,
compared to nondepressed participants, depressed indi-
viduals ranked negative interpretations higher than they
did other possible interpretations. In a study assessing
biases using response latencies to target words that were
presented after ambiguous sentences, no interpretation
bias was found.[21, 22] Lawson et al.[19] examined startle
magnitude during imagery elicited by emotionally am-
biguous text. Using this measure, these authors reported
evidence for more negative interpretations in their de-
pressed sample and concluded that the failure to find a
bias in previous studies was due to the use of response
latencies. Cowden et al.,[23] however, found evidence for
a negative interpretation bias in dysphoric individuals as
indexed by faster response times to endorse an associa-
tion between negative words and ambiguous sentences.
The authors suggested that their use of self-referent ma-
terial, as opposed to other-referent material, may explain
the previous null findings in studies that used response-
time paradigms. Furthermore, a recent study reported a
negative interpretation bias in never-disordered daugh-
ters of depressed mothers, providing evidence for a
role of these biases in increasing risk for depression
onset.[24]
Depression and Anxiety
310 Joormann and Quinn
MEMORY
Memory biases such as increased accessibility of neg-
ative autobiographical material and decreased accessi-
bility of positive memories may lead to difficulties in
accessing mood-incongruent material that may interfere
with the selection and use of effective emotion regulation
strategies. Biased memory may also affect the interpre-
tation of emotion-eliciting situations thereby affecting
emotional reactivity and emotion regulation. Enhanced
memory for negative, relative to positive, information is
perhaps the most robust cognitive bias associated with
major depression.[25] In a meta-analysis of studies assess-
ing recall performance, Matt et al.[25] found that people
with major depression remembered 10% more negative
words than positive words. Research has also found a bias
for the recall of negative autobiographical memories.[26]
For example, using the Autobiographical Memory Task,
depressed participants were better able to generate spe-
cific memories in response to negative cues than in re-
sponse to positive cues.[27] Interestingly, depressed per-
sons also differ from their nondepressed counterparts in
that they do not appear to display a memory bias for pos-
itive information.[25] There is also emerging evidence to
indicate that memory biases persist even after depression
symptoms have remitted.[28]
Depression is associated not only with enhanced recall
of negative events and difficulties encoding positive ma-
terial, but also with the recall of rather generic memories
despite instructions to recall specific events (i.e. overgen-
eral memory).[29] Importantly, this research has demon-
strated that overgeneral memories are associated with
difficulties in problem solving and in imagining future
events, as well as with delayed recovery from episodes of
depression.[30–32] Moreover, overgeneral memories re-
main stable outside of episodes of the disorder[33] and
have been shown to predict later onset of depressive
episodes.[34, 35] Williams et al.[29] proposed that individ-
ual differences in cognitive control, and specifically in
inhibitory dysfunction, may underlie overgeneral recall
in depression. This relation is thought to occur in de-
pression because a reduced ability to inhibit prepotent
responses, in particular negative self-referent, rumina-
tive responses, may make it difficult for individuals to
focus on the goal of retrieving a specific event. In support
of this hypothesis, Dalgleish et al.[32] conducted a series
of experiments, which demonstrated that deficits in ex-
ecutive control and cognitive inhibition were associated
with overgeneral memory deficits in depression. In addi-
tion, studies have shown that rumination may maintain
overgeneral memory in depressed patients.[36] There-
fore, understanding overgeneral memory in the context
of emotion regulation in depression is an important goal
for future research.
COGNITIVE CONTROL
Cognitive control is related to the functioning of ex-
ecutive control processes such as inhibition, disengage-
ment and updating in working memory.[37, 38] Working
Depression and Anxiety
memory is a limited-capacity system that provides tem-
porary access to a select set of representations in the ser-
vice of current cognitive processes.[39, 40] Thus, working
memory reflects the focus of attention and the tempo-
rary activation of representations that are the contents
of awareness. Given the capacity limitation of this sys-
tem, it is important that the contents of working mem-
ory be updated efficiently, a task controlled by execu-
tive processes.[37, 41] Executive processes must selectively
gate access to working memory, shielding it from in-
trusion from irrelevant material, as well as discard in-
formation that is no longer relevant. In this context,
individual differences in the experience and resolution
of interference are likely to affect cognitive and emo-
tional functioning. The occurrence of intrusive thoughts
might be one consequence of poor interference resolu-
tion. Several researchers have suggested that rumination
and depression are associated with deficits in executive
functioning.[42–44]
There is emerging evidence that depression is charac-
terized by deficits in the inhibition of mood-congruent
material. The negative affective priming task was de-
signed to assess inhibition in the processing of emo-
tional information.[45] This task assesses response times
to positive and negative material that participants were
instructed to ignore. Joormann[45] found that dysphoric
participants and participants with a history of depressive
episodes exhibited reduced inhibition of negative mate-
rial. Thus, these participants responded faster when a
negative target was presented after a to-be-ignored neg-
ative distractor on the previous trial. As predicted, no
group difference was found for the positive adjectives.
Importantly, these findings were replicated using a neg-
ative priming task with emotional faces.[46]
Whereas these studies suggest that depression in-
volves difficulties keeping irrelevant emotional informa-
tion from entering working memory, depression may also
be associated with difficulties removing previously rele-
vant negative material from working memory (i.e. up-
dating). Difficulties inhibiting the processing of nega-
tive material that was, but is no longer, relevant might
explain why people respond to negative mood states and
negative life events with recurring, uncontrollable, and
unintentional negative thoughts. To test this hypothe-
sis, Joormann and Gotlib[47] used a modified Sternberg
task that combines a short-term recognition task with in-
structions to ignore a previously memorized list of words
to assess inhibition of irrelevant positive and negative
stimuli. We found that participants diagnosed with ma-
jor depression exhibited difficulties removing irrelevant
negative material from working memory. Specifically,
compared to never-depressed controls, depressed indi-
viduals exhibited longer decision latencies to an intru-
sion probe (i.e. a probe from the irrelevant list) than
to a new probe (i.e. a completely new word), reflecting
the strength of the residual activation of the contents of
working memory that were declared to be no longer rele-
vant. Importantly, this pattern was not found for positive
material. In sum, therefore, these findings indicate that
 2013 ADAA Scientific Symposium: Cognitive Processes in Depression
depression is associated with inhibitory impairments in
the processing of emotional material, specifically, with
difficulties removing irrelevant negative material from
working memory.[47, 48]
Deficits in cognitive control may not only affect a per-
son’s ability to discard irrelevant material from work-
ing memory, thereby increasing unwanted thoughts, but
these deficits may also make it difficult to intentionally
forget unwanted material. Using positive and negative
words, Power et al.[49] reported differential directed for-
getting effects for depressed and nondepressed partici-
pants. Hertel and Gerstle[50] found that, compared with
controls, dysphoric participants recalled more words
they were supposed to forget, with a tendency toward in-
creased recall of to-be-forgotten negative words. More-
over, the degree of forgetting was significantly correlated
with self-report measures of rumination and unwanted
thoughts.
As outlined above, depression is characterized by
deficits in inhibition, updating of working memory, and
forgetting. Importantly, these deficits have also been
linked to the use and effectiveness of emotion regulation
in depression, particularly to an increased tendency to
ruminate.[51] Joormann[52, 53] reported a correlation be-
tween rumination and deficits in cognitive inhibition as
assessed by negative priming. Joormann and Gotlib[47, 48]
also found that difficulty removing negative irrelevant
words from working memory was highly correlated with
self-reported rumination as were difficulties manipulat-
ing negative material in working memory. Finally, Joor-
mann and Tran[54] demonstrated that participants who
scored high on a trait measure of rumination exhibited
reduced forgetting of negative material in this task.
Whitmer and Gotlib[44] also found that depressed
individuals who completed a rumination induction ex-
hibited poorer switching ability than depressed and
nondepressed individuals who completed a distraction
induction and healthy controls who completed a rumi-
nation induction. Last, among depressed participants but
not healthy controls, rumination was associated with re-
duced ability to update working memory.[55] More re-
search investigating the relation of cognitive control (in-
hibition, updating, and shifting) and emotion regulation
in depression is needed. However, early evidence from
clinical and healthy samples suggests that deficits in cog-
nitive control are associated with induced rumination
and poorer reappraisal ability.
To summarize, MDD has been found to be associated
with biases in attention, interpretation, and memory that
affect the processing of negative and positive material. In
addition, deficits in cognitive control may interfere with
the ability to override biased attention and interpretation
resulting in more frequent use of maladaptive ER strate-
gies and impairments in the use of adaptive strategies.
More research is clearly needed, however, that directly
links cognitive biases and deficits in cognitive control
to emotion regulation and emotional responding under
stress.
311
TREATMENT IMPLICATIONS
The outlined relation among cognitive processes and
emotion regulation in psychiatric disorders has led to
the recent development of novel approaches to treat-
ment that directly target cognitive biases and executive
control in the hopes of improving emotion regulation
ability and decreasing psychological symptoms. Recent
studies examining cognitive bias modification and cog-
nitive control training seem particularly promising.[56]
Most of these studies have been conducted in anxiety
disorders but more and more papers have provided en-
couraging data that these trainings may also apply to
depression.[57, 58] The basic idea of these trainings is to
retrain people’s cognitive processing which, in theory,
should enable them to more effectively responding to
emotion-eliciting situations. Importantly, these studies
employ control groups that do not undergo the train-
ing that allows the authors to conclude that the training
lead to the changes in emotional responding in the ex-
perimental compared to the control group. The major-
ity of studies have focused on attention bias retraining
but more recent studies have also used interpretation
bias and memory training as well as executive control
training.
In a typical attention-training paradigm, the dot probe
is presented more consistently after the nonthreat rele-
vant stimuli (rather than equally following threat and
nonthreat stimuli), so that participants learn to attend to
neutral stimuli and away from threat or sad stimuli. The
first studies that have used this approach demonstrated
that training highly anxious people to disengage their
attention from threat material leads to changes in mood
and reduced reactivity to stressful events. MacLeod
et al.,[59] for example, first established that attentional
biases could be modified by working with participants
who scored in the middle third of the distribution on
the State-Trait Anxiety Inventory. They found that fol-
lowing attentional training away from threat, partici-
pants reported reduced negative affect to a standardized
stress manipulation. They also demonstrated that the
changes in emotional responding were mediated by the
training-induced changes in biases. A more recent study
of attentional bias training extended MacLeod’s find-
ings by showing that positive attentional biases can also
be trained.[60] Participants who had been trained to at-
tend to positive stimuli subsequently looked less at neg-
ative images during a stress induction.[60] So far, most of
these studies have been conducted in anxiety disorders
but at least two recent papers have provided encourag-
ing data that a training aimed at modifying attention bi-
ases may also apply to depression.[57, 58] No studies thus
far have examined, however, whether modifying cogni-
tive biases in depressed participants leads to changes in
the use or effectiveness of emotion regulation strategies
and thus to changes in emotional responding. Clearly,
this presents an important direction for future research.
It is also important to note, however, that a recent
Depression and Anxiety
312 Joormann and Quinn
metaanalysis on the effectiveness of cognitive training
studies has found only small effect sizes, particularly for
attention retraining.[56] Clearly more research is needed
to examine the mechanisms that underlie cognitive
trainings.
Other studies have focused on modifying memory bi-
ases but these trainings have not yet been tested with
depressed participants.[61] One particularly promising
study found that training dysphoric individuals to be
more concrete and less overgeneral in their thinking led
to a significant reduction in depressive symptoms and
rumination.[62]
Recently, researchers have also begun to modify in-
terpretive biases. Mathews and Mackintosh[63] used am-
biguous scenarios to train individuals to make either
positive (nonanxious) or negative (anxious) interpreta-
tions of ambiguous text in a sample of anxious individ-
uals. The authors compared state anxiety levels prior to
and after the training and reported that participants in
the negative training condition displayed elevated lev-
els of anxiety whereas those in the positive training
condition demonstrated decreased symptoms of anxi-
ety. These findings support the hypothesis that inter-
pretive biases play a causal role in anxiety levels. Yiend
et al.[64] demonstrated that the effects of interpretive
training on anxiety were still present after a 24-hr de-
lay between the training and a subsequent test. In a re-
lated study, participants who received interpretive train-
ing using ambiguous homophones were subsequently
presented four distressing television clips of real-life
emergency rescue situations.[65] Participants who were
trained to interpret ambiguity in a nonthreatening man-
ner had an attenuated anxiety reaction to the subsequent
video stressor.[65, 66] Beard and Amir[67] reported that
changes in negative emotion were mediated by training-
induced changes in negative interpretive style. These re-
sults suggest that changes in interpretation biases can
indeed lead to changes in emotional responding.[67, 68]
Indeed, a recent study found that interpretation bias
training reduced depressive symptoms in a group of clin-
ically depressed participants.[69] In the previously men-
tioned metaanalysis of cognitive training studies[56] , in-
terpretive bias training showed the strongest effect sizes
of all training approaches but clearly more research is
needed to understand the mechanisms underlying cog-
nitive bias training.
Of special importance are studies that have started to
investigate the possibility of training cognitive control in
depression and of examining the effects of this training
on emotion regulation. Joormann et al.,[70] for example,
showed that depressed participants could be trained to
forget negative material by practicing active suppression
and did particularly well when they were provided with
a strategy of how to keep irrelevant material from enter-
ing working memory (i.e. by using thought substitutes).
Siegle et al.[71] presented preliminary data demonstrat-
ing that a brief intervention targeted at increasing cog-
nitive control in severely depressed outpatients led to
significant decreases in both depressive symptoms and
Depression and Anxiety
rumination. Indeed, work by this group suggests that
training in attentional control may be an effective treat-
ment component for depression.[72] In this training, pa-
tients learn to selectively attend to certain sounds while
ignoring irrelevant sounds. After two weeks of this train-
ing, patients exhibited decreases in depressive symp-
toms compared to patients who received treatment as
usual.[71] Notably, the training consisted of short ses-
sions (15 min) that used nonaffective stimuli such as
the sound of birds. This suggests that cognitive con-
trol can be improved with practice and further supports
the hypothesis that individual differences in cognitive
control may affect emotion regulation. Cognitive con-
trol training using an executive control task also yielded
transferable gains to improved control over affective
stimuli[73] and improved emotion regulation.[74] A simi-
lar training showed effects on thought control over intru-
sive memories.[75] Whereas these results are promising,
more research is needed to understand the mechanisms
of how bias modification is effective and moderators that
examine when it works.
In addition to cognitive bias training studies, it is
also important to note that studies have examined the
effects of more traditional treatment approaches such
as Cognitive-behavioral therapy (CBT) and mindful-
ness meditation on cognitive biases and emotion regula-
tion. Studies have shown, for example, that mindfulness
training enhances working memory, improves sustained
attention,[76] and decreases overgeneral memory.[77] In
addition, recent studies have found that CBT interven-
tions decrease attention biases[78, 79] and change memory
biases.[80] These findings suggest that changes in cogni-
tive biases may underlie improvements in emotion reg-
ulation and psychiatric symptoms that result from psy-
chological interventions such as CBT and mindfulness.
More research is clearly needed, though, to examine this
proposition systematically.
SUMMARY
Given that sustained negative affect and difficulties ex-
periencing positive affect are the hallmark features of
depression, basic research on the regulation of affect
provides important information for an improved under-
standing of the etiology, maintenance, and treatment of
this debilitating disorder. This review focused on de-
pression but we should note that many of the cognitive
processes and emotion regulation difficulties discussed
in this article are not specific to depression but rather
seem to represent transdiagnostic risk factors that are
common across many disorders. Clearly more research is
needed to examine the interaction of cognition and emo-
tion regulation in other disorders and to fully understand
the role of comorbid conditions. We examined cognitive
processes that may underlie difficulties in emotion reg-
ulation. Research on cognitive biases and deficits that
are associated with MDD may help us better understand
maladaptive ER and difficulties implementing adaptive
ER strategies. Indeed, biased cognition in conjunction
 2013 ADAA Scientific Symposium: Cognitive Processes in Depression
with deficits in cognitive control may guide emotional
responding in depression and explain difficulties to over-
ride maladaptive responding with the use of more adap-
tive emotion regulation strategies. Recent findings sug-
gest, however, that cognitive trainings can be used to
modify cognitive biases and strengthen cognitive con-
trol that in turns improves stress reactivity and emotion
regulation. In addition, CBT and mindfulness interven-
tions may enhance cognitive control thereby strength-
ening the ability to regulate negative affect. These stud-
ies have important implications for the development of
novel treatment approaches.
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