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2016

Cognitive Vulnerability to Depression: A Longitudinal

Study using Eye-gaze Tracking to Study Attentional
Biases in Never Depressed, Non-Relapsed, and
Relapsed Individuals

Newman, Kristin

Newman, K. (2016). Cognitive Vulnerability to Depression: A Longitudinal Study using Eye-gaze

Tracking to Study Attentional Biases in Never Depressed, Non-Relapsed, and Relapsed
Individuals (Unpublished doctoral thesis). University of Calgary, Calgary, AB.
doi:10.11575/PRISM/25347
http://hdl.handle.net/11023/3338
doctoral thesis

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 UNIVERSITY OF CALGARY

Cognitive Vulnerability to Depression: A Longitudinal Study using Eye-gaze Tracking to Study

Attentional Biases in Never Depressed, Non-Relapsed, and Relapsed Individuals

by

Kristin Renee Newman

A THESIS

SUBMITTED TO THE FACULTY OF GRADUATE STUDIES

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE

DEGREE OF DOCTOR OF PHILOSOPHY

GRADUATE PROGRAM IN CLINICAL PSYCHOLOGY

CALGARY, ALBERTA

SEPTEMBER, 2016

© Kristin Renee Newman 2016

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Abstract

Cognitive models of depression propose that attentional biases are an important cognitive

vulnerability in those with a history of depression (e.g., Gotlib & Joormann, 2010; Yiend, 2010;

Beck & Haigh, 2014). This study prospectively examined attentional biases in never and

previously depressed individuals, who were separated into relapsed and non-relapsed groups.

Analyses examined total fixation times, temporal profiles of attention, and prediction of relapse.

The evidence from all analyses suggested that attention to positive information is a key

vulnerability or resiliency factor related to depression relapse. Specifically, relapsed participants

attended to positive images less overall, decreased attention to positive images over the study

period, and exhibited significant differences in their temporal profiles of attention for positive

images relative to those non-relapsed and never depressed. Less time attending to positive

images at the initial visit was predictive of depression relapse, although limited by a small

sample size. The attentional biases of the non-relapsed participants reflected both resiliency

against and vulnerability to relapse, as they exhibited attentional biases to positive information

similar to never depressed participants, but attended to depression-related information more than

never depressed participants. Attention to depression-related information was not predictive of

depression relapse. Overall, findings indicated that attentional biases to positive information may

be most relevant to relapse vulnerability, whereas attentional biases to depression-related

information may be more relevant to the maintenance of depressive episodes. The differences

observed between relapsed and non-relapsed participants indicate that groups of previously

depressed individuals are heterogeneous, which should be taken into account in future research

that examines vulnerability to depression. The implications of the study findings are discussed as
 iii

related to cognitive models of depression and the limitations that may contribute to inconsistent

findings in the literature on attentional biases and cognitive vulnerability to depression.

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Acknowledgements

I would first like to acknowledge and thank my supervisor, Dr. Christopher Sears for his

guidance, assistance, and support throughout the last 8 years in which I have conducted research

in the area of cognitive vulnerability to depression, beginning with and building upon my

honours project. He has always been extremely generous and willing to help in any way possible

to contribute to my success and I sincerely appreciate that. Second, I would like to recognize and

thank Amanda Fernandez who was essentially my right hand and knew all aspects of this project

as if it were her own, during recruitment, running of participants, and data organization. She

made a significant and valuable contribution to this project, and I am so grateful for her help.

Third, I want to thank Leanne Quigley, who was also an immense help with study design, data

collection, and statistical analyses. Fourth, I would like to thank the many research assistants

who helped with data collection and organization. Last I want to say thank you to my children,

Jessica, Alex, and Adam, and my partner, Lee, all of whom have stood by me for many years,

living a non-traditional and academically focused family life, encouraging me every step of the

way, showing interest in my research, and pushing me to complete one of the most significant

accomplishments of my life, continually asking me if I am done writing my dissertation yet.

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Table of Contents

Abstract………………………………………………………………………..…………………ii

Acknowledgements……………....................…………………………………………….……..iv

Table of Contents……………………………………………………………………..……….…v

List of Tables………………………………………………………………………………….…vi

List of Figures…………………………………………………………………………………..vii

Chapter 1……………………………………………………………………………………..…..1

Chapter 2………………………………………………………………………………………..32

Chapter 3………………………………………………………………………………………..52

Chapter 4………………………………………………………………………………………..92

Chapter 5………………………………………………………………………………....……108

References……………………………………………………………………………………...139

Appendix A- Consent Form………………………………...………………………………...158

Appendix B- Debriefing Form………………………………………………………………..162

Appendix C- Psychological Services Information Sheet……………………………………164

Appendix D- Demographics Inventory………………………………………………………166

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List of Tables

Table 1. Characteristics for the Relapsed, Non-Relapsed, and Never Depressed Participants 30

Table 2. Demographic Characteristics of Participants 31

Table 3. Initial versus Follow-up visits Total Fixation Times (ms) for Face Images 39

Table 4. Total Fixation Times (ms) to Naturalistic Images During Initial and Follow-up

Visits 45

Table 5. Time Course Fixation Times: Relapse vs. No Relapse vs. Never Depressed Face

Images 57

Table 6. Time Course Fixation times: Relapse vs. No Relapse vs. Never Depressed

Naturalistic Images 73

Table 7. Correlations between BDI Initial Visit Scores and Naturalistic/Face Image Fixation

Times 101

Table 8. Logistic Regressions for Naturalistic Images 102

Table 9. Logistic Regressions for Face Images 103

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List of Figures

Figure 1. Participant flow and exclusions 29

Figure 2. Temporal changes in attention to happy face images in relapsed, non-relapsed, and

never depressed individuals at the initial visit 59

Figure 3. Temporal changes in attention to sad face images in relapsed, non-relapsed, and never

depressed individuals at the initial visit 60

Figure 4. Temporal changes in attention to threat face images in relapsed, non-relapsed, and

never depressed individuals at the initial visit 61

Figure 5. Temporal changes in attention to neutral face images in relapsed, non-relapsed, and

never depressed individuals at the initial visit 62

Figure 6. Temporal changes in attention to happy face images in relapsed, non-relapsed, and

never depressed individuals at the follow up visit 66

Figure 7. Temporal changes in attention to sad face images in relapsed, non-relapsed, and never

depressed individuals at the follow up visit 67

Figure 8. Temporal changes in attention to threat face images in relapsed, non-relapsed, and

never depressed individuals at the follow up visit 68

Figure 9. Temporal changes in attention to neutral face images in relapsed, non-relapsed, and

never depressed individuals at the follow up visit 69

Figure 10. Temporal changes in attention to threat images in relapsed, non-relapsed, and never

depressed individuals at initial visit 75

Figure 11. Temporal changes in attention to positive images in relapsed, non-relapsed, and never

depressed individuals at initial visit 76

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Figure 12. Temporal changes in attention to depression-related images in relapsed, non-relapsed,

and never depressed individuals at initial visit 77

Figure 13. Temporal changes in attention to neutral images in relapsed, non-relapsed, and never

depressed individuals at initial visit 78

Figure 14. Temporal changes in attention to depression-related images in relapsed, non-relapsed,

and never depressed individuals at follow up visit 83

Figure 15. Temporal changes in attention to positive images in relapsed, non-relapsed, and never

depressed individuals at follow up visit 84

Figure 16. Temporal changes in attention to threat images in relapsed, non-relapsed, and never

depressed individuals at follow up visit 85

Figure 17. Temporal changes in attention to neutral images in relapsed, non-relapsed, and never

depressed individuals at follow up visit 86

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Chapter 1: Introduction

Depression is arguably the most common mental health disorder with lifetime prevalence

rates ranging from 11.3% in a Canadian epidemiological study (Patten et al., 2015) to 16.6% as

cited in the most recent National Comorbidity Survey Replication (NCS-R) study (Kessler et al.,

2005). In fact, Kessler, Petukhova, Sampson, Zaslavsky, and Wittchen (2012) reported a major

depressive episode to be “the most prevalent lifetime syndrome” (p. 175) considered in their

analyses. In addition to its widespread prevalence, depression is a debilitating mood disorder—

even a single episode of depression impacts the mental health outcome and overall functioning of

those affected, with approximately 12% of Canadians experiencing functional impairment during

an episode (Patten et al., 2010). The severity and chronicity of impairment increases in those

who experience recurrent episodes of depression, with further impact to overall functioning and

general outcomes (Gotlib & Hammen, 2002). In order to reduce and, ultimately, prevent the

recurrence of depressive episodes, it is important to understand the vulnerabilities and risk

factors associated with experiencing multiple episodes and why some individuals are more

susceptible. The present research examined how a cognitive vulnerability in the form of biased

attentional processing may be a factor underlying the relapse and recurrence of depressive

episodes.

To set the context for the present study, an overview of depression as a diagnosis and the

risk factors that confer vulnerability to depression relapse will be reviewed. This review will be

followed by a focus on cognitive vulnerabilities and the methodology used in the literature to

assess these vulnerabilities. Throughout this review, questions related to cognitive vulnerabilities

will be highlighted as they related to the study rationale. The results of this study will be

presented in three chapters as they consist of related, yet separate analyses. A description of the

methodology will be presented first, followed by a presentation of each of the three analyses,
 2

including an introduction, results and discussion. A General Discussion section will follow to

integrate all findings, address limitations, and provide conclusions from both a theoretical and

clinical perspective.

Major Depressive Disorder

Diagnostic criteria and description. For clarity regarding the diagnosis of depression,

the criteria as per the Diagnostic and Statistical Manual, Fourth Revised Edition (4th ed., text

rev.; DSM-IV-TR; American Psychiatric Association, 2000) will be reviewed, as this was the

version of the DSM used in the present study. Major depression is a syndrome comprised of a

total of nine criteria, in which at least one of two cardinal criteria must be met, for most of each

day for at least two weeks. These two cardinal criteria are sadness/feeling down and anhedonia,

defined as a loss of interest or pleasure in activities that one normally enjoys engaging in. In

addition to the cardinal criteria, seven other criteria are often present in individuals with a

diagnosis of major depression. The remaining seven criteria include a disturbance in appetite

(feeling more or less hungry than usual), a disturbance in sleep (sleeping more or less than

typical), psychomotor agitation or retardation, feelings of worthlessness or excessive guilt, an

inability to concentrate or make decisions, a lack of energy, and the presence of suicidal ideation.

Major Depression can occur on one occasion (Major Depressive Disorder; MDD, Single

Episode) or on multiple occasions (MDD, Recurrent Subtype). The diagnosis of depression is

polythetic; to meet criteria for a diagnosis of depression at least five of the nine criteria must be

present, yet they may be present in different combinations for each affected individual (DSM-IV-

TR; APA, 2000).

In addition to meeting the specific criteria for a diagnosis of depression, a number of

specific psychological (e.g., irritability, reduced libido, anxiety/nervousness, hypersensitivity to

rejection/criticism, pessimism, hopelessness, cognitive distortions, low self-esteem, self-

 3

preoccupation), behavioral (e.g., frequent crying, interpersonal conflict, anger outbursts, reduced

productivity, social withdrawal, substance use, self-sacrifice/victimization, avoidance of

emotional and sexual intimacy), and physical symptoms (e.g., fatigue, heaviness in arms and

legs, sexual arousal difficulties, erectile dysfunction, pains and aches, headaches, muscle tension,

gastrointestinal upset, heart palpitations) are commonly seen in those who are depressed

(Cassano & Fava, 2002). These symptoms contribute to the significant functional impairment

and daily burden for affected individuals as well as their families. Depression is also known to be

a significant risk factor for suicide, and data indicates that approximately 21% of those who

experience recurrent depression will attempt suicide (Cassano & Fava, 2002). A large-scale

study (e.g., Global Burden of Disease Study) identified depression as the fourth ranked medical

condition with the greatest disease burden in the world (Murray & Lopez, 1997). This ranking

accounted for the sum of years of life lost due to premature mortality and years of life lived with

a disability. This study further predicted that depression would be the condition with the second

greatest disease burden worldwide by 2020, second only to ischemic heart disease, and indeed

more recent estimates have placed depression second to all illnesses (Vos, Flaxman, Naghavi,

Lozano, & Michaud, 2012). This significance as a health burden solidifies the importance of

identifying factors that contribute to the development and recurrence of depression.

Course of depression. When considering the course of depression, there are important

distinctions between remission and recovery from depression, and between depression relapse

and depression recurrence. According to criteria established by Frank et al. (1991), a partial

remission occurs when an individual is still experiencing some symptoms, but not enough to

meet criteria for a major depressive disorder; a full remission from depression is defined as at

least a 2-8 week period where an individual is asymptomatic. Recovery from depression is

defined as full remission where one is free of symptoms of depression for at least 8 weeks (Frank
 4

et al., 1991). Depression relapse is the return of symptoms sufficient to meet full criteria for

depression during the remission period, whereas depression recurrence is considered a new

episode of depression that occurs after a period of full recovery from a depressive episode. These

distinctions are important for researchers studying risk factors for depression recurrence.

For individuals who experience an episode of depression, 60% will experience a second

episode, and of those who experience a second episode, 70% will have a third, and 90% of those

who have experienced three or more episodes will continue to have additional episodes (Monroe

& Harkness, 2011). Recurrent episodes typically onset within five years of the first episode, and

those who have had more than one episode of depression will typically experience between five

to nine additional episodes during their lifetime (Burcusa & Iacono, 2007).

Depression is a diverse disorder from an etiological standpoint with numerous pathways

to the development of an initial episode. The contributors to depression relapse or recurrence

vary and may not necessarily be due to the same factors that led to the initial episode; in fact, the

predictors of initial episodes of depression have been found to differ from the predictors of

depression recurrence (Monroe & Harkness, 2011). Given the highly recurrent nature of

depression, it is thought that an inherent vulnerability is present in those who are susceptible to

experiencing multiple episodes. Delineating the precise nature and origin of that vulnerability is

complicated. Monroe and Harkness (2011), in a review on the recurrence of major depression,

noted: “the primary obstacle for theory and research is that we currently possess few, if any,

clinically or scientifically useful predictors for who, once initially depressed, will or will not

eventually recur” (p. 656). This assessment is still relevant today, as the specific factors involved

in what distinguishes those individuals who will only experience an isolated episode of

depression from those who will experience multiple episodes are not fully understood.
 5

Vulnerability factors for depression recurrence. A number of factors have been

identified as potentially contributing to increased risk or vulnerability to subsequent episodes of

depression. One prediction model suggests that depression relapse is best understood to occur as

a consequence of multiple and diverse factors spanning different risk domains (vanLoo, Aggen,

Gardner, & Kendler, 2015). These risk factors include biological, psychological, and

environmental factors. Examples of biological risk factors related to depression recurrence

include specific gene alleles in women (Zubenko, Hughes, Stiffler, Zubenko, & Kaplan, 2002),

higher cortisol levels thought to result in a hypersensitive stress-response (Bos et al., 2005), and

an attenuated startle response in response to an intense stimulus, proposed as a potential

endophenotypic marker for identifying those at risk of depression recurrence (O’Brien-Simpson,

DiParsia, Simmons, & Allen, 2009).

Psychological risk factors include the personality attribute neuroticism (proneness to

emotional instability, stress, and anxiety), found to be an underlying trait of depression and a

predictor of depression chronicity, including the number of episodes experienced (Riso,

Miyatake, & Thase, 2002). Symptoms of anxiety that occur specifically during each depression

episode have been found to be related to risk for depression relapse (vanLoo et al., 2015). In

addition, specific psychological symptoms that reflect episode severity experienced within a

depressive episode may be predictive of future recurrent episodes, including suicidal ideation

(Barkow et al., 2003), sleep disruption (Alpert, 2006), and the age at onset of the first episode,

with a greater risk of recurrence found in those with an earlier initial onset, (although not all

studies have found evidence of this; e.g., see Burcusa & Iacono, 2007). Residual symptoms of

depression (e.g., anxiety, loss of appetite, loss of libido, and increased hypochondriasis) have

been found to increase risk for subsequent episodes, and one study found that this holds even

after a course of cognitive therapy (Taylor, Walters, Vittengl, Krebaum, & Jarrett, 2010). In
 6

addition, the number of previous episodes of depression has consistently been found to be

predictive of future susceptibility, with more episodes indicating a greater risk for the

development of a future episode (Burcusa & Iacono, 2007; vanLoo et al., 2015).

Documented environmental factors contributing to recurrence vulnerability include the

experience of childhood adversity, such as early traumatic experiences and/or maltreatment (Riso

et al., 2002; Nanni, Uher, Danese, 2012; vanLoo et al, 2015). A family history that includes

depression or recurrent depression has been found to predict depression recurrence in the

adolescent offspring of affected family members (Lewinsohn, Rohde, Seeley, Klein, & Gotlib,

2000). Interestingly, recurrent depression has been found to have stronger familial transmission

relative to the transmission of depression in general (Klein, Lewinsohn, Rohde, Seeley, &

Durbin, 2002). Life stress is another important factor that may impact depression recurrence, but

considerable debate exists in the literature regarding the exact role it plays in depression

recurrence (for a review, see Monroe & Harkness, 2005). Chronic stress has been found to be

more relevant to recurrence than an acute severe stressor (Backs-Dermott, Dobson, & Jones,

2010). In general, the type and/or severity of stressful life events are proposed to be an important

consideration for the initial onset of depression, but likely different than events involved in

depression recurrence (Monroe & Harkness, 2005; Monroe et al., 2006; Monroe, Slavich, Torres,

& Gotlib, 2007).

Cognitive vulnerabilities to depression. Cognitive factors have also been found to

contribute to depression vulnerability. Cognitive models of depression propose that the

vulnerability originates in the biased processing of emotional information (Beck, 1987; Beck &

Clark, 1988; Gotlib & Joormann, 2010). Cognitive vulnerability is defined as a persistent, stable,

internal characteristic that predisposes one to the development and emergence of depressive

symptomatology (Ingram, Miranda, & Segal, 1998). This vulnerability is thought to be latent and
 7

therefore not readily observable, and is presumed present even when no overt symptoms of

depression are apparent (Beck, Rush, Shaw, & Emory, 1979; Beck & Haigh, 2014). According to

cognitive models of depression, the activation of this underlying vulnerability is due to a

diathesis-stress interaction, where depression onset is thought to occur as a result of the

interaction of maladaptive cognitions and/or biased information processing combined with a

negative life event (Gotlib & Joormann, 2010). Whether or not cognitive vulnerability

contributes specifically to the recurrence of depression versus initial onset remains unclear, and

this is therefore a key question for depression researchers.

As noted, cognitive vulnerability can manifest as biases in thinking and information

processing. According to the General Cognitive Model proposed by Beck and Haigh (2014),

when the ability to function adaptively is disrupted and not proportionate to life events, clinical

disorders such as depression can develop. This model further posits that this occurs due to an

exaggeration of biases in normal information processing which activate schemas that control

how information is perceived, ultimately leading to maladaptive functioning in cognitive,

emotional, motivational, and behavioral systems. Faulty information processing is thought to

lead to maladaptive reactions that manifest as cognitive biases, including errors in interpretation,

attention, and memory. For example, the presence of a negative cognitive style or a

dysfunctional style of thinking could impact how one interprets, attends to, and remembers

information, and may be a trait-like cognitive vulnerability in those with a history of depression

that increases susceptibility to future depressive episodes (Beck et al., 1979; Ingram et al., 1998;

Clark, Beck, & Alford, 1999; Scher, Ingram, & Segal, 2005).

Attentional biases. One mechanism through which a negative cognitive style can manifest

is through maladaptive attentional processing, or biases in attention to emotional information

(Beck, 1987; Gotlib & Joormann, 2010; Beck & Haigh, 2014). An attentional bias is the
 8

tendency to preferentially attend to specific types of valenced information and/or stimuli in the

environment. For example, several studies have found that depressed individuals attend to sad

information more and to positive information less than never depressed individuals (e.g., for

reviews see Gotlib & Joormann, 2010; Yiend, 2010). Some research suggests that those with a

history of depression exhibit biases in attention similar to those seen in depressed individuals

(e.g., McCabe, Gotlib, & Martin, 2000; Joormann & Gotlib, 2007; Sears, Newman, Ference, &

Thomas, 2011; Newman & Sears, 2015).

Cognitive models of depression maintain that attentional biases for emotional information

are not merely symptoms of depression but may also be an important trait-like cognitive

vulnerability factor for depression recurrence (Gotlib & Joormann, 2010). According to some

researchers, an attentional bias for negative information is both an etiological and maintaining

factor of depression, with attention to depression-related stimuli leading to an increase in

negative affect in the short term, ultimately resulting in long term distortions in interpretations,

beliefs, and assumptions about the world (e.g., DeRaedt & Koster, 2010, Armstrong & Olatunji,

2012). Researchers have found that those vulnerable to depression (e.g., due to a history of

depression) will also reduce attention to positive stimuli in their environment (McCabe et al.,

2000, DeRaedt et al., 2012; Soltani et al., 2015), and it has been hypothesized that the ability to

effectively process positive stimuli may be an important resilience factor that assists recovery

from negative mood states and protects against depression recurrence (DeRaedt & Koster, 2010).

DeRaedt and Koster proposed that impairments in attentional processes, evidenced through

either prolonged processing of negative material and/or a lack of engagement with positive

material, are central factors related to increased depression vulnerability, and that a lack of

control over attentional processes is a key factor in the vulnerability to subsequent depressive

episodes. A major goal of the present study was to examine how attentional biases manifest both
 9

during and subsequent to depressive episodes to understand their role in the recurrence of

depression.

Attentional biases in dysphoric and depressed individuals. To determine if attentional

biases confer a vulnerability to depression and how they might be implicated in the mechanisms

related to depression relapse, it is important to first evaluate how they manifest during a

depressive episode. Attentional biases in dysphoric and depressed individuals have been studied

using a variety of paradigms, all with the purpose of understanding maladaptive attentional

processes associated with depression. Three methodologies have figured most prominently in

investigations of attentional biases. Numerous studies have used the modified emotional Stroop

task (Nunn, Mathews, & Trower, 1997; Gilboa & Gotlib, 1997; for a review see Epp, Dobson,

Dozois, & Frewen, 2012) and the dot probe task (Joormann & Gotlib, 2007; Mogg, Millar, &

Bradley, 2000; Bradley, Mogg, & Millar, 2000; Winer & Salem, 2016). Peckham, McHugh, and

Otto (2010) conducted a meta-analysis of 22 dot-probe and emotional Stroop task studies. They

concluded that depressed individuals evidence greater biased attention toward negative stimuli

and away from positive stimuli relative to non-depressed individuals, with the dot-probe task

found to be a more robust measure of attentional biases. However, it should be noted that

attentional bias scores as measured by the dot probe task have been found to have poor

reliability, especially when measuring attentional biases to threat-related images in individuals

who are assessed as high anxious or high socially anxious (Waechter, Nelson, Wright, Hyatt, &

Oakman, 2014; & Stolz, 2015). To date, the reliability of the dot-probe task for measuring

attentional biases in depressed individuals has not been examined, making this an important

consideration when using this methodology. Other tasks used to study attention have included

the dichotic listening task (e.g., Ingram, Steidtmann, & Bistricky, 2008), visual search tasks (e.g.,
 10

Wenzlaff, Rude, Taylor, Stultz, & Sweatt, 2001), and the deployment of attention task (e.g.,

McCabe et al., 2000).

Considered together, the studies using these methodologies have reported conflicting

findings, some inconsistent with the presence of attentional biases in depression (see Mogg &

Bradley, 2005, for a review), some suggesting evidence of attentional biases when the Stroop

and dot-probe stimuli are presented for longer durations (e.g. Bradley, Mogg, & Lee, 1997;

Gotlib, Krasnoperova, Yue, & Joormann, 2004), and some that support the presence of negative

attentional biases in depression regardless of stimulus presentation time (Peckham et al., 2010).

These studies have been informative, but a disadvantage is that the particular tasks used

measured attention primarily through response latencies, which require the focus of attention to

be inferred and not directly measured (Yiend, 2010).

Eye-gaze Tracking and the Measurement of Attention in Depression

To date, the most direct approach to examine attentional processes in depressed

individuals is eye-gaze tracking, and several studies have used eye-gaze tracking paradigms to

examine attention to emotional images or words (see Armstrong & Olatunji, 2012, for the most

recent review). The primary advantage of eye-tracking paradigms is that they can provide a

continuous measure of the focus of attention over an extended interval, as compared to response

latency-based tasks such as the dot-probe task that measure the focus of attention at a single

moment in time. Eye-gaze tracking allows for a direct and continuous measure of attention as

gaze direction inherently coincides with the focus of attention (Wright & Ward, 2008). Although

research examining the reliability of eye-tracking paradigms in the measurement of attentional

biases is sparse, the literature to date on attention to threat stimuli does suggest that it is most

reliable when viewing occurs over longer time periods (e.g., time periods of 5000 ms or greater),

and less reliable at shorter time intervals (e.g., less than 1500 ms; Waechter et al., 2014).
 11

Some of the best evidence for attentional biases in depression has emerged from studies

that have used eye tracking methods to examine shifts of attention over time when multiple

emotional images compete for attention (Caseras, Garner, Bradley, & Mogg, 2007; Eizenman et

al., 2003; Kellough, Beevers, Ellis, & Wells, 2008; Leyman, DeRaedt, Vaeyens, & Philippaerts,

2011; Sears, Thomas, LeHuquet, & Johnson, 2010; Sears et al, 2011; Newman & Sears, 2015). It

is relevant to note that these studies have most typically included samples of either dysphoric

(analogue samples) or depressed (clinical samples) individuals and compared them to either non-

dysphoric individuals or never depressed individuals. In addition, the emotional images

presented have been either photographs depicting various scenes, people engaged in various

situations, animals, or objects (typically referred to as naturalistic images) or images depicting

emotional faces (e.g., faces from the NimStim Facial Expressions database (Tottenham et al.,

2009; http://www.macbrain.org/resources.htm)

Consistent with previous literature that used different measures of attention, a meta-

analysis of the studies to date that have used eye tracking in currently depressed and dysphoric

individuals found increased attentional engagement to dysphoric stimuli and/or decreased

engagement with positive stimuli (termed an “anhedonic bias”) relative to never depressed

individuals (Armstrong & Olatunji, 2012). No specific biases for attention to threatening stimuli

in depression were observed (Armstrong & Olatunji, 2012), which suggests that the attentional

bias associated with depression-relevant (sad) stimuli does not generalize to all negative

information.

Attentional biases and naturalistic image stimuli. Two studies that examined

attentional biases in dysphoric individuals noted specific differences in attention to positive and

negative images. Caseras et al. (2007) presented pairs of images for 3000 ms; the images were

either positive (described as images of “people engaging in enjoyable activities and looking
 12

happy”), negative (described as images of people “looking unhappy or crying”), or neutral

control images (described as images of people in “non-emotional situations”). Compared to non-

dysphoric individuals, the dysphoric individuals exhibited a greater attentional bias (longer gaze

durations) for negative images relative to control images. There were no group differences in

attention to the positive images or in the initial orienting to positive or negative images (Caseras

et al., 2007).

The second study was carried out by Sears et al. (2011), who examined attention to four

types of images (depression-related, anxiety-related, positive, and neutral) over a 10-second trial.

They found that dysphoric participants spent less time attending to positive images than never

depressed participants. Although there were differences in the first fixations that indicated more

frequent initial orienting to depression-related images by the dysphoric participants, there were

no differences in the group’s total fixation times to the depression-related images. Both of these

results were different from the findings in Caseras et al. Of course, it is possible that the longer

viewing times in Sears et al.’s study contributed to the differences observed in attention to

positive and depression-related stimuli.

Using samples of clinically depressed participants, three studies used an eye-tracking

paradigm to examine attention to naturalistic images. Eizenman et al. (2003) presented depressed

and never-depressed participants with four types of images (positive, dysphoric, threat-related,

and neutral) and examined fixation times to the images over a 10.5 second viewing time. Their

findings indicated that the depressed participants attended to dysphoric images more than never-

depressed participants, evidence for a negative attentional bias in depression. Similarly, Kellough

et al. (2008) showed depressed and never-depressed participants sets of four images (positive,

dysphoric, threat-related, and neutral) over a 30-second viewing time. Like Eizenman et al.,

Kellough et al. found that depressed participants spent more time attending to depression-related
 13

images (e.g., images depicting themes of sadness and loneliness) than never-depressed

participants. Unlike Eizenman et al. however, Kellough et al. also found that depressed

participants attended to positive images significantly less than never-depressed participants.

Newman and Sears (2015) examined attentional biases in currently, previously, and never

depressed individuals. They found that depressed participants attended more to depression-

related images and less to positive images relative to previously and never depressed

participants. These findings are consistent with those observed in Kellough et al., providing

further evidence that individuals experiencing clinical depression exhibit attentional biases for

both depression-related and positive information that are different from those observed in never

depressed individuals. Taken together, the results of these studies lend strong support to the idea

that attentional biases in depression manifest through both elaborative processing of depression-

related content and deficits in engaging with positive content, which may be factors related to the

maintenance of a depressive episode.

Attentional biases and face image stimuli. In addition to using naturalistic images to

examine attentional biases, researchers have used images portraying differing facial expressions

(e.g., sad, threatening, or happy) to examine attentional biases in dysphoric, depressed, and never

depressed individuals. The perception of facial emotion is important in terms of adaptive social

development, social functioning, and emotional regulation (Bistricky, Atchley, Ingram, &

O’Hare, 2011). Depressed individuals are thought to be sensitive to social and interpersonal

information such as facial expressions, which provide information regarding the mood state of

others such as the perception of rejection or criticism in facial expressions (Leyman, DeRaedt,

Vaeyens, and Philippaerts, 2011).

Research suggests that those exhibiting depressive symptoms and those vulnerable to

depression (e.g., those with a history of depression) interpret, attend to, and remember facial
 14

affect in a maladaptive way (Bistricky et al., 2011), for example, interpreting neutral or

ambiguous facial expressions as sad (Bourke et al., 2010). Considered together, a number of

studies using various methodologies to examine facial processing have converged on the idea

that depressed individuals experience specific difficulty processing positively valenced facial

information. These difficulties are evidenced in several ways, including slower detection of

happy faces relative to controls (Suslow et al., 2001), misinterpreting happy faces as neutral (Gur

et al., 1992), and deficits in recognizing subtle expressions of happiness (Joormann & Gotlib,

2006; LeMoult et al., 2009).

Biased attention for facial expressions could exacerbate or maintain depressive states via

different processes (Gilboa-Schechtman, Ben-Artzi, Jeczemien, Marom, & Hermesh, 2004;

Gotlib et al., 2004; Bistricky et al., 2011). For example, attention to sad faces can lead to an

increase in depressed mood. This could occur when an individual observes a negative facial

expression that in turn triggers negative self-evaluation. The incorrect interpretation of facial

expressions can lead one to assume that others are judging them, which could in turn lead to

impaired social interactions (Bistricky et al., 2011).

In studies that have used the dot probe task, depressed individuals have been found to

exhibit biased attention to sad faces (Gotlib, Krasnoperova, Yue, & Joormann 2004; Gotlib,

Kasch et al., 2004) and to lack the positive attentional bias for happy faces observed in never

depressed individuals (Bourke, Douglas, & Porter, 2010; Bistricky et al, 2011; Winer & Salem,

2016). Similar findings have been reported for those with a history of depression (Joormann &

Gotlib, 2007; Suslow et al., 2004). A study that used an exogenous cueing task found evidence

suggesting that patients with a diagnosis of major depressive disorder exhibit biased attention to

angry faces relative to non-depressed individuals (Leyman et al., 2007). Leyman et al. argued
 15

that angry faces strongly signal information regarding social rejection, which is information that

depressed individuals are very attuned to in their interpersonal interactions.

Eye-gaze tracking has also been used to examine attention to face stimuli. One study

compared dysphoric and never depressed participants’ attention to happy and sad face images

and found that dysphoric participants attended to sad faces significantly more and to happy faces

significantly less than never depressed participants (Leyman et al., 2011). Another study

examined attention to emotional face images (happy, sad, angry) in groups of depressed and

never depressed participants (Duque & Vazquez, 2015). Similar to Leyman et al., their findings

indicated that depressed participants attended to sad faces more and to happy faces less than

never depressed participants.

Attentional Biases in Previously Depressed Individuals

In contrast to the research on attentional biases in depressed and dysphoric individuals,

the literature on attentional biases in individuals with a history of depression is at a nascent stage

of inquiry. The most salient question regarding attentional biases in those with a history of

depression is whether or not they are a trait characteristic (as opposed to being present only

during an active episode) that contributes to susceptibility to the development of future

depressive episodes (Gotlib & Joormann, 2010; DeRaedt & Koster, 2010). Many studies have

used cross-sectional designs to investigate this question, in which the attentional biases of

remitted depressed individuals are examined at a single point in time, with the purpose of

determining if they exhibit biases similar to those observed in never depressed or currently

depressed individuals (e.g., Sears et al., 2011; Isaac, Vrijsen, Rinck, Speckens, & Becker, 2014;

Soltani et al., 2015; Newman & Sears, 2015; Woody, Owens, Burkhouse, & Gibb, 2015). Part of

the challenge in delineating the nature and role of attentional biases as a factor that contributes to

cognitive vulnerability is the inherent limitations of cross-sectional designs for this purpose—
 16

they make it difficult to draw conclusions about the relationship between attentional biases and

depression recurrence, and to determine if attentional biases are a causal factor related to the

development of subsequent episodes or a consequence (e.g., scar) of experiencing previous

episodes (Just et al, 2001; Beevers & Carver, 2003). These limitations highlight the need for

longitudinal research that examines changes in attention over time in the same individuals. A

longitudinal study design allows one to determine how attentional biases manifest from the

period of remission/recovery to relapse in the same individuals and may help elucidate the

specific changes in biases that contribute to relapse, especially when compared to those who do

not relapse. In addition, a longitudinal design allows for attentional biases to be examined as

prospective predictors of future depressive episodes in those with a history of depression, testing

cognitive theories that suggest cognitive factors are likely causally involved in depression relapse

(Beevers & Carver, 2003).

The Present Research

The present study used an eyetracking paradigm to examine attentional biases as a

cognitive vulnerability factor in depression relapse, using a prospective, longitudinal design to

avoid the limitations of cross-sectional studies. This study examined attentional biases in a group

of remitted depressed women to: 1) determine if and how attentional biases differ in those

individuals who relapse versus those who do not relative to individuals with no depression

history, and 2) determine if attentional biases are predictive of depression relapse.

As noted, previous eye tracking studies have used either naturalistic images or face images.

Given that the category of stimuli used (e.g., naturalistic or face) is one potential explanation for

the variation in reported findings, the present study used both image categories (presented to

participants in separate blocks). Although not the main research question, the use of both

naturalistic and face images within a single longitudinal investigation allowed for a
 17

determination of whether attentional biases were consistent across both image categories in the

same groups of participants in a manner that has not been previously explored.

Study participants were women with a history of clinical depression (previously

depressed) and women with no history of clinical depression (never depressed). Both groups

were followed for six months and contacted every two weeks. There were three key analyses

conducted, presented as Chapter 2, Chapter 3, and Chapter 4. Chapter 2 examines attentional

biases at the first and follow up visit. The goal was to determine whether and how attentional

biases in previously depressed participants changed over time when depression relapse occurred.

To do so, attentional biases in previously depressed participants (separated into a relapsed and

non-relapsed group at the follow up visit) and never depressed participants were examined at

both the initial and follow up visits. Changes in attentional biases from the initial to follow up

visits were examined (i.e., total fixation times to each image type at the initial and follow up

visits were compared), to determine if there were differences between participants who relapsed

over the six month time period and those who did not.

Chapter 3 further elaborates on the data examined in Chapter 2, with a more detailed

examination of the attentional biases via a time course analysis of the fixation data. As discussed

in detail in Chapter 3, previous studies (Arndt, Newman, & Sears, 2014; Soltani et al., 2015)

found differences in the temporal profiles of attention between dysphoric and never depressed

participants, and between previously depressed and never depressed participants. These studies

showed that there were group differences in the way that attention to emotional images changed

over the course of the 8- or 10- second presentations of the images. In the present study, the time

course analyses divided the fixation times over the 8-second presentations into 2-second intervals

to determine if the temporal profile of attention unique to each group changed as a function of

relapsing or not relapsing.

 18

Chapter 4 examines attentional biases measured at the initial visit as predictors of

depression relapse over the six-month study period to determine if attentional biases as a

cognitive vulnerability factor can predict subsequent depression onset. This analysis used logistic

regression to predict depression relapse.

A description of the methods used in this study are presented next. The three subsequent

chapters, as described above, will provide a rationale for each analysis and a review of the

relevant literature and hypotheses, followed by the results and a brief discussion. Chapter 5 will

present an integrated discussion of the entire set of findings of this thesis, including limitations

and future directions.

General Method

Participants

Only female participants were recruited given the noted gender differences in the

prevalence, etiology, course, and overall experience of depression (e.g., Kessler, McGonagle,

Swartz, Blazer, & Nelson, 1993; Piccinelli & Wilkinson, 2000). There is also evidence of gender

differences in the processing of emotional stimuli (Donges, Kersting, & Suslow, 2012; Kemp,

Silberstein, Armstrong, & Nathan, 2004; Montagne, Kessels, Frigerio, deHaan, & Perrett, 2005).

One group of participants met criteria for a history of clinical depression, and were in either a

current remission (asymptomatic for 2 to 8 weeks) or recovery (asymptomatic for greater than 8

weeks), both operationally defined by the consensus definitions proposed by Frank et al. (1991).

Including participants both remitted and recovered maximized the final number of participants.

Therefore, there was one group of individuals with a depression history that included both

remitted and recovered individuals, collectively termed the previously depressed group. This

group was created based on diagnostic criteria for a Major Depressive Disorder (MDD) in the

past, as defined in the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition
 19

(DSM-IV; APA, 2000), and assessed using the Structured Clinical Interview for DSM-IV Axis I

disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 1995). A never depressed control group

was also recruited and evaluated using the SCID-I interview. This group consisted of individuals

who had no current or previous history of depression. When the groups were created, participants

were excluded if they met criteria for a history of or current presentation of psychosis or mania,

current depression, or current alcohol or drug abuse/addiction.

Participants were recruited through a variety of methods, including a pre-screening

process using the online research participation system at the University of Calgary, community

flyer postings, advertisements on the University of Calgary website, a news feature on a local

televisions station, and a news story on the Alberta Health Services website. Participants first

completed an online screening measure that included preliminary assessment of historical or

current depression using the BDI-II, PHQ-9, and PHQ-9L (see below for description of

measures) to determine potential group assignment. In addition, the screening assessed for

exclusion criteria including current depression, current or previous psychosis or mania, or current

alcohol or drug abuse/addiction. Participants who appeared to meet the study criteria based on

the online screening were invited to participate in the study and scheduled for their first

laboratory session if they volunteered. All participants provided informed consent prior to their

participation, and attended two separate lab visits. During the initial visit, participants were

assessed with the Structured Clinical Interview for DSM-IV diagnoses (SCID) by a trained

interviewer, described below. The previously depressed participants had experienced a previous

episode of MDD, but did not meet criteria at the initial visit (the last episode prior to testing

ranged from less than six months previous to their lab visit to more than one year previous to

their visit). Participants completed several self-report questionnaires on a computer, as described

below. After completing the interview and questionnaires, participants’ attention to images was
 20

measured using the eye-tracking methodology described below. Participants were reminded of

the follow up procedure at the end of the lab visit.

Measures

To assess for depression, history of depression (or lack thereof), and mental health status

at the first and follow-up visits, the following measures were used:

Diagnoses. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I;

First, Spitzer, Gibbon, & Williams, 1995) was used to assess each participant’s current state and

history of depression. The SCID-I is a commonly used semi-structured interview that determines

the presence of current and lifetime Axis I disorders based on diagnostic criteria outlined in the

DSM-IV (SCID-I; First et al., 1995). The SCID-I is the most widely used semi-structured

diagnostic interview among North American researchers (Summerfeldt & Antony, 2002); it is

organized into nine diagnostic modules.

In the present study, participants were administered the relevant modules to assess for the

presence of past and current depression, dysthymia, mania, psychotic episodes, and substance

abuse. Exclusionary criteria included the presence of current or previous psychosis, a current

depressive episode, dysthymic disorder, current or previous mania, and current substance use

disorder.

Each diagnostic module of the SCID-I includes both required probe questions and

suggested follow-up questions. Responses to individual items are rated on a 3-point scale,

including 1 for “absent or false”, 2 for “sub-threshold”, and 3 for “true or present”. Items that can

not be rated due to insufficient information are rated by marking a fourth option, “?”. Probe and

follow-up questions, which involve asking for specific examples, are used as necessary to

determine if specific diagnostic criteria are met. A skip-out option is available if the participant

does not meet a critical criterion required for diagnosis of a particular disorder.
 21

The SCID-I is often the preferred choice among semi-structured interviews (e.g., Scherrer

& Dobson, 2007) and is commonly used in research for diagnostic purposes (e.g., Gemar et al.,

2001; Gotlib et al., 2004). Interrater reliability has been determined to be in the moderate to

excellent range for Axis I disorders (Lobbestael, Leurgans, & Arntz, 2011), and inter-rater

reliabilities for current versus lifetime diagnosis have ranged from r = 0.75 to r = 0.85 (Hook et

al., 2007).

The Patient Health Questionnaire-9. The Patient Health Questionnaire-9 (PHQ-9;

Spitzer, Kroenke, & Williams, 1999) is a 9-item depression scale used to assess depression

symptoms, functional impairment, and severity. The PHQ-9 is based on the diagnostic criteria

for major depressive disorder as described in the DSM-IV and allows one to make a tentative

diagnosis of depression. This measure assesses how often over the past two weeks a person has

been bothered by each of the criteria for depression: depressed mood, anhedonia, appetite

change, sleep disturbance, psychomotor agitation or retardation, loss of energy, feelings of

worthlessness or guilt, diminished concentration and suicide attempts. Responses are rated on a

4-point scale (“Not at all”, “Several days”, “More than half the days”, and “Nearly every

day”). Categorical scoring can be used to establish a diagnosis of current or past depression,

based on meeting one of the two cardinal criteria (depressed mood, anhedonia), as well as

endorsing at least four of the other criteria. Severity scores between 5-9 indicate minimal

symptoms of depression, 10-14 indicate minor/mild major depression, 15-19 indicate moderately

severe major depression, and scores greater than 20 indicate severe major depression. The PHQ-

9 can be modified to assess a lifetime history of depression (PHQ-9 Lifetime; Cannon et al.,

2007). To do so, the original instructions are changed from: “Over the last 2 weeks, how often

have you been bothered by any of the following problems?” to “For the 2 weeks in your life (or

longer) that you were the most blue, sad, or depressed, how often were you bothered by any of
 22

the following problems”. Participants were determined to meet criteria for past depression

through endorsement of at least five criteria (at least one of the first two cardinal criteria plus at

least four other criteria).

The Beck Depression Inventory-Second Edition. The Beck Depression Inventory

(BDI-II) (Beck, Steer, & Brown, 1996) is a 21-item self-report inventory that measures

depressive symptoms over the past two weeks. Each item is rated from zero to three, with a total

score that can range from 0-63, with higher scores indicating more symptoms of depression. The

BDI-II has excellent internal consistency in student (α = .93) and outpatient samples (α = .92)

and excellent test-retest reliability (r = .93) (Beck et al., 1996). The BDI-II was used in this study

to measure depression severity. The BDI-II was also used as an online screening measure to

assess for both present and past symptoms of depression, to determine potential study eligibility.

Beck Anxiety Inventory. The Beck Anxiety Inventory (BAI) is a self-report inventory

consisting of 21 items, each describing a common symptom of anxiety. Participants are asked to

rate how much they have been bothered by each symptom over the past week on a 4-point scale,

ranging from 0 (“not at all”) to 3 (“severely – it bothered me a lot”). Possible total scores range

from 0-63, with higher scores indicating greater symptoms of anxiety. The BAI has high internal

consistency in both clinical and non-clinical populations (α = .92-.96) and a test-retest reliability

of r = .75 (Beck, Epstein, Brown, & Steer, 1988). The BAI also has concurrent validity with

other measures of anxiety, including the Hamilton Anxiety Rating Scale-Revised (r = .51), and

the State-Trait Anxiety Inventory (State r = .47, Trait r = .58; Beck & Steer, 1993).

Unpleasant Events Schedule. To evaluate recent negative events or life stressors, the

Unpleasant Events Schedule (UES; Lewinsohn, Mermelstein, Alexander, & MacPhillamy, 1985)

was used. The UES is a self-report measure that assesses how often a number of stressful events,

including both daily hassles and major life events, have occurred over a given time period, as
 23

well as the perceived distress or level of unpleasantness in relation to each given event

(Lewinsohn et al., 1985). The original UES contained 320 items. In the present study, a 31-item

short form that consists of individual items found to be strongly related to mood was employed

to assess participants’ recent experience of stressful events (Lewinson & Amenson, 1978). The

items are rated twice on a 3-point scale: a first rating of frequency for the UES-A score (0 = this

has not happened in the past specify time period— for example 30 days; 1 = this has happened a

few times (1 to 6) in the past specify time period; 2 = this has happened often (7 or more) in the

past specify time period), and a second rating of perceived unpleasantness for the UES-B score (0

= This was not unpleasant; 1 = This was somewhat unpleasant; 2 = This was very unpleasant).

Both the UES-A and UES-B scores have possible scores from 0-62, and higher scores indicate

increased occurrence or perceived unpleasantness, respectively, of recent negative life events.

The short form, based upon the original version of the UES, has shown strong psychometric

qualities (Nezu et al., 2000). Test-retest reliability for various forms of the UES range from

approximately r = 0.60 to 0.80 for the majority of subscales, with higher reliability found for

commonly occurring events. There is less research available regarding the psychometric

properties of the 31-item short form. For the mood-related UES items that comprise the short

form, the reported test-retest reliability ranges from r = 0.70 to 0.80; and these items more

readily distinguish depressed and non-depressed individuals relative to the non mood-related

items in the original UES (Lewinson & Amenson, 1978).

Perceived Stress Scale. The Perceived Stress Scale (PSS-10) is a 10-item self-report

inventory that assesses the degree to which one perceives life events to be stressful, and higher

scores have been found related to the development of psychopathology (Cohen & Williamson,

1988). The 10 items on this measure assess perceptions of stress over the previous month, and

are rated on a 5-point Likert scale, ranging from 0 (“never”) to 4 (“very often”) with higher
 24

scores indicating greater perceived stress. Questions ask about how often over the last month a

person has experienced a variety of stressors (e.g., being upset about an unexpected event,

lacking control over important things in life, feeling nervous, feeling unable to cope). The PSS-

10 has been found to have acceptable psychometric properties (Lee, 2012), including high

internal consistency in clinical populations (α = .89; Roberti, Harrington, & Storch, 2006).

Demographics inventory. A demographics inventory asked questions about age,

ethnicity, previous episodes of depression and anxiety, experiences with medications and

psychotherapy, and recent changes in mood.

Eye Tracking

Apparatus. Attention to emotional images was assessed using eye gaze tracking and

recording. Eye movements were recorded using an EyeLink 1000 eye-tracking system (SR

Research Ltd., Ottawa, ON) which uses infrared video-based tracking technology. The system

has a 1000 Hz sampling rate (allowing for a temporal resolution of 2 ms), and a typical gaze

accuracy of 0.25-0.50 degrees of visual angle. Stimuli were shown on a 21-inch monitor

positioned approximately 60 cm away from the participant. Participants used a chin rest to

minimize head movements and increase tracking accuracy.

Eye tracking stimuli and procedure. During each of the two laboratory visits,

participants’ eye movements were tracked and recorded while they viewed sets of images

presented on the computer display. Participants were shown two separate blocks of images (one

block of naturalistic images and one block of face images), with a short rest period between

blocks. The presentation of these blocks was randomized across participants using an online

randomizer tool (https://www.randomizer.org). Different sets of images were used for the initial

and follow-up visits.

The naturalistic images consisted of 160 images depicting people, places, and objects
 25

(these images were used by Sears et al., 2011). Four types of images were presented: depression-

related, threat, positive, and neutral. Thirty images of each type were presented. The depression-

related images included scenes of people appearing sad and unhappy, neglected animals (e.g., a

puppy in a small steel cage), scenes of poverty, and dark, gloomy landscapes. The threat images

involved themes of threat and injury, and included scenes of people being threatened with

weapons, people with physical injuries (e.g., an untreated burn on an arm), dangerous situations

(a person walking along a cliff), motor vehicle accidents, and threatening animals. The positive

images showed people smiling and laughing, children playing, puppies and kittens, and vacation

activities or destinations (e.g., a beach at a tropical resort). The neutral images included people in

various activities and had no obvious positive or negative theme (e.g., a woman talking on the

telephone, a group of people having a meeting). They also included pictures of objects (e.g., a

bicycle, a computer) and a variety of neutral landscapes (e.g., office buildings). Sears et al.

(2011) had each of these images categorized by 152 female undergraduate students and reported

that 90% of the raters agreed upon the category that each image was assigned to. The valence of

each of these images was rated in the same study, with mean valence ratings of 3.43, -3.31,

-3.61, and .12, for the positive, depression-related, threat, and neutral images respectively, based

on a scale from -5 (very negative) to +5 (very positive).

The face images consisted of photographs of male and female faces, taken from the

NimStim Facial Expressions database (Tottenham et al., 2009;

http://www.macbrain.org/resources.htm). Four different types of facial expressions were used:

sad, threat, happy, and neutral (corresponding to the naturalistic images categories of depression-

related, threat, positive, and neutral images). As the database contained face images with both

open and closed mouths, each image category was comprised of an equal number of faces with

open and closed mouths. In addition, the threat image category was comprised of an equal
 26

number of angry and frightened faces (with an equal distribution of open and closed mouths), as

both were deemed to potentially evoke a threat-related response.

The rationale for comparing attentional biases for naturalistic images and face images is

because researchers have speculated that attentional biases in those with current depression

(Gotlib et al., 2004; Kujawa et al., 2011) and a history of depression (Joormann and Gotlib,

2007) may be more pronounced for social information. By using both types of images, this study

was the first to directly compare attentional biases for both face and non-face stimuli.

Participants were provided with written and spoken instructions at the beginning of the

session. As noted, they were shown four images on each trial. One image was placed in each of

the four corners of the display. Images were randomly assigned to the four display locations;

across all the trials each image type was equally likely to appear in each corner. At the start of

each trial the participants fixated on a black dot in the centre of the display to calibrate the eye

tracker (the calibration display). The four images were then presented for eight seconds and

participants’ eye gaze was tracked and recorded throughout the trial. Participants were instructed

to view the images in any fashion they wished (similar to the procedure of Kellough et al., 2008;

Sears et al., 2011). The two blocks of thirty trials each (naturalistic images and face images) each

required approximately 12 minutes to present. The main dependent variable, as measured by the

eye tracking system, was the total duration of time spent fixating each image (total fixation

time).

Second Lab Visit and Group Formation

Participants (remitted depressed and never depressed) were contacted twice per month by

phone for the six months following their first lab visit. When contacted, they were screened

using the BDI and PHQ-9 to assess for symptoms of depression. During each phone contact,

depression relapse (or onset in the never depressed group) was assessed using the BDI-II (score
 27

=/> 13) and the PHQ-9 (threshold required to meet depression criteria- see criteria for the PHQ-9

description above). Participants returned to the lab for a follow up visit and group assignment

was determined as per the following protocol. Specifically, the first group was participants

identified as experiencing depression relapse (the relapsed group). At the time of relapse, these

participants were scheduled to come in for their follow up visit as quickly as possible. The

average time from the initial study visit to relapse was 98 days (14.2 weeks). The second group

consisted of participants who did not experience depression relapse (the non-relapsed group) at

any time during the six-month follow up period. These participants were scheduled to return to

the laboratory six months after the initial visit. The third group consisted of participants with no

depression history (the never depressed group). These participants were also scheduled to return

to the laboratory six months after their initial visit. Participants were given a $25 gift card for

each laboratory visit.

Participant Flow and Dropout:

A total of 3155 women completed the initial online survey to determine eligibility for the

study, 2797 students and 358 community members. Eligibility was based on meeting criteria for

a history of depression or no history of depression as per the online measures (PHQ, PHQ-L, and

BDI). From the 3155 survey participants, there were a total of 289 eligible participants (152

student participants and 137 community participants) who were scheduled to attend the first lab

visit. There were 145 participants excluded at or following the first visit for the following

reasons: (a) current or prior mania, current substance abuse, current depression, psychosis,

relocation out of the city, did not meet depression criteria as per the SCID, did not attend the first

lab visit and did not return correspondence to set a new visit date (n = 59) (b) eyetracking

calibration errors (n = 20), (c) attrition/drop out (n = 51), and (d) participants who did not

identify criteria for relapse during phone screenings, but endorsed criteria for relapse during the
 28

study period at the follow up visit (n = 15). Ultimately, 146 participants who completed both the

initial and follow up visits were included in analyses. See Figure 1 below for participant flow.
 29

RPS students who

Community participants

completed survey: who completed survey:
2797 358





Total:
3155


Eligible student participants: Eligible community participants:
152 137


*Eligibility determined as meeting criteria
as never depressed or for hx of depression

Initial session
total:
289

EXCLUSIONS:
-Excluded from study at initial visit due to mania, current substance abuse, current
depression, psychosis, moving away, did not meet criteria, no show: 59
-Excluded due to eyetracking data errors: 20
-Drop Outs: 51
-Missed relapses: 15
Total excluded: 145

Total participants:
146

Figure 1. Participant Flow and Exclusions

 30

Participant data

The following two tables report the demographic and measure data for the 146 study

participants whose data are analyzed in Chapters 2, 3, and 4.

Table 1.

Characteristics for the Relapsed, Non-Relapsed, and Never Depressed Participants

Relapsed Non-Relapsed Never Depressed

Measure
(n = 14) (n = 103) (n = 27)

M SD M SD M SD

Age 29.5a 12.1 29.7a 12.3 21.4b 8.2

MoodT1 1.43a 2.2 2.6b 1.7 2.8b 1.5

MoodT2 -.86a 2.6 2.5b 1.8 3.3c 1.0

BAIT1 7.6a 6.1 9.1a 7.6 2.8b 3.2

BAIT2 17.4a 9.3 9.8b 7.6 2.5c 1.8

BDIT1 10.7a 7.3 7.5a 6.1 1.7b 2.5

BDIT2 25.3a 10.3 7.8b 7.2 1.1c 1.6

PHQCT1 6.2a 4.9 4.0b 3.6 0.77c 1.1

PHQCT2 15.5a 4.6 4.3b 4.1 0.70c 1.0
PHQ-L 21.5a 7.0 19.6a 5.6 1.2b 2.2

UES-A 28.36a 9.1 20.7b 7.7 10.7c 4.8

UES-B 28.14a 8.8 21.6b 10.9 16.1c 13.9

PSS 25.93a 3.5 16.53b 6.6 8.89c 4.0

#PE 8.0a 8.0 5.8a 13.0 0b 0

Note: Age = in years. Mood = current mood rating from –5 (very negative) to +5 (very positive). BAI =
Beck Anxiety Inventory [T1/T2 = Time 1 and Time 2]. BDI = Beck Depression Inventory [T1/T2 = Time
1 and Time 2]. PHQ-C = Patient Health Questionnaire (Current). PHQ-L = Patient Health Questionnaire
(Lifetime). #PE = Number of previous episodes of depression. UES-A = Unpleasant Events Schedule
form A (frequency of unpleasant events); UES-B = Unpleasant Events Schedule Form B (perceived
unpleasantness of events). PSS = Perceived Stress Scale. Means having the same subscript in the same
row are not significantly different at p < 0.05.
 31

Table 2.

Demographic characteristics of participants

Relapsed Non-Relapsed Never Depressed

(n = 14) (n = 103) (n = 27)

Community participant 43% 60% 7%

Student participant 57% 40% 93%

Married 21% 21% 7%

Divorced or Separated 21% 13% 0
Never married 57% 64% 93%

Cultural background 78% Caucasian 76% Caucasian 44%Caucasian

28% Asian

Current therapy for MDD 21% 15% 3%

Past therapy for MDD 85% 66% 0%
Current antidepressants 35% 24% 0%
Past antidepressants 71% 53% 0%
 32

Chapter 2: Analysis of Attentional Bias Total Fixation Times

Depression researchers hypothesize that cognitive vulnerabilities in those with a history

of depression are reflected in biased information processing (Beck et al., 1979; DeRaedt &

Koster, 2010; Gotlib & Joormann, 2010). The research to date has attempted to delineate how

attentional biases manifest in those with a depression history with the purpose of understanding

their unique role in depression relapse. One focus of interest is whether or not attentional biases

are a trait-like feature in vulnerable individuals, which would require that they be present during

the time that active symptoms of depression have remitted. If so, it is possible that attentional

biases may negatively impact the perception and interpretation of information of those in the

remitted state and thereby contribute to the likelihood of relapse.

Taken together, research on attentional biases in previously depressed individuals

suggests that in some circumstances they exhibit attentional biases similar to those observed in

depressed and dysphoric individuals. On the other hand, the findings of these studies have not

been consistent, with different results observed with respect to attention to negative and positive

stimuli (e.g., Joormann & Gotlib, 2007; Leyman et al., 2011; Sears et al., 2011, Armstrong &

Olatunji, 2012, Epp, Dobson, Dozois, Frewen, 2012; Woody, Owens, Burkhouse, and Gibb,

2016). In addition, one recent study found no evidence that attentional biases in remitted

individuals were similar to those observed in depressed individuals (e.g., Isaac, Vrijsen, Rinck,

Speckens, & Becker, 2014).

Using a dot-probe task, Joormann and Gotlib (2007) examined attentional biases in the

processing of emotional faces in never, previously, and currently depressed individuals. Neutral

faces were paired with either a happy or sad face. Previously and currently depressed individuals

were found to selectively attend to sad faces, whereas never depressed individuals avoided sad

faces and oriented toward happy faces. The findings indicated that previously and currently
 33

depressed individuals exhibited a similar attentional bias to sad, depression-related stimuli

(Joormann & Gotlib, 2007). This finding is consistent with the idea that previously depressed

participants attend to sad information similar to currently depressed participants and different

from never depressed participants, lending support to the existence of a cognitive vulnerability in

those previously depressed.

Using an eye-tracking task, Sears et al. (2011) examined attentional biases in previously

depressed, never depressed, and dysphoric participants. The participants viewed sets of

depression-related, anxiety-related, positive, and neutral images while their eye fixations were

tracked and recorded over a 10-second trial. They found that previously depressed and dysphoric

participants attended to positive images less than never depressed participants. Previously

depressed participants also attended to anxiety-related images more than never depressed

participants. In addition, the previously depressed and dysphoric participants were found to

exhibit a bias in the initial orienting of attention, whereby they initially oriented to depression-

related images more frequently than never depressed participants. These findings suggest that

individuals with a history of depression exhibit attentional biases similar to those with dysphoria,

and imply that attentional biases are not merely transient symptoms of depression, but are instead

an underlying vulnerability factor in those susceptible to the disorder.

Soltani et al. (2015) examined attentional biases for emotional face images (happy, sad,

threatening, and neutral) in never depressed, remitted depressed, and currently depressed

participants. Participants viewed sets of four face images for 8-seconds while their eye fixations

were tracked and recorded. The remitted and currently depressed participants attended to sad

faces significantly more than never depressed participants, and they attended to happy faces

significantly less than never depressed participants. Consistent with the findings of Joormann

and Gotlib (2007) and Sears et al. (2011), Soltani et al.’s results (2015) provide further evidence
 34

in support of the idea that attentional biases for emotional stimuli may persist beyond an active

depressive episode.

On the other hand, a few studies have reported different results and have reached

different conclusions. For example, Woody et al. (2016) used both the dot probe and eye-

tracking to examine attentional biases in remitted and never depressed female participants. Pairs

of face images (one neutral face, and one angry, happy, or sad face) were displayed for 1000ms,

followed by a probe. At the same time, eye gaze was also tracked, and the proportion of time

attended to emotional and neutral images was recorded. Similar to Joormann and Gotlib (2007),

Woody et al. found that remitted depressed participants had greater attentional bias scores

(computed using response latencies) for sad faces relative to never depressed participants.

However, the eye-tracking measurements indicated that the remitted depressed participants

exhibited more attention to angry faces, but not sad faces. Woody et al. suggested their findings

were similar to those of Sears et al. (2011), where previously depressed participants attended

more to anxiety-related images than never depressed participants (although Sears et al. did not

use face images). They did not find any differences between their remitted and never depressed

groups in attention to happy faces, unlike other studies (Sears et al., 2011; Soltani et al., 2015).

Isaac et al. (2014) examined attention to face images in groups of currently depressed,

remitted depressed, and never depressed participants. Participants viewed sets of four face

expressions (e.g., sad, angry, happy, neutral) while their gaze was tracked and recorded, and they

found that remitted and never depressed participants did not differ in their attention to sad face

images. Remitted and never depressed participants also attended similarly to happy face images,

and attended more to the happy faces than the currently depressed individuals. These results are

quite different from the findings of Sears et al. (2011) and Soltani et al. (2015), where the

remitted participants attended to positive images different than never depressed participants.
 35

Isaac et al. proposed that successful treatment of depression may lead to increased processing of

positive stimuli, which could explain why their results were different than those of other

investigators. Taken together, the small number of studies examining attentional biases in

previously depressed individuals indicate that there is no consensus as to whether the attentional

biases characteristic of current depression persist or diminish upon remission of a depressive

episode.

There is also a lack of consensus as to whether remitted depressed individuals attend to

positive stimuli similar to never depressed individuals. Some studies have reported reduced

attention to positive stimuli relative to never depressed individuals (Sears et al., 2011; Soltani et

al., 2015), whereas others have reported no differences in attention to positive stimuli relative to

never depressed individuals (Isaac et al., 2014; Newman & Sears, 2015). The results are more

often consistent for sad and depression-related stimuli, with a number of studies finding evidence

for greater attentional biases for sad stimuli relative to never depressed individuals (Joormann &

Gotlib, 2007; Sears et al., 2011; Soltani et al., 2015; Woody et al., 2016; Newman & Sears,

2015). Increased attention to threat/anxiety-related images (Sears et al., 2011) and angry faces

(Woody et al., 2016) has also been observed in those remitted from depression.

Analysis 1: Attentional Biases Analyzed via Total Fixation Times

For Analysis 1, attentional biases were examined to determine how they manifest in

previously depressed and never depressed participants at both initial and follow-up assessment

visits spanning a six-month time frame. The previously depressed participants were divided into

non-relapsed and relapsed groups based on relapse status. Attentional biases at both lab visits

were compared for each group to determine if differences existed between never depressed

individuals, individuals who did not relapse (non-relapsed), and individuals who did relapse

(relapsed) over the six month time period.

 36

Each of the comparisons within this first set of analyses were novel additions to the

literature. The first comparison examined attentional biases for emotionally valenced images

among previously depressed (relapsed and non-relapsed) and never depressed participants at the

initial lab visit. The second comparison examined the attentional biases of the three groups at the

follow up visit. Unlike previous studies that have compared previously and never depressed

individuals, the comparisons at both visits in the present study were different in that the

previously depressed group was differentiated into those who subsequently relapsed and those

who did not. This distinction was important in revealing if attentional biases were different in

those who transitioned from the previously depressed to relapsed state, allowing for an

examination of differences between previously depressed participants who do relapse, those who

do not relapse, and those never depressed. A third comparison, also a new addition to the

existing literature, examined the differences in attentional biases between the initial and follow

up visits, to determine if within-group changes occurred between the initial to follow up visit.

The prospective examination of attentional biases in these groups at both visits allowed for a

more precise understanding of how attentional biases may or may not contribute to depression

relapse more precisely than previous cross-sectional studies. By comparing attentional biases for

faces and naturalistic images, this set of analyses also allowed for an exploration of similarities

and differences between these two categories of images.

Hypotheses

Relapsed group. The hypotheses for the following total fixation time analyses were

based on the literature to date that suggests that remitted depressed individuals attend more to

depression-related or sad information relative to never depressed individuals (Joormann &

Gotlib, 2007; Sears et al., 2011; Soltani et al., 2015; Woody et al., 2016; Newman & Sears,

2015), and attend less to positive information than never-depressed individuals (Sears et al.,
 37

2011; Soltani et al., 2015). Specifically, it was hypothesized that at the initial visit, individuals

who relapsed (through the study period) would attend less to positive images and more to

depression-related images relative to those who did not relapse and never depressed individuals.

It was further hypothesized that this group difference would be more pronounced for the relapsed

participants at the follow up visit (i.e., once relapsed).

Non-relapsed group. As a non-relapsed group has not been studied previously, there

were several potential outcomes. Given their history of depression, the first possibility is that

they would exhibit attentional biases similar to previously depressed participants in prior studies

at both visits (less attention to positive images and greater attention to depression-related

images). A second possibility is that the non-relapsed participants would exhibit attentional

biases similar to the never depressed participants, attending more to positive and less to

depression-related images, or potentially increasing their attention to positive stimuli and

decreasing their attention to depression-related stimuli from the initial to follow up visits.

Never depressed group. As observed in previous research, the never depressed

participants were hypothesized to attend more to positive images and less to depression-related

images relative to both the non-relapsed and relapsed groups, at both visits, and to maintain a

similar pattern of attention to emotional images during both visits.

Results and Discussion

The fixation data were processed using the EyeLink Data Viewer analysis software (SR

Research) to filter for blinks, missing data, and other recording artifacts (using the default

settings). To be included in the analyses, a fixation had to be at least 100 ms in duration. The

dependent variable was the total fixation time for each image during the 8-second presentation,

with longer total fixation times reflecting greater attention to an image. Total fixation times were
 38

calculated for each image type for each of the 30 trials at both the initial and follow-up visits,

and then averaged across all trials for each visit.

Analyses of Data for Face Images

The design was a 3 (Group: relapsed, non-relapsed, never depressed) x 4 (Face Type:

happy, sad, threat, neutral) x 2 (Visit: initial, follow up) mixed-model analysis of variance

(ANOVA), with Face Type and Visit as within-subject factors. The fixation data for the face

images are listed in Table 3.

 39

Table 3.

Initial versus Follow-up visits Total Fixation times (ms) for Face Images

Relapsed Non-Relapsed Never Depressed

(n = 14) (n = 104) (n = 28)

Image Type Initial Follow Initial Follow Initial Follow

visit up visit visit up visit visit up visit

Sad 1533 1624 1411 1373 1377 1332

(390) (397) (366) (352) (280) (338)

Threat 1483 1564 1388 1417 1454 1445

(317) (474) (318) (366) (204) (311)

Happy 1960 1384 2054 2109 2151 2133

(634) (295) (719) (850) (578) (702)

Neutral 1506 1558 1564 1564 1508 1542

(241) (443) (277) (358) (218) (357)

Note: Standard deviations in parentheses.

 40

The most important results were the two-way interaction between Group and Face Type,

F(6, 429) = 2.41, p = .02, partial η2 = 0.33, and the three-way interaction between Group, Face

Type, and Visit, F(6, 429) = 3.03, p = .006, partial η2 = 0.04. The two-way interaction between

Group and Face Type reflected group differences in attention to the face images (averaged across

the initial and follow up visit), and the three-way interaction indicated that the pattern of group

differences for the initial and follow up visits were not identical. Another way of interpreting the

three-way interaction is that one or more of the groups attended to the images differently during

the initial visit and the follow up visit. To explore the three-way interaction, separate analyses of

the eye tracking data from the initial and follow up visits were first conducted (Group x Face

Type mixed-model ANOVAs). A separate set of analyses examined within-group comparisons

of the initial and follow up visits to look for changes in each groups’ attention to the images in

the initial and follow up visits.

Group differences at the initial visit. For the initial eye tracking session, the Group x

Face Type interaction was not significant, F(6, 432) = 0.62, p = .71, partial η2 = 0.009. The main

effect of Face Type was significant, F(3, 432) = 29.22, p < .001, partial η2 = 0.16. Participants

attended to happy faces the most (2056 ms), with small differences in fixation times between

neutral (1526 ms), threat (1439 ms), and sad faces (1438 ms). The absence of an interaction

between Group and Face Type at the initial visit indicates that the groups attended to the faces

similarly during their first visit.

This outcome was somewhat surprising given the previous studies reporting differences

in attention to emotional faces between previously and never depressed individuals (Joormann &

Gotlib, 2007; Soltani et al., 2015; Woody et al., 2016). There are several possible reasons why no

group differences were observed during the initial visit. One possibility is that the relapsed and

non-relapsed groups reflect different group characteristics than prior studies that used a
 41

previously depressed group. It is also possible that biases for face stimuli are more difficult to

detect in general (which, if true, would be further exacerbated by the small number of relapsed

participants in the analysis). Another possibility is that at the first visit, none of the participants

were actually experiencing depression; and therefore there were no attentional biases because the

biases are a symptom of depression and not a trait-based characteristic as predicted by cognitive

models of depression. Overall, these findings were not consistent with some cross-sectional

studies that examined attentional biases of previously depressed participants for faces (e.g.,

Soltani et al., 2015). On the other hand, Isaac et al. (2014) found no differences in attentional

biases for happy or sad faces between previously depressed participants and a never depressed

control group.

Although the absence of group differences for the initial visit appear contrary to the idea

that a cognitive vulnerability exists between episodes of depression, recall Isaac et al.’s

suggestion that successful treatment of depression helps restore processing of positive

information, which may help to protect against a future episode. If true, this could explain the

absence of attentional bias findings for participants in the non-relapsed group. Consistent with

this reasoning, a number of relapsed and non-relapsed participants had received either therapy or

medications as treatment for their depression (see Table 2).

Group differences at the follow up visit. For the follow-up eye tracking data session,

the Group x Face Type interaction was significant, F(6, 432) = 3.96, p < .001, partial η2 = 0.05,

as was the main effect of Face Type, F(3, 432) = 9.45, p < .001, partial η2 = 0.62. The interaction

was followed up by comparing the three groups (never depressed, relapsed, and non-relapsed)

for each face type (sad, threat, happy, neutral). The three groups differed in their attention to sad

faces, F(2, 144) = 3.53, p = .03, partial η2 = 0.05, and happy faces, F(2, 144) = 5.35, p = .006,

partial η2 = 0.07, but not for threat faces or neutral faces (both F’s < 1). The relapsed participants
 42

attended to sad faces significantly more than the non-relapsed participants (1624 ms vs. 1375

ms), t(117) = 2.47, p = .01, and significantly more than the never depressed participants (1624

ms vs. 1332 ms), t(40) = 2.52, p = .01. There was no difference between the non-relapsed and the

never depressed participants, t(131) = 0.57, p = .56. For the happy faces, the relapsed participants

attended to the faces significantly less than the non-relapsed participants (1383 ms vs. 2101 ms),

t(117) = 3.19, p = .002, and significantly less than the never depressed participants (1383 ms vs.

2133 ms), t(40) = 2.90, p = .004. There was no difference between the non-relapsed participants

and the never depressed participants, t(131) = 0.19, p = .84.

To summarize, differences were apparent between the three groups in their attention to

sad and happy faces, but not in their attention to threatening or neutral faces. When considering

the differences at the follow-up visit, it should be remembered that the groups were qualitatively

different from the groups at the initial visit, as the relapsed participants shifted from a non-

depressed to a depressed state from the initial to follow up visit.

As predicted, those who relapsed by the follow-up visit attended to happy faces

significantly less and to sad faces significantly more than the non-relapsed and never depressed

participants, and the non-relapsed and never depressed participants did not differ. Although

relapsed individuals have not been previously studied in a manner similar to the present study,

these findings are consistent with the eye tracking literature that finds currently depressed

individuals attend less to happy faces when compared to those with no history of depression

(e.g., Isaac et al., 2014; Soltani et al., 2015; Duque & Vazquez, 2015) or those with a history of

depression (Newman & Sears, 2015). Consistent with Isaac et al. was the finding that non-

relapsed (previously depressed) and never depressed participants did not differ in their attention

to happy faces. This finding implies that the non-relapsed participants employ attention in a

manner similar as those never depressed. This pattern of attending may reflect the presence of a
 43

positive protective bias to attend to positive information and avoid negative information in non-

relapsed participants (and never depressed participants), hypothesized to be protective against

negative mood states (e.g., Mathews & Antes, 1992; McCabe et al., 2000; Caseras et al., 2007;

Joormann and Gotlib, 2007; Ingram et al., 2008; Peckham, et al., 2010; Ellis et al., 2011).

Within-group analyses (initial vs. follow up). An alternative procedure for following up

the three-way interaction between Group, Face Type, and Visit is to look at changes in attention

between the initial and follow up visits for each group separately. To do so, the fixation data was

analyzed using a 2 (Visit: initial, follow up) x 4 (Face type: happy, sad, threat, neutral) mixed-

model analysis of variance (ANOVA), with Image Type and Visit as within-subject factors.

For non-relapsed participants, there was no interaction between Visit and Face Type, F(3,

309) = .603, p = .613, partial η2 = 0.006, which indicated that there were no differences in the

way the images were attended to during the initial and follow-up visits. The same was true for

the never depressed participants, as there was no interaction between Visit and Face Type, F(3,

81) = .131, p = .94, partial η2 = 0.005.

For relapsed participants, there was an interaction between Visit and Face Type, F(3, 39)

= 6.24, p = .001, partial η2 = 0.32, which indicated that there were differences in the way the

images were attended to during the initial and follow-up visits. T-tests were used to compare the

initial and follow-up fixation data for each image type. These revealed a significant decrease in

attention to happy faces between the initial and follow up visits (1960 ms vs. 1384 ms), t(13) =

4.07, p = .001. There were no significant differences in attention to threat faces t(13) = .661, p =

.52, (1483 ms vs. 1564 ms), sad faces t(13) = .784, p = .44, (1533 ms vs. 1624 ms), or neutral

faces t(13) = .488, p = .63, (1506 ms vs. 1558 ms).

When considering how attentional biases changed over time, those who relapsed

decreased attention only to happy faces, whereas the never depressed and non-relapsed
 44

participants did not attend to the faces differently during the initial and follow-up visits. Another

important finding was that relapsed and non-relapsed participants attended to happy faces

similarly at the initial visit. These findings suggest that a decrease in attention to happy faces

may be relevant to consider as a contributing factor to depression relapse. Extrapolated further,

and when considering that the non-relapsed participants maintained their attention to positive

information at both visits (whereas the relapsed participants decreased their attention), it could be

inferred that the lack of a positive bias observed during the follow up visit was a relevant

contributor to the relapse. Alternatively, the lack of positive bias at the follow up visit could be a

symptom of the relapse.

Contrary to the hypotheses, those who relapsed did not exhibit increased attention to the

sad faces during the follow up visit relative to their initial visit; however they did exhibit greater

attention to sad faces at the follow-up visit relative to the non-relapsed and never depressed

participants. Other studies have suggested that perception of negative emotional states (as

inferred from faces) could be relevant in those who experience depression relapse. One study

found that individuals who relapsed over a six-month period perceived more negative emotions

in ambiguous faces at either or both of an initial and follow up visit relative to those who did not

subsequently relapse, which indicated that negative interpretations of facial information is

relevant in those who experience depression relapse (Bouhuys, Geerts, & Gordijn, 1999).

Analyses of Data for Naturalistic Images

The design was a 3 (Group: relapsed, non-relapsed, never depressed) x 4 (Image Type:

positive, depression-related, threat, neutral) x 2 (Visit: initial, follow up) mixed-model analysis

of variance (ANOVA), with Image Type and Visit as within-subject factors. The fixation data

are listed in Table 4.

 45

Table 4.

Total Fixation times (ms) to Naturalistic Images During Initial and Follow-up Visits

Relapsed Non-Relapsed Never Depressed

(n = 14) (n = 103) (n = 27)

Image Type Initial Follow Initial Follow Initial Follow up

visit up visit visit up visit visit visit

Depression 1953 2068 1780 1576 1579 1372

(439) (696) (492) (508) (414) (385)

Threat 1870 2151 1656 1764 1677 1798

(412) (344) (459) (534) (545) (585)

Positive 1588 1375 2020 2133 2193 2190

(350) (441) (669) (889) (694) (698)

Neutral 881 754 1019 981 1100 1072

(320) (264) (298) (366) (363) (304)

Note: Standard deviations in parentheses.

 46

The most important results were the two-way interaction between Group and Image

Type, F(6, 423) = 5.37, p < .001, partial η2 = 0.07, and the absence of a three-way interaction

between Group, Image Type, and Visit, F(6, 423) = 1.77, p = .10, partial η2 = 0.02. The two-way

interaction between Group and Image Type reflected group differences in attention to the images

averaged over the initial and follow up visits, and the absence of the three-way interaction

indicated that these differences were similar during the initial eye tracking session and the follow

up eye tracking session. To follow up the two-way interaction, t-tests were used to compare the

groups for each image type, averaging over the initial and follow-up visits.

For the threat images, the relapsed participants attended to the images significantly more

than the non-relapsed participants (2010 ms vs. 1709 ms), t(115) = 2.32, p = .02. There was a

marginally significant difference between the relapsed participants and the never depressed

participants (2010 ms vs. 1737 ms), t(39) = 1.82, p = .07, but no difference between the never

depressed and the non-relapsed, t(128) = 0.28, p = .77. For the depression-related images, the

relapsed participants attended to the images significantly more than the non-relapsed participants

(2010 ms vs. 1677 ms), t(115) = 2.71, p = .007, and significantly more than the never depressed

participants (2010 ms vs. 1475 ms), t(39) = 3.77, p = .0005. The non-relapsed participants also

attended to the depression related images more than the never depressed participants (1677 ms.

vs. 1475 ms), t(128) = 2.17, p = .03. For the neutral images, the non-relapsed participants

attended to the images significantly more than the relapsed participants (1000 ms vs. 817 ms),

t(115) = 2.20, p = .02, and the never depressed participants attended to the neutral images more

than the relapsed participants (1085 ms vs. 817 ms), t(39) = 2.79, p = .007. The non-relapsed

participants and the never depressed participants did not differ in their attention to neutral

images, t(128) = 1.35, p = .17. For the positive images, the relapsed participants attended to the

images significantly less than the non-relapsed participants (1481 ms vs. 2076 ms), t(115) =
 47

3.15, p = .002, and significantly less than the never depressed participants (1481 ms vs. 2191

ms), t(39) = 3.25, p = .002. The non-relapsed participants and the never depressed participants

did not differ in their attention to positive images, t(128) = .80, p = .42.

Summary of initial and follow-up visits. The pattern of results obtained with the

naturalistic images was different than the pattern obtained with the face images. For the

naturalistic images, there was no indication that the groups differed in their attention to the

images during the initial and follow up visits. Instead, at each visit, relapsed participants attended

to depression-related and threat images more, and to positive images less than non-relapsed and

never depressed participants. These findings are consistent with previous cross-sectional studies

that indicate that previously depressed and currently depressed/dysphoric individuals attend more

to depression-related information (Newman & Sears, 2015) and less to positive information (e.g.,

Isaac et al., 2014; Soltani et al., 2015; Duque & Vazquez, 2015; and Leyman et al., 2011).

Another important finding was that non-relapsed (previously depressed) participants

attended to positive images similarly to never depressed participants, suggesting a pattern of

attention different from that typically observed in some studies with previously depressed

individuals (Sears et al., 2011; Soltani et al., 2015). This finding likely reflects a qualitative

difference between non-relapsed participants in the present study and previously depressed

participants in other studies. Relative to the never depressed participants, the non-relapsed

participants attended more to depression-related images, but their attention was attenuated in

comparison to the relapsed participants. These findings suggest that even though they did not

relapse, the non-relapsed participants exhibited some differences in attention that may increase

their susceptibility to a future episode of depression. Alternatively, their reduced attentional bias

for depression-related images could suggest they are less vulnerable to relapse, especially

relative to those that did relapse. Overall, the attentional biases of non-relapsed participants
 48

differed from never depressed (more attention) and relapsed participants (less attention) in the

case of depression-related images, but not for positive images, which likely reflects the different

nature of the non-relapsed group relative to previously depressed groups created in other studies.

The non-relapsed group in the present study is likely comprised of individuals with an attenuated

yet slight vulnerability to depression relapse relative to other groups of previously depressed

individuals that are likely combinations of those who relapse and those who do not.

Within-group analyses (initial vs. follow up). Despite the absence of a three-way

interaction, separate analyses of the initial eye tracking session data and the follow up session

data were carried out to facilitate comparisons between the two image categories (faces vs.

naturalistic). These analyses looked at changes in attention between the initial and follow up

visits for each group; the data for the initial eye tracking session and the follow-up eye tracking

session were compared for each group separately. To do so, the data were analyzed using a 2

(Visit: initial, follow up) x 4 (Image Type: positive, depression-related, threat, neutral) repeated

measures (ANOVA), with Image Type and Visit as within-subject factors.

Relapsed group. For relapsed participants, there was an interaction between Visit and

Image Type, F(3, 39) = 3.38, p = .02, partial η2 = 0.20, which indicated that there were

differences in the way the images were attended to during the initial and follow-up visits. T-tests

were used compare the initial and follow-up fixation data for each image type. There were

significant differences for threat images and for positive images, t(13) = 3.04, p = .009, and t(13)

= 2.10, p = .05, respectively. For threat images there was a significant increase in fixation time

(1869 ms vs. 2151 ms) from the initial to follow-up visit, whereas for positive images there was

a significant decrease in fixation time from the initial to follow up visits (1587 ms vs. 1374 ms).

Note that the same difference was observed for happy faces in the face data described above (i.e.,

a decrease in fixation times for happy faces in the first and follow up visits). For neutral images
 49

and depression-related images there were no significant differences between the initial and

follow-up visits, t(13) = 1.67, p = .11, and t(13) = .746, p = .46, respectively.

Non-relapsed group. For non-relapsed participants, there was a significant interaction

between Visit and Image Type, F(3, 306) = 7.03, p < .001, partial η2 = 0.07, which reflected

differences in the way the images were attended to during the initial and follow-up visits. T-tests

were used compare the initial and follow-up fixation data for each image type. There were

significant differences for threat images and depression-related images, t(102) = 2.72, p = .008,

and t(102) = 4.11, p < .001, respectively. For threat images there was a significant increase in

fixation times (1656 ms vs. 1764 ms) from the initial to follow up visit, whereas for depression-

related images there was a significant decrease in fixation time (1780 ms vs. 1576 ms). For

neutral images (1019 ms vs. 981 ms) and positive images (2020 ms vs. 2133 ms) there were no

significant differences, t(102) = 1.18, p = .24, and t(102) = 1.56, p = .12, respectively.

Never-depressed group. For the never depressed participants, there was no interaction

between Visit and Image Type, F(3, 78) = 2.40, p = .07, partial η2 = 0.11.

Summary of within-group changes. When considering the changes in attention from the

initial to the follow-up visit within each group, the relapsed participants decreased their attention

to positive images, did not change their attention to depression-related images, and increased

their attention to threat images. These changes in attention over the study period were likely due

to the different states that the relapsed group was in during the initial and follow-up visits (e.g.,

not depressed at the initial visit and currently depressed at the follow-up visit). It is clear then

that those who ultimately relapsed exhibited different attentional biases in both their non-

depressed and currently depressed states, which distinguished them from the non-relapsed and

never depressed participants.

 50

In contrast to the relapsed participants, the non-relapsed participants did not change their

attention to the positive images from the initial to follow-up visit. The fact that non-relapsed

participants did not exhibit decreased attention to positive images at the follow-up visit (unlike

the relapsed participants) reinforces the idea that a protective positive bias is reduced in those

most vulnerable to depression relapse and becomes even less apparent at the onset of the

subsequent depressive episode. This important finding suggests that as the positive bias

decreases, the vulnerability to relapse is increased.

Also in contrast to the relapsed participants, the non-relapsed participants decreased their

attention to the depression-related images from the initial to follow up visit. This decrease in

attention could be conceptualized as a change in their attentional biases reflective of the success

they have had in maintaining a non-depressed state.

The relapsed participants attended more to the threat images relative to the non-relapsed

and never depressed participants. Interestingly, both the relapsed and non-relapsed participants

increased their attention to the threat images from the initial to follow up visits. Other studies

have found that previously depressed individuals attend to threat images differently (e.g.,

previously depressed participants have been found to attend more to anxiety-related and angry

face images relative to never depressed participants in Sears et al., 2011, and Woody et al., 2016,

respectively). Other evidence to suggest that threat-related information is relevant to depression

was obtained by Newman and Sears (2015). They found that never depressed participants who

experienced a sad mood induction increased their attention to positive information and decreased

their attention to threat-related information, which suggested that those with no depression

history exhibited a protective bias in the form of decreasing attention to threatening information

when in a sad mood state. In the present study, it is possible that increased attention to threat

stimuli contributed to relapse vulnerability, but it is unclear why increased attention to threat was
 51

also observed in those who did not relapse. Perhaps relapse is most likely in those who

concurrently exhibit both a decrease in attention to positive stimuli and an increase in attention to

threat stimuli.

In addition to findings specific to the attention literature, other evidence exists that is

suggestive of a relationship between threat-related stimuli and depression vulnerability. For one,

previously depressed individuals have been found to have a greater recognition of fearful faces

than those with no depression history (Bhagwagar, Cowen, Goodwin, & Harmer, 2004).

Bhagwagar et al. pointed out that the amygdala may play a role in depression, and proposed that

there may be abnormalities in the amygdala that are reflected in an increased recognition of

fearful face expressions, suggestive of a trait-like cognitive vulnerability. Their findings provide

converging evidence regarding a potential role for attentional biases to threat or anxiety-related

stimuli in previously depressed and relapsed individuals. Beck and Bredemeier (2016) also

discussed the idea that depressed individuals are likely to display heightened vigilance for danger

in their environment, and cited evidence to suggest that increased activity in the amygdala has

been observed in depressed individuals.

Considered together, analyses of total fixation times at the initial and follow up visits

reveal that non-relapsed participants exhibit some key differences from relapsed participants that

are likely critical distinguishing factors related to depression vulnerability. One important

implication of these findings is that despite having a history of depression in common, the non-

relapsed and relapsed groups are actually two qualitatively different and heterogeneous groups of

individuals. Consequently, it may not be valid to combine them together into a single group of

“previously depressed” individuals. This point will be discussed in more detail in the General

Discussion.
 52

Chapter 3: Analysis of Temporal Profiles of Attentional Biases

As noted, attentional biases are thought to be a cognitive vulnerability factor that may

contribute to depression relapse, and closely examining the allocation of attention can lead to an

understanding of how attentional biases manifest in those vulnerable to depression. One of the

advantages of using eye-gaze tracking to examine attentional processing is that the focus of

attention can be evaluated over an extended interval of time. Attentional allocation can be

studied by examining fixation times in smaller intervals to observe how attention changes over

time (e.g., to determine if there are patterns of engagement and disengagement occurring over

time). As such, in addition to examining total fixation times to emotional stimuli, an equally

important analysis is to evaluate the specific pattern of attention throughout a presentation

interval time period (the temporal profile) (Kellough et al., 2011; Soltani et al., 2015). It is

possible that examining temporal profiles could provide additional insight with respect to how

attentional biases manifest as a vulnerability factor for depression relapse.

A few studies have examined the temporal profile of attention to emotional information

by dividing total fixation times into smaller intervals to precisely determine how attention to

images changes over time; two studies examined dysphoric or depressed individuals (Arndt et

al., 2014; Kellough et al., 2008), and one study examined individuals with a history of depression

(Soltani et al., 2015).

In Kellough et al. (2008), clinically and never depressed participants were shown sets of

four images (dysphoric, threatening, positive, and neutral) for 30 seconds while their eye gaze

was tracked. The fixation data was divided into six 5-second intervals to examine changes in

attention over the 30-second presentation. They found that depressed participants attended more

to dysphoric images and less to positive images than never depressed participants, and that these

differences were maintained throughout the 30-second trial. These findings supported the idea
 53

that depressed individuals tend to engage in elaborative processing of depression-related

information, which distinguishes them from never depressed individuals who attend more to

positive information. In a similar study, Arndt et al. (2014) examined changes in attention to

emotional images in dysphoric and never depressed participants. The 10-second image

presentation was divided into 2-second intervals for the purpose of their analysis. Arndt et al.

found that dysphoric and non-dysphoric participants exhibited different patterns of attention to

positive and depression-related images only after 4 seconds had elapsed. Specifically, the

dysphoric participants attended to the positive images significantly less than the non-dysphoric

participants during the 4-10 second interval. Trend analyses were also carried out to examine the

changes in attention over time, and revealed that the dysphoric participants maintained their

heightened attention to depression-related images throughout the 10-second presentation,

whereas the non-dysphoric participants decreased their attention to depression-related images

over the course of the presentation. They also found that non-dysphoric participants increased

their attention to positive images over the course of the presentation, which was true for

dysphoric participants as well, but the increase was attenuated relative to the non-dysphoric

participants. The findings of Kellough et al. and Arndt et al. support the idea that attentional

biases in depression involve an elaborative style of information processing and that depressed

and dysphoric individuals exhibit temporal profiles of attention that are distinct from those of

never depressed individuals.

To date, only one study has examined the temporal profile of attention in individuals with

a history of depression. Soltani et al. (2015) examined temporal changes in attention to emotional

faces in remitted depressed, currently depressed, and never depressed individuals. Participants

viewed sets of four face images (happy, sad, threatening, and neutral) during an 8-second

presentation, which was divided into 2-second intervals to measure changes in attention over
 54

time. They found that currently and remitted depressed individuals attended more to sad faces

and less to happy faces during the 4-8 second interval relative to never depressed individuals.

The currently depressed individuals also attended less to happy faces than never and remitted

depressed individuals during the 0-2 second interval, indicating an early difference in how

currently depressed individuals attend to positive information. A trend analysis revealed that the

never depressed participants increased their attention to happy faces and decreased attention to

sad faces over the 8-second interval, evidence for the presence of a protective attentional bias.

The remitted depressed participants also increased their attention to happy faces throughout the

8-second presentation in a similar but attenuated fashion relative to the never depressed

participants, whereas the currently depressed participants decreased their attention to happy faces

during the first few seconds of the presentation. The currently and remitted depressed

participants exhibited sustained attention to sad faces throughout the 8-second interval, with the

remitted depressed participants shifting their attention away from the happy faces slightly later

than the depressed participants.

Overall, the findings of Soltani et al. were consistent with previous studies that found

sustained attention to negative stimuli in both depressed and dysphoric individuals (Kellough et

al., 2008; Arndt et al., 2014). The findings further suggested that those with a history of

depression exhibit similarities to those currently depressed (e.g., elaborative processing of

negative material), but also exhibit differences from those currently depressed (e.g., attend more

to happy faces and move attention away from positive information later). Soltani et al. pointed

out that the previously depressed participants’ attention to the happy faces was quantitatively

different, yet qualitatively similar to the profile of never depressed participants. These findings

were noted to have important implications for how the temporal profile either represents a risk

factor for further depressive episodes or is a protective factor associated with remission from
 55

depression. In the present study, the analysis of temporal profiles provides additional information

about attention to emotional images as a function of depression vulnerability, complimentary to

the previous analyses that examined total fixation times.

Analysis 2: Temporal Profiles of Attention

Using the same data set described in Chapter 2, this set of analyses expanded on the first

set of results by examining the temporal profiles of each group to delineate how attentional

biases manifest in previously depressed participants (divided into non-relapsed and relapsed) and

never depressed participants at both the initial and follow up assessment visits. The temporal

profiles of attention observed at each visit were examined in two ways. First, between-group

differences in fixation times to each image type in the two image categories (face and

naturalistic) were evaluated at each 2-second interval. This evaluation provided an understanding

of how the groups attended to the images differently at different points in time during the

presentation. Second, the temporal profiles of each group were examined separately via within-

group trend analyses, to understand the overall group specific trend of attention across the full

interval. In addition, and a new contribution to the literature, the profiles were examined at both

the initial and follow up visits, which captured any between-visit changes that occurred. The goal

was to identify differences in the temporal profiles that distinguish previously depressed

individuals who relapsed versus those who did not relapse, to identify specific patterns of

attentional biases related to relapse vulnerability.

Given the reasoning that attentional biases are thought to be trait-like factors that confer

vulnerability to depression relapse (e.g., Gotlib & Joormann, 2010; DeRaedt & Koster, 2010)

and taking into consideration the literature to date (Soltani et al., 2015; Arndt 2014; Kellough et

al. 2008), it was predicted that the temporal profiles of attention of the relapsed and non-relapsed

participants would be similar, with an increase in attention to depression-related/sad stimuli and

 56

a decrease in attention to positive/happy stimuli during the 8-second presentation. Despite these

similarities, it was further hypothesized that the relapsed participants would exhibit more

pronounced profiles (e.g., perhaps a sharper increase and overall greater attention to depression-

related/sad stimuli overall, and a sharper decrease and less attention to positive/happy stimuli

overall) at the initial and especially the follow up visit relative to the non-relapsed participants.

In addition, both non-relapsed and relapsed participants were predicted to exhibit temporal

profiles different from those of never depressed participants, who were predicted to exhibit a

decrease in attention to depression-related/sad stimuli and an increase in attention to

positive/happy stimuli throughout the 8-second presentation time.

Results and Discussion

Time Course Analyses - Data for Face Images

The design was a 3 (Group: relapsed, non-relapsed, never depressed) x 4 (Face Type:

happy, sad, threat, neutral) x 4 (Time Interval: 0-2 seconds, 2-4 seconds, 4-6 seconds, 6-8

seconds) mixed-model analysis of variance (ANOVA), with Face Type and Time Interval as

within-subject factors. For the ease of interpretation, the data for the initial and follow up visits

were analyzed separately. The time course data for the initial and follow up visits are listed in

Table 5.
 57

Table 5.

Time course fixation times: Relapse vs. No Relapse vs. Never Depressed Face Images

Relapsed Non-relapsed Never Depressed

(n = 14) (n = 104) (n = 28)

Face Type Initial Follow up Initial Follow up Initial Follow up

0-2 seconds

Sad 376 (86) 389 (60) 374 (69) 363 (67) 365 (43) 381 (63)

Threat 320 (57) 359 (71) 333 (63) 364 (65) 346 (54) 354 (68)
Happy 438 (102) 322 (68) 380 (88) 384 (83) 393 (56) 370 (71)
Neutral 322 (58) 329 (66) 342 (60) 344 (60) 371 (67) 359 (75)

2-4 seconds

Sad 394 (121) 391 (129) 362 (116) 342 (118) 391 (116) 345 (116)
Threat 418 (97) 428 (146) 371 (108) 388 (115) 390 (91) 422 (96)

Happy 481 (150) 344 (75) 505 (196) 531 (225) 493 (125) 475 (137)
Neutral 394 (43) 410 (128) 414 (98) 396 (110) 403 (81) 406 (88)

4-6 seconds

Sad 346 (88) 410 (149) 332 (119) 318 (130) 308 (92) 306 (108)
Threat 363 (122) 386 (192) 334 (117) 327 (136) 382 (104) 332 (112)

Happy 523 (226) 374 (115) 566 (237) 577 (299) 594 (215) 598 (252)
Neutral 417 (125) 383 (139) 404 (103) 424 (149) 378 (83) 409 (137)

6-8 seconds
Sad 388 (141) 405 (167) 325 (147) 324 (135) 303 (107) 289 (129)

Threat 342 (110) 379 (158) 331 (134) 314 (141) 323 (115) 324 (139)

Happy 546 (231) 321 (133) 585 (281) 602 (322) 647 (281) 667 (327)

Neutral 353 (112) 399 (157) 380 (125) 381 (142) 339 (113) 355 (130)

Note: Standard deviations in parentheses

 58

Group differences at the initial visit. For the initial visit, the most important result was

the marginally significant three-way interaction between Group, Face Type, and Time Interval,

F(18, 1287) = 1.52, p = .07, partial η2 = .02. The three-way interaction was followed up by

comparing the groups for each image type separately (Group x Time Interval interaction

contrasts). However, none of these follow up interactions were statistically significant (all p’s >

.10), which suggested that the groups did not differ significantly in their attentional profiles to

the happy, sad, threat, and neutral faces at the initial visit. (See Figures 2, 3, 4, 5)

Linear trend analyses. Another way of exploring the three-way interaction is to examine

differences between the groups in their linear trends for each image type. For example, if never

depressed and non-relapsed participants increased their fixation times over time for positive

images, whereas relapsed individuals decreased or had constant fixation times for positive

images, then this pattern would produce an interaction between Group and Interval in the linear

trend (or the quadratic trend). However, an examination of these linear and quadratic trend

interactions revealed none that were statistically significant (all p’s > .10). This outcome

indicates that the groups did not differ significantly in the way that their attention to the faces

changed over time during the 8-second presentation of the faces.

 59

Figure 2. Temporal changes in attention to happy face images in relapsed, non-relapsed, and
never depressed individuals at the initial visit.
 60

Figure 3. Temporal changes in attention to sad face images in relapsed, non-relapsed, and never
depressed individuals at the initial visit.
 61

Figure 4. Temporal changes in attention to threat face images in relapsed, non-relapsed, and
never depressed individuals at the initial visit.
 62

Figure 5. Temporal changes in attention to neutral face images in relapsed, non-relapsed, and
never depressed individuals at the initial visit.
 63

Summary of initial visit findings and relation to the literature. Contrary to

hypotheses, there were no group differences in the attentional profiles for the face images at the

initial visit. That is, the analyses found that the three groups attended to the faces in a similar

manner throughout the 8-second presentations of the images, which is consistent with the

analyses of the overall fixation times reported in Chapter 2. These results were unexpected given

that Soltani et al. (2015) found differences in the temporal patterns of attention to face images

between currently, remitted, and never depressed groups. On the other hand, as pointed out

previously, the relapsed and non-relapsed groups in the present study may represent qualitatively

different groups relative to the currently and remitted depressed groups examined by Soltani et

al., which may have precluded a similar set of findings in the present study.

Group differences at the follow up visit. For the follow up visit, the most important

results were the two-way interaction between Group and Face Type, F(6, 429) = 4.16, p < .001,

partial η2 = .06, and the three-way interaction between Group, Face Type, and Time Interval,

F(18, 1287) = 2.62, p < .001, partial η2 = .04. The three-way interaction was followed up by

comparing the groups for each image type separately (Group x Time Interval interaction

contrasts). This interaction was significant for happy faces, F(6, 429) = 3.85, p = .001, partial η2

= 0.05, but not for sad faces, F(6, 429) = 1.71, p = .11, threat faces, F(6, 429) = 1.20, p = .30, or

neutral faces, F(6, 429) = 1.13, p = .34. The follow up visit time course data for the happy faces,

sad faces, threat faces, and neutral faces is shown in Figures 6, 7, 8, and 9, respectively.

A follow up analysis of the data for happy faces revealed significant group differences for

all four time intervals: for the 0-2 second interval, F(2, 143) = 3.77, p = .025, partial η2 = 0.05,

for the 2-4 second interval, F(2, 143) = 5.63, p = .004, partial η2 = 0.07, for the 4-6 interval, F(2,

143) = 3.56, p = .031, partial η2 = 0.05, and for the 6-8 second interval, F(2, 143) = 6.15, p =

.003, partial η2 = 0.08.

 64

For the 0-2 second interval the relapsed participants attended to the happy faces

significantly less than the non-relapsed participants (322 ms vs. 384 ms), t(116) = 2.72, p = .007,

with the difference between the relapsed and never depressed (370 ms) participants being

marginally significant, t(40) = 1.84, p = .07. The difference between the non-relapsed and never

depressed participants was not significant, t(130) = 0.80, p = .42.

A similar pattern was observed for the 2-4 second interval, as the relapsed participants

attended to the happy faces significantly less than the non-relapsed participants (344 ms vs. 531

ms), t(116) = 3.25, p = .001, and the never depressed participants (475 ms), t(40) = 1.97, p = .05.

The difference between the non-relapsed and never depressed participants was not significant,

t(130) = 1.31, p = .19.

The same pattern of group differences was observed for the 4-6 second interval, with the

relapsed participants attending to the happy faces significantly less than the non-relapsed

participants (374 ms vs. 577 ms), t(116) = 2.56, p = .011, and the never depressed participants

(598 ms), t(40) = 2.45, p = .015. The difference between the non-relapsed and never depressed

participants was not significant, t(130) = 0.34, p = .73.

Finally, for the 6-8 second interval the same pattern was again observed, with the

relapsed participants attending to the happy faces significantly less than the non-relapsed

participants (321 ms vs. 602 ms), t(116) = 3.16, p = .002, and the never depressed participants

(667 ms), t(40) = 3.39, p = .001. The difference between the non-relapsed and never depressed

participants was not significant, t(130) = 0.98, p = .32. Thus, for each of the four intervals in the

follow-up visit data, the relapsed participants attended to the happy faces significantly less than

the non-relapsed participants and the never depressed participants, and the non-relapsed and

never depressed participants did not differ.

 65

Linear trend analyses. An examination of the linear and quadratic trend interactions

revealed a significant Group x Interval interaction in the linear trend for happy faces, F(2, 143) =

4.87, p = .009, partial η2 = .06, and for sad faces, F(2, 143) = 3.75, p = .026, partial η2 = .05. An

examination of the data for the happy faces (Figure 6) shows the source of the linear

interaction—the relapsed participants’ attention to the happy faces was relatively constant

throughout the 8-second presentation, whereas the never depressed and non-relapsed participants

increased their attention to the happy faces over the course of the presentation. For the sad faces

a different pattern of group differences was observed: the never depressed and non- relapsed

participants decreased their attention to the sad faces over the 8-seconds, whereas the relapsed

participants’ attention to the sad faces was relatively constant over the 8-second interval.

 66

Figure 6. Temporal changes in attention to happy face images in relapsed, non-relapsed, and
never depressed individuals at the follow up visit.
 67

Figure 7. Temporal changes in attention to sad face images in relapsed, non-relapsed, and never
depressed individuals at the follow up visit.
 68

Figure 8. Temporal changes in attention to threat face images in relapsed, non-relapsed, and
never depressed individuals at the follow up visit.
 69

Figure 9. Temporal changes in attention to neutral face images in relapsed, non-relapsed, and
never depressed individuals at the follow up visit.
 70

Summary of follow up visit findings and relation to the literature. Although there

were no differences observed at the initial visit, differences in the temporal patterns of attention

to the face images were evident at the follow up visit. These differences primarily involved

attention to happy faces, with the relapsed participants attending to happy faces less than the

non-relapsed and never depressed participants during each of the 2-second intervals of the 8-

second presentation. These findings are somewhat different from Soltani et al. (2015), where the

currently and previously depressed participants attended less to happy faces than the never

depressed during the last 4 seconds of their 8-second presentation.

Contrary to hypotheses, but certainly an important finding with implications for

vulnerability to depression relapse, the non-relapsed and never depressed participants did not

differ in their attention to happy faces at the follow up visit. In addition, for relapsed participants,

attention to happy faces was relatively constant throughout the 8-second presentation, whereas

for non-relapsed and never depressed participants, attention to the happy faces increased

throughout the 8-seconds. Similarly, the previously and never depressed participants in Soltani et

al. also increased their attention to happy faces throughout their 8-second presentation. However,

the relapsed participants in the present study behaved differently from the currently depressed

participants in Soltani et al. (who decreased their attention to happy faces early on, as opposed to

holding attention constant throughout). When considered together, these findings suggest that a

temporal profile in which one increases their attention to positive social information, as opposed

to maintaining a constant level of attention or decreasing attention to positive information, may

provide resiliency against depression relapse.

Recall that Soltani et al. (2015) noted that for their previously depressed individuals,

attention to the happy faces was quantitatively different, yet qualitatively similar to the profile of

never depressed individuals, and suggested there may be important implications for how the
 71

temporal profile either represents a risk factor for future depressive episodes or is a protective

factor associated with remission from depression. The present study separated the previously

depressed group into those who relapsed and those who did not, and this distinction led to the

finding that those who relapsed differed from non-relapsed and never depressed participants both

qualitatively (e.g., attend less to happy faces through all time intervals) and quantitatively (e.g.,

holding attention constant to happy faces). The non-relapsed and never depressed groups were

found to attend to happy faces more and to increase attention over time to the happy faces

throughout the entire time interval. It appears that a factor associated with depression relapse is a

shift in how attention to positive stimuli is allocated. Those who do not relapse express greater

interest to positive stimuli (e.g., attend more to and increase attention over time), which can be

inferred to be a protective factor that helps to maintain their remission, whereas those who

relapse do not express greater interest and are therefore at risk.

With respect to attention to sad faces at the follow up visit, the never depressed

participants decreased attention to sad faces over the 8-second presentation time (e.g., as

observed by Soltani et al.). It was found that relapsed participants’ attention to sad faces did not

differ over the 8-second presentation (similar to the currently depressed participants in Soltani et

al., 2015), whereas the non-relapsed participants decreased their attention to sad faces throughout

the 8-second interval (unlike the previously depressed participants in Soltani et al., who held

their attention constant to sad faces). This difference may be related to the fact that Soltani et

al.’s previously depressed group likely included a mix of individuals who would subsequently

relapse along with individuals who would not. The evidence suggests that the non-relapsed

participants in the present study possess a greater resiliency against depression relapse as their

attentional biases were different than the biases of those who did relapse.
 72

It is notable that no differences were observed for the threat faces at the follow up visit,

considering that Woody et al. (2016) found that those with a history of depression attended more

to angry face images, with attention to angry faces predictive of a shorter time to depression

relapse. Therefore, the present findings may reflect the resiliency against relapse of the non-

relapsed group (i.e., they have a history of depression but do not attend more to threat faces).

The findings demonstrate that those who do not relapse are different from those who do,

the primary difference in this study being greater engagement with positive social information

and lower engagement with sad social information in a manner similar to those with no

depression history. These results imply that it is likely crucial for those vulnerable to relapse to

engage with others who provide them with positive social feedback, like those who have never

experienced depression. The relapsed participants’ pattern of constant viewing of both happy and

sad social information as opposed to the non-relapsed and never depressed participants’ patterns

of viewing (e.g., increased attention to happy faces and decreased attention to sad faces

throughout the 8-seconds) may be associated with relapse.

Time Course Analyses - Data for Naturalistic Images

The design was a 3 (Group: relapsed, non-relapsed, never depressed) x 4 (Image Type:

positive, depression-related, threat, neutral) x 4 (Time Interval: 0-2 seconds, 2-4 seconds, 4-6

seconds, 6-8 seconds) mixed-model analysis of variance (ANOVA), with Image Type and Time

Interval as within-subject factors. The data for the initial and follow up visits was analyzed

separately. The time course data for the initial and follow up visits are listed in Table 6.
 73

Table 6.

Time course fixation times: Relapse vs. No Relapse vs. Never Depressed Naturalistic Images

Relapsed Non-relapsed Never Depressed

(n = 14) (n = 104) (n = 28)

Image Type Initial Follow up Initial Follow up Initial Follow up

0-2 s
Depression 453 (124) 452 (144) 434 (86) 422 (92) 398 (69) 409 (78)

Threat 568 (126) 563 (117) 501 (123) 495 (114) 553 (140) 520 (90)

Positive 290 (73) 293 (69) 373 (104) 380 (116) 382 (92) 349 (83)
Neutral 114 (43) 138 (87) 162 (79) 180 (83) 171 (73) 199 (74)
2-4 s

Depression 505 (116) 480 (202) 491 (136) 400 (146) 382 (390) 382 (390)

Threat 515 (122) 652 (127) 451 (150) 517 (183) 520 (194) 520 (194)
Positive 350 (75) 321 (118) 437 (159) 476 (238) 456 (147) 456 (147)

Neutral 232 (99) 183 (84) 263 (98) 247 (112) 279 (101) 279 (101)
4-6 s

Depression 467 (154) 548 (170) 432 (178) 364 (177) 411 (170) 317 (160)

Threat 377 (139) 469 (102) 349 (138) 382 (167) 347 (156) 407 (188)
Positive 468 (133) 355 (146) 555 (230) 601 (289) 584 (222) 597 (221)

Neutral 265 (95) 230 (71) 306 (123) 287 (126) 313 (124) 307 (127)
6-8 s

Depression 498 (177) 569 (250) 404 (198) 381 (203) 332 (182) 253 (151)
Threat 387 (143) 451 (138) 337 (164) 361 (195) 282 (165) 339 (235)

Positive 446 (186) 391 (176) 631 (280) 666 (341) 734 (330) 762 (345)

Neutral 254 (143) 197 (93) 276 (111) 233 (126) 318 (128) 277 (113)

Note: Standard deviations in parentheses.

 74

Analyses of initial visit data. For the initial visit, the most important results were the

two-way interaction between Group and Image Type, F(6, 1269) = 3.09, p = .006, partial η2 =

0.04, and the three-way interaction between Group, Image Type, and Time Interval, F(18, 1269)

= 1.69, p = .034, partial η2 = 0.02. The three-way interaction was followed up by comparing the

groups for each image type separately (Group x Time Interval interaction contrasts). This

interaction was significant for threat images, F(6, 423) = 2.26, p = .036, partial η2 = 0.03, and for

positive images, F(6, 423) = 2.05, p = .057, partial η2 = 0.03, but not for depression-related

images, F(6, 423) = 1.29, p = .26, partial η2 = 0.02, or neutral images, F < 1. The time course

data for the threat images, positive images, depression-related images, and neutral images is

shown in Figures 10, 11, 12, and 13, respectively.

 75

Figure 10. Temporal changes in attention to threat images in relapsed, non-relapsed, and never
depressed individuals at initial visit.
 76

Figure 11. Temporal changes in attention to positive images in relapsed, non-relapsed, and never
depressed individuals at initial visit.
 77

Figure 12. Temporal changes in attention to depression-related images in relapsed, non-relapsed,

and never depressed individuals at initial visit.
 78

Figure 13. Temporal changes in attention to neutral images in relapsed, non-relapsed, and never
depressed individuals at initial visit.
 79

A follow up analysis for the threat images revealed significant group differences for the

0-2 second interval, F(2, 141) = 3.08, p = .049, partial η2 = 0.04, but not for the 2-4, 4-6, or 6-8

second intervals, F(2, 141) = 1.26, p = .287, F < 1, F(2, 141) = 2.11, p = .124, respectively. For

the 0-2 second interval the non-relapsed participants attended to the threat images less than the

relapsed participants (501 ms vs. 568 ms), t(115) = 1.85, p = .065, and less than the never

depressed participants (501 ms vs. 553 ms), t(128) = 1.91, p = .057. However, the relapsed and

never depressed participants did not differ in their attention to threat images during the 0-2

second interval, t(39) = 0.34, p = .727. Overall, for the first two seconds of the 8-second

presentation, the relapsed participants attended to threat-related images more than the non-

relapsed participants, with no group differences in attention to the threat-related images during

the last six seconds.

For the positive images there were significant group differences for the 0-2 second

interval, F(2, 141) = 4.67, p = .011, partial η2 = 0.06, and the 6-8 second interval, F(2, 141) =

4.76, p = .010, partial η2 = 0.06, but not for the 2-4 second interval or the 4-6 second interval,

F(2, 141) = 2.68, p = .072, partial η2 = 0.04, and F(2, 141) = 1.29, p = .278, respectively. For the

0-2 second interval, the relapsed participants attended to the positive images significantly less

than the non-relapsed participants (290 ms vs. 373 ms), t(115) = 2.92, p = .004, and the never

depressed participants (290 ms vs 382ms), t(39) = 2.80, p = .006. The non relapsed and never

depressed participants did not differ in their attention to positive images, t(128) = 0.41, p = .678.

The same pattern of group differences was present for the 6-8 second interval: the relapsed

participants attended to the positive images significantly less than the non-relapsed participants

(446 ms vs. 631 ms), t(115) = 2.30, p = .023, and the never depressed participants (446 ms vs

734), t(39) = 3.08, p = .002. Again, the non relapsed and never depressed participants did not

differ in their attention to positive images for the 6-8 second interval, t(128) = 1.66, p = .097.
 80

Overall, at the 0-2 and 6-8 second intervals, the relapsed participants attended less to positive

images relative to the non-relapsed and the never depressed participants, whereas in the middle

of the 8-second viewing period (from 2-6 seconds), there were no group differences in attention

to positive images.

Linear trend analyses. An examination of the linear and quadratic trend interactions

revealed a significant Group x Interval interaction in the linear trend for threat images, F(2, 141)

= 4.81, p = .010, partial η2 = .06. As can been seen in Figure 10, the never depressed participants

decreased their attention to threat images in a linear fashion over the 8-second presentation,

whereas the relapsed and non-relapsed participants decreased their attention to threat images

from 0-6 seconds and were then unchanged for the remainder of the presentation. For the

positive images (see Figure 11) neither the linear or quadratic interaction was significant, F(2,

141) = 2.11, p = .124, partial η2 = .03, and F(2, 141) = 2.42, p = .092, partial η2 = .03, reflecting

that there were no differences between groups in their trends of attending to the positive images.

Summary of initial visit findings and relation to the literature. Analyses of the time

course of the initial visit revealed that group differences for the positive images were only

present at the beginning (0-2 second interval) and end (6-8 second interval) of the viewing time,

but not for the interval spanning 2-6 seconds. For the 0-2 and 6-8 second intervals, the relapsed

participants attended to positive images significantly less than the never depressed and non-

relapsed participants, who did not differ in their attention to positive images. The relapsed

participants exhibited an attentional profile where they initially did not attend to positive stimuli,

then briefly attended, and then subsequently disengaged, relative to non-relapsed and never

depressed participants, indicating that those most vulnerable to depression do not initially attend

to or sustain attention to positive information. Notably, Soltani et al. (2015) found that currently

depressed participants attended less to positive images than previously and never depressed
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participants during the 0-2 second interval, which in the present study is similarly evidenced by

the relapsed individuals (who had not yet relapsed). The similar lack of initial attention between

the currently depressed group in Soltani et al. and the relapsed group (prior to relapse) in the

present study is suggestive of an attentional bias characterized by an initial lack of engagement

with positive information that likely confers vulnerability to depression relapse.

Contrary to the hypothesis, the non-relapsed and never depressed participants exhibited a

similar attentional profile for the positive images. It could be inferred that the non-relapsed

participants maintained their depression-free state due to their tendency to attend to the positive

information in a manner similar to those never depressed (suggestive of a protective bias), as

opposed to exhibiting a viewing pattern similar to those who subsequently relapsed. On the other

hand, although there were group differences in the overall level of attention to positive images,

there were no group differences in the temporal profile of their attention to the images.

No group differences were evident in the temporal pattern of attention for the depression-

related images at the initial visit. For threat images, differences were observed for the 0-2 second

interval: the non-relapsed participants attended to the threat images less than the relapsed and the

never depressed participants who did not differ in their attention. Interestingly, the non-relapsed

and relapsed participants exhibited a similar trend in attention to threat images, where they

decreased attention over the first 6 seconds and then maintained attention during the 6-8 second

interval, whereas the never depressed participants decreased attention through the entire 8

seconds. It is possible that the non-relapsed participants initially attended less to or avoided

threat images (in the 0-2s interval) as part of an attentional strategy to maintain their non-

depressed state. The non-relapsed participants may be more vulnerable to the effects of threat

and potentially less resilient to the effects of a transient negative mood state compared to never

depressed participants. Therefore, they may have to actively avoid attending to threatening
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information unlike those who have never experienced depression and may possess other

protective buffers against threatening information. The similar trend in attention to the relapsed

participants suggests that the non-relapsed participants, although possibly engaging in a different

attentional strategy initially, still exhibit a temporal profile similar to those most vulnerable to

relapse. However, they may be protected against relapse in part due to their initial avoidance of

threat and in part due to the positive bias they exhibited (similar to bias observed in the never

depressed participants). The implications of attention to threat as a vulnerability factor in

depression relapse will be further addressed in the General Discussion.

Analyses of Follow-up Visit Data. Analysis of the data for the follow-up visit revealed

that the most important results were the two-way interaction between Group and Image Type,

F(6, 1269) = 5.59, p < .001, partial η2 = 0.07, and the three-way interaction between Group,

Image Type, and Time Interval, F(18, 1269) = 3.56, p < .001, partial η2 = 0.05. The three-way

interaction was followed up by comparing the groups for each image type separately (Group x

Time Interval interaction contrasts). This interaction was significant for depression-related

images, F(6, 423) = 6.63, p < .001, partial η2 = 0.09, and for positive images, F(6, 423) = 4.49, p

< .001, partial η2 = 0.06, but not for threat images, F < 1, or neutral images, F < 1. The data for

the depression-related images, positive images, threat images, and neutral images are shown in

Figures 14, 15, 16, and 17 respectively.

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Figure 14. Temporal changes in attention to depression-related images in relapsed, non-relapsed,

and never depressed individuals at follow up visit.

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Figure 15. Temporal changes in attention to positive images in relapsed, non-relapsed, and never
depressed individuals at follow up visit.
 85

Figure 16. Temporal changes in attention to threat images in relapsed, non-relapsed, and never
depressed individuals at follow up visit.
 86

Figure 17. Temporal changes in attention to neutral images in relapsed, non-relapsed, and never
depressed individuals at follow up visit.
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A follow up analysis for the depression-related images revealed significant group

differences for the 4-6 second interval, F(2, 141) = 8.57, p < .001, partial η2 = 0.108, and the 6-8

second interval, F(2, 141) = 11.65, p < .001, partial η2 = 0.142, but not for the 0-2 or 2-4 second

intervals, F < 1, F(2, 141) = 2.22, p = .112, partial η2 = 0.031, respectively. For the 4-6 second

interval the relapsed participants attended to the depression-related images more than the non-

relapsed participants (548 ms vs. 364 ms), t(115) = 3.70, p < .001, and more than the never

depressed participants (548 ms vs. 317), t(39) = 4.02, p < .001. The non-relapsed and never

depressed participants did not differ in their attention to depression related images, t(128) = 1.24,

p = .215. For the 6-8 second interval the relapsed participants again attended to the depression-

related images more than the non-relapsed participants (569 ms vs. 381 ms), t(115) = 3.31, p =

.001, and more than the never depressed participants (569 ms vs. 253 ms), t(39) = 4.79, p < .001.

Unlike the 4-6 second interval, the non-relapsed and never depressed participants did differ in

their attention to depression related images in the 6-8 second interval (381 ms vs. 253 ms), t(128)

= 2.95, p = .004. Overall, the relapsed participants attended more to depression-related images

for the last 4 seconds of the 8-second time period relative to the non-relapsed and never

depressed individuals. In addition, the non-relapsed participants also exhibited heightened

attention to depression-related images relative to the never depressed participants in the last 2

seconds of the presentation.

For the positive images there were significant group differences for the 0-2 second

interval, F(2, 141) = 4.37, p = .014, partial η2 = 0.06, the 2-4 second interval, F(2, 141) = 3.20, p

= .04, partial η2 = 0.04, the 4-6 second interval F(2, 141) = 5.27, p = .006, partial η2 = 0.07, and

the 6-8 second interval, F(2, 141) = 5.94, p = .003, partial η2 = 0.07. For the 0-2 second interval,

the relapsed participants attended to the positive images significantly less than the non-relapsed

participants (293 ms vs. 380 ms), t(115) = 2.81, p = .006, but did not significantly differ from the
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never depressed participants in their attention to the positive images (293 ms vs 349 ms), t(39) =

1.56, p = .120. The non relapsed and never depressed participants also did not differ, t(128) =

1.33, p = .185. A slightly different pattern of group differences was present for the 2-4 second

interval with the relapsed participants attending to the positive images significantly less than the

non-relapsed participants again (321 ms vs. 476 ms), t(115) = 2.53, p = .012, and also attending

less to the positive images than the never depressed participants (321 ms vs 456 ms), t(39) =

1.90, p = .059. The non-relapsed and never depressed participants did not differ in their attention

to the positive images, t(128) = .43, p = .666. A similar pattern was observed for the 4-6 second

interval, with the relapsed participants attending to the positive images significantly less than the

non-relapsed participants again (355 ms vs. 601 ms), t(115) = 3.22, p = .002, and also attending

less to the positive images than the never depressed participants (355 ms vs. 597 ms), t(39) =

2.74, p = .007. The non-relapsed and never depressed participants did not differ in their attention

to the positive images, t(128) = .07, p = .944.

Finally, for the 6-8 second interval, the same pattern was seen again, with the relapsed

participants attending to the positive images significantly less than the non-relapsed participants

(391 ms vs. 666 ms), t(115) = 2.93, p = .004, and also attending less to the positive images than

the never depressed participants (391 ms vs. 762 ms), t(39) = 3.40, p = .001. The non relapsed

and never depressed participants did not differ in their attention to the positive images, t(128) =

1.33, p = .184. Overall, throughout the entire 8- second presentation, the relapsed participants

attended less to the positive images relative to the non-relapsed participants and the never-

depressed participants, with the exception of the 0-2 second interval where the relapsed and

never depressed participants did not differ in attention to positive images.

Summary of follow-up visit findings and relation to the literature. At the follow up

visit there were significant group differences in attention to the depression-related images during
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the last 4 seconds of the 8-second presentation; the relapsed participants attended to the

depression-related images more than the non-relapsed and never depressed participants,

consistent with elaborative processing of depression-related information. Relative to the never

depressed participants, the non-relapsed participants exhibited similar attentional biases during

the 4-6 second interval, but then attended more to depression-related images during the 6-8

second interval (although still less than the relapsed participants). This pattern is a potentially

important distinguishing characteristic of the non-relapsed participants, and suggests an

increased resiliency relative to the relapsed participants to engage less with sad information.

When considering the present findings, it is relevant that Soltani et al. (2015) found that

currently and previously depressed participants (possibly similar to the present study’s relapsed

and non-relapsed groups) attended more to sad faces during the last 4 seconds of their 8-second

presentations, similar to the present findings. However, it is important to remember that Soltani

et al.’s previously depressed group was likely a mix of individuals, some of whom relapsed and

some who did not, whereas in the present study the previously depressed participants were

differentiated into those who relapsed and those who did not. Therefore the present study builds

on Soltani et al.’s findings by demonstrating that the non-relapsed participants evidenced both

different and similar attentional biases relative to those who relapsed. Overall, the current results

were consistent with previous findings suggesting that differences in attention to depression-

related information tend to emerge or become more pronounced in later stages of processing

(i.e., over a time period of several seconds).

For the positive images there were significant group differences in attention within all

time intervals. During the 0-2 second interval, the relapsed participants attended to the positive

images significantly less than the non-relapsed participants, but neither group significantly

differed from the never depressed participants during this interval. These findings were contrary
 90

to the hypothesis that the non-relapsed participants would evidence similar, yet attenuated

differences from the relapsed participants. When considering the initial stages of viewing, it

appears that the non-relapsed participants put more effort initially into attending to positive

information (e.g., as compared to the never depressed participants who did not attend more than

the relapsed participants), which may reflect an active strategy to maintain resiliency against

depression, whereas the never depressed may have different protective mechanisms that reduce

the importance of using attentional processes to regulate their mood.

Contrary to the hypothesis suggesting that the relapsed and non-relapsed participants

would exhibit similar attentional profiles, the relapsed participants diverged significantly from

both the non-relapsed and never depressed participants during the 2-8 second intervals,

allocating less attention to the positive images. In addition, the non-relapsed and never depressed

participants exhibited similar attention to the positive images during these time intervals, which

provides interesting information regarding potential mechanisms of resiliency in those who did

not relapse. Given the present evidence that highlights the different temporal profiles of attention

for positive stimuli between those who relapsed and those who did not, it can be inferred that the

lack of elaborative processing of positive stimuli is a potential factor relevant to susceptibility to

depression relapse.

Notably, although differences were present in attention to threat-related images at the

initial visit, these differences were not apparent at the follow up visit. When considering

attention to threat and depression-related images as a factor related to depression vulnerability,

one viewpoint (Woody et al., 2016) is that when individuals are in the previously depressed state,

they may be more likely to attend to externally relevant threat-related cues, such as signs of

interpersonal conflict (e.g., angry faces), whereas once in a depressed (e.g., relapsed) state,

attention is more likely directed towards self-referential negative information that is more mood
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congruent (e.g., sad or depression-related information). An evaluation of the present findings

indicates that the relapsed individuals attended consistent with Woody et al.’s suggestion; at the

initial visit the relapsed and non-relapsed participants exhibited a different temporal pattern of

attention to threat images relative to the never depressed participants, and at the follow-up visit

depression-related stimuli became a more salient focus of elaborated attention.

Overall, the findings at both the initial and follow-up visits provide new information on

attention in previously depressed individuals. There are clear differences in attentional biases

between non-relapsed and relapsed individuals who in prior studies were likely grouped together

into a single “previously depressed” group. This difference could have led to some of the

ambiguous findings seen in the literature, as it is difficult to know what proportion of future

relapsers to non-relapsers were present in any previous study’s “previously depressed” group.

The present findings provide evidence that those who ultimately relapse exhibit different

attentional profiles for depression-related, threat-related, and positive information relative to

those who do not relapse. Those who do not relapse appear to exhibit similar attentional biases to

those with no depression history, albeit with some subtle differences that may represent ongoing

vulnerability factors. Further discussion of the relevance of the present findings to cognitive

vulnerability to depression will be presented in the general discussion.

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Chapter 4: Analysis of Attentional Biases as Predictors of Depression Relapse

A number of risk factors have been identified as predictive of depression onset, including

various biological, psychological, and environmental factors (Monroe & Harkness, 2005;

Burcusa & Iacono, 2007; Kendler & Gardner, 2016). As depression is a highly recurrent

disorder, research has also sought to determine what factors are predictive of depression relapse,

while at the same time recognizing that these factors are not necessarily the same as those

predictive of depression onset (Burcusa & Iacono, 2007). Those impacted by depression

recurrence experience significant impairment in daily activities in addition to neurobiological

and psychological changes that can lead to greater susceptibility to subsequent relapses

(Simpson, DiParsia, Simmons, & Allen, 2009). The study of predictors of depression relapse is

therefore important, as an understanding of factors that contribute to relapse can lead to the

identification of those at risk as well as to the development of preventative measures aimed at

ameliorating the occurrence of subsequent depressive episodes.

Risk Factors in Depression Recurrence

Specific factors thought to lead to a higher risk of developing a pattern of multiple

relapses over time (e.g., a chronic course of depression) have been identified and include a

younger age of depression onset, severity of first depressive episode, lengthier duration of

depressive episodes, number of prior depressive episodes, and familial history of mood disorders

(as reviewed in the meta analyses of Holzel, Harter, Reese, & Kriston, 2011, and Burcusa &

Iacono, 2007). However, as pointed out in the literature (e.g., Just et al., 2001; Monroe &

Harkness, 2011), the majority of studies that have examined risk factors were cross-sectional in

nature and while certainly informative, prospective studies are necessary in order to establish

causal relations. In addition to noting the lack of useful predictors of depression recurrence,

Monroe and Harkness (2011) pointed out that direct comparisons between those who experience
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depression recurrence and those who do not are required for a better understanding of the factors

that predict depression recurrence.

A survey of the literature indicates that a variety of potential predictors of depression

relapse have been examined in prospective studies, which compare individuals who relapse to

those who do not. Identified predictors of depression relapse include the presence of

dysregulation/hyperactivity of the hypothalamo-pituitary-adrenocortical (HPA) axis as related to

cortisol functioning (Aubry et al., 2007; Zobel et al., 2001; Pintor et al., 2009), blunted positive

mood reactivity; Lethbridge & Allen, 2008), higher rates of life stress (Lethbridge & Allen,

2008), an attenuated startle response (O’Brien-Simpson, DiParsia, Simmons, & Allen, 2009),

and suicidal ideation (Oquendo et al., 2013). In addition, one study examined multiple risk

factors with the goal of developing a prediction model for recurrence of depressive episodes

(vanLoo et al., 2015). These factors included the presence of symptoms during the index episode,

internalizing symptoms upon interview, psychiatric and family history, personality, childhood

trauma, recent adverse life events, marital status, and issues with friends and financial strain.

While each of these factors alone were small but significant predictors of relapse, the

combination of these factors most successfully predicted relapse (vanLoo et al., 2015).

Cognitive risk factors in depression recurrence. Vulnerabilities related specifically to

cognitive functioning have also been implicated in both the onset and relapse of depression. The

General Cognitive Model (Beck & Haigh, 2014) posits that depression occurs due to an

exaggeration of biases in normal information processing which activates schemas that control

how information is perceived, ultimately leading to maladaptive functioning in cognitive,

emotional, motivational, and behavioral systems. Cognitive vulnerability can manifest in both

styles of thinking and biases in the processing of information in the environment. Whether or not
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cognitive vulnerability contributes specifically to the recurrence of depression (as well as the

initial onset) has not yet been determined, although theoretical models propose that this is likely.

To date, cognitive factors involved in depression vulnerability have been examined in

both cross-sectional and prospective studies. Although studying previously depressed individuals

using cross-sectional designs has provided important information on cognitive vulnerabilities, it

has been pointed out that such studies are limited in that they demonstrate only that cognitive

biases are correlated with having experienced previous episodes of depression. The key question

is whether cognitive biases confer vulnerability to future episodes of depression (Just et al.,

2001). For this reason depression researchers have concluded that prospective designs are the

superior method for identifying cognitive vulnerability to depression. That is, if a cognitive or

information processing bias plays a role in causing depression, then its presence or absence

should be predictive of vulnerability to future depressive episodes, and distinguish those who do

relapse versus those who do not.

When searching for factors that predict cognitive vulnerability to depression, the

available prospective research has examined both explicit maladaptive cognitive patterns of

thinking and implicit cognitive measures, such as information processing biases, as predictors of

depression. The Temple Wisconsin Cognitive Vulnerability to Depression Project (Alloy et al.,

2006) examined maladaptive cognitive patterns as markers of cognitive vulnerability in non-

depressed individuals. Maladaptive cognitive styles are based on hopelessness theories of

depression (Abramson, Metalsky, & Alloy, 1989) and dysfunctional attitudes are based in Beck’s

theories of depression (Beck, 1967). Together, these have been termed “maladaptive cognitive

patterns” (Haeffel et al., 2005) and are thought to increase the risk of depressive onset in those

vulnerable to depression (e.g. Alloy et al., 2006). To examine maladaptive cognitive patterns,

Alloy et al administered the Cognitive Style Questionnaire (CSQ) and Dysfunctional Attitudes
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Scale (DAS). Participants were placed into either high risk or low risk groups based on their

scores on these measures and were compared on their likelihood of developing depression over a

2.5 year time period. Maladaptive cognitive patterns were found to predict the onset and

recurrence of depressive episodes in those at high cognitive risk for depression. Alloy et al.

concluded that negative cognitive styles conferred vulnerability to both first onsets and

recurrences of clinically significant depressive disorders, although this prediction was stronger

for first onset of depression relative to depression recurrence. It is possible that other types of

cognitive measures would be more predictive of depression recurrence, and a noted limitation of

Alloy et al.’s study was the reliance on self-report measures of cognitive vulnerability, suggested

to be less sensitive in the detection of cognitive biases relative to measures of

cognitive/information processing (Rude, Durham-Fowler, Baum, Rooney, & Maestas, 2010).

Rude et al. (2010) used both a self-report questionnaire (the DAS) and an implicit

measure of cognitive processing (the Scrambled Sentences task) to predict future episodes of

depression in a sample of non-depressed females with and without previous episodes of

depression. The Scrambled Sentences task requires participants to unscramble phrases into a

coherent sentence, which can be either positive or negative (e.g., “winner born I am loser a”).

Not only were both the DAS and Scrambled Sentences Task found to be predictive of future

episodes of depression, each made unique contributions to that prediction, and the researchers

suggested that these two different types of cognitive measures may assess for distinct aspects of

vulnerability to depressive episodes. The researchers proposed that the use of the cognitive

processing task helped capture unique aspects of cognitive biases that self-report measures could

not capture. They suggested that individuals were less aware of their automatic or implicit biases

as compared to how they would portray themselves on self-report measures, and that the

examination of differing sources of cognitive biases allows for the assessment of depression
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vulnerability from alternative perspectives. They deemed it important for future research to

examine these differing types of cognitive vulnerabilities to provide “converging evidence” of

cognitive biases in depression (p. 112). Other researchers (Beevers, Strong, Meyer, Pilkonis, &

Miller, 2007) have also emphasized the need for studies that prospectively examine other forms

of cognitive vulnerabilities not measured by questionnaire, specifically, biased information

processing.

Cognitive factors in the form of information processing biases have also been studied as

potential predictors of depression onset. Connolly, Abramson, & Alloy (2015) examined

information processing biases in a non-clinical sample of adolescents to determine if they

predicted depressive symptoms. They used a self-referent encoding task (SRET) that measures

the preferential processing of negative self-referent information. This task is based on the idea

that individuals who endorse and remember negative self-referent words are depressed or exhibit

a cognitive vulnerability to depression. The purpose of the study was to explore performance on

the SRET as predictive of future depressive symptoms in adolescents at a nine-month follow-up.

The findings indicated that biased processing of negative words and a decreased recall of

positive self-referent words were predictive of depressive symptoms at the follow up visit.

These findings suggested that not only are negative information processing biases a risk factor

for the development of depressive symptoms in youth, but that cognitive processes as related to

positive information were relevant as well (Connolly et al., 2015).

In another prospective study, Beevers and Carver (2003) sought to determine if

attentional biases predicted an increase in depressive symptoms in a mixed group of never

depressed and remitted depressed individuals. They examined if attentional biases in

combination with sustained negative mood after a negative mood induction interacted with

intervening life stress to predict increases in dysphoria seven weeks later. To measure attentional
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biases, they used a dot-probe task with pairs of positive and negative words as stimuli. Their

results indicated that attentional biases for negative words following a negative mood induction,

in combination with the occurrence of stressful life events (determined by a self-report measure

of life stress), predicted increased symptoms of dysphoria seven weeks later. In addition, they

also found that slower recovery from the induced negative mood state predicted increased

symptoms of dysphoria. Importantly, attentional biases to negative information and a slower

mood recovery were each unique predictors of subsequent symptoms of dysphoria. This study

was important in that it was a first attempt to investigate the possibility that attentional biases

could predict depression vulnerability. Some important limitations of the study included the use

of a non-clinical sample and the relatively short follow up period of the study (7 weeks) over

which dysphoric symptoms were assessed.

Attentional biases as predictors of depression relapse. Only one study has specifically

examined attentional biases as a predictor of depression relapse. Woody et al. (2016) used a dot

probe task in combination with eye-gaze measurements to examine attentional biases in a

remitted depressed group and a never depressed group. Pairs of face images (one neutral face,

and an angry, happy, or sad face) were displayed for 1000 ms for the dot probe task, and eye

tracking occurring simultaneously. Attentional allocation as per the eye-tracking was calculated

as the proportion of time within each trial that the participant fixated on the emotional (angry,

happy, or sad) versus the neutral images, dividing the time within each trial the participant

fixated on the emotional face by the total time spent fixated on either face during the trial.

Attention to emotional faces was defined as proportion scores greater than .50, and scores less

than .50 indicated attention away from the emotional faces.

The results of the dot-probe task indicated that at the initial session the remitted

depressed participants exhibited biased attention for sad faces relative to the never depressed
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participants. The analyses of the eye-tracking data indicated that the remitted depressed

participants exhibited more attention towards angry faces, but not to sad faces. No differences

were found between groups in their attention to happy faces with either measure. Most relevant

to the present study, Woody et al. also conducted prospective analyses to determine if the biases

observed during the initial session were predictive of depression recurrence over a two-year time

period. They found that greater attention to angry faces at the initial session was predictive of a

shorter time to depression recurrence, whereas the response latencies to angry and sad faces in

the dot-probe task did not predict depression recurrence. Woody et al. suggested that the

discrepancy in the results obtained in the dot probe and eye-tracking tasks may best be explained

by referring to research that has demonstrated a lack of relationship between eye-tracking indices

of attention and reaction time measures in the dot-probe task (e.g., Waechter et al., 2014). They

also pointed out that eye-tracking as a measure of attention has been found to have greater test-

retest reliability as compared to response latencies measurements in the dot-probe task. Woody et

al. concluded that selective attention to angry faces is a cognitive vulnerability that confers risk

for depression recurrence, and also that the use of eye-tracking as a measure of attentional biases

is more reliable and may provide the best measure of prediction for depression recurrence.

Analysis 3: Prediction of Depression Relapse

When considering that only one study to date has examined attentional biases specifically

as predictors of depression relapse, it is clear that further research using eye-tracking as a

measure of attentional allocation is required to further explore the specific attentional biases

involved in relapse vulnerability. In the following analyses, attentional biases were prospectively

examined as predictors of depression relapse in individuals with a history of depression. The

central research question was whether specific biases in attention to one or more of the image

types distinguished those who relapsed from those who did not, and were therefore predictive of
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depression relapse. Specifically, logistic regression analyses were used to determine if attentional

biases (measured as total fixation times) for positive images, depression-related images, and/or

threat images (considered separately) were predictive of depression relapse. The use of both

naturalistic images and face images provided an opportunity to evaluate the utility of both image

categories for predicting depression relapse.

Results

Prediction of relapse was evaluated using a hierarchical logistic regression procedure in a

group of previously depressed participants, separated into a group of relapsed participants (n =

15) and a group of non-relapsed participants (n = 105). The predictor variables were the average

total fixation times, calculated for each image type for each of the 30 trials at the initial visit,

over the 8-second presentation, and then averaged across all trials. Longer total fixation times

reflected greater attention to an image. The dependent variable was defined as depression relapse

(presence versus absence of relapse). When using logistic regression, 10 to 15 events per

predictor variable is desired in order to have a stable model (Babyak, 2004). Given that only 15

participants relapsed, the number of predictors that could be entered into a model was limited.

Therefore, the initial visit total fixation times for each image type were analyzed separately. BDI

scores were found to be correlated in some cases with total fixation times for some of the image

types (see Table 7), and therefore were also included in the analyses as a means of determining if

total fixation times were predictive of relapse after accounting for depressive symptoms present

at the initial visit (i.e., as a control variable). For the hierarchical logistic regression analyses,

BDI scores at the initial visit were entered in the first step of the analysis, with fixation times to

the image type entered in the second step. This analysis allowed for an evaluation of whether

fixation times to an image predicted relapse above and beyond BDI scores alone.
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Because of the small number of relapsed participants (n = 15), a bootstrapping procedure

was used for the logistic regressions. Bootstrapping is an internal validation method that helps to

provide an accurate estimate of model performance for new participants, and is particularly

useful when the sample size is small, as small sample sizes can lead to an overestimation of the

actual performance in similar participants (Steyerberg et al., 2001). Bootstrapping is a

resampling with replacement technique that uses the available data set to create many new

samples called bootstrap samples, which are equal in size to the original sample, but have a

different data structure. The bootstrap sample technique is repeated multiple times, typically

from 1000-10000 times (Steyerberg et al., 2001; Roelen et al., 2012). In the present study,

bootstrap samples were drawn with replacement (n = 1000) from the data set. Tables 8 and 9

show the results of the logistic regression analyses both with and without the use of

bootstrapping, for the naturalistic and face images, respectively.

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Table 7.

Correlations between BDI initial visit scores and naturalistic/face image fixation times

Image type r p

Naturalistic images
Positive -.30 < .001
Depression-related .17 < .05
Threat .22 < .01*

Face images
Positive -.19 < .02
Depression-related .06 .46
Threat .03 .72
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Table 8.

Logistic regressions for positive, threat, and depression-related naturalistic images

Variable B Wald Exp (B) CI CI p value

(lower) (upper) Bootstrap No Bootstrap

Step 1: BDI initial .092 5.695 1.097 1.017 1.183 .014* .017*
visit

Step 2: BDI initial .083 4.366 1.087 1.005 1.175 .052* .037*
visit
Positive FT -.001 2.739 .999 .998 1.000 .030* .098
Step 1: BDI initial .092 5.695 1.097 1.017 1.183 .011* .017*
visit

Step 2: BDI initial .089 5.207 1.093 1.013 1.180 .029* .022*
visit
Threat FT .001 1.357 1.001 .999 1.002 .219 .244
Step 1: BDI initial .092 5.695 1.097 1.017 1.183 .011* .017*
visit

Step 2: BDI initial .092 5.507 1.097 1.015 1.185 .026* .019*
visit
Depression FT .000 .703 1.000 .999 1.002 .381 .402

Note: CI = confidence interval; FT = fixation time.

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Table 9.

Logistic regressions for happy, threat, and sad face images

Variable B Wald Exp (B) CI CI p value

(lower) (upper) Bootstrap No Bootstrap

Step 1: BDI initial .090 5.400 1.094 1.014 1.181 .016* .020*
visit

Step 2: BDI initial .090 5.282 1.094 1.013 1.180 .024* .022*
visit
Happy FT .000 .049 1.000 .999 1.001 .805 .824
Step 1: BDI initial .090 5.400 1.094 1.014 1.181 .018* .020*
visit

Step 2: BDI initial .093 5.696 1.098 1.017 1.185 .016* .017*
visit
Threat FT .001 1.215 1.001 .999 1.003 .256 .270
Step 1: BDI initial .090 5.400 1.094 1.014 1.181 .016* .020*
visit

Step 2: BDI initial .092 5.511 1.096 1.015 1.183 .022* .019*
visit
Sad FT .001 .864 1.001 .999 1.002 .391 .352

Note: CI = confidence interval; FT = fixation time.

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The omnibus tests of model coefficients indicated that the model with predictors was

significantly different than the constant only model, therefore indicating that the addition of the

predictors improved the fit of the data to the model, X2 (2) = 7.28, p = .026. The constant only

model accounted for 87.5% of correct/accurate classification. The model was improved when the

predictors were added and increased the predictive power of the model, X2 (2) = 8.99, p = .011,

accounting for an additional 13.6% of the variability as indicated by Nagelkerke’s R2. Next, to

control for BDI as a likely predictor of depression relapse and because they were modestly

correlated (see Table 7), initial visit BDI scores were entered as Step 1 into the model, and were

found to significantly predict relapse (see Table 8). This finding indicates that those who had

higher BDI scores at the initial visit were more likely to relapse. The addition of positive

attentional bias scores to the model increased relapse prediction above and beyond the initial

visit BDI scores (see Table 8). These findings indicate that less time spent attending to the

positive images at the initial visit was associated with a greater risk of relapse, even after

depressive symptoms at the initial visit were accounted for. Although significant, the odds ratio

at Exp (B) = .999 corresponds with a very small effect size.

As can be seen in Table 8, fixation times for threat and depression-related naturalistic

images did not predict depression relapse. Similarly, as seen in Table 9, fixation times for happy,

threat, and sad face images were not predictive of depression relapse.

Discussion

Although the results indicated that less time spent attending to the positive naturalistic

images at the initial visit was predictive of depression relapse through the six-month study

period, reduced attention to happy faces was not predictive of depression relapse. These findings

suggest that differences exist in attentional distribution to social information relative to

information attended to in the naturalistic images, which are more heterogeneous and contain
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more diversity in content. As noted when discussing the total fixation time results, it could be

that attentional biases to face stimuli are therefore more difficult to detect, further limited by the

small size of the relapsed group.

In contrast to the findings for the positive images, attentional biases towards the

depression-related/sad face images and/or the threat naturalistic/threat face images were not

predictive of depression relapse. As discussed, only one other study to date (Woody et al., 2016)

has examined attentional biases as measured through eye-tracking as predictors of depression

relapse. Woody et al. found that a higher proportion of gaze duration towards angry faces was

predictive of a shorter time to depression recurrence, with no differences observed in the

proportion of gaze duration towards the happy face images. In contrast to their findings, the

present study found that less attention to the positive images at the initial visit was predictive of

depression relapse over the six-month study period.

There are several important methodological differences between Woody et al.’s study and

the present study that may account for the discrepancy in findings (note that Woody et al. used

the same database of face images for stimuli that were used in the present study). For one, the

present study presented four image types together, different from Woody et al. which presented

participants with pairs of images, one emotional face image (either happy, sad, angry) and one

neutral image. Presenting four images, three with emotional content, produces much more

competition for attention relative to the case when only two images are presented, only one of

them with emotional content. It is possible that these display differences could have made the

threatening faces much more salient in the Woody et al. study than they were in the present

study, given that they were always paired with non-emotional neutral faces in their study, which

could explain why threat faces predicted relapse in the Woody et al. study but not the present

study. Future research should evaluate this possibility by comparing attentional allocation to
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emotional images with varying numbers of images (e.g., four vs. two images), using a free

viewing eye-tracking task, to test for differences in attentional distribution when more or less

emotional information is present.

Another major difference was that Woody et al. tracked eye movements during the dot-

probe task, whereas in the present study a free viewing task was used. Lastly, Woody et al.

presented their pairs of images for 1000ms, whereas in the present study the four images were

presented for 8000 ms. The short presentation time in the Woody et al. study limited the

evaluation of attentional biases to those that could be observed within a 1000 ms interval,

whereas in the present study attentional biases measured over a much longer interval could be

observed. Ultimately, for all of these reasons, it is very difficult to compare the data from the two

studies. These differences highlight the general lack of consistency in the methods used to

evaluate attentional biases for emotional stimuli. At this point, it appears that greater

standardization in the measurement of attentional biases is required to ensure that results across

different studies can be compared appropriately.

The major limitation in this analysis was the small number of relapsed participants. This

clearly limited the power for predicting depression relapse. Nevertheless, the findings for the

positive naturalistic images are promising, especially when considering the small number of

relapsed individuals in the analysis (assuming of course that the effect is not a Type I error partly

due to the small sample size). In addition, the number of relapsed participants relative to the

number of potential predictors was small, and did not allow for a simultaneous examination of

other predictors (e.g., number of previous episodes, life stress, age at onset) that may have

impacted the variance attributed to attentional biases. Although exact sample size calculations

for prediction models do not exist, the general rule is that for each candidate predictor there

should be at least 10 to 15 events (Babyak, 2004). Thus, it was simply not feasible to enter
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multiple predictors into the model. Another limitation related to the prediction analyses was that

the exact number of days from the prior episode to the day of relapse was not measured, in part

due to participant uncertainty regarding specific dates of previous depressive episodes. This

limited the type of predictive analyses that could be performed (e.g., survival analysis could not

be used).

The overarching question in terms of prediction when considering the findings of the

present analysis is whether or not attention to positive information has value in terms of actually

being a predictor of depression relapse. The present study provides some evidence to suggest that

this is the case, despite the study limitations. However, questions still remain as to the precise

threshold of attention required before relapse occurs. For example, one consideration is if there is

a point at which decreased attention to positive information actually facilitates relapse. Another

consideration is if attention to positive information remains reduced once in a depressive episode

and contributes to maintaining ongoing symptoms of depression. Future studies could examine

this question more closely by observing attention at multiple time points preceding and following

depression relapse. One of the most important questions is whether or not attentional biases

represent an idiographic risk factor, with individual variability in susceptibility to relapse as a

function of attentional biases. It is possible that a threshold, if it exists, is related to individual

factors, and is not necessarily broadly applicable. These are questions that future research could

parse out through a more specific and thorough prospective examination of attentional biases.

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Chapter 5: General Discussion

Major Depressive Disorder is a very common and highly recurrent disorder, with a one-

year prevalence rate in Canada cited at 4.1% to 4.6% (O’Donovan, 2004). Estimates indicate that

depression recurrence will occur in more than half of those who experience an initial episode,

and as the number of recurrent episodes increase, so does the likelihood that a chronic course of

depression will occur (Monroe & Harkness, 2011). Given the significant financial, personal, and

societal costs associated with experiencing multiple episodes of depression, it is important to

determine the factors that contribute to depression recurrence.

The purpose of the present study was to examine attentional biases as factors that confer

cognitive vulnerability to depression relapse. An understanding of how attentional biases

manifest in previously depressed individuals who experience a subsequent relapse or not has the

potential to elucidate how attentional biases contribute to cognitive vulnerability. In the present

study, attentional biases were examined at an initial and follow up visit, over a six-month study

period, in previously and never depressed individuals. The group of previously depressed

individuals was further divided into two groups: those that relapsed (the relapsed group) over the

six months and those that did not (the non-relapsed group). Participants were either assessed at

the end of the six-month period (if they had not relapsed) or assessed as soon as possible after a

relapse occurred within the six-month study period. A never depressed group was also followed

for the purpose of comparison. This is the first study to use a longitudinal design to evaluate

if/how attentional biases change over time in previously depressed individuals who relapse.

Three separate sets of analyses were conducted. The first set of analyses compared

attentional biases of each of the three groups at the initial and follow up visits as measured by

their total fixation times for both naturalistic (depression-related, positive, threat, neutral) and

face (sad, happy, threat, neutral) images. The second set of analyses compared the attentional
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biases of each of the three groups at the initial and follow up visits as measured by their temporal

profiles of attention (where the 8-second presentation was divided into 2 second intervals to

examine changes in attention over time). The third set of analyses used logistic regression to

determine if relapse events could be predicted by attention to emotional images at the initial visit.

The overall findings are best reviewed by examining each of the three sets of analyses for each

of the emotionally valenced image types separately, both naturalistic images and faces (e.g.,

positive/happy faces, depression-related/sad faces, threat-related/threat faces, and neutral/neutral

faces).

Attention to Positive/Happy Images

Overall, the most striking and perhaps most meaningful findings were obtained for

positive/happy face images. Taken together, the findings from the three sets of analyses converge

to indicate that attention to or away from positive information is related to depression relapse

vulnerability. In general, the findings for the positive images were relatively consistent for the

naturalistic and face image categories and when comparing the initial and follow up visits. The

overall trend indicated that the relapsed participants attended less to positive images (happy faces

and positive naturalistic images), decreased their attention to positive images over the study

period, and exhibited significant differences in their temporal profiles of attention for

positive/happy images relative to those who did not relapse and those never depressed.

Specifically, the relapsed participants’ attention to happy faces was relatively constant

throughout the 8-second presentations, whereas for non-relapsed and never depressed

participants attention to these images increased over the 8-second presentation. In addition, those

who relapsed exhibited differences in their temporal profiles for the positive naturalistic images

from the initial to follow up visits. At the initial visit, those who relapsed attended less to the

positive images at the beginning and end of the presentation, whereas at the follow up visit they
 110

attended less to the images less throughout the entire 8-second presentation relative to the non-

relapsed and never depressed participants. In addition, the logistic regression analysis suggested

that reduced attention to positive images at the initial visit predicted depression relapse; the

previously depressed participants who attended less to positive images at the initial visit were

more likely to experience depression relapse, even after controlling for BDI scores at the initial

visit. It should be noted that the prediction of relapse was limited by the small number of

relapsed individuals, but the results at the very least highlight the need for a replication study

with a much larger sample.

In contrast, and contrary to what was hypothesized, the non-relapsed and never depressed

participants generally attended to positive images in a similar manner. They exhibited no

substantial differences in how they attended to the positive and happy face images overall in

terms of their total fixation times, or in terms of their temporal profiles during both the initial and

follow up visits. Both groups attended to positive naturalistic and happy face images more than

those who relapsed and generally increased their attention to those images over the 8-second

presentations.

These findings provide compelling evidence to suggest that a key contributor to

depression relapse is a shift in how attention to positive information is allocated between the

remitted/recovered and relapsed state. It is notable that the relapsed participants decreased their

attention to positive information from the initial to follow up visit, which may have contributed

to increased susceptibility for relapse. In contrast, for the non-relapsed participants, attention to

positive information was similar during the initial and follow up visits, a pattern of attending that

could reflect a protective factor that helps maintain their remission.

Anhedonia. The fact that relapsed individuals allocated less attention to positive

information is a phenomenon consistent with one of the two cardinal criteria of depression,
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anhedonia, or the loss of interest and/or pleasure in activities and experiences once deemed

pleasurable (DSM-IV-TR; APA, 2000). As discussed by Pizzagalli (2014), anhedonia is

considered a trait marker of depression vulnerability. This key symptom of depression involves a

distinct lack of engagement and interest in positive and pleasurable information and experiences.

The present study findings suggest that this particular symptom could be driven in part by a

deficit in attentional processes that impact the ability to capture or notice positive information in

the environment. Interestingly, it has recently been proposed that anhedonia is in consideration

as a potential endophenotype of depression, with evidence to suggest it meets the criteria in

terms of heritability, state independence, familial association, and biological and clinical face

validity (Pizzagalli, 2014).

As the present study suggests that decreased attention to positive information may

increase susceptibility to depression relapse, one question to consider is at what point decreased

attention to positive information reaches a threshold at which relapse occurs, or alternatively, if

attention to positive information changes after relapse has already occurred. One way to examine

this question would be to prospectively assess attentional biases in previously depressed

individuals, similar to the present study, but at more time points throughout the study period.

Multiple assessments of attentional biases between remission and relapse would provide data that

would allow one to establish the point at which attentional allocation is further decreased or

withdrawn from positive information. Continued evaluation of attention to positive information

from the relapse through the subsequent remission would provide further information as to when

increased engagement with positive information re-emerges, and if it corresponds with the

remission.

Theoretical explanations for reduced attention to positive information. When

considering the origins of, or explanation for decreased attention to positive information, it is
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evident that a number of broadly linked mechanisms either underpin or correspond with

information processing biases. One comprehensive review postulated mechanisms in the form of

a working model through which anhedonia operates in depression (Pizzagalli, 2014). This model

hypothesized that a combination of behavioral (e.g., lowered likelihood of recognizing and

responding to rewards and reinforcements), neurochemical (e.g., attenuated dopamine function),

and neurobiological abnormalities (e.g., actual functional and structural dysfunctions in the

ventral and dorsal striatum, and orbitofrontal cortex), in combination with environmental

experiences (e.g., stressors) impacts the ability for individuals to process pleasure and reward in

an adaptive fashion (Pizzagalli, 2014). One possibility is that attentional biases may be

secondary to neurobiological and neurochemical abnormalities, which are then impacted by

environmental stressors and lead to behavioral responses that further reinforce attentional

allocation. At this time, it is unknown how the specific behavioral, neurochemical, and

neurobiological components of this model interact to impact attentional processes to positive

information, but it is highly likely that a lack of/reduced attention to positive information

contributes to the overall experience and maintenance of anhedonia in some fashion.

Reward devaluation hypothesis. At the environmental and behavioral levels, the reward

devaluation hypothesis (Winer & Salem, 2016) is a theoretical model that proposes that anxious

and depressed individuals are likely to avoid and actively inhibit rewarding stimuli and positive

information. The hypothesis suggests that avoidance is possibly due to a lack of exposure to

positive information during developmental years, which potentially manifests as an eventual

impairment in the encoding of positive information. This model further proposes that differences

in how individuals respond to positivity may be more relevant than negative influences in

causing or maintaining psychopathology. These differences are referred to as vantage sensitivity

(possessing factors that allow one to benefit from positive experiences), and vantage resistance
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(possessing characteristics that decrease or eliminate one’s ability to benefit from positive

experiences). Vantage resistance is thought to play a role in eventual avoidance of positive

stimuli. Finally, it is hypothesized that those experiencing symptoms of depression begin to

perceive that although positive information appears to be rewarding, it is actually associated with

negative or even harmful outcomes, which results in reduced attention to positive information

(Winer & Salem, 2016).

To evaluate the empirical support for this theory, Winer and Salem (2016) conducted a

meta-analysis of 75 studies that utilized dot-probe methodology to examine attentional biases in

both anxious and depressed populations. They found that only participants who endorsed

depression or dysphoria avoided positive information—those who endorsed anxiety symptoms

did not exhibit this pattern of avoidance. The researchers concluded that these findings support

the hypothesis that those who are depressed devalue rewarding information. This meta-analysis

also revealed that both depressed and anxious individuals exhibited attentional biases for

negative information, suggesting that it is the attention to positive stimuli that distinguishes those

who are depressed from those who are anxious. Although this meta-analysis examined

attentional biases as measured using the dot-probe task, these findings are still relevant to the

present study as they indicate that different methodologies that examine attentional biases tend to

converge on similar findings related to how attentional biases for positive information manifest

in those who are depressed.

The present study indicated that attentional biases to positive information distinguished

those who relapsed versus those who did not, with less attention to positive stimuli at the initial

visit predictive of depression relapse, and decreased attention to positive images from the initial

to follow up visits only observed for those who relapsed. Although the theory discussed by

Winer and Salem (2016) proposed how attentional biases manifest in those who are depressed,
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the findings of the present study infer that this is a process that likely unfolds between remission

and relapse. For example, the differences in temporal profiles of the relapsed participants from

the initial to follow up visits indicate that from remission to relapse, changes occurred in the way

that positive stimuli were attended to. Attention at the initial visit was similar to the non-relapsed

and never depressed participants in the middle of the 8-second presentation (but significantly less

at the beginning and end), compared to the follow up visit where attention across the entire 8-

second presentation was sharply reduced relative to the non-relapsed and never depressed

participants. These findings support the idea that avoidance of, or reduced engagement with

positive information is one attentional mechanism that contributes to depression relapse

vulnerability.

Overall, the present findings, by focusing on attentional processes as a potential marker

of depression vulnerability, contribute to a larger body of evidence suggesting that the

engagement or lack of engagement with positive information has important relevance to the

experience of depression. Consistent with this conclusion are the studies that have examined

other cognitive processes in those who are actively depressed or vulnerable to depression, where

the results indicate that these individuals often lack a positivity bias (e.g., do not attend more to

positive stimuli than neutral stimuli), or tend to exhibit a bias away from positive stimuli (e.g.,

Surguladze et al., 2004; Gollan, Pane, McCloskey, & Coccaro, 2008; Gotlib et al., 2004; Ramel

et al., 2007). In addition, depressed individuals have been found to display blunted reactivity to

positive information (Rottenberg, 2005; Rottenberg, Gross, & Gotlib, 2005), and those with a

history of depression have been found to exhibit dysregulated positive affect (e.g., lowered

emotional reactivity) that has been postulated to confer risk to depression relapse (Lethbridge &

Allen, 2008).
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Attention to Depression-Related/Sad Images

Recall that there were no specific differences in total attention allocated to depression-

related or sad face images at the initial visit, nor were the temporal profiles of attention for the

depression related/sad face images different at the initial visit. In addition, attention to

depression-related/sad face images at the initial visit was not found to be predictive of depression

relapse at the follow up visit. As discussed earlier, the literature on attention to negative

emotional stimuli has been mixed in studies examining individuals with a history of depression,

with some studies indicating that previously depressed individuals tend to allocate more attention

to depression-related/sad emotional stimuli relative to never depressed individuals (e.g.,

Joormann & Gotlib, 2007; Soltani et al., 2015; Newman & Sears, 2015). Other studies have

reported mixed findings on attention to depression-related/sad emotional stimuli (e.g., Sears et

al., 2011; Woody et al, 2016), with some observing no differences relative to never depressed

groups (e.g., Isaac et al., 2014), and others observing differences only after participants

experienced a sad mood induction procedure (e.g., Ingram, Bernet, & McLaughlin, 1994;

McCabe et al., 2000). Given the diversity of these findings, it is perhaps not surprising that no

differences in attention to depression-related/sad face images were observed between the

relapsed, non-relapsed, and never depressed groups at the initial visit. It is possible that attention

to sad information is simply not a consistent factor that distinguishes individuals who

subsequently relapse from those who do not.

At the follow up visit, patterns of attention to depression-related/sad face images were

generally opposite to those observed for the positive images. That is, the relapsed participants

attended longer to depression-related/sad face images, held their attention relatively constant to

the sad face images over the 8-second presentation (whereas non-relapsed and never depressed

participants decreased attention to sad faces), and attended more to depression-related images
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over the last 4 seconds. In contrast, the non-relapsed and never depressed participants decreased

their attention to the depression-related images from the initial to follow up visits (the

corresponding differences were not observed for the sad face images). However, unlike never

depressed participants, non-relapsed participants attended to depression-related naturalistic

images more during the last 2 seconds of the presentation. In addition, when averaged over the

initial and follow up visits, the non-relapsed participants attended more to depression-related

images relative to the never depressed participants. Taken together, these findings indicate that

although the non-relapsed and never depressed participants exhibited similar temporal patterns of

attention for depression-related images, the non-relapsed participants still exhibited differences

in attentional biases suggestive of increased cognitive vulnerability.

A key point to keep in mind when interpreting the data for the depression-related/sad

images is that because differences were observed only at the follow up visit, when depression

was active, it appears that biased attention to depression-related or sad information may be more

relevant once depression has occurred, as opposed to being a vulnerability factor. This is an

important distinction for depression researchers. For example, attentional biases for sad

information have been proposed to maintain the presence of a sad mood state, therefore

extending the length of depressive episodes (Clasen et al., 2013). Consistent with this idea, the

results of one study indicated that modifying a negative attentional bias led to a decrease in

depression symptoms (Beevers, Clasen, Enock, & Schnyer, 2015). One five-week prospective

study in individuals with initially elevated depressive symptoms concluded that negative

attentional biases corresponded with a worsening and maintenance of depressive symptoms, as

well as a lower likelihood of natural recovery (Disner, Shumake, & Beevers, 2016). Beck (2008)

succinctly described a number of events that ultimately culminate in an episode of depression,

that begin with an increased tendency to focus on negative information that strengthens over
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time, with positive information or experiences less able to influence or alter these negatively

biased perceptions (possibly as attention to positive information slowly decreases). Eventually,

processing of negative information becomes automatic and resistant to change, no processing of

positive information occurs, and the depressed state is reinforced and maintained.

As previously discussed, cognitive models of depression theorize that increased attention

to negative information and decreased attention to positive information operate to maintain

depression, and have proposed that these biases also operate between episodes of depression (e.g.

Gotlib & Joormann, 2010), yet research has not been consistent on this point for those with a

history of depression. Although not yet definitive, perhaps attentional allocation to sad

information is more accurately conceptualized as a maintenance factor, once depression has

already occurred, as opposed to a vulnerability factor for relapse. The fact that the present study

found no evidence that attention to depression-related/sad face images was predictive of

depression relapse supports this hypothesis, although the lower statistical power of the prediction

analyses must also be taken into account.

Attention to Threat Images

Although there were group differences in attentional biases for the naturalistic threat

images, no differences were observed for the threat face images. Across both visits, the relapsed

participants attended more to the threat images, and increased their attention to the threat images

from the initial to follow up visits. At the initial visit, the relapsed participants also decreased

their attention to threat images for the first 6 seconds, and held attention constant to these images

for the last 2 seconds, a pattern also observed for the non-relapsed participants. In contrast, never

depressed participants decreased their attention to threat images over the entire 8-second

presentation.
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The non-relapsed participants were similar to never depressed participants as they

attended to threat images less than relapsed participants at each visit. However, they were

different from never depressed participants, and similar to relapsed participants with respect to

their attention to threat images increasing from the initial to follow up visit. They also had a

similar temporal profile as the relapsed participants for threat images at the initial visit. However,

at the initial visit, the non-relapsed participants exhibited a potentially important difference from

both the never depressed and relapsed participants in the initial stages of viewing (they attended

to threat images less during the 0-2 second interval), possibly because they exert more attentional

control/effort in order to maintain their non-depressed state. When considering how attention to

threat-related images might play a role in vulnerability to depression relapse, it appears that

protective factors include less attention to threat images overall and in the initial stages of

viewing (early avoidance).

When considering the origin and manifestation of threat-related biases in depression,

depressed individuals have been found to exhibit vigilance for threat, with increased activity in

brain regions that modulate attention and vigilance, including the amygdala, related to increased

sensitivity and negative processing biases towards emotional stimuli (Beck, 2008), and reduced

activity in the prefrontal cortical areas (Beck, 2008; Bourke et al., 2010). Beck and Bredemeier

(2016) proposed that specific depression symptoms that promote vigilance (or are a consequence

of vigilance) include psychomotor agitation, difficulty concentrating, and insomnia, along with

anxiety and irritability. Of note, hyper-reactivity in the amygdala has been found to be related to

negative information processing biases in general for both threat and depression-related

information (Beck, 2008; DeRaedt & Koster, 2010).

The literature indicates that trait-related abnormalities in fear processing in previously

depressed and depressed individuals may be relevant to attention to threat images, with a number
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of findings observed in the processing of facial emotions (see Bourke et al., 2010 for a review).

For example, previously depressed individuals have been found to exhibit increased perception

and greater recognition of fearful facial expressions relative to never depressed individuals

(Bhagwagar et al., 2004). In addition, as previously discussed, Woody et al. (2016) found that

previously depressed females who attended more to angry face images during an initial visit

exhibited a shorter time to depression relapse than did remitted females who attended less to

angry face images, and concluded that women may be particularly sensitive to cues that elicit

perceptions of rejection, anger, or criticism by others. Although research with naturalistic threat

images is scarce, the results of the present study and those of Sears et al. (2011) indicate that

attentional biases for threatening information are not relevant only to facial processing, but are

also observed in the processing of more general threat-related stimuli.

Comparing Face Images and Naturalistic Images

Previous studies that have examined attentional biases for different emotionally valenced

image types have used either naturalistic or face images as stimuli, but not both. Participants in

the present study viewed separate blocks of naturalistic and face images, each with four images

of similar emotional valence (depression-related/sad, positive/happy, threat, and neutral). This

allowed for an evaluation of any similarities and differences in attentional biases as a function of

the category of images (e.g., naturalistic or face) viewed within the same group of individuals.

This section will point out the general patterns of similarities and differences observed in

attentional biases between the naturalistic and face images.

Total fixation time analysis. When considering total fixation times to positive emotional

stimuli, there were both consistent and inconsistent patterns of attention evident between the

naturalistic and face images. No group differences in total fixation times were observed at the

initial visit for either the naturalistic or face images. There was no interaction between group and
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visit (initial, follow-up) for the naturalistic images, and when collapsed across visits the relapsed

participants attended to the positive images less overall. On the other hand, group differences for

the face images were evident at the follow up visit; the relapsed participants attended less to the

happy faces relative to the non-relapsed and never depressed participants. Overall, the relapsed

participants exhibited decreased attention to both the positive naturalistic and happy face images

from the initial to follow-up visits, which demonstrated that among the same group of

remitted/relapsed participants, attention to positive information changed as a function of relapse.

For depression-related naturalistic images and images of sad faces, there was a different

pattern of results, with relapsed participants attending to sad faces at the follow-up visit more

than non-relapsed and never depressed participants, and attending to depression related

naturalistic images more when collapsed across both visits. Although relapsed participants did

not change attention to depression-related or sad face images from the initial to follow-up visits,

non-relapsed participants were found to decrease their attention to depression-related, but not sad

faces from the initial to follow-up visits.

With respect to threat images, group differences in attention were observed for the

naturalistic threat images but not for the face images. Previous studies have found that remitted

individuals attend more to both threat naturalistic and face images (Sears et al., 2011; Woody et

al., 2016). Notably, the current study used face images from the same data base (e.g., Tottenham

et al., 2009) as Woody et al., so one potential explanation for the different findings could be that

Woody et al. used only angry faces in their threat group, whereas the current study used an equal

mix of angry and fearful faces in the threat group. It is possible that the angry faces in Woody et

al. comprise a qualitatively different category of threat images than the mix of angry/fearful

faces used in the current study, possibly indicating that the angry faces are more socially salient

to those vulnerable to depression than the fearful faces. In addition, it may be that threat faces are
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qualitatively different from naturalistic threat images (comprised of a variety of threatening

images; e.g., frightening interpersonal scenes, vicious/scary animals, ominous natural disasters),

which could also explain the different findings between the face and naturalistic threat images in

this study. In the present study, the naturalistic images may have been a more salient stimuli for

measuring threat-related attentional biases, and a true parallel may not exist between the

naturalistic and face images, unlike the case for the happy faces and positive images, both of

which appear qualitatively very similar in terms of being pleasant stimuli.

Time course analyses and temporal profiles of attention. Comparisons of the time

course of attention for the face and naturalistic image types revealed that attention was not

consistent between the two image categories. At the initial visit, no group differences were

observed for face images. However, differences were observed for the naturalistic images (e.g.,

during the 0-2 and 6-8 second intervals, relapsed participants attended less to positive images

relative to non-relapsed and never depressed participants, and more to threat images during the

0-2 second interval). The aforementioned findings are notable in that if only attention to the face

images at the initial visit was being considered (as might be the case in a cross-sectional study),

it could be inferred that no group differences in attentional biases were evident. One important

implication is that it may be relevant to assess attentional biases using both image categories to

increase the likelihood of observing attentional biases and to understand the generalizability

versus specificity of the results.

At the follow up visit, findings were largely consistent between the positive naturalistic

and happy face images—the relapsed participants attended less to both positive image categories

throughout all time intervals relative to the other two groups. There was also an indication of a

group difference in the temporal profile of attention for the happy faces where the relapsed

participants held their attention relatively constant throughout the presentation, whereas the non-
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relapsed and never depressed participants increased attention to happy faces throughout the 8-

second interval.

Attentional profiles for depression-related naturalistic and sad face images were less

consistent at the follow up visit. Relapsed participants attended more to depression-related

naturalistic images relative to never depressed participants in the last 4 seconds of the viewing

period, differences not observed for the sad face images. No group differences were evident for

sad face images between groups when each time interval was examined, but there was

suggestion of differences in the temporal profile—the relapsed participants maintained attention

to the sad faces throughout the entire 8-second time interval, whereas the never depressed

participants decreased attention to sad faces throughout the 8-second time period. These trends

were not observed for depression-related naturalistic images. Overall, these findings suggest that

both the sad face and depression-related naturalistic images captured the relapsed participants’

attention to some extent, but there were differences in how attention was captured by naturalistic

images and faces throughout the presentations. In general, the relapsed participants focused

attention on the depression-related naturalistic images only during the latter half of the 8-second

presentation, whereas for sad faces attention was engaged throughout the 8-seconds.

Prediction of depression relapse. Only the positive naturalistic images were relevant in

the prediction of depression relapse. The findings indicated that those who displayed less

attention to the positive naturalistic images at the initial visit were more likely to relapse within

six months. This was not true for the happy face images. It is notable that the predictive value of

the happy face images was well outside a marginally significant range, which suggests that this

outcome was not due to a statistical power issue related to the small sample size.

Taken together, when considering total fixation time analyses, time course analyses, and

prediction of relapse, the findings were mixed when comparing the naturalistic and face images
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as stimuli. The most consistent findings across the image categories were evident for the positive

naturalistic and happy face images, with much less consistency observed for the other image

types (depression/sad and threat).

As mentioned, there were inconsistencies in attentional biases for the naturalistic and face

image categories. It is possible that the face images were too variable in appearance, with faces

inclusive of different genders, cultural background, and other factors. Although this type of

presentation is more representative of the variety of faces encountered in the natural

environment, an alternative idea would be to present uniform sets that only show the same face

but display different emotions. This would match each image set with respect to age, gender,

race, physical appearance, attractiveness, and leave only emotional expression as the difference

between face images (as noted in Gotlib et al., 2004).

As this aspect of the present study was intended to provide initial information and

observations of how attentional biases are captured by different image categories, the

overarching conclusion is that enough inconsistencies exist to warrant further study in this area.

Of note, it is interesting that attentional biases in some form were observed for the expected

emotional image types (positive/happy and depression-related/sad), but what remains unclear is

the reason each image category (naturalistic versus faces) elicits different patterns in attentional

allocation. It is possible that attentional allocation to naturalistic and face images reflects

different types of information processing due to the potentially different constructs that each

image category elicits. For example, attending to an emotional face may activate a cascade of

interrelated processes unique from that activated when attending to an image of a naturalistic

setting that may be an animal, group of people, or object with a completely different connotation,

even if the emotional valence is the same. Therefore, it is important for future research to

consider the validity of directly comparing studies of attentional biases for naturalistic and face
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images as if they are interchangeable stimuli, and subsequently draw definitive conclusions on

that basis. Gotlib et al. (2004) similarly asserted that assessment of information processing biases

leads to inconsistent findings when different stimuli are used, which certainly seems to be the

case when using faces and naturalistic image categories.

Relatedly, there is a significant body of literature that documents the uniqueness of the

processing of face information, and in particular eye gaze (as discussed in Chen, Helminen, &

Hietanen, 2016). One area of research suggests that amygdala activation is influenced by aspects

of eye gaze, and that the visual attention of an individual is impacted by the eye gaze direction of

another individual, which in turn influences facial perception and emotional response as a whole

(Straube, Langohr, Schmidt, Mentzel, & Miltner, 2010). Chen et al. found that the perception of

eye gaze impacts emotional state and consequently leads to positive or negative affective

evaluation of information (Chen et al., 2016). Given the relationship between amygdala

activation, emotion, and resultant attentional processes, it is likely that stimuli focused on just the

face, including a direct eye gaze toward the participant, elicits a different activation of attentional

processes than would stimuli of a different nature (e.g., naturalistic images that might include

people with averted eye gaze or animals/objects with no relevant eye gaze). Although these may

appear to be very specific details to consider in the study of attentional biases, there is growing

evidence that they are important nonetheless. Future research should continue to compare

attentional biases with face and non-face stimuli, and endeavor to establish the reliability and

validity of the use of images as measures of attentional biases.

Relevance to cognitive models of depression.

The present study findings highlight some important considerations regarding the

conceptualization of attentional biases as factors relevant to depression vulnerability. As

previously discussed, cognitive theories of depression suggest that information processing biases
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(e.g., attentional biases) are stable trait-like characteristics that confer vulnerability to depression

relapse, that are still present, yet latent, during periods of remission (DeRaedt & Koster, 2010;

Gotlib & Joormann, 2010). Most relevant to theories of cognitive vulnerability, the present

findings of (1) decreased attention to positive images from the initial to follow up visits in those

that relapsed, and (2) that less attention to positive images at the initial visit was predictive of

depression relapse over the study period, strongly suggest that a decreased positivity bias,

present in those with a history of depression at a time when symptoms are not active, contributes

in some way to depression relapse.

The findings related to both total fixation times and temporal patterns of attention also

offer some support for this theory. For example, although the non-relapsed and never depressed

participants demonstrated a number of similarities in their attentional biases, they did not exhibit

identical attentional biases. The non-relapsed participants exhibited subtle differences in

attentional biases relative to the never depressed individuals, which supports the presence of

ongoing vulnerability factors in individuals with a depression history. For example, the non-

relapsed participants attended differently to depression-related images (e.g., greater total fixation

times for depression-related images than never depressed participants; temporal profile

differences). These are important differences that could increase vulnerability to future episodes.

Next, the non-relapsed participants evidenced a different temporal pattern of attention for threat

images than the never depressed participants (e.g., less attention at the beginning of the 8-second

interval). As noted, one explanation could be that they are deploying their attention in a way that

helps to maintain their non-relapsed state. Last, the non-relapsed participants exhibited a

different temporal profile for positive images (e.g., attended more at the beginning of the interval

than the never depressed and relapsed participants). These were notable findings because they
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again indicated a different pattern of attention in the non-relapsed participants, possibly due to

mobilizing greater attentional resources because of increased vulnerability.

There was also some evidence inconsistent with the idea that attentional biases are trait-

like characteristics that confer depression vulnerability. One example is that the non-relapsed and

relapsed participants evidenced a number of differences in attentional biases from each other

despite both having a history of depression. If consistent with the theory, the non-relapsed and

relapsed participants would presumably exhibit similar attentional biases by virtue of their

depression history and presumed trait-like cognitive vulnerabilities. This suggests that attentional

biases may not be trait-like cognitive vulnerability factors in all previously depressed

individuals. In fact, the findings of the present study revealed that the non-relapsed participants

exhibited attentional biases that were at times more consistent with the never depressed

participants.

Overall, despite the differences from the relapsed participants, it is evident that the non-

relapsed participants allocated attention in a manner unique from both the never depressed and

relapsed participants, demonstrating both resiliency and vulnerability in terms of experiencing

future depressive episodes. These findings raise the possibility that attentional biases as trait-like

vulnerability factors may vary between individuals, as opposed to being entirely stable

characteristics found in all those with a history of depression. It is unclear if the vulnerability

factors persist as trait-like features or if they diminish over time. Relatedly, it is also still unclear

if the findings reflect a vulnerability to, or a consequence of depression. Originally proposed by

Lewinsohn, Steinmetz, Larson, Franklin, (1981), the scar hypothesis suggests that cognitive

vulnerabilities may be a consequence of previous depressive episodes, as opposed to an initial

vulnerability factor or a cause.

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In light of the present findings, the scar hypothesis deserves careful consideration.

Although the present study highlights that differences in attentional processing exist between

those that relapse and those that do not, and points to the possibility that reduced attention to

positive information may be relevant to depression relapse, a lack of clarity still remains with

respect to cognitive vulnerability as a scar of previous episodes or as a direct cause of relapse.

The fact that not all previously depressed individuals appear to possess a uniform vulnerability

suggests the possible presence of a modifiable scar (i.e., the non-relapsed participants displayed

some resiliency factors, it is unclear if they were or were not present prior to their last episode),

as opposed to an initial vulnerability factor. Although findings of the present study provided

information on changes over time that correspond with depression relapse, the presence of

vulnerability prior to the first depressive episode, or as a consequence of depressive episodes, is

not clarified. To rule out a scar as the vulnerability factor, an examination of attentional biases in

individuals before they experience an initial depressive episode would be required.

Limitations and Considerations for Future Research on Attentional Biases

Sample size of relapsed group. The present study was clearly limited by the small

sample size of the relapsed group (n = 15). There are a few potential explanations for the smaller

than expected sample size and ways to ameliorate this limitation in future studies.

First, the six-month follow up period may have been too short to capture a robust

relapsed group. It is likely that a study period of between one to two years would have resulted in

a much larger number of relapsed participants. Second, and also related to the six-month follow

up period, is that there may have been individuals in the non-relapsed group who relapsed after

six months, and were therefore not assessed as relapsed. If so, the non-relapsed group may have

contained a variety of qualitatively different individuals (i.e., individuals who relapsed after 12

months, for example, and others who never relapsed again or relapsed after several years).
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The third possible reason for the small sample size was that a heterogeneous group of

previously depressed individuals was recruited which included both remitted and recovered

individuals, some who may have been less likely to relapse than others. By definition, “remitted

depressed” indicates that the individual has experienced at least a two to eight week period of

being asymptomatic, and “recovered depressed” indicates a symptom-free period of at least eight

weeks or longer (Frank et al., 1991). The participants in the present study included individuals

from both groups, with a combination of individuals who had recently experienced depression

(e.g., within the last few months) and those who had not experienced depression for many years.

It is possible that those who had remained symptom-free for many years were qualitatively

different in terms of their cognition and their overall course of depression. The implication could

be that some individuals were unlikely or less likely to relapse (e.g., those who have fully

recovered for several years), especially within a six-month time frame, relative to those who had

very recently experienced a depressive episode. This issue is further elaborated on below in the

discussion of the validity of previously depressed groups in depression research.

The final major limitation that negatively impacted the sample size was that some who

relapsed were not identified at the time of relapse (n = 15), but retrospectively (at the six month

follow-up), and reported symptoms consistent with a relapse that had occurred during the study

period. As they were monitored by phone at bi-weekly intervals for symptoms of depression, it

was unclear if their depressive symptoms were under-reported during the telephone follow-ups,

if their retrospective recall of depressive symptoms at the six-month follow up visit was

incorrect, or if the symptoms were inaccurately evaluated during the bi-weekly phone follow-

ups. Therefore, these individuals had to be excluded from all analyses due to the potential

unreliability of the depression relapse diagnosis. Future studies should take measures to avoid

these outcomes given that the present study has shown that they are not uncommon.
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Together these limitations suggest two possibilities for future research. First, a six-month

follow up period is too short for a prospective study like the present study; some participants

who did not relapse by the six-month point may have relapsed at a later time. Therefore,

extending the study period to at least one year and ideally two years, if feasible, would provide

the best chance at capturing depression relapse (simultaneously creating a larger and more

representative relapsed group). Another modification would be to create groups with less

variability in terms of time since the last episode, perhaps limiting the group to those who have

experienced an episode within the prior two-year period. This could eliminate a number of

individuals who recovered years ago and are less likely to experience relapse.

Given all of these limitations, the fact that there were a number of significant findings

despite the small size of the relapsed group size is promising and bodes well for future studies

that are able to recruit a larger group of relapsed individuals. Most promising is the preliminary

finding that reduced attention to positive images at the initial visit appeared to be predictive of

depression relapse. It will be important for future studies to attempt to replicate this finding with

larger samples of relapsed participants. This is especially true given the novelty of this finding,

as only one other eye-tracking study has attempted to determine if attentional biases can be used

to predict relapse (Woody et al., 2016).

Extending the prospective evaluation of attentional biases. Another limitation of the

present study is that the examination of attentional biases occurred at only two time points

(initial and follow up visit), which undoubtedly impacted the extent to which the data could be

used to reach conclusions about the association between attentional biases and depression

relapse. As noted, questions still remain with respect to the precise threshold at which attention

for positive information decreases to a point where relapse occurs, or even if reduced attention to

positive information is one of the mechanisms that contributes to cognitive vulnerability. One
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way to parse out this question would be more frequent monitoring of attentional biases from the

initial visit through relapse. In addition, continuing to monitor through to the following remission

would provide crucial information on the manifestation of attentional biases for positive

information throughout the entire course of depression, allowing for additional conclusions to be

drawn (e.g., does attention to positive information begin to increase as depression remits or only

after remission occurs?)

The validity of previously depressed groups in depression research. One significant

implication of the present study findings that lends itself to future research is the validity of

employing previously depressed groups in studies that examine attentional biases. The present

findings suggest that there are differences in the attention of those who relapse and those who do

not, with the conclusion that the previously depressed groups common in the literature may not

be the homogenous groups they are considered to be. Instead, these groups are likely

heterogeneous, consisting of individuals who will both relapse and those who will not, with

corresponding differences in attentional biases depending upon the proportion of those who

subsequently relapse in a “previously depressed” group. Therefore, it is clear that combining

both types of individuals into a “previously depressed” group may obscure findings and

contribute to inconsistencies across studies. As it is not generally possible to predict who will

relapse and who will not when creating study groups, one strategy may be to strictly adhere to

definitions of either remission or full recovery, which may ensure that a more homogenous group

is created.

Monroe and Harkness (2011) spoke to the challenges inherent in conducting meaningful

research in the determination of risk factors in depression recurrence. One major challenge they

identified is the potential for differing vulnerabilities between individuals who experience a first

episode of depression (with potential for recurrence), those who experience multiple episodes of
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depression, and those who experience only a single lifetime episode of depression (and will not

recur). They pointed out that common research practices often do not take into account that these

groups may substantially differ from one another in many important ways. These practices may

therefore limit the ability to accurately determine predictors of recurrence, and prevent an

understanding of why some individuals only experience one episode of depression (which is also

important for understanding risk for recurrence). To address this limitation, Monroe and

Harkness suggested that the best research practices for determining predictors of recurrence

involve either the impractical solution of following individuals over a lifetime, or conducting

prospective comparisons between those who have experienced at least three lifetime episodes

versus those deemed to have experienced a single lifetime episode. They argued that even those

who experience two episodes of depression may be different from those who experience three or

more episodes; for example, those who have experienced two episodes are relatively less likely

to recur than those with three, and the two episodes could have been separated by many years,

with varying etiologies for each occurrence.

Also relevant, research has found qualitative differences (e.g., distinct etiologies and

maintenance factors) between those with chronic and non-chronic depression (Klein & Kotov,

2016), and proposed that those who experience shorter episodes (less than six months) should be

classified as having a “benign subtype of depression” (p. 346), different from those with much

longer and more severe episodes (Klein & Kotov, 2016). One could assume that these

differences would also impact or be reflected in attentional processes in terms of likelihood

of/and time to relapse. It will be important for future research to further delineate boundaries and

compare such groups to determine what differences are evident and how attentional biases are

impacted.
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Antidepressants and impact on attentional biases. Although the present study

documented differences between the relapsed and non-relapsed groups in terms of their past and

current antidepressant use (see Table 2), this factor was not incorporated into the evaluation of

attentional biases. However, the literature indicates that it may be important to consider the effect

of antidepressant use on attentional biases, as they have been found to impact the processing of

emotional information in some studies (Harmer, Goodwin, & Cowen, 2009; Bhagwager et al,

2014; Outhred et al., 2014; Wells, Clerkin, Ellis, & Beevers, 2014). Harmer et al. (2009) found

that a single dose of an antidepressant increased the ability of depressed participants to recognize

and remember positive facial expressions, and increased response times towards positive self-

referent adjectives relative to a group of depressed participants not administered an

antidepressant. Bhagwager et al. (2014) found that increased perception and recognition of

fearful facial expressions was normalized following a dose of citalopram antidepressant. Outhred

et al. (2014) found that one dose of escitalopram led to alterations in amygdala activation, which

resulted in a positive processing bias for positive and negative images. In another study, Wells et

al. (2014) reported findings suggesting that antidepressants may normalize the processing of

emotional information. Wells et al. examined attentional biases in depressed individuals who

were either medicated or non-medicated, relative to a never depressed control group. They used

eye tracking to examine attentional biases for dysphoric, threat, positive, and neutral images in

never depressed and depressed individuals who had taken antidepressants for greater than two

years versus those not taking antidepressants. They found that, similar to the control group, the

medicated depressed individuals attended to positive images more than un-medicated depressed

individuals. They also found that the medicated depressed individuals exhibited fewer fixations

for the dysphoric images relative to the un-medicated depressed individuals. Overall, Wells et al.
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proposed that the use of antidepressants modified and normalized the processing of emotional

information, which in turn led to an elevated mood, as opposed to elevating mood directly.

Although the impact of antidepressant use on attentional biases has not been specifically

examined in previously depressed individuals, one might expect that if antidepressants impact

information processing in depressed individuals then they may also effect a change in the

attentional biases of those with a history of depression. In the present study, approximately 35%

of the relapsed group and 24% of the non-relapsed group were currently taking antidepressants.

In terms of previous antidepressant use, approximately 71% of the relapsed group and 53% of

the non-relapsed group had used antidepressants in the past (see Table 2). Antidepressant use in

the present study could have contributed to a general attenuation of attentional biases, potentially

leading overall to greater attention to positive images and a reduction of attention to both threat

and depression-related images. Of course, the impact on attentional biases in general would

likely depend on the length of time taking antidepressants, whether it was past or current use (or

both), and possibly the specific type of antidepressant (research to date has not determined if

different types of antidepressants exert different effects on attentional biases, but this is a

possibility). In any case, the use of antidepressants is a likely limiting factor in studies that

examine information processing given their potential impact on attentional biases. Relatedly, it is

also possible that engaging in therapy (e.g., cognitive behavioral therapy) could also exert an

impact on attentional biases, and a number of the present study participants had engaged in or

were engaged in therapy (see Table 2). Although cognitive behavioral therapy has been found to

impact attentional biases in those with anxiety disorders (Tobon, Ouimet, & Dozois, 2011),

similar research has not been conducted with depressed individuals. It seems likely, however,

that attentional biases would be impacted through cognitive restructuring, one of the techniques
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employed in cognitive behavioral therapy, which works to modify maladaptive thought patterns

that are often observed in those with depression.

Generalizability of findings. Given that all participants in the present study were

women, the results may not generalize to males. A strength of the present study was the use of a

structured diagnostic interview in a combined undergraduate and community sample, which

allowed for the confirmation of prior depressive episodes and extended the generalizability of the

findings to clinical populations. A limiting factor would be the lack of assessment of anxiety

disorders, which can often be comorbid with depression. Future studies could increase

generalizability by assessing and accounting for the presence of anxiety disorders.

Clinical Application of Attentional Biases

Clinically relevant applications of the present research include efforts directed at

identification, prevention, and intervention of depressive episodes. With respect to identification

and prevention, the measurement of attentional biases could be used to identify those at risk for

relapse, and based on the present findings, it appears that positive attentional biases hold promise

as a useful measure of identification. As a potential marker of the development and presence of

anhedonia, designing a way to determine ‘anhedonic attentional bias scores’ and thresholds at

which relapse occurs would be the first step. Woody et al. (2016) discussed that in clinical

settings, individuals at risk for depression relapse could be identified through selective attention

tests, and noted that eye-tracking is a relatively low cost method of measuring attentional biases.

Ideally, selective attention tests would need to be psychometrically tested and evaluated, with

norms established, especially given recent concerns regarding reliability of current measurement

of attentional biases which could ultimately impact the assessment of attentional biases

(Rodebaugh et al., 2016).

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The other application involves attentional bias modification (ABM) or retraining, a

developing area of research, which could be relevant to both prevention and intervention efforts.

Once those at risk of depression were identified, it may be possible to prevent relapse by

targeting positive attentional biases specifically. One study of remitted depressed individuals

found that after a two week period of engaging in positive attentional bias modification tasks

(using face images), two specific risk markers were reduced: depressive symptoms as per the

BDI and a measure of waking cortisol. The authors proposed that the ABM task was a “cognitive

vaccine” that could be used to prevent depression (Browning, Holmes, Charles, Cowen, &

Harmer, 2012). The findings of the present study suggest that targeting attention to positive

information in the period of remission is likely most important in terms of prevention. Another

important application involves intervention if relapse occurs, and the present findings indicate

that active efforts toward both amelioration of attention to depression-related information while

simultaneously increasing attention to positive information would be important. It should be

noted however, that despite some promising findings (e.g., Beevers et al., 2015), a number of

issues related to ABM have been identified, and a recent meta-analysis suggests that this training

procedure has only been found to have a small effect size in studies examining anxiety, with

little information on effectiveness in depression (Mogoase, David, & Koster, 2014). Ideally,

there would need to be greater understanding and operationalization of the stimuli with

guidelines for both the appropriate targets of attention and the amount of attentional retraining

required for prevention and intervention. The literature on ABM is in early stages. With further

research that continues to refine and operationalize attentional biases as cognitive vulnerability

factors, in addition to continued efforts towards the development of psychometric properties of

emotional stimuli, ABM is an area with great potential.

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Conclusions

The purpose of this study was two-fold. The first focus involved determination of how

attentional biases manifest in previously and never depressed individuals, and the second

involved an examination of attentional biases as predictors of depression relapse. This study was

different from previous studies in that it followed a group of previously depressed individuals

over a six-month study period, and separated them into relapsed and non-relapsed groups.

The most important findings related to attention to positive information. The results

indicated that those who relapse generally attend to positive information (e.g., happy faces and

positive naturalistic images) less than those who do not relapse, and exhibit a temporal profile of

attention characterized by a decrease in attention to positive information over time. When

considering all findings of the present study, the evidence consistently demonstrated that

attention to positive information is a key vulnerability or resiliency factor related to depression

relapse. Those who relapsed also exhibited differences in their attention to both sad/depression-

related and threat-related information relative to non-relapsed and never depressed participants.

Also important to consider is the attentional biases exhibited by the non-relapsed participants, as

these findings highlight potential resiliency factors that help to ameliorate likelihood of relapse.

For example, non-relapsed participants were similar to never depressed participants in their

attention to positive information. In addition, although they attended to depression-related

information more than never depressed participants, they did not attend as much to depression-

related information as relapsed participants, which possibly protects them from depression

relapse.

An examination of temporal profiles indicated that non-relapsed and never depressed

participants attended similarly to both positive/happy and depression-related/sad stimuli (with

some nuanced differences). One implication of these findings is that the non-relapsed
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participants may have developed strategies, similar to never depressed participants, in the way

that they direct their attention that contribute to the maintenance of their non-depressed state.

The findings that the non-relapsed participants exhibited different patterns of attending than the

relapsed participants suggests that the relapsed participants attend to information in a manner

that is a likely contributing factor in their depression relapse, especially given that in the present

study, their patterns of attention were observed to differ from those who do not relapse, both

before and after a relapse occurs.

The final analysis of this study examined attentional biases as predictors of depression

relapse. The findings are largely preliminary due to the small sample size of the relapsed group,

but suggest that participants who exhibited less attention to positive naturalistic images at the

initial visit were more likely to relapse during the course of the study period.

Given the clear differences in attentional allocation between individuals who relapse and

those who did not, one important implication for future research concerns the use of previously

depressed groups presumed to be homogenous by virtue of their history of depression. The

present study showed that previously depressed groups are likely heterogeneous, with different

patterns in their attention to emotional information related to their unique course of depression

and their likelihood of relapse.

The present study contributes to the overall body of literature and suggests that attention

to positive information may be more relevant to relapse vulnerability than attention to depression

related information, which may be more relevant to maintenance of depressive symptoms. The

continued study of how these cognitive processes manifest throughout the course of depression is

important to understanding the specific risk factors to consider in the development of

identification, prevention, and intervention plans in those vulnerable to depression. These efforts
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are especially critical given the impact and burden of depression on individuals, the health care

system, and society as a whole.

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Appendix A: Consent Form

Cognitive Sciences Lab

Department of Psychology

Research Project: Cognitive Vulnerability to Depression: A Longitudinal

Investigation Using Eye Gaze Tracking to Study Attentional
Biases as Predictors of Depression Recurrence

Principle Investigators: Kristin Newman, M.Sc.

Supervisor: Christopher R. Sears, Ph.D.

Funding Agency: Alberta Innovates Health Solutions (AIHS)

This consent form, a copy of which has been given to you, is only part of the process of informed
consent. It should give you the basic idea of what the research is about and what your
participation will involve. If you would like more detail about something mentioned here, or
information not included here, please ask. Please take the time to read this form carefully and to
understand any accompanying information.

The University of Calgary Conjoint Ethics Research Board has approved this study.

Purpose of the Study

We are studying how attentional processes in those with a history of depression predict future
episodes of depression. Groups of participants will include people with a history of depression who
have experienced a different number of previous depressive episodes. This information has the
potential to assist in efforts to understand depressive relapse by examining how attention to
information in the environment may or may not impact the development of subsequent episodes of
depression.

What Will I Be Asked to Do?

Your participation will first involve the completion of an interview, which will take
approximately one hour. You will be asked about symptoms of depression, anxiety, and other
mental health difficulties. Participants who: 1) are female 2) are between the ages of 18 - 65 3)
have a history of one or more previous episodes of depression, 4) do not have a current
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Substance Abuse Disorder, Eating Disorder, Pervasive Developmental Delay, or Bipolar

Disorder will be asked to participate in the study.

After the interview, you will be asked to complete a number of questionnaires that assess
demographic characteristics, life stress, and current mood. It is expected that it will take you
approximately 15 minutes to complete these questionnaires. Once you have finished completing
the questionnaires you will seal them in the envelope and leave the sealed envelope on the table
for the researcher.

Next, you will be shown pictures on a computer screen and you will be asked to freely look at
the pictures. You will be shown two different blocks of 30 sets of four pictures, one set at a time.
While you are looking at the pictures your eye movements will be monitored by an eye tracking
device that will record where you are looking and for how long. The eye tracker is mounted on a
lightweight headband that is comfortable to wear during testing. It does not touch your eyes or
interfere with your vision in any way. You will have the opportunity to practice this task and to
ask questions and the researcher will demonstrate and explain everything to you before you
begin.

Your participation today may require between 60-120 minutes of your time. After you have
finished the researcher will be happy to answer any questions you might have about the study.
You will also be given an Information Sheet which includes supplementary information on this
area of research.

You will receive 1-2 bonus credits for your participation today, depending on the amount of time
it takes you to complete the study. If you are not a university student, you will receive a gift card
in the amount of $25 at Cadillac Fairview shopping centers.

In addition, you will be contacted bi-weekly by the researcher to assess your level of depressive
symptoms. If/when your level of symptoms reaches a specific threshold or when six months have
passed (whichever comes first), you will be asked to return to the lab to undergo another
interview and eye-tracking session, which should take approximately 60 minutes of your time. In
return for your participation on the second visit to the lab, you will be given the option of
receiving a bonus credit (if applicable to you) or a gift card in the amount of $25 at Cadillac
Fairview shopping centers.

Collection and Storage of Personal Information

You will be asked to provide information such as your age and ethnicity. All information you
provide will be kept anonymous and confidential. There are legal exceptions to this
confidentiality, including any information you may provide regarding 1) harm to yourself or
others, or 2) the current and ongoing abuse of a child. The interview will also collect information
on current and past psychological disorders. You will be asked to complete a demographic
questionnaire that asks about your age, gender, relationship status, medication history, familial
depression history, psychotherapy experiences, etc. You are free to choose which questions to
answer. You will also complete a questionnaire that measures symptoms of depression. You are
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free to choose which questions to answer. You will complete these questionnaires in a private
room and will seal them inside an envelope for privacy. You will not put your name on any
questionnaires. Your questionnaires will be identified by number only and will be kept in
complete confidentiality.

Upon entry into the study, each participant will be assigned a number code, and all data for each
participant will be filed by this code to ensure confidentiality. A master coding sheet containing
participant contact information (name, telephone number, coded ID number) will be stored in a
locked cabinet separate from the data files, and only the investigator and supervisor of this
project will have access to these files. Results from this study will be analyzed by group and
individual participants will not be identifiable in any presentation or publication of the findings.
All information and data from this investigation will be kept in a secure area under the control of
the investigator for a period of 5 years following publication of the data, after which time the
data will be destroyed.

Should you decide to withdraw from the study, any information provided up to the point of
withdrawal will be retained and potentially used by the experimenter, unless you explicitly
request that the data be destroyed, in which case this request will be honored. For the purpose of
quality control, the interview portion of the study will be audiotaped. Tapes will be erased after a
period of 5 years. Tapes will only be identified using the number codes provided at the start of
the study.

Are There Any Risks or Benefits If I Participate?

There will be no physical injury or physical discomfort involved in this study. Please note that a
few of the pictures you will be shown might be disturbing to some people (e.g., depictions of
blood, bodily injuries, insects, weapons, death, etc.). It is not necessary to look at a picture if
you find it too disturbing. If at any time you feel too uncomfortable with the pictures you are
being shown you may withdraw from the study with no penalty.

As a result of your participating in this study, you will be provided with information regarding
current and past diagnoses, will learn of available resources for the treatment of psychological
disorders within the community, and will further be provided with the option of being provided
with the study’s findings upon its completion. You will also be provided with a $25 gift
certificate eligible for use at participating Cadillac Fairview shopping centers. You may also
indirectly benefit from the potential this study holds in informing efforts at understanding,
treating, and preventing depressive episodes.

Do you wish to be provided with the results of this investigation, when they become available?
YES ___ NO ___
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From time to time, other research may be carried out in the Cognitive Sciences Laboratory at the
University of Calgary for which you may be appropriate as a participant. If you are willing to be
contacted by investigators for possible future participation in further research, please indicate
below by placing your initials on the appropriate line:

I AGREE to be contacted: _____ OR I DO NOT AGREE to be contacted: _____

Signatures

Your signature on this form indicates that you 1) understand to your satisfaction the information
provided to you about your participation in this research project, and 2) agree to participate in
this study.

Your signature in no way waives your legal rights nor releases the investigators, sponsors, or
involved institutions from their legal and professional responsibilities. You are always free to
withdraw from this study at any time, for any reason. You should feel free to ask for clarification
or new information throughout your participation.

Participant’s Name: (please print) _____________________________________________

Participant’s Signature _____________________________________ Date: _______________

Researcher’s Name: (please print) _____________________________________________

Researcher’s Signature: ____________________________________ Date: ________________

Questions/Concerns
If you have any questions or concerns after you have participated in the study you can contact
the researchers for more information (Kristin Newman at kristinnewman@shaw.ca or
Christopher Sears at sears@ucalgary.ca).

You have participated in this study as part of your educational experience in the Psychology
Department. In exchange for your time you can expect to gain some understanding of research
and some of the ideas currently being explored in psychology. If, after the study, you have
concerns regarding your experience, you may register your concerns with Dr. Tavis Campbell,
Chair, Psychology Department Ethics Committee (220-7490, t.s.campbell@ucalgary.ca). If you
have any concerns about the way you’ve been treated as a participant, please contact Russell
Burrows, Research Services Office, University of Calgary at (403) 289-0693; e-mail
rburrows@ucalgary.ca.
A copy of this consent form has been given to you to keep for your records and reference. The
researchers have also kept a copy of the consent form for their records.
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Appendix B: Debriefing Form

Cognitive Sciences Lab

Department of Psychology
Debriefing Information Form

Project Title: Cognitive Vulnerability to Depression: A Longitudinal

Investigation Using Eye-Gaze Tracking to Study Attentional
Biases as Predictors of Depression Recurrence
Investigators: Kristin Newman, M.Sc.
Supervisor: Christopher R. Sears, Ph.D., Department of Psychology

IMPORTANT: It is critical that our future participants be unaware of our exact hypotheses, so
we ask that you help us preserve the integrity of our research by not discussing your experiences
with other students. Thank you for your understanding and consideration of this request.

Thank you for participating in one of the Cognitive Sciences Lab’s research studies. This study is
examining how attention to emotional stimuli predicts depression onset. We are exploring
whether how they view positive, negative, and neutral images plays a role in the later
development of depressive symptoms. By analyzing the eye tracking data we are able to examine
where people look and for how long while they look at the different types of images.

This type of research has important implications for our understanding of the relation between
cognition and depression, and the data you have contributed to our study will help us advance
our knowledge of these relations. If you have any questions about this study you can contact the
researchers for more information (Kristin Newman at kristinnewman@shaw.ca, or Dr. Sears at
sears@ucalgary.ca).

As explained in your consent form and by the researcher, this is a longitudinal study. This means
that we will be contacting you on a bi-weekly basis through email or phone (whichever you
indicated your preference to be) to assess any symptoms of depression you may be experiencing
with a questionnaire. These bi-weekly assessments will each take approximately 5 minutes of
your time. If, during the 6 months following your first visit to the lab, you do develop symptoms
of depression, we will then ask you to return to the lab to participate in a second session of eye-
tracking. If you do not develop symptoms of depression during that 6 month time period, at the 6
month mark we will ask you to return to the lab to participate in a second session of eye-tracking.
In return for your participation on this second laboratory visit, you will receive bonus course
credits through the RPS system OR a gift card for a local shopping mall in the amount of $25.

If you have any concerns about depression or anxiety and would like to speak to a trained
counselor, we suggest contacting the Student Counseling Centre, room 375, MacEwan Student
 163

Centre. Their office hours are Monday to Friday 9:00 am to 4:00 pm and they can be reached at
210-9355, #2 for counseling. They are also online at www.ucalgary.ca/counselling/. Counseling
sessions are free of charge. For other psychological services options, please see the attached
Mental Health Resources Information sheet.

Please do not hesitate to ask for clarification on any aspect of the study or ask any questions you
may have at this point. Thank you for participating in our research study.
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Appendix C: Psychological Services Information Sheet

Counseling/Psychological Services Information Sheet

If you are experiencing difficulty in your life, feeling depressed, anxious, stressed, or in
crisis, there are resources both on and off campus to help you.

ON CAMPUS

Wellness Centre counseling centre: http://www.ucalgary.ca/counselling/

o Business hours: 9:00 - 4:00 Monday through Friday
o Phone numbers: 210-Well or 210-9355, #2 for Counselling
o Located in: MacEwan Student Centre, Room 370
o In an emergency situation, advise the receptionist that this is an emergency and a
counsellor will see you as quickly as possible

à Highly trained and caring counsellors, knowledgeable about student concerns and ways to
help. Four most common concerns that students seek counselling for are depression, anxiety,
self-esteem, and stress.

à An on-call counsellor available each day for scheduling sessions. These can be booked or
there are drop-in times available on a first-come first-serve basis.

à The first three sessions are free and all subsequent sessions are subject to a minimal fee,
which can often be recovered through health plans.

OFF CAMPUS

U of C Health Clinic: 210-9355 (psychiatrists on staff)

Calgary Distress Centre: 266-1605 (24 hours, speak to a trained counsellor)

Alberta Mental Health Line: 1-877-303-2642

Calgary Mental Health Crisis: 266-1605 (mobile response)

South Calgary Health Centre: 943-9300 (walk-in therapy and urgent care)

Sheldon Chumir Health Centre: 955-6200 (urgent mental health services)

Calgary communities against sexual abuse: 237-6905 (24 hours)

Foothills Hospital: 944-1315 (psychiatric emergency)

Peter Lougheed Hospital: 943-4904 (psychiatric emergency)

 165

Rockyview Hospital: 541-3537 (psychiatric emergency)

OTHER CONTACTS

Canadian Mental Health Association- Calgary region:

http://www.cmha.calgary.ab.ca/mentalhealth/default.aspx

http://www.cmha.calgary.ab.ca/gethelp/default.aspx

 166

Appendix D: Demographics Inventory

Your responses to the following questions are completely confidential. Please do not put
your name anywhere on this form.

Your age: ________

Your gender: Male Female

Ethnicity:
Caucasian First Nations (Indigenous Peoples)
African American Hispanic
Asian East Indian
Middle Eastern Multi-Racial (please specify)__________________
If none of the options above are applicable to you, please provide your own: ________________

Is English your first (native) language?

Yes No

If English is NOT your first (native) language, how fluent are you with the English language?

1 2 3 4 5

Not fluent Very fluent

Are you presently in a romantic relationship?

Yes No

Please rate your current mood using the following scale, where –5 equals "very negative mood", +5
equals "very positive mood", and 0 equals "neither positive nor negative":

–5 –4 –3 –2 –1 0 +1 +2 +3 +4 +5

Very Negative Very Positive

 167

To your knowledge, has anyone in your immediate family ever experienced an episode or more than one
episode of clinical depression?

Yes No

If you answered yes to the above question, please answer the following.
If you answered no, then skip down to the next page (page 3).

If yes, who?

Mother Father Sister

Brother Step-Mother Step-Father

If yes, did that person receive a diagnosis from a medical professional?

Yes No Unsure

If yes, did that person receive treatment?

Yes No Unsure

If yes, do you think that this person’s depression impacted your life in a negative way?

Yes No Unsure

In what way was your life impacted? (check all that apply)
Emotionally Physically Financially

In your estimation, how many episodes of depression have you experienced in your life?

None One Between two and five More than five

If you have experienced depression, how long ago was your last depressive episode?

Not applicable
Currently experiencing a depressive episode
Less than a month ago
Less than six months ago
Less than a year ago
More than a year ago
 168

Have you ever been diagnosed with depression by a mental health professional?

Yes No

Are you presently receiving therapy or counseling for depression?

Yes No

Have you had therapy or counseling for depression in the past?

Yes No

Are you taking medication for depression right now?

Yes No

Have you taken medication for depression in the past?

Yes No

Do you think you have been depressed lately?

Yes No

If you have previously experienced depression and depressive episodes, what did you do to overcome it?

Not applicable
I did nothing, it went away on its own
I used antidepressant medication
I received professional counseling
I used antidepressant medication and received counseling from a therapist

If you used antidepressant medications, for how long did you use them?

1-6 months
7-12 months
13-18 months
19-24 months
More than 24 months
 169

If you received counseling from a therapist, for how long did you go?

1-6 months
7-12 months
13-18 months
19-24 months
More than 24 months

Have you ever been diagnosed with anxiety by a mental health professional?

Yes No

Are you presently undergoing therapy or counseling for anxiety?

Yes No

Have you had therapy or counseling for anxiety in the past?

Yes No

Are you taking medication for anxiety right now?

Yes No

Have you taken medication for anxiety in the past?

Yes No

Do you think you have been feeling especially anxious lately?

Yes No

Thank you for answering these questions! Your responses will be kept completely confidential.

Once you have finished completing the questionnaires please seal them in the envelope and put the
sealed envelope in the box on the table.