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    Cause or Symptom - A Longitudinal Test of Bidirectional Relationships Between Emotion Regulation Strategies and Mental Health Symptoms

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    Emotion (930 Roe Poca Aca Nisan Cause or Symptom? A Longitudinal Test of Bidirectional Relationships Between Emotion Regulation Strategies and Mental Health Symptoms Amy Dawel', Yiyun Shou', Amelia Gulliver”, Nicolas Cherbuin’, Michelle Banfield, Kristen Murray’, Alison L. Calear®, Alyssa R. Morse’, Louise M. Farrer”, and Michael Smithson" " Research School of Psychology, The Avsiralian National University * Centre for Mental Health Research, Research Schoo! of Population Health, The Australian National University > Centre for Research on Azcing, Health and Wellbeing, Reseach School of Population Health, The Australian National University ‘Previous work has generally conceptualized emotion regulation as contributing to mental cals out comes, and not vice vena, The present tady challenges this assumption by wsing a prospective design to investigate the directionality of underlying relationship between emotion repulation and mental health in dhe contest of major popultion-level stressor. We surveyed large nationally representative sample of adults (13-91 years, V = 704) at oe I-mont intervals across the acute lockdown phase of the COVID-19 pandemic in Australia, using standardized measures of depression and anxiety symp- toms. Ath time point, we alo measured the ae of two emotion regulation sratepies cognitive reappraisl and emstonal suppesson—previusly associated with adaptive and maladaptive mental heath outcomes, respectively. We found cognitive eapprais was unrelated to mental health symp: toms. In contrast, greiter enon suppression was roby associated with higher symptom level for both depression and ans. Longtail analyses eval thi mssoiation elected biectonal ra eships. Higher symploms of depression and anxiety each predic greater subsequent use of emo: sal suppression, and greater une of emotional suppression rected higher subsequent syenploms This idinetionality suggests emotional suppression is bth syplomatic and pralicive of psyeholog cal distress. The lack ofa relationship fr cognitive reappraisal is discussed with respect othe pandemic context and evidence that high stress might reduce people's ability to use this strategy effectively. Given the song emphas's on reappraisal in clinical practice, there isa ential need to understand for ‘whom, wha and when his strategy f elf jed publishers. Keywords: reappraisal, suppression, depression, anxiety, coronsvinus Supplemental materials: psdo.rg/10.1057em90001018.supp The ability to effectively regulate one’s emotions is core to psy ‘chological wellbeing, Conversely, problems with emotion rezul tion are 3 transdiagnostie Feature of pxychopathological distress ‘observed in many mental disorders, including depression and ansi- ety (Campbell-Sills etal, 2006; Cludius et al. 2020). Emotion regulation is often described in terms of helpful and unhelpful sirategies, such as cognitive reappraisal and emotional suppression respectively. Unfortunately, the overriding focus on how emotion regukition contributes 10 psychological functioning has obscured the possibility that some psychopathologies might, in tur, drive emotion regulation straegies. For instance, emotional suppression, Which is generally characterized as causing unhelpful or maladap- Live outcomes, might be betler understood as symptomatic of intense negative alfet. Iis important to understand the underlying “This artcle was published Online Fira November 29,2001 Amy Dawe! @ hpssoreid ong 0000-001-5568-3121 YYiyun Show ® psc or/0O00- 102-7385. Amelia Gllver © hups:forcid.on/0000-0001-6351-9844 [Nicolas Cherbuin @ bitps:/rcd.rg/0000-0001-6881-G748 Michele Banfetd © hups/foreid.ong40000-0002-3024-1687 Kriten Murray @ hupsoreidoy/0000-0002-6928 0640 Alison L. Calear © fpr. r/00.0002. 7028-725, Alyssa R. More @ bnpsoreid. oc J0000-0001-6948-1082 Louise M.Farer @ lntp:/forid.p/0000-0001-5604-4631 Michael Smithson @ Ipsos )00(0-0003-145.2192 sii Ths sty was fro hy the ANU Cais of Heh and Modine, ANU Reearch Schoo! of Pyehlosy. and ANU Research School of Pipuation Health. Yiyun Shou is supp by ARC DECRA DEIBO00015. Lise M. Fane is sapped by ARC DECRA DEIGOIOI3®2. Amin Gulive and Alysa K. Mone are supponed by funding provided by tke ACT Heath Direorte for ACACIA: The ACT Consumer and Caer Metal Heth Resear Uni Alison L Caer supprd by NHMRC Fellowships 1122514 sia 1173146, Thak you w Purce Fue for seu astance wih is ject Wehave no confi of interest to dsc Correspondence concerning this article should be addressed to Amy Dawel, Rerch Scho! of Pachology, The Auslin National University, Bulking 39, Canbora, ACT 2600, Ausra. Eni: amy dawel@ anus 1512 nature of the association between diferent emotion regulation strat= ‘pies und psychopathology because interventions that target emo: tion regulation are popular in clinical practice (Barlow etal, 2017; ‘Wang. etal, 2020). While targeting factors that have a significant causal role can be expected to modily psychopathology, targeting those that are simply epiphenomena will na (Chudius eta, 2020), Recent literature has also highlighted that no emotion regulation strategy is likely tobe universally helpful or harmful across all con- texts e2, Ford etal, 2019; Haines eta, 2016; MeRae, 201 Troy ef al, 2013), For insance, it is unclear whether cognitive reappraisal is helpful in highly stressful contexts (Cavanagh, Fitz~ serald & Uny, 2014; Raio et al, 2013; Troy & Mauss, 2071). In the present study, the COVID-19 pandemic provided us with a ‘unique opportunity to investigate how emotion regulation strategies are assoviated with mental health during a population level stressor. ‘Emotion Regulation Strategies: Reappraisal and ‘Suppression ‘The present study focuses on (wo emotion regulation strategies characterized by extensive theoretical and empirical work: cogni- tive reappraisal and emotional suppression (Gross, 2013; Gross & John, 2003; John & Gross, 2004). Reappraisal involves reinter- preting an event or its outcomes preempaively alter an antic ppaled emotional response. Suppression refers @ any allempt to inhibitor hide the expression of emotions once they occur. The focus on these two strategies originated from Gross’ process ‘model of emotion regulation (Gross, 2001; 2015). A key point of Gross’ theorizing is that people are driven to regulate their emo- tions when there is a mismatch between their desired or gol stale and their antieipated or actual state (Gross, 2015). Thus, the aim ‘of emotion regulation is to achieve the goal state (although it may ‘not always be successful in doing $0). However, emotion regulation is not always associated with pos- itive outcomes, Broadly speaking, the extensive body of empirical work on emotion regulation has associated reappraisal with posi tive psychological outcomes, but suppression with negative ones (Alda ct a, 2010; Gross, 2013: Gross & John, 20003; John & Gross, 2008; but ef. Ford et al, 2019; Haines et al, 2016; McRae, 2016; Troy et al, 2013; for arguments about strategy si uation fit). For instance, meta-analyses that have scrutinized the association between emotion segullion and psychopathology ind cele that reappraisal and suppression are aswciated with adaptive and maladapiive mental health outcomes, respectively (Aldao et al, 2010; Hu etal, 2014), including specifically for anxiety and depression (ALI etal, 2010). The vast majority of evidence supporting the association between ‘these (wo emotion regulation stratezies and thei putative outcomes has cither not tested the direction of this relationship (c.g. eros sectional correlations; Gross & John, 2003) or only tested the rela- tionship in one direction, with emotion regulation asthe independ cent (eg, experimental studies; John & Gross, 2004) oF predictor variable (eg, longitudinal work; Aldao & Nolen-Hoeksema, 2012; Brewer et al, 2016, Cameron & Overall, 2018; Kraaij et al, 2002), Implicit in this approach is the sssumption that emeaion re ulation has only a causal role in mental health. The idea that emo- tion regulation may be an outcome as well as a contributor to ‘menial heath xymptomy has been largely overlooked, DAWEL ET AL. Why Might Emotion Regulation Strategy Use Be an Outcome of Psychological Distress? ‘There are strong theoretical and empirical reasons suggesting ‘hat emotion regulation might be an outcome, not just a cause, oF psychological distess. First, theorizing suggests emotion regu ‘don strategies are actioned when there is a mistnatch between bow 4 person feels or anticipates feeling and how they want 10 feel Ge, the goal state; Gross, 2015). A Togical consequence of this argument is that anticipating or experiencing higher levels of ‘unwanted emotions, such as intense worry in anxiety, oF low ‘mood in depression, should cause people to use emotion regulation strategies more frequently. ‘Supporting this line of argument, studies of spontancous emotion regulation indicate people attempt to regulate their emotions more in situations where they are likely « be experiencing distessing emotions, or if they have history of psychopathology. For Instance, emotion regulation suategies ure used more when viewing negative compared to pesitive film clips (Gruber etal, 2012; Volo- hoy & Demaree, 2010) oF high compared to low intensity negative Images (Milyavsky et aly 2019), Alo, individuals in remission from mood or anxiety disorder use reappraisal and suppression ‘more than contol participants without a prior diagnosis (when viewing negative film clips; Camphetl-Sills ct al, 2006; Ehring ct al, 2010; Gruber etal, 2012), Previous longitudinal studies have also demonstrated associations between higher levels of mental Death symptoms and greater subsequent use of suppression (in ad Iescents; De France eta, 2019: Larsen etal, 2012), although mot reappraisal (in adolescents and adulis; De France ct al, 2019; Ever- ‘est & Joormann, 2020; Haines eta, 2016). ‘Adtonally, recent empiical work fas reveated large with-in Vidal satiation inthe use of diferent emotion regulation tages ‘over short petods of ume (Benson etal, 2019; Gross & John, 2003; hanes eal, 2016; Sheppes etal, 2011) Indeed, dese studies sug- gest he amount of within individual variation may be greater than tha between individuals, For instance, Benson et al. (2019) found almost ‘wo thins ofthe variation in how much individuals used suppression snd cognitive reappraisal across deren social situation was within person vatation. Inthe context of Ue present sty dis high level of variation opens up the possibilty tht emotion regulation could be influenced by psychological functioning, AI in ll, there are compe: Ting reasons to consider that emotion regulation might be an outcome ‘of psychological dite, Evidence tha emotion regulation isn ut come, not just a cause, of psychological functioning would reshape bow these proseses are conceptualized in clinical patie, Present Study “The present study was conducted during the acute lckdown phase of the COVID-19 pandemic in. Australia. This sitvation provided ‘unique opportunity to survey the natural operation of emotion regu tion in the context of severe populaton-Fevel stressor that saw sig nificant clevatons in’ mental health problems across the general population (Darvel etal, 2000; Pires et al, 2020; Xiong etal 2000). Our primary research question concerned the underlying die ‘ionaity of established associations between two emotion regulation Sniegies—cognitive reappraisal and emotional suppression—and ‘menial health symptoms, To investigate this diretionaliy, we use prospective longitudinal design, measuring, emotion regulation and EMOTION REGULATION AND MENTAL HEALTH sympioms of depression and. generalized anxiety three times at ‘monly intervals. Inline with previous evidence, we predicted that ‘oven, greater reappraisal and suppression would demonstrate uni- ‘arate associations with lower and higher levels of mental bealin sympioms, respectively. However, we reasoned that these associations might be confounding symptomatic with causal elfets of emotion regulaion. Our key prediction was thal, because people are theoreti- cally motivated lo engage in emotion regulation when they wish to avoid or get rid of unwanted emotions, experiencing higher levels of ‘mental health symptoms at earlier ime points would be associated ‘vith greater reappraisal and suppression at ltr time points. Method Participant Recruitment and Sample Characteristics ‘The present study use data rom Waves 2,4 an 6 of The Aus- tralian National COVID-19 Mental Health, Behavior and Risk Communication Survey (COVID-19 MHBRCS; Batterhum ct a, 2021 Dawel ct al, 2020). This longitudinal survey used quota sampling to obiain& sample representative ofthe Australian adult population by az, gender and peographical location (by satefer- fitory) rom a market panel managed by Qualies Research Serv ices. ‘The study was approved by The Australian National University Human Ethics Committee (protocol 20201132). The first survey wave Was initiated atthe end of March 2020 (Wave 1=28-31 March), with data collected foruigythercaler tuntl the end of June 2020 (7 waves). To provide content, on 24-25 March 2020 in Australia nonessential businesses were or- dered to close, Australians were encouraged to work from home, sand banned from traveling, overseas. Various state borders were Closed eros the period of the sey, and social distancing was widely practiced. By the time Wave 2 stated on 11 April 2020; Astrala was under fll nationwide lockdown (Our min analyses use dita rom the 704 participants who had complete data on the emotion regulation, depression and anxiety measures for the three waves im which emotion regulation was measured (ie, Waves 2, 4 and 6) Table | reports key demo- {raphics for thc sample, Comparison with equivalent gender and sage data from the Australian Bureau of Statistics (2016) indicate we achieved good representation of the Australian population on those attributes, with the exception that younger and older adults wor slightly under and overrepresented, respectively. Tis pa tem relects greater ation of younger adult and lower ation folder adults fom our Wave 1 sample (see Table 1 of Dawel et al, 2020 for Wave 1 sample demographics). Note, as in many areas of psychology, « considerable amount of previous work on motion regulation has tested college student samples (ex. Brewer etal, 2016; Gross & Jon, 2008; Miyavsky et al 2019), ln this contest, ou sample provides valuable representative lta across the alt ie sp from 18 wo 91 years age. The large size and representative nature of our sample alo allowed ws to est the generalizability of our findings across gender and age cohorts Design ‘At cach wave, participants complcted an online questionnaire ‘administered by Qualtrics Research Services, Bach survey took approximately 15-25 minutes to complete, depending on wave Isis content. Here, we describe the three questionnaire measures used inthe current analyses. The full project protocol and measures for Waves 1-7 can be found here: huips://psychology.anu.edu.au/ researeh/projects/australian-national-covvid-19-mental-health -behaviour-and-isk-communication-survey. Questionnaires Emotion Regulation: Emotion Regulation Questionnaire (ERO; Gross & John, 2003) Adapted to Two-Week Timeframe. We apd the primary mewsure wed for assessing bubitual suppres and reappraisal, the Emetion Regulation Questionnaire (ERQ: Gross 4 Jol, 2003), tothe same two-week time window used for our meas- tres of depression and anwiely. Participants were asked to indicate “Over the last 2 weeks, to what extent have you used the following, salegies to deal with your emotions..." frou Strongly Disagree 7 Strongly Agre, foreach of en items adapted from the orginal ERQ (6 reappraisal tems + 4 suppression items; Gross & John, 2003). We changed the wording of the orignal ERQ) ites nly insofar a was roeded to change the timeframe of reference Irom habitual use to the past two weeks We did not change the statement content, just the temporal tense. For example item 1 of the ERQ was changed from “When | want to fee! more positive emotion (suchas joy er amuse sen), change what Pm thinking about.” to "When I wanted o feel ‘more positive emotion (such as joy or amusement, I changed what L swas thinking about” (sce Supplement SI forall tems). Total subscale scores are calculated by summing item scores, with higher scores in- icaive of greater use of reappraisal or suppression emotion regula tion strategies. Depression: Patient Health Questionnaire (PHQ-9; Spitzer et al, 1999). The PHQ.9 comprises nine items that ask how often someone has experienced symploms associated with depression (e-., “le imterest or pleasure in doing things”, “oeling down, depressed, ‘orhopeless") over the las wo wecks. Response options are: 0 = Nor ‘at all, |= Several days, 2= More than half the days, 3 = Nearly ev ry day. Toval wale scores are ealeulaied by summing item seaes, with higher scores indicating higher levels of depression, Anxiety: Generalized Anaiety Disorder Sereener (GAD- Spitzer ef al, 2006). The GAD-7 comprises seven items that ask how often someone has experienced symptoms associated ‘with generalized anxiety disorder (e., “Feeling nervous, anxious, ‘oron edge”, “not being able o slop or control worrying”) over the lust two weeks, Response options are: 0 = Nor at all, |= Several days, 2 = More than half the days, 3 = Nearly every day. Total scale scores are calculated by summing item scores, wih higher scores indicating higher levels of anxiety Results Questionnaire Means, Range, and Reliability Table 2 reports the means, standard deviations, range of scores and internal reliability for cach questionnaire measure at each "The most complex mode ete in this manuscript has 35 parameter, Base onthe 20-1 dia point o parameter rato rl the avilable N= 704 inthe current study is sufficient for stable lest resis, Also, a previots Simla sty shows thal CLPM with 3 waves of data performs well ‘with N= 500 Wa etal, 2018) Power analyses used to deere Nf the tex Wave 1 sample are describe in Dave et. (2020), 1514 ‘Tablet Sample Demographics Samplem Samples (Pop. 6)" Genaer Male a 337 3) Female 26 463 (so. 18-34 ua 203 03) 3544 ins 179 (78) 45S be in2 (073) 55-68 we 202 asa) 654 65 2a 205) Ethnicity European(Caucanin su m3 Asin io 26 Otherfnned n tor Household income (pretax) ‘Up wo $30N/veek around 46 6s sto.oonyea") $300-$575 por week rot 4s (ss0.000/ycur) $576-$1,075 per weck 10 at (S56.000/ycu) $1,076-S1.700 per week 12 188 86 ne (si250001yex) More than $2A00/weck be iss (S125.0001yea) Pree nat oy a 33 "Population data for gender and age are From the 2016 Australian Census (Australian Bureau of Statistics, 2016), Equivalent data for ethnicity and tronehol income were ct available ‘wave for our main sample of N'= 704 (see Supplement $2 for de- scriptive latisties forall ofthe data that was usable at each wave, and comparison of main sample data with data excluded at each wave). In all eases, the actual range of scores was spread across DAWEL ET AL. ‘he full potential range, Internal consistency was in the acceptable {o good range for ERQ-suppression, and excellent for all other scales at every wave (Groth-Marmat, 2009), Data Analysis Overview ‘We first examined univariate associations between ERQ-suppres- sion, ERQ-reapprasal, PHQ-9 (depression) and GAD-T (anxiety) scores within and across waves. Because scores were non-sormally distributed for every measure al every wave, we used Spearman's p correlations. The non-acrmalty of tke ERQ suppression and ERQ- reappraisal score distributions was primarily due to 3 mille response bias (Le., some participants responded “neutral” 1 every Saternent within the suppression andor reappraisal subscales ofthe [ERQ a one or more waves). To check our findings were cobust 10 this response pattem, we reran all of our analyses excluding data {rom participants who showed a middle response bias for both ERQ subscales within any given wave (15,9% ofthe sample showed this pattem in a least one wave; 2.3% ofthe sample showed this patter at all three waves). Removing the 15.9% of participants. who showed a middle response bias on both measures Within any single ‘wave didnot change the pater of findings. Next, we moved on to building crosslagged panel models (CLPMs) to test the directionality of relationships between emo- tion regulation and mental health symptoms. Each model included data from all dee waves of interest (2, 4 and 6) for one of our emotion regulation measures (ERQ-suppression or ERQ-reap- praisal) and one of our mental health symptom measures (PHQ9 for depression of GAD-7 for anxiety). We initially tested the rela- tionships hetween these variables separately for Wave 2 to 4 and Wave 4 to 6, using linear regression models. Because the findings from these madels were consistent with our final CLPMS, the results of regression analyses are reported in Supplement S3. Note, a is typical in nonelinical samples, the PHQ.9 and GAD-7 Table2 Descriptive Statistics for Questionnaire Measures, N Range (Cronbach's a Seale Wave a so ‘ewal Posen Dewar Prior studies ERQRapprESon ” 159 4s aos. 428 n 58-16, 96-80" ws 158 48 48 81 ™ 8 50 38 4 ERO-seapprasa ~” 268 69 6a 6a 92 75.82, 89.90" os 24 68 a 98 ™ m0 68 6a PHQ-9 (depression) ~” 56 60 om O27 92 86.894, 93%, 92" 4 S ST oz 92 ™ ts 56 0% 3 GAD-T(ansiwy) ~” 4s so oat on oe 9,934, 854, 92 ws 40 49 oa 94 ™“ 36 46 0-31 a "There are minor differences inthe for Cranach a values fecause these calculations did not tolerate any missing ten missing data for a singe em wit ofthe remaining item scores multiplied by the wal numberof tems. Whe df Sion is a good metho for dealing with missing dats (Shvive eta 2006) 2001. = (Baiterham etal, 2019). (vam Spiker etal, 2018) (lle eta, 2017). and sore participants had ina given scale IT single tem was missing fom a scale with >S items, then total core was calculated as the average re are few cas with msn vals (8 "(Gros & John, 2013). * (reece (Spier etal, 2006). the situation here), mean input al 2020). * (Kroenke eta. EMOTION REGULATION AND MENTAL HEALTH variables had high frequencies at their Howest possible value resulting in incorigible positive skew. However, we have previ ‘ously found with tis dataset that using compound Poisson-gamma (Tweedie dissibution) generalized linear models produces results which are consistent with Iinear models (Dawel et al. 2020), sug- ‘2esting our Tinea regression moxels are robust to this skew. fn the CLPMs we secounted for the non-normality of our variables by using maximum likelihood estimation with robust errors and ‘Satorro-Benter sealed test statistics. Standard CLPM models were constructed following Hamaker et al 2015) and estimated using the lavaan package in R (Rosseel, 2012). The model ft was eval= ‘uated by comparing each CLPM model with a null model that assumed the specified emotion regulation and mental health vara bles were not associated across waves (i, the erss-lagged paths were removed), using robust Comparative Fit Index (CFD, Stand- ardized Root M Square Residual (SRMR), AIC and BIC values. We also tested the stationarity of the relationships by comparing the standard CLPM model with a restricted model that constrained both the autoregressive and cross-lagged paths to be the same across waves. A nonsubstanial difference in model fit indicates staionavty. Finally, we examined gender differences by testing the moderation effects of gender on each path, Univariate Associations Between Emotion Regulation Strategies and Mental Health Table 3 reports Spearman's p correlations within each measure across waves, and between each measure within and across waves. ‘To imempret the correlations, we used a Bonferroni corrected value of 0579 = 016 to adjust forthe family of nine correlations within each pair of variables (@-., 3 waves of FRQ.suppression x 3 waves of PHQ.9 = 9 correlations). As expected, greater suppres- sion wat significantly associated with higher levels of both depres- sion and anxiety within and across every wave, with p ranging From 334 to 4 ll ps <.001 We also repeated these analyses using (a) Pearson's (Wo faci tate comparisons with previous data), (b) all oF the usable data from each wave (eg. including data from participants who Isis responded at w2 and w4 but not w6), (e) excluding daa from par ticipants who showed a middle response bias on both ERQ suab- scales within any given wave, (A) for males and females separately, and (e) for each age cohort sepsrately, Detaled results From these analyses ate reported in Supplements S4-S8, and invat= Iably show greater suppression was associated with higher levels ‘of both depression and anxiety within and across every wave, with p ranging from 231 to 494, all ps < 01. Overall, these findings for suppression are highly consistent with past work associating suppression with maladaptive mental health outcomes However, in stark contrat, reappraisal did not show the expected ‘adaptive relationship with mental heath symptoms, Examining the correlations both within and across waves, there was not one instance in our main analyses (sce Table 3) where we observed a significant association between greater reappraisal and lower levels of depres son or anxity. The only correlation between reappraisal and depres son oF anxiety that was significant im our rain analyses was in the ‘opposite-o-expected direction: greaer reappraisal a 2 was associ ted with higher anxiety at W2, p= -109, p = .004. Our Supplemen. tary analyses ko Found minimal evidence of the expected aapive relationship between reappraisal and depression of anxiety symptems (Gee Supplement S0 for fll evaluation of the evidence). Finally, its worth noting that cach of the ERO subscales corre lated only moderately with itself across waves (average interwave oF 615 for reappraisal and 584 for suppression), consistent with ‘our premise that the use ofthese strategies ean change over rela: Lively shoet periods of time. We also found that how much an ind vidual's score changed on ome of the ERQ subscales from wave to ‘wave correlated with how much their score changed on the other subscale across the same time period: (#2 ERQ-suppression — w4 ERQ-suppression) was significundy conelated with (W2 ERQ- appraisal — w4 ERQ-reappraisa), p = 348, p <.OO1, and (w4 ERQ-suppression — w6 ERQ-suppression) was significantly eorre= lated with (w4 ERQ-reappraisal ~ w6 ERO reappraisal), =.282, p< 001. These results indicate that if someone reported using fone strategy more (or less) they also reported using the ther stat- egy more (or less) than they hal a the previous wave. Table3 Spearman's 9 Correlations Between Measures Within and Across Waves, N = 704 ERQ reappraisal ERQ suppression PHO (depression) (GAD-T (anxiety) Scalewave we wt wd ww ERO-eapprisal “ zoe we sree gees [ERQ suppression v2 ae “4 os ise be sagee we 035 Tost tapes “Ss3re" —gusre PHQ.9 (depression) wa 033 0242S ggTe0 39H sgLeee we 040 O13 ORK Aes jameee “hopes gorse we 41 O03 O47 “Baseow aggree “eager “rogew sage GAD. ansiey) id Orr 0H 06) aE gee aTaee sree ase 73K we on O12 04) Aaaee Cyamere “agaeee “rages xoress“Tayess rages we om) 009 _71__“Baere_3otree “asgrer “rarvew agree “xszeer “rarer snore ‘Note. Bolded values are significant as indicated By asterisks ae 6. p= 00 1516 Figure 1 Cross-Lagged Panel Models (CLPMS| Suppression and (B) Reappraisal DAWEL ET AL. 5) for Depression and Anxiety With (A) ‘A. Suppression se Suppression KP Suppression Suppression 5 & Depression Depression Suppression Suppression Amiety ‘Aniey B. Reappraisal Reappratal_ Lf Reaporatsal_ (“4 “Reaporasal , ge sf F a xe re 3 + JON No Depression (2 “Depression (22 Depression Reapprabal [Reappraisal a{_ Reappraisal * ey ¥ 5 : Xe 8 ‘ we oy Amiery (2 “of Aniety Not _Sanesion = ERQ sopresn: Rapa = BRO rapa: Depeson = PHOS Amity = GAD, Fane are snail eta, Unbroken lines inate sii Disha nes indicat no igi pat, #p<05.ep <1. p< 00 Do Depression and Anxiety Symptom Levels Predict ‘Subsequent Use of Emotion Regulation Strategies, and Vice Versa? The core question in this study was whether the use of emotion regulation strategies i symptomatic, as well as causa, of depression andlor anxiety. Figure | reveals the nsw to this question is yes for suppression, but no for reapprasl Additional details of the CLPM. esl, including 85% confidence intervals and mode! comparisons, are in Supplements SIO-SL First, Figure 1 shows that higher levels of both depression and anxiety significanly predicted greater suppression at subsequent ‘waves. In nn, greater suppression signficanlly predicted higher levels of depression and anxiety at subsequent waves, i three out Of four instances, Together, these results suppor a bidirectional relationship between suppression and depression/anxiey. Im contrast, Figure IB shows the use of reappraisal didnot signift- cantly prodict depression nor anxiety at subsequent waves. Nor did depression or aniety signifcanily predict the use of reappraisal subsequent waves. Though surprising in the context of the broader literature (Alda0 eal, 2010; Hu et a, 2014), the finding of no rela Lionship betwoen reappraisal and depression or anxiety is consistent ‘with our univariate and regression results (See Supplements S3-8), For both suppression and reappraisal the tests of staonartyindi- «ated that both the autoregressive and eros- fag paths were not sig nificantly diferent across waves. The AIC and BIC values all favored the more parsimonious mods where the paths between variables ‘were consraied tobe the same ares waves (Supplement $10). EMOTION REGULATION AND MENTAL HEALTH Gender Differences Moderation analyses revealed some significant gender differen ces in the models (Supplement $10). Fist, anxiety at Wave 2 pre dicted suppression at Wave 4 moce positively for males than Females, = —068, SE=.034, 85% CI [-.134, — 002}, p= 048. Second, suppression at Wave 4 predicted anxiety at Wave 6 more powitively for males than females, l= —046, SE = 020, 059% CL [-086, ~006), p = 023. Third, depression at Wave 2 predicted depression at Wave 4 more positively for males than females, sup pression model: = —.076, SE = 032, 954% CI [-.139, —013}, p= 019; reappraisal model: B = —068, SE = .029, 95% CI [-.125, —011), p =.020. Finally, reappraisal at Wave 4 predicted depression at Wave 6 more positively for males than females, B= ~041, SE= 021, 95% Cl [081,001], p= 046. Discussion The present study provides compelling evidence thatthe associ tion between emotional suppression and mental health symptom is bidirectional. Our key finding. was that higher levels of depression ‘or anxiety symptoms predicted grester subsoquent use of emotional suppression, As causal theories of emotion regulation sugges, this relationship was also found o be significant in reverse. Importantly, ‘ationaity tests showed these relationships involving suppression were stable aeross waves. In contrast, cognitive reappraisal was not associated with symptoms of mental disorders in our sample, This, effect was robust; it held in univariate and longitudinal analyses, for ‘males and females, and across age cohorts. While this finding con- flicts with previous meta-analytc findings (Aldao eta, 2010; Hu Lal, 2014), iis consistent with recent work showing reappraisal is not always associated with reduced mental health symptoms (cg. Cavanagh, Fitzgerald & Unry, 2014; Haines eta, 2016), ‘Our hypothesis that emotion regulation sirtegy use might be -gymplomatis, nt just eausil, of psychopathological distress was sap pred for suppression. Higher depression and anviety. symptoms bok predicted grester use of emotional suppression al ter waves. However, there also remained a forward contibution of suppression to mental health symploms. Together, these findings indicate Unt the well-established association between higher suppression and poorer ‘menial health reflects bidirectional relationship, The bidiectonality fof this association may be one reason why effect sizes tend 10 be ile large in studies of suppression and mental health relative to some other emovon regulation suategies, Including cognitive weap rasa, for which effets are smaller (Aldao etal, 2010). While fur- ther research is needed (0 tease apart how much each direction of clfcet contributes to the overall association between suppression and ‘menial health, our results from a nationally representative adult sam- ple suggest that both depression and anxiety symptoms predict sap pression at Teast as suongly as dhe reverse. In comrast, previous Tongitudinl work in adolescents found evidence was strongest for a Uuniiretional relationship whereby depression predicted subsequent ‘suppression but rarely the reverse (De France et al, 2019; Larsen et al, 2012). Thus, the findings from adolescens suggest that suppres- sion did not have any causal role in depression. The reason forthe difference between our adult ndings and previous adolescent find ings is unclear, but could be related to age specially, othe pan ‘demic context in which we conducted our study Isi7 ‘A key question is why mental health symptoms lead to greater suppression, While the present study is unable to answer this ques tion direcily, we have proposed that the psychological distress and intense negative emotions associated with psychopathology’ Including anxiety and depression symptoms—are likely to mot vate people to regulate their emotions, including via suppression. Theoretically, this argument aligns with Milyavsky et al.'s (2019) recent application of cognitive energetics theory (Kruglanski etal, 2012) to emotion regulation. This theoretical framework contends that emotion regulation isthe outcome of driving forces (es. bow important it is to regulale an emotion) in combination with restraining forees (eg, how difficult iti to regulate an emotion). In the present study, the psychological distress associated with pression oF anxiety symptoms can be conceptualized as a driv= ing force for emotion regulation. This driving force may be further increased in people with mood disorders because they tend {0 appraise negative oF strong emotions as unacceptable (e4 T shoulda’ feel this way"; Camphell-Sils ets, 2006). Suppott- Ing this argument, such appraisals are associated with increased suppression (Campbell-Sills etal, 2006). Distressed individuals. may also be motivated to suppress the expression of their emotions by social display rules that encourage them to hide negative feel- ings (Matsumoto et al, 2008). For instance, distressed individuals in Wester cultures may believe they need to put on a “happy face.” Ic will he important for future research to test these theoreli- cal ideas more directly. [Neurobilogical evidence also points tothe possibility os bide tional relationship between psychological distress and suppression Some of the brain regions most consistently implicated in anxiety and depression symplomaiology include the amyzzda, the hippo- campus, the thalamus and striatum (Espinoza Oyauce et a, 2020), “These sre evolutionarily old structures which are strongly connected {© frontal cortical regions Known. to be involved in suppression Including the anterior cingulate and medial prefrontal cortex (Pan et al, 2018) I is therefore expected that the activity of older limbic regions would be modulated by newer Lrontal regions underlying suppression processes. However, itis also well-established that Tim- bic activity, and specifically in the amygdala, also modulates trent activity (Garcia etal, 1999; MeGaugh, 2004), and! dus greater psy chological distress associated with increased limbic activity is likely to modulate suppression processes in frontal regions. In addition, the anterior cingulate and medial prefrontal cortex, which undertc sup- pression (Henman ct al, 2014), are also involved in the neuropatho- Physiology of depression (Pandya et a, 2012). 1s implausible that ‘unidirectional influences would oscur between suppression and psy chological distress within the same eotical region, ‘Turning. now to cognitive reappraisal, we found no evidence that the use of this strategy was associated with depression nor anxiety. Our results are contrary to the usual finding that cognitive reappraisal is associated with reduced mental health symptoms (eg. Aldao etal.,2010), including when faced with various tres sors (eg., in PTSD, Boden et al, 2012; and depression, Troy et al, 2010), However, our results are in line with those of Cavs ragh, Fitzgerald and Umy 2014), who found no association between EROQ-reappraisal scores and mental health symptoms fol- lowing the 2011 earthquake, tsunami and nuclear ers in Japan ‘One possibility is that people are notable to successfully use cog nitive reappraisal when they are acutely stressed. Speaking to this possibility, Rao ct al. (2013) found that people who were trained 1518 10 use cognitive reappraisal to regulate their emotions in a fear conditioning paradigm were less able 10 do. so when acutely sessed (but ef. Shermohammed et al, 2017 for evidence that coznitive reappraisal can be effective when moderate stress Is induced). A second possiblity is that reappraisal isan ineffective sirategy for responding to the factors thal were impacting most strongly on mental health symptoms during the lockdown, For instance, major factors associated with mental health problems ‘during lockdown in Australia included financial distess and dis- ruption 1 work and social functioning (Batterham et al., 2021; Dawel et al, 2020), Reappraisal may be an ineffective strategy for managing the acute emotional impacts of such large and sud- den disruptions, when reframing the situation is difficult or unreal- istic (glewiex etal, 2020) (Overall, our results for cognitive reappraisal highlight the impor- tance of recent arguments that no emotion regulation strategy is tni- vesally helpful or harmful (e., Ford et al, 2019; Haines et a. 2016; McRae, 2016; Troy et al., 2013), Understanding when and for whoo reappraisal helps is eriical hecause this strategy is core to many psychological therapies. For example, reappraisal is espoused as a key component of psychological interventions for cmotional disorders (eg, Barlow et al, 2017), and a brief reap- praisl intervention isthe focus of one of three studies in the Psy- ‘chological Science Accelerator Rapid Response COVID-19 Project (iupsipsysciace.onp/stxties/psacr-1-2-¥; Wang ct al, 2020). Limitations and Future Directions There are several important limitations to consider. Fist the results of the present study are limited to self-reported general use ‘over two-week periods, with waves spaced at monthly intervals ‘Medium-term data like this is useful, but only part of the picture. is plausible dhat these associations will have distinct fast and slow dynamics, wih the shorter-term dynamies being more situa- tionally influenced and the longer-term dynamies more steongly influenced by psychological tits. Ecological momentary assess- ‘ment (EMA) methods have potential to give more nuanced insight into associations between emotion regulation and mental health cover shorter time periods, including providing nuanced informa- tion about strategy situation fi Inthe present study, itis possible that some people applied reappraisal in situations where it did help ‘with mental health symptoms, bu others did not, or applied cogni- tive reappraisal in ways that were unbelpl ‘A limitation of the ERQ is that it measures the extent to which people use reappraisal and suppression, not their ability to use them effectively. Logically, emotion regulation strategies should only impact mental health symptoms if they are used elfectively —and using a sirtegy more does not necessarily equate to using it more cfectively (Troy et al, 2010). Indeed, Cavanagh et al, 2014) found reappraisal ability but not use was associated with reduced ‘mental health symptom following the 2011 Japan eriss, Ie would bbe benetical for future studies to routinely measure reappraisal abil- ity as well as use, SelF-report measures can also be subject © perso- nal biases (Wilhelm & Grossman, 2010), and thus it would be helpful to include behavioral measures of emotion regulation such ‘as Cavanagh otal’ (2014) measure of reappraisal ability. Implicit to the correlational design ofthis study, causation can- not be definitively demonstrated but only inferred. 1s aso possi ble that a third variable might explain the observed association DAWEL ET AL. between suppression and depression or anxiety. For instance, ress, Which has known associations with all three variables (Aldao eta, 2010; McEwen ots, 2012; Park etal, 2019), could account forthe associations we observed or mediate the elfect of suppression on depression and anxiety, of vice versa. A Key next step will be to se experimental methods to cally test whether a bidirectional relationship exists between suppression axl mental Death symptoms. 1 will also be important See iF the findings of the present study generalize o nonerisis times. For instance, to test it a Tongitudinal bi- or uni-directional relationship between cogni- tive reappraisal and mental health symptoms can be found once the pandemic recedes ‘A final imitation is that, although we deliberately designed the study to be representative ofthe Australian population, i s poss bile the survey did not adequately capture all groups. For example, the study was conducted online, so people without Intemet access were not able to be included. In addition, an important question for future reseurch is whether a bidirectional relationship between suppression and mental health is universally present across cul tures and ethnicities, Meta analytic work indicates suppression is rot associated with poorer mental health in Eastern cultures (Hu et al, 2014), and Asian Americans endorse suppression more than European Americans (Gross & John, 2003; Mauss eta, 2010) yet experience smaller increases in anger expression and experience when provoked (Mauss eta, 2010). These East-West differences in findings for suppression may rellct Easter cultural norms that value not openly showing or expressing emotions to pret group harmony (Bond, 1993). That i, the drivers and outcomes of sup= pression may differ in Easter relative to Wester cultures Implications for Clinical Practice ‘There is no universal emotion regulation strategy that is useful for all people in all situations, particularly during dramatic and lifesaliering events, Indeed, evidence-based psychological treat ments, such as cognitive behavior therapy (CBT), aim to equip cl ents with a range of skills so that these can be employed effectively in diferent situations as relevant wo a cient. For examm- ple, in CBT for anxiety and depression, a highly distressed client ray be encouraged to fist use techaigues olber than cognitive reappraisal, such as breathing or grounding exercises (Barlow et al, 2017) Indeed, other data from the present survey indicate that many people turned to breathing techniques during. lockdown: ‘over 80% of respondents who had a history of paychologieal ther- apy reported using breathing techniques, and most found breathing ‘very or somewhat helpful (Gulliver etal, 2021). The key for els cians isto equip clients with a variety of tools for effectively man- ‘aging emotions and knowledge about when to use different took, ‘The present study emphasizes that cognitive reappraisal is not always effective for reducing mental health symptoms. The find ings are a reminder that clinicians should careflly explore with their clients the conditions under which they find cognitive reap- praia helpful, including when they are likely to have the neve sary cognitive resources required for this, and remain cognizant that some clients may not find this strategy helpful a all ‘Ourresults suggest a fundamentally new interpretation of the phe- ‘nomenon of emotional suppression: that itis not just @ driver Put also a sympom of distress. I may be uselul to monitor emotional suppression in clinical practice, particularly for clients who have EMOTION REGULATION AND MENTAL HEALTH iiculty reporting thee Ievel of dstess. However, our finding dha ‘the relationship between suppression and mental health symptoms is bidirectional reinforces the role of suppression in perpetating mex {al bealdh symptoms, consisent with traditional causal argument ‘These findings suggest tht the relationship between emodional sup- pression and mental health is perhaps more complex than previously ‘conceptualized. In clinical settings, it is therefore important 10 explore with clients the underlying Urivers and functions of emo- tional suppression rather than instructing them to avoid suppressing their emotions. Rather dhan asking clients to avoid suppressing their ‘emotions, we suggest Ut clinicians explore the underlying beliefs that are driving suppression in the firs place. For example, belies about negative and strong emotions being unacceptable are associ- fated with increased suppression (Campbell Sills etal, 2006). If psychological distress is indeed driving suppression, directly helping, lients to reduce their flt distress (¢., breathing exercises) is also likely to alleviate suppression, Conclusion The present study found a bidirectional relaionship between higher symptoms of depression or anxiety and greater emotional suppression, The nature of this relationship is consistent with sup- pression having a symptomatic as well as causal role in mental hhcalth disorders. However, unlike previous research (Aldo et a, 2010), we did not find a relationship between cognitive reappraisal and depression ot anxiety symptoms, These results challenge the accepted wisdom that cognitive reappraisal is universally helpful and bolster recent arguments that applying different strategies in the right situations is key (Ford etal, 2019 Haines. etal, 2016; MeRae, 2016; Troy etal, 2013). 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