An observational treatment study of metacognition in anxious-depression

Abstract

Prior studies have found metacognitive biases are linked to a transdiagnostic dimension of anxious-depression, manifesting as reduced confidence in performance. However, previous work has been cross-sectional and so it is unclear if under-confidence is a trait-like marker of anxious-depression vulnerability, or if it resolves when anxious-depression improves. Data were collected as part of a large-scale transdiagnostic, four-week observational study of individuals initiating internet-based cognitive behavioural therapy (iCBT) or antidepressant medication. Self-reported clinical questionnaires and perceptual task performance were gathered to assess anxious-depression and metacognitive bias at baseline and 4-week follow-up. Primary analyses were conducted for individuals who received iCBT (n=649), with comparisons between smaller samples that received antidepressant medication (n=82) and a control group receiving no intervention (n=88). Prior to receiving treatment, anxious-depression severity was associated with under-confidence in performance in the iCBT arm, replicating previous work. From baseline to follow-up, levels of anxious-depression were significantly reduced, and this was accompanied by a significant increase in metacognitive confidence in the iCBT arm (β=0.17, SE=0.02, p<0.001). These changes were correlated (r(647)=-0.12, p=0.002); those with the greatest reductions in anxious-depression levels had the largest increase in confidence. While the three-way interaction effect of group and time on confidence was not significant (F(2, 1632)=0.60, p=0.550), confidence increased in the antidepressant group (β=0.31, SE = 0.08, p<0.001), but not among controls (β=0.11, SE = 0.07, p=0.103). Metacognitive biases in anxious-depression are state-dependent; when symptoms improve with treatment, so does confidence in performance. Our results suggest this is not specific to the type of intervention.

Keywords: antidepressant; anxious-depression; confidence; human; iCBT; metacognition; neuroscience; transdiagnostic.

Figure 1.. Cross-sectional findings at baseline in the iCBT arm.

β=standardised beta coefficient, r=correlation coefficient, p=p-value, AD = Anxious-Depression, CIT = Compulsivity and Intrusive Thought, SW = Social Withdrawal. The error bars represent the standard error around the standardised beta coefficient. N=649. (A) AD and CIT were associated with metacognitive bias, while SW was not, using linear regression analysis. (B) The residual values for confidence (controlling for age, gender and education) were negatively correlated with AD. (C) The residual values for confidence (controlling for age, gender and education) were positively correlated with CIT.

Figure 2.. Treatment findings in the iCBT arm.

β=standardised beta coefficient, AD = Anxious-Depression, CIT = Compulsivity and Intrusive Thought, SW = Social Withdrawal, OCD = Obsessive compulsive disorder, r=correlation coefficient, p=p-value (unadjusted), ***=p < 0.001, **=p < 0.01, *=p < 0.05. The error bars represent the standard error around the standardised beta coefficient. Regression analyses were used for all tests. N=649. (A) Psychopathology symptoms improved with four weeks of iCBT. (B) Confidence was significantly higher and, (C) the task was more difficult at 4-week follow-up. (D) Those with the largest improvements in AD had the greater increases in confidence. (E) Change in confidence also scaled with improvements in trait anxiety, depression and alcohol misuse.

Figure 2—figure supplement 1.. Changes in psychiatric dimensions and scale scores from baseline to follow-up in the iCBT arm (N=649) using regression analyses.

β = standardised beta coefficient, SE = standardised error, t = t-value, p = p-value (unadjusted), AD = Anxious-depression, CIT = Compulsivity and intrusive thought, SW = Social withdrawal, OCD = Obsessive compulsive disorder.

Figure 2—figure supplement 2.. The interaction effect of time and psychiatric dimension/scale change on mean confidence in the iCBT arm (N=649) using regression analyses.

β=standardised beta coefficient, SE = standardised error, t=t-value, p=p-value (unadjusted), AD = Anxious-depression, CIT = Compulsivity and intrusive thought, SW = Social withdrawal, OCD = Obsessive compulsive disorder.

Figure 3.. Comparing iCBT, antidepressant and control groups.

β=standardised beta coefficient, AD = Anxious-Depression, CIT = Compulsivity and Intrusive Thought, SW = Social Withdrawal, OCD = Obsessive compulsive disorder, r=correlation coefficient, p=p-value, ***=p < 0.001, **=p < 0.01, *=p < 0.05. The error bars represent the standard error around the standardised beta coefficient. Regression analyses were used for tests. (A) The majority of psychiatric scales improved in the antidepressant arm (N=82) after 4 weeks of treatment, while the controls (N=88) only had significant reductions in OCD symptoms and alcohol misuse at follow-up. (B) While confidence increased in the antidepressant arm, there was no significant change in confidence among controls. The larger increase in confidence in the antidepressant arm compared to controls was trended towards significant. (C) The antidepressant arm had a greater increase in task difficulty (a reduction in dot difference across stimuli) from baseline to follow-up, relative to controls. (D) Although not significant, the association between change in confidence and change in anxious-depression was in the expected negative direction in the antidepressant arm and among controls.

Figure 3—figure supplement 1.. Changes in psychiatric dimensions and scale scores from baseline to follow-up in antidepressant (N=82) and control (N=88) arms using regression analyses.

β=standardised beta coefficient, SE = standardised error, t=t-value, p=p-value (unadjusted), AD = Anxious-depression, CIT = Compulsivity and intrusive thought, SW = Social withdrawal, OCD = Obsessive Compulsive Disorder.

Figure 4.. Study methods.

(A) Participant flow chart (CONSORT chart). Participants were considered ‘completers’ if they had metacognitive and transdiagnostic psychiatric dimension data at baseline and follow-up and met task inclusion criteria. (B) Overview of study design from study intake (week 0) to follow-up (week 4) assessments across groups. (C) Metacognitive (visuo-perceptual decision-making) task design (N=210 trials). On each trial, participants were asked to judge and choose the sunflower that contained more seeds (i.e. higher number of dots) and then provide a confidence rating on their decision.