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Running Head: EFFECT OF MBSR ON RUMINATION COULD MBSR REDUCE VULNERABILITY TO DEPRESSION BY REDUCING RUMINATION? A PRELIMINARY REVIEW Trainee Name Nicola Motton, College of Life and Environmental Science, University of Exeter Supervisor Willem Kuyken, College of Life and Environmental Science, University of Exeter Nominated journal Clinical Psychology Review Word count 3,969 This work is submitted in partial fulfilment of requirements for the doctorate in clinical psychology 1 EFFECT OF MBSR ON RUMINATION 2 Abstract Depression is a public health problem that commonly begins in childhood or adolescence and is associated with functional impairment and depressive relapse in later life. Rumination is strongly implicated in the onset and maintenance of depressive symptoms and depression. Preventative interventions should target rumination as a means to reduce depressive symptoms and offset the risk of depression. This review examines the literature relating to whether Mindfulness-Based Stress Reduction (MBSR), an eight week intervention that aims to reduce the distress that arises from physical or psychological problems, could be usefully be applied with a non-clinical population as a preventative intervention, by examining whether MBSR reduces rumination. The literature on this topic to date is limited and suffers a number of methodological flaws, however the existing evidence supports the notion that MBSR reduces rumination, at least in adults. Methodologically sound research is now required to determine whether MBSR reduces rumination in children and adolescents, in order to determine whether it could be used as a preventative intervention for depression. Keywords: Mindfulness-based stress reduction, rumination, prevention, depressive symptoms, depression. EFFECT OF MBSR ON RUMINATION 3 COULD MBSR REDUCE VULNERABILITY TO DEPRESSION BY REDUCING RUMINATION? A PRELIMINARY REVIEW The National Institute of Mental Health has highlighted that research should focus not just on developing effective ways of treating and preventing the recurrence of mood disorders, but also on ways of preventing new onsets of mood disorders (Hyman, 2001). Given that depression that occurs in early life is associated with more chronic and recurrent depression in adulthood (Coryell et al., 2009), and greater suicidality (Thompson, 2008; Williams et al., 2012; Zisook et al., 2007) childhood or adolescence is a critical period for preventative interventions to be introduced. Preventative interventions should target the reduction of depressive symptoms, as they are strongly predictive of later depression (Pine, Cohen, Cohen, & Brook, 1999; Shankman et al., 2009). Despite growing interest in preventative interventions for depression in the last few years, with promising findings to date (Cuijpers, van Straten, Smit, Mihalopoulos, & Beekman, 2008), a recent large scale RCT (N = 5030) of classroom-based Cognitive Behavioural Therapy (CBT) found no reduction in depressive symptoms in at-risk adolescents compared to an attention control group or usual school provision (Stallard et al., 2012). This finding begs further consideration of what methods of intervention may be more effective. In order to reduce depressive symptoms and prevent depression, interventions must target factors that explain their onset and maintenance. Rumination, defined as “behaviours and thoughts that focus one’s attention on one’s depressive symptoms and on the implications of these symptoms” (Nolen-Hoeksema, 1991, p. 569) has been strongly implicated in the onset and maintenance of depression; rumination has been found in prospective studies to predict higher levels of depressive symptoms following a stressful event, even after accounting for baseline levels of depressive symptoms (Nolen-Hoeksema & Morrow, 1991). EFFECT OF MBSR ON RUMINATION 4 Rumination contributes to the maintenance and exacerbation of depressive symptoms in adolescents (Burwell & Shirk, 2007), and predicts the onset of new depressive episodes in adolescents (Broderick & Korteland, 2004), as well as adults (Nolen-Hoeksema, 2000). Some research suggests rumination may serve as a mechanism through which other risk factors such as neuroticism and self-criticism exert their effect on vulnerability to depression (Kuyken, Watkins, Holden, & Cook, 2006; Spasojević & Alloy, 2001). Given the substantial evidence that attests to the role of rumination in the onset and maintenance of depressive symptoms and depression, interventions that aim to reduce depressive symptoms must reduce rumination as a means to achieving this. Mindfulness may be one such means of reducing rumination. Mindfulness has been described as “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgementally to the unfolding of experience moment by moment” (KabatZinn, 2003, p. 145). In a theoretical sense, mindfulness represents a helpful alternative to the over-engaged style of processing entailed by rumination that perpetuates low mood, as mindfulness involves allowing emotions to pass in and out of awareness without overinvolvement (Kabat-Zinn, 1990). Indeed, correlational data suggest high trait mindfulness is associated with greater wellbeing on a number of indicators, including lower levels of depression and anxiety, greater life satisfaction and positive affect, and a lower tendency to ruminate (Brown & Ryan, 2003). In recent years there has been growing interest in mindfulness interventions, and a body of research has now accumulated that suggests mindfulness is helpful for adults with a range of physical and psychological problems (Baer, 2003; Brown, Ryan, & Cresswell, 2007; Greeson, 2009, Grossman, Niemann, Schmidt, & Walach, 2004, Hofmann, Sawyer, Witt, & Oh, 2010). In particular, mindfulness interventions are effective at reducing depressive symptoms in adults (Deyo, Wilson, Ong, & Koopman, EFFECT OF MBSR ON RUMINATION 5 2009; Kuyken et al., 2008; Teasdale et al., 2000), and preliminary research with adolescents suggests the same (Biegel, Brown, Shapiro, & Schubert, 2009). Two of the most studied mindfulness interventions are Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Stress Reduction (MBSR). MBSR was originally developed as an intervention for outpatients with stress, chronic pain, and illness (KabatZinn, 2003). This eight-week group program aims to enhance individuals’ ability to be mindful, and to apply mindfulness in their day-to-day lives (Samuelson, Carmody, KabatZinn, & Bratt, 2007). MBCT is also an eight-week group program aimed at enhancing mindfulness through regular practice (Kuyken et al., 2008), however the program was designed with the aim of preventing the recurrence of depression (Segal, Williams, & Teasdale, 2002). This review focuses on MBSR, as arguably it is more appropriate than MBCT for the purposes of reducing low-grade depressive symptoms and rumination in a primarily non-clinical population, given that MBSR was designed for adults without a history of significant psychological problems. Understanding whether MBSR reduces rumination is an important question, as it is essential that the processes, or mechanisms, that produce change in interventions are well understood, in order that they may be enhanced to maximise effectiveness (Kazdin, 2007). Mechanisms of change are derived from theory before being tested empirically (Labelle, Campbell, & Carlson, 2010). In this instance, it is theorised that mindfulness interventions reduce rumination as a result of teaching individuals to respond mindfully; examining the literature on this question is an important first step to determining whether rumination may serve as a mechanism of change for MBSR. Existing research examining the mechanisms of change in MBSR has focused predominantly on enhancing mindfulness (Labelle et al., 2010), providing strong evidence that MBSR does indeed enhance mindfulness (Carmody & Baer, 2008; Cohen-Katz et al., EFFECT OF MBSR ON RUMINATION 6 2005; Nyklíček & Kuipers, 2008; Shapiro, Brown, & Biegel, 2007), and enhanced mindfulness mediates some of the benefits found in MBSR (e.g. Carmody & Baer, 2008). Comparatively fewer studies have examined the effects of MBSR on rumination, and none of the literature on mindfulness interventions with children and adolescents has examined potential mechanisms of change (Harnett & Dawe, 2012). There have been a number of reviews in recent years examining the application of mindfulness interventions with adults (e.g. Baer, 2003) and children and adolescents (e.g. Burke, 2009), however there are as yet no published reviews of the effect of MBSR on rumination. This review examines the question of whether MBSR may have the potential to be used as an intervention for reducing depressive symptoms and the risk of later depression, by examining whether MBSR reduces rumination. Search strategy The following electronic databases were searched: PsycARTICLES, PsycINFO, MEDLINE, JSTOR, Science direct, SCOPUS, ISI Web of Knowledge, Springer Link and EBSCO e-journals. The search terms “rumination” and “mindfulness based stress reduction” were used. Articles were included if the study measured the effect of a mindfulness-based stress reduction course on levels of rumination. Dissertations and conference papers were excluded from the review. Nine articles met criteria for inclusion. The effect of MBSR on rumination Table 1 summaries the studies included in this review. Studies are described in chronological order culminating with the most recent research. One of the first studies of MBSR that examined rumination also examined the effect on depression, anxiety, and dysfunctional attitudes with 23 participants compared to a wait EFFECT OF MBSR ON RUMINATION 7 list control group of 11 participants (Ramel, Goldin, Carmona, & McQuaid, 2004). All participants had a lifetime diagnosis of a mood disorder (one quarter met criteria for a current depressive episode). Within-groups analyses were conducted with data from the 23 participants who completed MBSR, whereas between-groups analyses were conducted using data from 11 intervention participants and 11 controls matched on age, gender, and baseline score on the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Both within and between-groups analyses found participants who received MBSR experienced reduced depression, anxiety, dysfunctional attitudes, and importantly, rumination. Notably, greater amounts of mindfulness practice predicted greater reductions in rumination, suggesting regular implementation of mindfulness may be enhance the benefits of MBSR. Rumination accounted for reductions in depressive symptoms providing some support for the meditational mechanism proposed in this review. The design benefited from a control group, which enabled between-group comparisons to be made. However the sample was small, and half the sample met criteria for an anxiety disorder in addition to a lifetime diagnosis of a mood disorder. In addition, one quarter of the sample met criteria for a current major depressive episode. The lack of homogeneity in the sample limits the generalisability of the findings, limits the extent to which conclusions can be drawn as to how the intervention affects individuals with different presentations, such as current or historical depression or anxiety, and limits comparability with other studies. The authors acknowledge randomisation would have enabled the effects of the intervention to be more conclusively attributed to the intervention. Finally, the study had no follow-up period, thus it is unknown whether changes were maintained over time. An RCT conducted with medical students experiencing significant levels of stress compared a condensed version of MBSR with somatic relaxation sessions and a wait-list control group (Jain et al., 2007). Both interventions were delivered over four short (one and a EFFECT OF MBSR ON RUMINATION 8 half hour) sessions, and participants in each intervention attended a six-hour retreat. The aim of the study was to compare the effect of MBSR and somatic relaxation on psychological distress. The study found that both interventions significantly reduced distress and increased positive mood states, with neither intervention significantly better at reducing distress or increasing positive mood than the other. However MBSR participants showed a reduction in rumination, and this reduction partially mediated the effect of the mindfulness intervention on reducing distress. The benefit of including an active control is that it provides some evidence of the specificity of the effects of MBSR, which in this instance demonstrated MBSR affects rumination, unlike the relaxation intervention, and that this reduction accounted for the reductions in distress. Although not strictly examining depressive symptoms, this study lends support to the hypothesis that rumination could be a mechanism through which MBSR exerts its effects. The limitations of this study were the relatively small sample size (N=81 across three conditions), and the inclusion of exclusively medical students who had identified themselves as experiencing significant levels of stress, which limits the generalisability of the findings to other populations. The mindfulness intervention was also a condensed version of MBSR, thus it is difficult to extrapolate what effects the full MBSR intervention may achieve, and comparability across studies is not possible. Limitations aside, the RCT design and comparison to an active treatment (somatic relaxation) was a strength of the design, and enabled the unique effects of MBSR to be distinguished through comparison to a similar intervention. This study suggests that even a shortened version of MBSR can reduce rumination. A study of 54 trainee therapists who completed an MBSR programme found participants who completed the intervention reported decreased rumination and increased mindfulness and self-compassion following intervention compared to controls (Shapiro et al., 2007). Furthermore, increases in mindfulness were mediated by reductions in rumination, anxiety EFFECT OF MBSR ON RUMINATION 9 and stress, and increases in self-compassion. The participants who took part in the 8 week MBSR programme imbedded in a 10-week stress management course, did so as a compulsory aspect of their course, although study participation was voluntary. The control group who had enrolled on a different course, received the same amount of contact time with a trained instructor, but instead of receiving the MBSR intervention, the time was spent studying research methods and psychological theory. The study benefited from inclusion of a control group, however there was no randomisation, and group allocation was based on the students’ course choice, which could have resulted in systematic differences between the intervention and control group. The generalisability of the findings is also limited due to the sample containing exclusively students. Because the intervention contained stress management sessions in addition to MBSR, comparison with other studies is impaired, and the specificity of the effects of MBSR cannot be examined from these data. Finally, no follow-up data were collected; therefore it is not known whether the outcomes were maintained over time. Another study which employed an RCT design compared an adapted version of MBSR to Easwaran’s Eight-Point Program (EPP; Easwaren, 1991), an intervention that shares common components to MBSR, in 44 college students (Oman, Shapiro, Thoresen, Plante, & Flinders, 2008). Both interventions reduced stress, increased forgiveness and showed a trend towards significance in reducing rumination, all of which was maintained at two-month follow-up. Generalisability of the findings is limited due to the sample consisting exclusively of undergraduates from a Roman Catholic University. The small sample size limited statistical power, which could have accounted for the observed reduction in rumination not reaching statistical significance. The design was strengthened by a two-month follow up period, allowing some measure of the maintenance of effects. A follow-up paper that conducted meditational analyses on these data found that enhancing mindfulness EFFECT OF MBSR ON RUMINATION 10 Table 1 Characteristics and findings of studies measuring effect of MBSR on rumination. Author(s) Study Design Pre-post betweenparticipant Mindfulness intervention 8 week MBSR Jain et al., 2007 RCT Shapiro et al., 2007 Betweenparticipant , pre-post Condensed MBSR over 4 x 1½ hour sessions, and one 6 hour retreat 8 week MBSR imbedded in 10 week stress management course Oman et al., 2008 RCT: Prepost, f/up betweengroup Ramel et al., 2004 Adapted MBSR Control Wait list control Somatic relaxation sessions + wait list control Sessions in research methods and psychological theory with trained instructor Easwaran’s Eight-Point Program (EPP; Easwaren, 1991) Participants N Adults with 34 history of mood disorder (1/4 currently depressed) Highly stressed 81 medical students FollowOutcomes up None Reduced rumination (reduced depression, anxiety and dysfunctional attitudes) Rumination Measure RSQ None Reduced rumination (both active conditions reduced distress and increased positive mood) DER RRQ Trainee therapistsparticipation in MBSR was compulsory to their course 54 None Reduced rumination (increased mindfulness and self-compassion) College students 44 2 month Trend towards significance RRQ in reducing rumination (improved stress, increased forgiveness) Enhancement of mindfulness mediated reductions in rumination (Shapiro et al., 2008) EFFECT OF MBSR ON RUMINATION Deyo et al., 2009 11 Withinparticipant , pre-post 8 week MBSR None Self-selected adults with psychological and/or physical health problems Women who had completed cancer treatment 22 Labelle et al., 2010 Pre-post between participant 8 week MBSR Wait-list control MartínAsuero & GarcíaBanda ,2010 Campbell et al., 2012 Withinparticipant pre-post 8 week MBSR Pre-post between participant 8 week MBSR None 77 None None Predominantly health care professionals 29 3 month Wait-list control Women receiving cancer treatment 70 None Reduced rumination (Fewer depressive symptoms, better overall wellbeing) Reduced rumination (depressive symptoms reduced, mindfulness increased), reductions in rumination mediated the impact of MBSR on depressive symptoms Reduced rumination Reduced rumination (enhanced mindful attentiveness) RRQ RRQ ECQ RRQ Reduced rumination RRS (increased mindfulness, increased self-compassion, decreased fear of emotions and difficulties regulating emotions) Note. DER = Daily Emotion Report (Nolen-Hoeksema, Morrow, & Fredrickson, 1993); RSQ = Rumination subscale of the Response Style Questionnaire (RSQ; Nolen-Hoeksema & Morrow, 1991); RRQ = The Rumination-Reflection Questionnaire (Trapnell & Campbell, 1999); RSQ = Ruminative Responses Scale (Nolen-Hoeksema & Morrow, 1991), ECQ = Emotional Control Questionnaire (Roger & Najarian, 1989). Robins et al., 2012 RCT: prepost between participant 8 week MBSR Wait-list control Non-clinical adult sample 41 2 month EFFECT OF MBSR ON RUMINATION 12 accounted for reductions in rumination (Shapiro, Oman, Thoresen, Plante, & Flinders, 2008). This provides further support for the hypothesis explored in this paper; that improving mindfulness reduces rumination. A study of MBSR for 22 adults with a range of physical and psychological problems who self-selected for an MBSR program, found participants reported less rumination, enhanced mindfulness, fewer depressive symptoms, and improved overall wellbeing following the programme (Deyo et al., 2009). A trend approaching statistical significance between increases in mindfulness and reductions in rumination was observed. This study was limited however by the lack of control group, small sample size, and reliance on self-report measures. Additionally the heterogeneity of the sample curtails the generalisability of the findings. Nevertheless MBSR reduced rumination and suggested this may be related to enhancements in mindfulness. A study of 77 women who had completed cancer treatment investigated the effects of MBSR using a wait-list control design (Labelle et al., 2010). Participants who received the intervention reported significantly reduced rumination, in addition to reduced depressive symptoms and increased mindfulness relative to controls. Furthermore, reductions in tendency to ruminate mediated the effect of MBSR on depressive symptoms. Mindfulness was not found to significantly mediate the effect of MBSR on depressive symptoms. This finding directly supports the hypothesis that reduction in depressive symptoms following MBSR is at least in part accounted for by reducing rumination. This study was limited however by lack of randomisation and comparison to an active control condition, and lacked any follow-up. A further limitation of this study was that the sample included exclusively women, which is particularly limiting given that women tend to ruminate more than men (Nolen-Hoeksema & Jackson, 2001). Therefore it is difficult to conclude whether these EFFECT OF MBSR ON RUMINATION 13 findings would also apply to men, as it is possible different processes promote or reduce rumination in women than men. A within-groups pre-post study of the effect of MBSR on 29 professionals found reductions in rumination, and reduced distress and negative affect following the intervention, which was maintained at 3-month follow-up (Martín-Asuero & García-Banda, 2010). This study was limited by the lack of a control condition, however it benefited from the longest follow-up period in any of the studies in this review, suggesting that MBSR may reduce rumination for up to 3 months. A wait-list controlled study of 70 women who were receiving cancer treatment found in between-groups analyses that MBSR reduced rumination and increased mindful attention in participants who received the intervention compared to controls (Campbell, Labelle, Bacon, Faris, & Carlson, 2012). There were a number of limitations to the study however including lack of randomisation, lack of an active control condition, and lack of follow-up. As noted with the previous study of women who had completed cancer treatment (Labelle et al., 2010), an exclusively female sample is limiting given the gender difference in rumination (NolenHoeksema & Jackson, 2001), thus further research with equal gender distribution across study arms is required. The most recent study that examined the effect of MBSR on rumination was an RCT that measured the effects on emotion regulation in a non-clinical sample of adults (Robins, Keng, Ekblad, & Brantely, 2012). A non-significant trend towards reduced rumination was observed following the intervention, however by 2-month follow-up, within-groups analyses found participants who had received the intervention reported significantly lower levels of rumination. The authors suggest that mindfulness practice may have accounted for the observed reduction in rumination at follow-up, which is consistent with the notion that it is the direct application and regular practice of mindfulness that may account for the effects of EFFECT OF MBSR ON RUMINATION 14 MBSR. However this study did not measure mindfulness practice thus it is not possible to draw this conclusion from these data. A notable strength of this study was the randomised controlled design, which allowed the observed findings to be attributed to the intervention, and inclusion of a follow-up period, enabling examination of the effects across time. Discussion This review sought to examine whether MBSR has the potential to serve as an intervention for reducing depressive symptoms and the risk of later depression, by examining whether MBSR is effective at reducing rumination. The 9 studies reviewed here provide preliminary evidence that MBSR reduces rumination, at least with adults. In relation to rumination as a mechanism of change for reducing depressive symptoms, a number of studies examined the relationship between increases in mindfulness and reductions in rumination following MBSR, with one study concluding that reductions in rumination mediated the effect of MBSR on depressive symptoms (Labelle et al., 2010), and another that reductions in rumination mediated the effect of MBSR on distress (Jain et al., 2007). This supports the hypothesis that rumination may be a mechanism through which MBSR could reduce depressive symptoms. One factor that warrants future investigation is mindfulness practice; two studies found the extent to which participants practiced mindfulness was related to more positive outcome (Ramel et al., 2004; Shapiro et al., 2008), and one study attributed the finding that rumination reduced at follow-up but not post-intervention to the result of practice, although practice had not been measured (Robins et al., 2012). Theoretically it could be expected that more frequent practice of mindfulness reduces rumination to a greater extent, a habitual thinking patterns are likely to take repeated practice to overcome. Future research should measure participant practice across time to explore whether greater practice does indeed predict better outcome. EFFECT OF MBSR ON RUMINATION 15 Further research is warranted regarding the impact of MBSR on rumination, as the existing literature contains methodological flaws. The literature in this area is limited; only 9 articles were available for review. Most studies utilised a pre-post between-participant design, however three studies randomly allocated participants to condition (Jain et al., 2007; Oman et al., 2008; Robins et al., 2012). Two studies had no control condition (Deyo et al., 2007; Martín-Asuero & García-Banda, 2010), however three studies included an active control, either somatic relaxation sessions, or the Easwaran’s Eight-Point Program (EPP; Easwaren, 1991), a programme which shares some similarity with mindfulness as it involves regular meditation practice using passages of text. Only two studies included a follow-up (Martín-Asuero & García-Banda, 2010; Robins et al., 2012), the longest follow-up period was 3 months. Three studies did not deliver “pure” MBSR, one was condensed to a shorter four-session programme with a 6-hour retreat, one followed an adapted programme, and another was embedded in a longer stress management course (Jain et al., 2007; Oman et al., 2008; Shapiro et al., 2007). The participants varied from self-selected community samples with no particular psychological or physical difficulties, to adults with serious physical health conditions or stress. All studies relied exclusively on self-report measures of rumination. The dearth of randomised controlled studies and comparison to active treatments limits the extent to which the observed reduction in rumination in most studies can be attributed to MBSR and not participant characteristics or non-specific treatment effects. Comparability between studies is limited due to several studies delivering adapted MBSR programmes. In addition, adaptations to the MBSR interventions were described in limited detail, rendering replication of these studies challenging. The use of heterogeneous samples also limits comparability and hinders conclusions regarding which individuals benefit most from MBSR. Additionally, many studies used small samples, which could have accounted for the non-significant reductions in rumination found in two studies (Oman et al., 2008; Robins EFFECT OF MBSR ON RUMINATION 16 et al., 2012). Larger samples would have increased statistical power. All studies used selfreport measures exclusively. Future research could employ experimental designs to provide a richer test of the hypothesised benefits of mindfulness, for example to measure whether participants who have received MBSR recover quicker from a low mood induction task as a result of reduced rumination. Finally, although a number of studies included follow-up assessments, the longest follow-up period was three-months, thus it is difficult to conclude to what extent reductions in rumination can be maintained over time. Future research that aims to further examine the potential of MBSR to reduce rumination requires larger samples to maximise statistical power, must randomise participants drawn from homogenous groups to either MBSR or an active control, measure outcomes at multiple time points, and include a lengthy follow-up period. Mediation analyses will provide a first step to unpicking whether rumination does indeed mediate the effects of MBSR. In addition, the effect of quantity of mindfulness practice on outcome requires further investigation. Conclusions Despite the methodological weaknesses of the literature, the evidence reviewed here suggests that MBSR can reduce rumination, at least with adults. This finding is particularly significant given the strong links between rumination and depressive symptoms (Burwell & Shirk, 2007) and the later onset of depression (Broderick & Korteland, 2004; NolenHoeksema, 2000). Further research is required to determine whether MBSR, through reducing rumination, can reduce depressive symptoms and prevent depression. It is particularly pertinent that this question is examined with children and adolescents, as this age group is arguably a critical period to introduce interventions aimed at reducing depressive symptoms, given that half of all psychological disorders occur for the first time during EFFECT OF MBSR ON RUMINATION 17 childhood or adolescence (Kessler et al., 2005; Patel, Flisher, Hetrick, & McGorry, 2007), with 75% of adults who meet criteria for major depressive disorder having experienced their first episode prior to the age of 18 (Kim-Cohen et al., 2003). This review suggests that MBSR may be effective in reducing rumination in adults, however it is currently unknown whether the same is true for children or adolescents. There are as yet no studies of mindfulness interventions with children or adolescents that have investigated the mechanisms of change (Harnett & Dawe, 2012), although literature in this area is growing (Burke, 2009). Research on the effects of MBSR on rumination in children and adolescents should begin initially with piloting and feasibility studies, and progress to evaluation studies (Craig et al., 2008). This review suggests that MBSR reduces rumination in adults. Research must now investigate whether this finding applies to children and adolescents, as an intervention that reduces rumination would reduce one of the key risk factors for depressive symptoms and depression (Burwell & Shirk, 2007; Broderick & Korteland, 2004; Nolen-Hoeksema, 2000). If the findings of this review can be replicated with children and adolescents, MBSR may well have the potential to be used as an intervention for the reduction of depressive symptoms and prevention of depression. EFFECT OF MBSR ON RUMINATION 18 References Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125-143. Beck, A. T., Ward, C. 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