Decision making and its correlates in recurrent depressive disorder

Abstract

Objective:

Decision-making (DM) is simply choosing among alternatives or defining one's course of action. A depressed individual does not perceive himself as a decision-maker as ruminations reinforce dysfunctional metacognitive beliefs and poor executive functioning. The aim was to study and compare the relationship among DM, metacognition, and executive functioning in those with recurrent depressive disorder (RDD) and in healthy controls (HCs).

Methods:

A cross-sectional comparative group study design was used with a sample size of 40, with 20 participants in each group. The tools used were Mini International Neuropsychiatric Interview, General Health Questionnaire, Melbourne Decision Making Questionnaire, Metacognitive Questionnaire, Wisconsin Card Sorting Test, and Controlled Oral Word Association Test.

Results:

The RDD group had significantly higher scores on buck-passing (BP), procrastination (PR), hypervigilance, and dysfunctional metacognitive beliefs, and poor performance on executive functioning than HC. PR was inversely correlated with executive functioning and dysfunctional metacognitive beliefs in the RDD group, whereas in the HC group, BP was positively correlated with executive functioning and dysfunctional metacognitive beliefs.

Conclusion:

DM has a significant relationship with executive functions and dysfunctional metacognitive beliefs; therefore, changes in any one variable contribute to changes in the other two. The altered attentional and executive control due to dysfunctional metacognitive beliefs leads to poor DM, resulting in psychosocial dysfunction. The underlying metacognitive beliefs and executive functioning play a crucial role in DM, the process determining psychosocial functioning.

INTRODUCTION

Decision-making (DM) is choosing among alternatives or defining one's course of action. It involves assessment of all the available options, cost-benefit analysis, and evaluating the outcome of the selected option.[1] The somatic marker hypothesis (SMH) explains role of emotions in DM through the ventromedial prefrontal cortex (vmPFC).[2,3] VmPFC controls both cognitive processes and emotions,[4] thus a person with depressive disorders is less likely to actively take decisions as he is spiraling the cognitive triad of negative belief about self, world, and future along with depressogenic cognitions centered around hopelessness, helplessness, and worthlessness.[5] According to SMH, these neural changes result in difficulty in planning, choosing friends, partner, or activities. Decisions taken by individuals are usually those with disadvantageous outcomes that are different from one's premorbid self. This impairs the functioning and might lead to disability in the long term as some of the deficits in working memory, sustained attention, verbal fluency, and visuo-motor skills continued to persist even in euthymic state of illness.[6,7] The severity and intensity of depressive symptoms and episode is correlated to the cognitive dysfunction and impaired psychosocial functioning.[6,8] The poor judgement leading to over or under estimation of one's own cognitive capacities due to poor awareness might also lead to behaviors resulting into lowered self-esteem and increased affective symptoms.[9,10] A depressed individual does not perceive himself as a decision maker due to worry and low self-esteem.[11,12] The dysfunctional metacognitive beliefs have been found to be related with psychopathology with negative beliefs about uncontrollability and danger of worry being the strongest predictor of depression.[13] Therefore, metacognition is one's ability to control thinking processes through various strategies, such as organizing, monitoring, and adapting and alterations in metacognitive beliefs in clinical population can disrupt daily functioning.[14,15]

The knowledge of underlying processes of DM and metacognitive beliefs and its role in depressive disorders might contribute in the development of novel interventions for depressive disorders. This might result in decreasing the disability caused due to depressive disorders. Consequently, we studied DM, metacognitive beliefs and executive functioning among individuals with depressive disorder in comparison to healthy controls (HCs).

MATERIAL AND METHODS

Design and setting

A cross-sectional comparative group design was employed. The sample comprised 40 participants, 20 participants with diagnosis of recurrent depressive disorder (RDD)[16] and 20 HCs. The clinical sample was recruited from the outpatient department (OPD) of Psychiatry of a government tertiary care center located in an urban area. HCs were bystanders of the patients visiting non-psychiatry OPDs of the center.

Participants

The participants included in the clinical sample were 20–45 years of age, having a minimum of 10 years of education, those having 2–5 depressive episodes in the past. Whereas those having any psychiatric comorbidity, suicidality, unstable medical condition, terminal illness or neurological condition; undergoing evidence-based psychotherapy or electroconvulsive therapy or yoga, currently or in the past 6 months, were excluded. HCs were males and females aged 20–45 years having a minimum of 10 years of education without any psychiatric morbidity (score of <3 on GHQ), unstable medical condition, terminal illness, or neurological condition; or practicing therapy or yoga, currently or in the past 6 months.

Tools used

General Health Questionnaire (GHQ-12) was used to assess psychological distress in HCs. The General Health Questionnaire (GHQ 12) was developed by Goldberg (1972). It has 12 items and measures an individual's well-being, depressive and anxiety symptoms, and sleep-related issues over a period of recent 4 weeks. The scale has four response options: better than usual, same as usual, less than usual, and much less than usual. The cutoff for the scale is 3; a score of more than 3 indicates the presence of psychological symptoms.

Mini International Neuropsychiatric Interview (MINI 7.0.2) developed by Sheehan et al. assesses 17 most common mental disorders based on DSM 5 and ICD10.[17] It has been shown to have very good reliability and validity when compared to other longer structured diagnostic interviews SCID-P and CIDI. It was used to make an objective diagnosis of RDD and rule out psychiatric comorbidities. The administration includes screening questions in a grey box, and the interviewer is guided by an algorithm, where one can be led to the entire module after the screening question or can skip and move to the next module. In this way, the administration generates a diagnosis. The time taken for administration has a median of 15–22 minutes.

Beck Depression Inventory (BDI-II) developed by Beck, Steer, and Brown in 1996 measures the severity of depression.[18] It includes 21 items on a 4-point Likert scale, with scores ranging from 0 to 3. The total maximum score comes up to 63. A score of 0–13 indicates minimal depression, a score of 14–19 indicates mild depression, 20–28 indicates moderate depression, and a score of 29–63 indicates severe depression.

Melbourne Decision Making Questionnaire (MDMQ) developed by Leon Mann et al. in 1997 includes 22 items responded to on a 3-point scale, with 0 (not at all true), 1 (somewhat true), and 2 (very true). Higher scores indicate the dominant style of DM. The items assess four subscales that measure DM styles, vigilance (VG) (rational approach, implying adequate attention, processing, and evaluation of information in DM), buck-passing (BP) (leaving DM to others and avoiding responsibility), procrastination (PR) (putting off or delaying DM), and hypervigilance (HV) (an anxious hurried approach, spending a great amount of time trusting one's DM).[19]

The Metacognitive Questionnaire (MCQ 30), developed by Wells and Hawtton in 2004, assesses the metacognitive model of psychological disorders.[20] It includes 30 items rated on a 4-point Likert scale from 1 to 4. The subscales assessing dysfunctional metacognitive beliefs include positive belief about worry, negative beliefs about uncontrollability and danger of worry, cognitive confidence, need for control, and cognitive self-consciousness. It takes around 25–30 minutes to complete. Higher scores indicate higher levels of dysfunctional metacognitive beliefs.

Wisconsin Card Sorting Test (WCST) is a sub-test from NIMHANS Neuropsychology Battery-2004 by Shobini L Rao.[21] WCST was developed by Heaton in 1981. It is a measure of set-shifting ability; however, it is also said to be the test of executive function. It includes four stimulus cards and 128 response cards. There are different geometrical figures in different colors. The subject has to place the response cards one by one against the stimulus card by using a certain rule of matching. The examiner gives feedback on whether the rule used by the subject is correct or wrong, according to which he has to change his rule of matching the cards; however, it is not told to the subject. The authors used four parameters of measuring score for the current study, namely total number of errors, perseverative errors, non-perseverative errors, and number of trials to complete the six categories. There are other scoring categories included in WCST. It takes around 30 minutes to complete.

Controlled Oral Word Association Test (COWA-FAS) is also a sub-test from NIMHANS Neuropsychology Battery-2004 by Shobini L Rao.[21] COWA-FAS was developed by Benton and Hamsher in 1989 as a measure of phonemic fluency. Each participant is instructed to speak as many words as he can starting with the consonant presented to him in span of one minute one consonant at a time. The mean of acceptable new words from three trials form the score. The current study used Hindi consonants (Ka, Pa, and Ma), and it took around 5 minutes to complete.

Procedure

The research proposal was approved by the Ethics Committee of the Hospital, and individual consent was taken from all the participants as per the Declaration of Helsinki.[22] The participants were approached to seek consent. The researcher gathered sociodemographic and clinical details of all the participants who consented, and those not fulfilling the criteria were excluded. The RDD sample was administered Mini International Neuropsychiatric Interview (MINI 7.0.2) to diagnose RDD and to rule out psychiatric comorbidity. Subsequently, Beck Depression Inventory (BDI-II) was administered to assess the severity of depressive episodes. HCs were assessed on the General Health Questionnaire (GHQ 12) to rule out psychiatric morbidity, and those having scores >3 were excluded.[23] The participants once recruited [Figure 1] were assessed on the tools, namely Melbourne Decision Making Questionnaire (MDMQ), Metacognitive Questionnaire (MCQ 30), Wisconsin Card Sorting Test (WCST), and Controlled Oral Word Association Test (COWA-FAS). The time taken for the assessment to recruit participants in both groups was approximately 25–35 minutes, whereas the tools to assess comparative measures took 50–70 minutes each.

Figure 1.

Procedure

Statistical analysis

The quantified data were analyzed using the Statistical Package for the Social Sciences version 20.0 for Windows. The sociodemographic variables of the two groups were compared using tests of significance, with the Chi-square test of goodness-of-fit being used for discrete variables and independent t-test being used for continuous variables. The difference in the scores of executive function, metacognition, and DM between the two groups were compared using independent t-test. The test of correlation was computed among executive functions, dysfunctional metacognitive beliefs, and DM styles for both groups. Further analysis of regression was computed for significantly correlated variables in both groups to quantify the variation produced in the dependent variable (DV) by the independent variable (IV).

RESULTS

Table 1 displays the participants' variables.

Table 1.

Descriptive statistics of sociodemographic details and scores on assessment measures in RDD and HC groups

Variables	M (SD)/f (%)		P
	RDD	HC
Age	36.30 (7.43)	36.50 (7.23)	0.952
Sex
Female	12 (60)	8 (40)	1.000
Male	8 (40)	12 (60)
Education	11.95 (2.58)	13.40 (2.23)	0.065
Marital status
Unmarried	3 (15)	12 (60)	0.114
Married	17 (85)	8 (40)
Occupation
Student	1 (5)	5 (25)
Unemployed	1 (5)	3 (15)	0.002**
Job	9 (45)	11 (55)
Housewife	9 (45)	1 (5)

***P<0.001; **P<0.01; *P<0.05. M – Mean; SD – Standard Deviation; f – Frequency; % – Percentage

Table 2 shows that the clinical sample had higher scores on dysfunctional metacognitive beliefs and poor performance on executive functioning than HC. The RDD group had significantly higher scores on BP, PR, and HV than HC.

Table 2.

Comparing the difference of scores on assessment measures between RDD and HC groups by using independent t-test

Variables	M (SD)		t (df 38)	P
	RDD	HC
WCST
NOE	49.65 (21.79)	31.70 (18.42)	−2.81	0.008**
PE	29.35 (14.59)	16.80 (9.54)	−3.22	0.003**
NPE	20.30 (9.20)	15.00 (9.59)	−1.78	0.082
TT	119.15 (14.48)	102.35 (21.97)	−2.86	0.007**
COWA	8.10 (2.95)	12.40 (3.17)	4.44	0.000***
MCQ 30
MCQ	78.25 (9.97)	63.45 (14.25)	−3.81	0.000***
POS	12.35 (2.98)	12.10 (5.00)	−0.19	0.849
NEG	18.30 (4.32)	12.05 (3.43)	−5.07	0.000***
CC	13.35 (4.73)	9.90 (4.42)	−2.38	0.022*
NC	16.70 (4.26)	12.20 (3.68)	−3.58	0.001**
CSC	17.05 (3.59)	17.20 (4.17)	0.122	0.904
MDMQ
VG	10.05 (2.30)	10.45 (1.43)	0.66	0.514
BP	7.30 (2.75)	4.70 (2.34)	−3.22	0.003**
PR	6.10 (3.04)	3.55 (2.91)	−2.71	0.010*
HV	6.10 (2.29)	3.75 (2.31)	−3.23	0.003**

***P<0.001; **P<0.01; *P<0.05; NOE – Number of Errors; PE – Perseverative Errors; NPE – Non-Perseverative Errors; TT – Total Trials; POS – Positive Belief About Worry; NEG – Negative Beliefs About Uncontrollability and Danger of Worry; CC – Cognitive Confidence; NC – Need For Control; CSC – Cognitive Self-Consciousness; VG – Vigilance; BP – Buck-Passing; PR – Procrastination; HV – Hypervigilance

Tables 3 and 4 show the correlation among measurement variables in the RDD and HC groups, respectively, with significant values of correlation of coefficient ranging between 0.40 and 0.70, indicating moderate to strong strength of relationship.[24] The correlation analysis in the clinical sample [Table 3] revealed an inverse relationship between executive functioning (PE) and dysfunctional metacognitive beliefs (NC) as well as DM (PR). This means as executive functioning improves, PR and the need for control decrease. PR also increased as cognitive confidence increased.

Table 3.

Relationship among executive function, metacognition, and decision-making by using correlation analysis in the RDD group (n=20)

Variables	WCST				COWA	MCQ 30						MDMQ
	NOE	PE	NPE	TT		MCQ	POS	NEG	CC	NC	CSC	VG	BP	PR	HV
WCST
NOE	1	0.948**	0.864**	0.808**	−0.516*	−0.279	−0.235	−0.285	0.011	−0.409	0.034	0.168	−0.131	−0.525*	−0.222
PE	-	1	0.660**	0.749**	−0.511*	−0.375	−0.244	−0.379	0.000	−0.482*	0.001	0.200	−0.113	−0.475*	−0.166
NPE	-	-	1	0.724**	−0.412	−0.066	−0.169	−0.073	0.027	−0.203	0.079	0.081	−0.130	−0.490*	−0.261
TT	-	-	-	1	−0.276	−0.101	−0.297	−0.152	0.033	−0.078	0.108	0.082	0.012	−0.434	−0.237
COWA	-	-	-	-	1	−0.010	0.133	−0.102	0.114	−0.039	−0.065	0.022	0.391	0.426	0.379
MCQ 30
MCQ	-	-	-	-	-	1	0.332	0.618**	0.500*	0.558*	0.486*	−0.149	0.152	0.279	0.142
POS	-	-	-	-	-	-	1	0.065	0.279	−0.261	−0.076	−0.217	0.173	0.379	0.396
NEG	-	-	-	-	-	-	-	1	0.002	0.495*	0.186	−0.060	−0.083	0.078	0.082
CC	-	-	-	-	-	-	-	-	1	−0.057	−0.116	−0.417	0.424	0.488*	0.288
NC	-	-	-	-	-	-	-	-	-	1	0.256	0.130	−0.234	0.047	−0.288
CSC	-	-	-	-	-	-	-	-	-	-	1	0.362	0.062	−0.328	−0.065
MDMQ
VG	-	-	-	-	-	-	-	-	-	-	-	1	−0.168	−0.339	−0.051
BP	-	-	-	-	-	-	-	-	-	-	-	-	1	0.417	0.612**
PR	-	-	-	-	-	-	-	-	-	-	-	-	-	1	0.723**
HV	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1

***Correlation is significant at 0.001; **Correlation is significant at 0.01; *Correlation is significant at 0.05

Table 4.

Relationship among executive functions, metacognition, and decision-making by using correlation analysis in the HC group (n=20)

Measures	WCST				COWA	MCQ 30						MDMQ
	NOE	PE	NPE	TT		MCQ	POS	NEG	CC	NC	CSC	VG	BP	PR	HV
WCST
NOE	1	0.962**	0.962**	0.935**	−0.204	0.123	0.198	−0.002	−0.131	0.274	0.081	−0.048	0.613**	−0.098	−0.008
PE	-	1	0.852**	0.874**	−0.208	0.124	0.264	−0.072	−0.058	0.210	0.042	−0.089	0.492*	−0.181	0.100
NPE	-	-	1	0.930**	−0.194	0.104	0.115	0.061	−0.197	0.312	0.101	−0.015	0.682**	−0.009	−0.121
TT	-	-	-	1	−0.292	0.122	0.219	0.034	−0.074	0.287	−0.050	−0.042	0.699**	0.052	−0.013
COWA	-	-	-	-	1	0.061	−0.106	0.173	0.089	−0.030	0.125	−0.309	−0.309	−0.054	−0.244
MCQ 30
MCQ	-	-	-	-	-	1	0.669**	0.729**	0.591**	0.744**	0.731**	0.279	0.462*	0.382	0.495*
POS	-	-	-	-	-	-	1	0.221	0.376	0.250	0.284	−0.058	0.528*	0.159	0.425
NEG	-	-	-	-	-	-	-	1	0.261	0.680**	0.526*	0.317	0.376	0.356	0.307
CC	-	-	-	-	-	-	-	-	1	0.157	0.155	0.149	−0.094	0.499*	0.517*
NC	-	-	-	-	-	-	-	-	-	1	0.635**	0.352	0.539*	0.255	0.266
CSC	-	-	-	-	-	-	-	-	-	-	1	0.292	0.259	0.068	0.147
MDMQ
VG	-	-	-	-	-	-	-	-	-	-	-	1	0.152	−0.088	−0.028
BP	-	-	-	-	-	-	-	-	-	-	-	-	1	0.157	0.112
PR	-	-	-	-	-	-	-	-	-	-	-	-	-	1	0.428
HV	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1

***Correlation is significant at 0.001; **Correlation is significant at 0.01; *Correlation is significant at 0.05

This is different from the findings in HC [Table 4] where executive functioning (NOE, PE, NPE, TT) and dysfunctional metacognitive beliefs (MCQ, POS, NC) were observed to be positively correlated with BP style of DM. Cognitive confidence was positively correlated with PR and HV DM.

Regression analysis determines the coefficient of determination (R²), predicting the amount of change in a DV contributed by an IV. The number of errors accounts for 23% of the total variation in PR (R² = 0.235). That is, for NOE and PR data, 23% variation is accounted for by the difference in the number of errors on WCST. This means 67% variation is not accounted for by the difference in the number of errors and might be due to inherent variability or other unknown factors. Similarly, perseverative error scores account for a 19% variation in the need for control and an 18% variation in PR. Non-perseverative errors and cognitive self-consciousness account for a 20% variation in PR [Table 5].

Table 5.

Relationship between IV and DV by using regression analysis in the RDD group (n=20)

IV	DV	r	Regression						Beta
			B	SE	F	Adjusted R2	t	P
NOE	PR	−0.525*	9.737	0.028	6.848	0.235	−2.62	0.017*	−0.525
PE	NC	−0.482*	20.824	0.060	5.445	0.190	−2.33	0.031*	−0.482
	PR	−0.475*	9.005	0.043	5.244	0.183	−2.29	0.034*	−0.475
NPE	PR	−0.490*	9.390	0.068	5.691	0.198	−2.39	0.028*	−0.490
CC	PR	0.488*	1.908	0.132	5.624	0.196	2.37	0.029*	0.488

***P<0.001; **P<0.01; *P<0.05. IV – Independent Variable; DV – Dependent Variable; r – Correlation; SE – Standard Error

The findings of regression analysis in HC [Table 6] reveal that variation in BP is 34% accounted by number of errors, 20% by perseverative errors, 44% by non-perseverative errors, and 46% by total trials taken in task completion. For metacognition, 24% variation in BP is accounted for positive beliefs about worry and 25% for the need for control. Cognitive self-consciousness accounts for a 21% variation in PR and less than 1% variation in HV.

Table 6.

Relationship between IV and DV by using regression analysis in the HC group (n=20)

IV	DV	r	Regression
			B	SE	F	Adjusted R2	t	P	Beta
NOE	BP	0.613**	2.23	0.024	10.81	0.341	3.29	0.004**	0.613
PE	BP	0.492*	2.67	0.050	5.74	0.200	2.39	0.028*	0.492
NPE	BP	0.682**	2.20	0.042	15.67	0.436	3.96	0.001**	0.682
TT	BP	0.699**	−2.93	0.018	17.19	0.460	4.15	0.001**	0.699
MCQ	BP	0.462*	−0.11	0.034	4.88	0.169	2.21	0.040*	0.462
	HV	0.495*	−1.35	0.033	5.85	0.203	2.42	0.026*	0.495
POS	BP	0.528*	1.71	0.094	6.96	0.239	2.64	0.017*	0.528
CC	PR	0.499*	0.29	0.134	5.97	0.207	2.44	0.025*	0.499
	HV	0.517*	9.97	0.075	0.41	0.032	0.64	0.531	0.149
NC	BP	0.539*	0.52	0.126	7.36	0.251	2.71	0.014*	0.539

***P<0.001; **P<0.01; *P<0.05

DISCUSSION

The study compares findings on DM, metacognitive beliefs, and executive functions in individuals with RDD in comparison to HC. The participants in the two groups significantly differed in their occupation types; however, the current study being small in sample size did not elicit if differences in occupation have any relation with assessment variables. It was revealed that the two groups differed on DM, with the RDD group having higher scores on BP, PR, and HV than HC. The HC group had a higher score on the VG style of DM, but it was not statistically significant. Previous studies have found that VG style is more prevalent among HC, whereas non-vigilant styles (HV, BP, and PR) have been reported in individuals with depressive disorders.[25] The non-vigilant styles of DM are also connected with low self-esteem and considered defensive avoidance where an individual chooses either PR to avoid failure or BP to avoid blame for bad consequences.[26] The RDD sample was also found to have significantly higher metacognitive dysfunctional beliefs than HC. The results of the studies have shown that the clinical sample got elevated scores on dysfunctional metacognitive beliefs with significant differences in domains, namely negative beliefs about uncontrollability and danger of worry, cognitive confidence, and need for control, as observed in the findings of the current study as well.[27,28] These dysfunctional metacognitive beliefs further predict worry and rumination, which then result in poor emotional coping responses manifesting in defensive DM.[29,30] Therefore, a task that might be cognitively important appears to be emotionally unattractive, leading to an avoidant or defensive style of DM.[25,26,31,32]

Dysfunctional metacognitive beliefs regulate cognitive attentional syndrome (CAS) and self-regulatory executive function (S-REF), resulting in poor executive functioning, which contributes to perseveration in DM.[13,33,34] Executive functions (EFs) are direct predictors of DM, and the performance of the RDD sample was significantly poorer than that of HC on tests of COWA (verbal fluency) and WCST, the most widely used measure of executive functions in research – involving organization, planning, set-shifting, etc., – linked with vmPFC.[35,36] The clinical sample had a greater number of errors than HC and took more trails to complete the task of executive functions.

The analysis of the relationship among variables revealed that executive functioning is inversely related to PR and dysfunctional metacognitive belief, which is further positively related to PR with 20%–23% variation. In contrast, in HC, error scores on tests of executive functioning were positively correlated with BP, implying that as executive functions deteriorate, BP increases; furthermore, dysfunctional metacognitive beliefs were found to be positively correlated with BP and HV, with 3%–46% variation accounted for. PR is considered to be a self-regulatory failure, and as executive control decreases, dysfunctional metacognitive beliefs increase.[29,37] PR is a dysfunctional DM style and is labeled as indecisiveness, wherein one avoids or does not work at all as one is distracted by pleasant activities or thoughts.[31,32] This explains why despite having anhedonia, many individuals with depressive disorders choose and indulge in activities that are not goal-oriented or are aimless.[38] In addition, evidence also comes from studies on worry and rumination, where these thoughts distract the individual from the goal and reinforce PR.[32,37]

In contrast, BP is more significantly correlated with anxiety, where the fear of being blamed is avoided by passing on the responsibility to another individual for making decisions.[26] The VG style, which is not a feature of the clinical population, was not seen even among the HCs in the current study. This might be attributed to findings that the two groups did not differ on positive beliefs about worry, a type of dysfunctional metacognitive belief that is also related to defensive DM[34,39] and is seen in people at risk.[40] The DM style varied even among HCs as they differ in personality traits and attachment style.[11,37] The current study also found that VG style in DM had a greater mean when compared with the clinical sample, whereas in the HC group, BP was chosen maximally over PR and HV. The current study also revealed a linear relationship between CC and PR; poor self-esteem in depressive disorders decreases cognitive confidence, causing a sense of doubt manifested in low self-confidence, which pushes individuals to procrastinate due to fear of failure.[12,29,30]

Limitations of the study

The sample size was too small, and the two groups were not matched. The clinical and confounding variables could neither be controlled nor statistically analyzed. Nevertheless, this study was novel in exploring the strength of the relationship among the three measures. This implies the role of cognitive remediation psychotherapies in addressing executive functions and that metacognitive beliefs may bring better treatment outcomes.

CONCLUSION

DM has a significant relationship with executive functions and dysfunctional metacognitive beliefs; therefore, changes in any one variable contribute to changes in the other two. The altered attentional and executive control due to dysfunctional metacognitive beliefs leads to poor DM, resulting in psychosocial dysfunction. Hence, psychological interventions must take this into consideration while addressing the psychosocial dysfunction of individuals with depressive disorders. The findings have valuable implications for mental health professionals (MHPs) in understanding the role of the DM process in the management and rehabilitation of individuals with depressive disorders. It is important for MHPs to educate the patients and families about this and suggest postponement of important decisions till the episode is resolved. Future studies can be carried out with a larger sample size and matched group design comparing the differences among persons with anxiety or mood disorders.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.