A systematic review of the effects of rumination-focused cognitive behavioral therapy in reducing depressive symptoms

Depression affects approximately 3.8% of the global population and has a high prevalence reported across countries, contributing substantially to global disease burden and personal, social, and economic costs. CBT is recommended for unipolar depression and shows benefits in prevention, remission, and reducing recurrence. However, CBT’s effectiveness may be limited by its less direct focus on depressive rumination—a key risk factor strongly associated with the onset, persistence, poor recovery, slower treatment response, and relapse of depression. Rumination, defined as repetitive, self-focused negative thinking, can become a mental habit driven by stimulus-response mechanisms and goal discrepancies. Traditional CBT’s emphasis on challenging thought content may be less effective in altering habitual rumination. RFCBT was developed by modifying CBT to directly target rumination. It conceptualizes rumination as a mental habit and employs functional analysis, stimulus control, behavioral activation, and training in concrete, action-oriented processing styles (e.g., If-Then contingency plans), aiming to identify and manage rumination cues and form adaptive thinking habits. Unlike standard CBT, RFCBT emphasizes transforming thinking processes rather than directly disputing negative thought content. Given rumination’s strong linkage to depressive disorders and higher relapse rates in depression compared to anxiety after standard CBT, this review specifically evaluates RFCBT’s effects on depressive symptoms across three stages: prevention of onset, treatment/remission, and prevention of relapse/recurrence, and discusses psychological and neurobiological mechanisms underlying RFCBT.

Design: Systematic review conducted per PRISMA guidelines. Databases and timeframe: PubMed, Web of Science, Google Scholar, and Embase, searched up to April 30, 2024. Framework: PICO-S (Population: individuals with depressive symptoms, diagnosed depression, or high risk; Intervention: RFCBT; Comparators: any comparator or none; Outcomes: depressive symptoms and rumination; Study designs: excluding abstracts, protocols without implemented RFCBT, conference papers, reviews). Search terms: (depress* OR mood OR affect OR rumination) AND ("Rumination Focused Cognitive behavio* Therapy" OR RFCBT), adapted to each database. Inclusion criteria: English-language, primarily targeted RFCBT, validated measures of depressive symptoms. Exclusion criteria: interventions integrating non-RFCBT elements, studies not focused on depressive symptoms/unipolar depression/depressed groups, protocols or conference papers without implemented RFCBT, reviews, unpublished non–peer-reviewed manuscripts. Study selection: Initial records = 382; after de-duplication = 324; title/abstract screening excluded 261; full-text assessed = 63; full-text excluded = 51; included = 12. Reasons for exclusion included language, lack of validated depression measures, not focused on depression or RFCBT, protocols/conference papers, reviews, and duplication with a published dissertation. Data extraction: Independently by two researchers (authors), capturing authors/year, country, sample size, sample characteristics, design, RFCBT format, duration, follow-ups, targeted stage, measures, and main findings, with consensus on discrepancies. Synthesis: Narrative synthesis of intervention characteristics and outcomes across prevention, treatment/remission, and relapse prevention stages.

Included studies: 12 total; 10 randomized controlled trials. Prevention of depression onset: 5 studies assessed prevention; 4 reported significant reductions in depressive symptoms post-intervention (Mak 2023; Cook 2019; Topper 2017; Jung 2019). Cook (2019) found guided i-RFCBT and unguided i-RFCBT reduced depression risk compared to usual care with similar effects (guided HR = 0.66, 95% CI [0.35, 1.25]; unguided HR = 0.64, 95% CI [0.33, 1.24]). Topper (2017) reported lower 12-month incidence of depression in group RFCBT (15.3%) and internet RFCBT (14.7%) vs waitlist control (32.4%), and greater reductions in repetitive negative thoughts for both active formats. Mak (2023) observed significant time effects on depression across RFCBT, mindfulness-based intervention (MBI), and psychoeducation, with differential trajectories for rumination between RFCBT and MBI (RFCBT showing reductions at 3 months and renewed decreases by 9 months; MBI returning to baseline by 9 months). Umegaki (2022) found significant rumination reductions but no significant post-intervention changes in depression, potentially due to low baseline depression. Treatment/remission: In non-responsive chronic depression, Moeller (2019) reported 71% therapeutic response and 50% complete remission, with sustained improvements at 3 months; Hvenegaard (2019) found greater observer-rated depression improvement post-treatment for group RFCBT vs group CBT, but no differences in self-reported depression or rumination at 6 months. Residual symptoms: Watkins (2011) showed RFCBT + treatment-as-usual (TAU) improved residual symptoms and remission rates vs TAU alone; changes in rumination mediated treatment effects. Relapse prevention: Jacobs (2016) and Bessette (2020) (adolescents/youth) reported lower depressive scores during 8 weeks and benefits maintained up to 2 years vs assessment-only; RFCBT was associated with slower and less frequent relapses and fewer hospitalizations for suicidality. Langenecker (2024) found greater decreases in rumination and targeted cross-network connectivity vs TAU. Delivery format comparisons: Unguided web-based RFCBT yielded similar effect sizes to guided versions (Cook 2019). Group vs internet RFCBT showed comparable efficacy in reducing incidence and repetitive negative thoughts (Topper 2017). Mechanisms: Rumination consistently mediated RFCBT effects on depressive symptoms (Watkins 2011; Jung 2019; Topper 2017), with repetitive negative thinking accounting for 38.9% of RFCBT’s effect on depression incidence (Topper 2017). Behavioral activation increased over time in i-RFCBT (Jung 2019; F(2.00, 104.19) = 15.40, p < 0.001) but did not mediate depression change. Neurobiological findings: RFCBT reduced connectivity between DMN (PCC) and CCN nodes (IFG/ITG) in remitted adolescents, associated with reductions in rumination and self-rated depression (Jacobs 2016; Langenecker 2024). Baseline heightened pDMN+ activation correlated with lower depression at 8 weeks, 1 year, and 2 years, with RFCBT groups showing lower depressive levels vs assessment-only (Bessette 2020). Overall: 10 of 12 studies reported significant reductions in depressive symptoms with RFCBT across stages; formats (guided/unguided, group/internet) showed comparable efficacy; comparative studies with CBT/MBI/psychoeducation did not demonstrate clear superiority of RFCBT on self-reported depressive symptoms, though observer-rated outcomes favored RFCBT in one trial.

Findings provide preliminary support that RFCBT reduces depressive symptoms across prevention, active treatment (including non-responsive chronic depression), mitigation of residual symptoms, and relapse prevention. Targeting rumination—a transdiagnostic but strongly depression-linked mechanism—appears central to RFCBT’s effects, with changes in rumination mediating symptom improvement. Comparable efficacy across guided vs unguided and group vs internet delivery suggests RFCBT’s potential scalability and cost-effectiveness. Comparisons with active controls (CBT, MBI, psychoeducation) showed mixed results: RFCBT did not consistently outperform these interventions on self-reported depression, though observer-rated outcomes favored RFCBT in one clinical trial, raising possibilities of earlier or specific benefits not captured by self-report or limited by attrition and power. Neurobiological evidence indicates RFCBT may modify DMN-CCN dynamics (reduced PCC–IFG/ITG connectivity) and that baseline network activation patterns relate to long-term depression trajectories, supporting a mechanistic role in reducing rumination-related neural looping and fostering resilience. Overall, RFCBT aligns with stage-specific treatment models for depression by addressing a mechanistic target (rumination) relevant to onset, maintenance, and relapse. However, the evidence base remains limited by small samples, heterogeneous populations, modest follow-up duration, and potential confounders, warranting larger, rigorous RCTs with long-term follow-up, active comparisons, and process-outcome analyses.

This systematic review indicates that RFCBT is a promising intervention for managing depressive symptoms across prevention, treatment, and relapse prevention stages. Ten of twelve included studies reported significant depressive symptom reductions, with rumination reduction frequently mediating effects. RFCBT delivery formats (guided vs unguided; group vs internet) showed similar efficacy, supporting scalability. However, across three comparative studies, RFCBT did not demonstrate clear superiority to mindfulness-based interventions, standard CBT, or psychoeducation on self-reported depressive symptoms, emphasizing the need for direct, adequately powered comparisons. Future research should include rigorous, stage-specific RCTs with extended follow-up, dismantling studies to identify effective components, mechanistic analyses integrating psychological and neurobiological markers, and investigations of moderators to determine which populations benefit most. Given rumination’s transdiagnostic relevance, evaluating RFCBT across comorbid and non-depressive conditions may broaden its clinical utility.

The evidence base is limited by the small number of included studies and sample sizes, with potential underpowering and attrition (e.g., loss to follow-up affecting detection of differences). Many studies lack mid-to-long-term follow-up, constraining conclusions on relapse prevention durability. Comparative effectiveness against other psychotherapies is insufficiently tested; overlaps with behavioral activation, mindfulness, and acceptance-based approaches complicate attribution of RFCBT-specific components. Some trials involve high-risk but non-clinically diagnosed populations, limiting generalizability to clinical samples, including treatment-resistant depression. Neuroimaging studies have small samples and potential confounds (concurrent treatments in controls, baseline group differences in rumination), and connectivity changes can be interpreted via multiple models (disease modification vs compensation). Environmental and metacognitive factors (e.g., high stress contexts, limited cue awareness) may moderate RFCBT efficacy, but are underexplored. Overall, more rigorous designs, larger samples, active controls, component analyses, and long-term mechanistic follow-up are needed.