Meta-cognitive beliefs in Major Depressive Disorder: A Comparison of Individuals with Major Depressive Disorder and Healthy Control

Meta-cognitive beliefs in Major Depressive Disorder: A Comparison of Individuals with Major Depressive Disorder and Healthy Control

Dr. Rupashree Brahma Kumari, Abinash Mishra^*

School of Psychology, Gangadhar Meher University, Sambalpur, Odisha, India

^*Corresponding Author

DOI: https://dx.doi.org/10.47772/IJRISS.2025.905000341

Received: 15 May 2025; Accepted: 16 May 2025; Published: 14 June 2025

INTRODUCTION

Major Depressive Disorder (MDD) is a prevalent mental illness affecting over 320 million people, equivalent to 4.4% of the global population (World Health Organization, 2017). MDD is primarily characterized by feelings of sadness, indifference, hopelessness, and persistent thoughts (Kanter et al., 2008; Otte et al., 2016). In recent years, there has been growing interest in identifying the cognitive aspects linked to MDD. There’s mounting evidence suggesting that impaired metacognition, the ability to assess and evaluate one’s own thought processes and actions, plays a significant role (Hoven et al., 2019; Rouault, Seow, et al., 2018; Trauelsen et al., 2016).

Several theories, including the Self-Regulatory Executive Function (S-REF, Wells & Matthews, 1994), propose that dysfunctional metacognitive processes contribute to the onset and persistence of mental disorders. According to the S-REF theory, certain forms of metacognitive beliefs may predispose individuals with depression to adopt counterproductive responses to their thoughts and inner experiences, resulting in ineffective coping strategies (Wells, 2011). One particular response pattern, known as the Cognitive-Attention Syndrome (CAS), involves excessive engagement in worry, rumination, heightened focus on threats and negative information, and excessive self-focus. CAS also includes ineffective regulation strategies such as avoidance and thought suppression (Sun et al., 2017). This syndrome gradually emerges due to metacognitive beliefs, such as the idea that worrying and ruminating serve a purpose, or that thoughts and emotions are inherently negative and uncontrollable and should be avoided and suppressed (Sun et al., 2017). Over time, CAS ensnares individuals with depression in prolonged emotional turmoil, leading to persistent thinking patterns and contributing to the onset and perpetuation of the clinical disorder.

LITERATURE REVIEW

Several studies have concentrated on the connection between metacognitive beliefs and symptoms of depression in patients diagnosed with Major Depressive Disorder (MDD). Saed, O. (2010) conducted a correlation study involving 260 non-clinical university students, examining the link between metacognitive beliefs and their levels of anxiety and depression. Their findings highlighted that negative beliefs concerning the uncontrollability and danger of persistent worrying were the most prominent indicators of both depression and anxiety. This study also affirmed a strong and positive relationship between the experience of negative emotions, such as anxiety and depression, and the dimensions of metacognition.

Similarly, in a separate study, Tajrishia, Mohammadkhani, and Jadidi (2011) explored the association between metacognitive beliefs and negative emotions in university students. They discovered that various dimensions of metacognition, including positive and negative beliefs about worrying, cognitive confidence, and the need to control thoughts, were significantly correlated with symptoms of depression and anxiety.

Sarisoy et al. (2013) further investigated metacognitive beliefs related to pathological worry in patients with unipolar and bipolar depressive disorder. Their study indicated higher scores in negative beliefs about the uncontrollability and danger of worrying, as well as beliefs about the need to control thoughts, in both the unipolar and bipolar depression groups compared to healthy controls. The bipolar group also displayed increased scores in lack of cognitive confidence compared to the healthy controls. Lashkary, Karimil, and Hashemi (2015) proposed that dysfunctional metacognitive beliefs, including both positive and negative beliefs about worrying, could potentially trigger rumination, leading to the development of depression, emphasizing the multifaceted nature of these metacognitive processes.

The impact of metacognitive beliefs extends beyond negative emotions, as Østefjells (2017) study revealed a significant mediating relationship between early emotional abuse and depression/anxiety. Their findings suggested that specific metacognitive beliefs, particularly those concerning the uncontrollability and danger of thoughts, serve as a mechanism through which early trauma influences the levels of depression/anxiety.

Furthermore, Nordahl (2018) assessed the influence of metacognition on depressive symptoms in patients with Social Anxiety Disorder, highlighting negative beliefs about worrying and low confidence in memory as the primary factors.

Research Gap:

While a substantial number of studies have explored the role of metacognition in emotional disorders, there appears to be a relative scarcity of research that specifically focuses on this topic within culturally diverse populations. More notably, there is a lack of empirical studies examining metacognitive beliefs in individuals diagnosed with Major Depressive Disorder (MDD) from the state of Odisha, India. This presents a significant gap in the existing literature, particularly considering the potential influence of cultural variables on metacognitive processes. Culture plays a vital role in shaping an individual’s thought patterns, emotional regulation, and coping mechanisms. Elements such as societal values, religious beliefs, and traditional customs can deeply affect how people interpret and manage their internal cognitive experiences. Therefore, it is plausible that cultural norms and beliefs in regions like Odisha may uniquely influence the nature and intensity of metacognitive beliefs associated with depression. Given this context, investigating metacognitive beliefs among individuals with MDD in Odisha could provide valuable insights into how culturally embedded thought patterns contribute to the onset, maintenance, or severity of depressive symptoms.

Rationale

Building upon prior research, the present study contributes to the growing body of evidence highlighting the presence of dysfunctional metacognitive beliefs in individuals with depression as well as in healthy controls (HC). Most existing research on metacognition in the context of depression has been conducted in Western cultural settings. These findings indicate that metacognitive processes may play a significant role in depression across diverse cultural backgrounds. To the best of our knowledge, limited studies have been conducted within the Indian context, and none have specifically focused on the population of Odisha. Few investigations in India have assessed and compared metacognitive beliefs between individuals with and without depression. Hence, the main objective of this study was to examine the metacognitive belief patterns of individuals diagnosed with depression from Odisha and to compare these patterns with those of healthy individuals, thereby addressing a notable gap in region-specific research.

METHODS

Participants

The study adopted a cross-sectional study design. A total of 120 participants were purposively selected in the study. All the patients reported with chief complaints indicating MDD, during the period of 05^th May 2022 to 30^th Aug 2023 were included in the study upon meeting certain inclusion and exclusion criteria. The eligible participants were who met the criteria of MDD according to the International Classification of Disease (ICD-10),  had given their consent to participate in the study,  participants within the age group of 18-45 years, having minimum educational qualification of matriculation level. Those participants who had or have, present substance dependence, mania, organic mental illness, history of psychosis intellectually disable and ASD and who were receiving any form of behavioural therapy werte excluded from the study. The HC individuals were the relatives of patients with MDD, who reported during the time of interview and served as informant, were selected as samples by meeting various inclusion and exclusion criteria. All the non-depressed individuals in HC group after giving their consent were gone through a structured clinical interview in order to be eligible to being included in the study. The eligible participants were who don’t have any previous history of suffering from any kind of psychological disorder and who reported sound mental health in Mental Status Examination during the period of clinical interview

Ethical Consideration

Before drawing the samples, the ethical approval for the study was obtained from Institutional Ethics committee (IEC) Gangadhar Meher University, Sambalpur (reference number:9852). After getting the ethical clearance, researcher of the current study reported the Director of Mental Health Institute, Centre of Excellence, Department of Psychiatry, SCB Medical College and Hospital, Cuttack. After rigorous process of verification of the requisite qualification of the researcher, Ethical approval from the IEC, the study was allowed to conduct in the institute. The data from the samples were collected by a RCI certified Clinical Psychologist.

After the selection of samples, and obtaining consent from patients, Beck Depression Inventory 2 (BDI2) was administered to assess the severity level of depression. Following which the Metacognitive belief questionnaire (MCQ-30) was administered to measure the specific metacognitive beliefs present among depressed individuals and HC.

Tools: The socio-demographic data like gender, age, marital status, domicile, educational qualification, onset, course and duration of illness etc were collected through demographic information form developed by the researcher.

Beck Depression Inventory 2 (BDI 2)

For the diagnosis and assessment of severity level of MDD, Beck Depression Inventory (BDI; Beck et al., 1961) was used. The scale contains 21 self reported items which evaluated the presence of depressive symptoms in the patient and provided information about the severity of the symptoms. Each of the 21 statements evaluated on a 4-point rating scale from 0 to 3, allowing for a highest attainable score of 63. It has been widely recognized as a consistent and thoroughly validated tool for measuring symptoms associated with depression.

Metacognition questionnaire (MCQ-30) was used to measure the key metacognitive belief among the participants. The questionnaire was developed by Wales and Katrayt Houghton (2004) Katrayt. It consists of 30 self-reported items which  evaluates individual differences in MCBs. The questionnaire consists of five subscales: ‘positive beliefs about Worry’ (PBW), ‘Beliefs about uncontrollability and danger’ (BUD) ‘cognitive confidence’ (CC), ‘Need to Control Thoughts’ (NCT) and ‘Cognitive Self-Consciousness’ (CSC), and. Each item is scored on the Likert scale of four options (from disagree 1, to completely agree 4).

Data analysis

Data Analyses were conducted using IBM SPSS V.20. Descriptive statistics like mean and standard deviation were employed to analyze socio-demographic data. Independent samples t-tests were used to determine differences between patients and controls in all the dimensions of metacognitions such as PBW ,BUD, CC, NCT, and CSC

RESULTS

Table 1: Socio-demographic details of the participants in both the group

The table-1 summarizes the socio-demographic characteristics of MDD and HC groups. Both groups consist of participants aged between 18-45 years. In terms of gender distribution, the MDD group is evenly split with 30 males and 30 females, while the HC group has a higher proportion of males (44) compared to females (16). Regarding marital status, in the MDD group, there are 27 married and 33 unmarried individuals. In contrast, the HC group has a higher number of married individuals (52) compared to unmarried individuals (8). Educational qualifications show that in the MDD group, 28 participants have a graduation degree or higher, and 32 have qualifications below graduation. Among the HC group, 43 individuals have a graduation degree or higher, while 17 have qualifications below graduation. Family size is another characteristic evaluated, where the MDD group includes 34 individuals from nuclear families and 26 from joint families. On the other hand, the HC group has 49 individuals from nuclear families and 11 from joint families. Finally, considering domicile, the MDD group has 34 participants from urban areas and 26 from rural areas. The HC group has a higher rural representation with 37 participants compared to 23 from urban areas.

Table-2 Showing mean differences among MDD and HC groups with respect to all the dimensions of MCBs

The above table shows comparison of MDD patients with HC in relations to five dimensions of MCBs. There were significant difference observed between all the dimensions of MCBs in MDD and HC group respectively.  As shown in table 2, t-tests revealed that patients with MDD reported significantly higher levels of unhelpful metacognitive beliefs than controls on all MCQ-subscales, except for cognitive confidence. Patients with MDD further reported significantly different levels of metacognitive beliefs. Specifically, patients reported less use of cognitive confidence, and more use positive beliefs about worry, beliefs about the need to control thoughts and cognitive self-consciousness. On the other hand, individuals in the control group reported more use of cognitive confidence and less use of other remaining metacognitive beliefs respectively.

Figure-1 Showing the graphical representation of all the dimensions of Metacognitive beliefs across patients with MDD and HC

DISCUSSION

The present study a Comparative study on metacognitive beliefs in Individual with MDD and HC was conducted at the Mental Health Institute, Centre of Excellence, Department of Clinical Psychology, SCB Medical college and Hospital, Cuttack. The aim of the study was to assess and compare the metacognitive beliefs of Individuals with MDD and HC respectively. A sample of 120 patients was included in the study, among which 60 patients of major depressive disorder and 60 non-depressed individual were assigned in the healthy control group. The sample was selected using purposive sampling method, as per the inclusion and Exclusion criteria. The socio-demographics were used to take general information of patients. Beck Depression Inventory -II was used as a screening tool to assess the presence and severity of symptoms of depression in both the group. MCQ-30 questionnaire was administered to assess the key metacognitive belief among the participants.

The [Table 2] shows comparison of MCBs in individual with major depressive disorder and HC respectively. As identified by Hatton and Wells (2004) the five dimensions of MCBs are Positive beliefs about worry, Beliefs about uncontrollability and danger of thoughts, Cognitive confidence, need to control thoughts cognitive self-consciousness.

Positive Beliefs about Worry (PBW)

The above Table 2 depicts the mean and standard deviation of Depressed Patients (20.50±1.66) and mean and standard deviation of individuals in the control group (17.62±1.87) on the dimension PBW, and significant difference was found between both the groups. that dysfunctional metacognitive beliefs and strategies give rise to a pattern of cognitive attentional processing known as the Cognitive Attentional Syndrome (CAS). This syndrome includes attentional biases towards threat-related information, preservative thinking (rumination), and worry. The metacognitive model assumes that an over-reliance on worry or inflexibility in this style of responding to negative thoughts can lead to problems of emotional self-regulation. Worrying can therefore contribute a non-specific vulnerability to emotional symptoms. Furthermore, this could also be explained by the fact that the individual, who holds these PBW believe perceives the anxiety as a positive factor and employs anxiety in several fields of life as a method of coping with undesired thoughts. A belief that anxiety is beneficial could result in intense anxiety levels that extend throughout the life of the individual. Thus, the negative emotional symptom like depression may increase. In the literature, certain studies reported that the positive beliefs sub-dimension affected primarily the depression levels (Barahmand, 2009; Clark & Wells; 1995; Morrison et al., 2003; Papageorgiou & Yılmaz, 2007; Wells; 2002; Wells, 2003).

Beliefs about Uncontrollability and Danger (BUD)

Significant difference was also found between the mean and Standard deviation of depressed patients (17.93±1.67) and in the control group (15.85±1.56) on the dimension BUD. This belief manifest as high frequency of anxiety and the continued presence of anxious thoughts, even when individuals make deliberate efforts to manage or suppress them. It has been proposed that maladaptive metacognitive beliefs—particularly the notion that negative thoughts are uncontrollable and inherently dangerous—may actively contribute to the persistence of cognitive patterns such as repetitive negative thinking (e.g., rumination) and constant threat monitoring. These patterns may, in turn, reinforce emotional disturbances. Based on the results of the study, it was suggested that these beliefs about the inability to control negative thoughts could significantly contribute to heightened levels of depression by maintaining or even worsening the cycle of negative cognitive and emotional experiences.

In the literature, certain studies reported that the uncontrollability and danger sub-dimension was associated with depression and many anxiety disorders (Davis, Chen, Jivet, Hauff, & Houben, 2016; Matthews, Hillyard & Campbell, 1999; Moritz et al., 2010; Spada et al., 2008; Taylor, 2010; Yılmaz et al., 2011). Participants in the clinical group were found to have notably elevated scores in comparison to the control group concerning negative beliefs about worry, especially beliefs surrounding the uncontrollability of these worries. (e.g., ‘‘When I start worrying I cannot stop’’) and danger (e.g., ‘‘My worrying is dangerous for me’’). This implies that the clinical group perceives a stronger requirement to regulate their thoughts than the healthy group. These results are consistent with theoretical accounts of emotional disorders, in which negative beliefs about worry are considered dysfunctional (Wells, 2009; Wells & Mathews, 1994, 1996), as well as with previous research that has reported a high level of these beliefs in paranoia and depression (Foster, Startup, Potts, & Freeman, 2010; Moritz, Peters, Larøi, & Lincoln, 2010; Morrison & Wells, 2007; Startup, Freeman, & Garety, 2007).

Cognitive Confidence (CC)

This belief reflects individuals’ lack of confidence in their memory, stemming from insecure beliefs.. The result of the current study revealed an elevated score on CC dimension among control group (21.77±1.74) than the depressed group (17.77±2.32) and the difference was also found significant. From the result, it can be suggested that the When individual doubts the reliability of their memory, it can undermine their cognitive confidence, subsequently activating negative metacognitive processes and leading to increased depressive symptoms. The present study findings were consistent with the previous studies which reported a negative correlation between cognitive insecurity that reflects the negative perceptions of the individual about memory performance and depression and anxiety levels (Köseoğlu, 2013; Lee et al. 2012; Mcdermott & Ebmeier, 2009; Nieto et al., 2010; Paelecke-Habermann et al., 2005).

Consistent with previous research highlighting memory impairments in individuals with depression (e.g., Hermens, Naismith, Redoblado-Hodge, Scott, & Hickie, 2010), the findings of our study reveal that those in the depression group exhibit a marked reduction in confidence regarding their cognitive abilities.. This may be linked to their high level of worry (Starcevic, 1995), because some evidence suggests that worry restricts working memory capacity (Hayes, Hirsch, & Mathews, 2008; Rapee, 1993).

Cognitive Self Consciousness (CSC)

The cognitive self-consciousness sub-dimension represents a tendency to frequently examine and reflect on one’s own thoughts. In the current study, this sub-dimension was associated with a heightened attention to internal psychological states and an increased vigilance in monitoring perceived threats in the present moment was predominantly found among depressed individuals (19.35±1.93) Compared to HC group (17.22±2.59). According to the Cognitive Attentional Syndrome model defined as by Wells and Matthews (1994), an individual’s intense focus on danger increases negative metacognitive beliefs about the potential threat and danger. In short, the findings of the study indicate that an individual’s heightened preoccupation with their own thoughts, the frequent evaluation of these thoughts, and an increased focus on internal cognitive processes may collectively contribute to elevated levels of rumination. Within the context of the current research, it can be stated that as participants demonstrated higher levels of cognitive attention, there appeared to be a simultaneous increase in both depressive symptoms and the tendency to engage in ruminative styles of thinking. This finding was consistent with the findings of previous studies that associated cognitive self-consciousness and psychopathologies such as depression, anxiety, and stress (Grøtte et al., 2014; Köseoğlu, 2013; Myers & Wells, 2005; Reuven et al., 2009).

Need to Control Thought (NCT)

This belief reflects the notion that an individual’s thoughts should be continuously observed and strictly regulated. Within the framework of the current study, it was found that the scores related to NCT sub-dimension were significantly elevated among individuals with depression in comparison to the healthy control (HC) group. Specifically, a stronger focus on perceived present threats was more prominent in the depressed group, who scored an average of 19.35 (±2.16), compared to an average score of 17.82 (±1.96) in the HC group. According to the Cognitive Attentional Syndrome model defined as by Wells and Matthews (1994 an individual’s belief that one should control thought levels could increase the anxiety about dangerous and could lead to an increase in depression, anxiety and stress levels. Similarly, certain studies demonstrated that the need to control thought levels was associated with depression, anxiety, and stress (Köseoğlu 2013; Morrison et al., 2000; O’Carrol & Fisher, 2013).

CONCLUSION

The current study was designed to investigate potential differences in metacognitive beliefs between individuals diagnosed with Major Depressive Disorder (MDD) and healthy control (HC) participants. Metacognition may refer to an individual’s capacity to consciously recognize and monitor their own cognitive processes, including attention, memory, and reasoning. It also includes the awareness and regulation of these processes through self-observation. Variations in metacognitive awareness could influence how individuals interpret and manage emotional and psychological experiences. It is possible that the presence of anxiety symptoms and maladaptive beliefs about cognitive functioning contributes to an increase in dysfunctional thinking patterns, which in turn may lead to greater emotional distress. Based on the findings of the present study, significant differences were observed between the MDD and HC groups across all measured dimensions of metacognitive beliefs (MCBs). Participants in the MDD group appeared to report elevated scores in every dimension except for cognitive confidence (CC), where the HC group demonstrated comparatively higher levels.

In the dimension of Positive Beliefs about Worry (PBW), individuals experiencing depression might hold the belief that worry serves a useful function. They may think that it helps prepare for adverse outcomes or prevents negative events from occurring. Such a belief system could promote chronic worrying and rumination, which are often associated with depressive symptoms. These beliefs may reinforce patterns of maladaptive coping, where worry is perceived as necessary or helpful, even though it might contribute to sustained psychological discomfort. A similar trend could be observed in the Beliefs about Uncontrollability and Danger (BUD) dimension. Individuals with MDD may perceive their thoughts as uncontrollable and potentially harmful. They might fear that negative thoughts could spiral out of control or lead to real-world consequences, a cognitive pattern sometimes referred to as thought-action fusion. This perception could increase their anxiety about thinking itself, contributing to a sense of helplessness and increased emotional strain.In terms of the Need to Control Thoughts (NCT) dimension, individuals with depression may believe that their thoughts must be strictly regulated to prevent emotional or cognitive distress. This perceived need for control might result in thought suppression, a strategy that paradoxically could heighten the frequency and intensity of unwanted thoughts. Such efforts might also lead to frustration and self-criticism when thought control is unsuccessful. Over time, this could create a repetitive cycle where intrusive thoughts become more persistent precisely because of the efforts to eliminate them. High scores in the Cognitive Self-Consciousness (CSC) domain may suggest that individuals with MDD tend to engage in heightened self-awareness of their thinking. They might frequently monitor and scrutinize their own thoughts, especially negative or distressing ones. This over-monitoring could lead to increased rumination and reduce the individual’s ability to disengage from maladaptive thought processes. In turn, this may sustain or worsen depressive symptoms by creating a feedback loop of repetitive negative cognition. In contrast, the healthy control group demonstrated higher scores in the Cognitive Confidence (CC) dimension. This dimension pertains to the degree to which individuals trust their cognitive abilities—such as memory, attention, and decision-making. Healthy individuals might exhibit more confidence in these areas, leading them to be less doubtful of their mental capabilities. This sense of cognitive trust could reduce the likelihood of engaging in unproductive thought cycles, such as repetitive worrying or rumination. Furthermore, they may experience fewer cognitive disruptions and hold more balanced evaluations of their mental processes, which might contribute to improved emotional regulation and psychological resilience.

In summary, the results of this study suggest that individuals with MDD differ significantly from healthy controls across several metacognitive domains. These differences might reflect underlying cognitive vulnerabilities that contribute to the onset and maintenance of depressive symptoms. By identifying and understanding these metacognitive patterns, future interventions could potentially be tailored to address these specific cognitive styles, thereby improving treatment outcomes for individuals struggling with depression.

Limitations and Recommendation for Future Studies

The current study has certain limitations. One major limitation is that the sample size was not sufficiently large, and the use of a convenience sampling method restricted the generalizability of the findings. Therefore, in order to enhance the impact and generalizability of future research, it is recommended that a larger sample size be used. Another limitation is that the current study compared the MDD group only with a non-clinical group. Future studies should include both another clinical group and a non-clinical group to gain a clearer understanding of the types of metacognitive beliefs (MCBs) that are more prominent in specific clinical conditions. Additionally, while the current study focused on identifying dysfunctional metacognitive beliefs in both the MDD and HC groups, it did not explore strategies for overcoming these unhelpful beliefs. To address this gap, future research could incorporate Metacognitive Therapy (MCT) as an intervention to help participants reduce or eliminate such maladaptive MCBs.

Conflict of Interest

The authors declare that they have no competing interests.

Funding

This research was conducted without financial support from any public, commercial, or non-profit funding agencies.

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