Measuring Self-blame-related Action Tendencies and Prediction of Prognosis in Major Depressive Disorder

Developing clinical and psychological markers which characterise the large subgroup of patients with major depression who do not benefit from serotonergic antidepressants offered as first line treatment is of utmost clinical importance but has so far not been achieved. Clinical and psychological indicators would be ideal in predicting non-response to antidepressant medications, given their wide availability. So far, however, these measures have failed to provide accurate predictions at the individual level. Novel predictors of prognosis and treatment response in major depressive disorder (MDD) can add value to the development of targeted treatments and stratified approaches to improve long-term outcomes of individuals with MDD.

The psychological underpinnings of patients' response to treatment have been an important direction of research. As proposed by the revised learned helplessness model, one central cognitive vulnerability to MDD is the tendency to excessively blame oneself for negative events occurring in one's life. Consistent with the theory, previous studies have demonstrated the importance of self-blaming bias both as a vulnerability factor and as a symptom of depression. For example, it has been shown that individuals with remitted MDD had increased self-contempt biases compared to healthy control participants in a recent study. As MDD is a life-long diagnosis, understanding the differences between remitted MDD and healthy controls could help to identify vulnerability traits associated with MDD. Thus, the finding of self-blaming biases in remitted MDD demonstrate the potential role of self-blame as a vulnerability trait and a novel cognitive marker for MDD that remain present during remission and possibly constitute vulnerability for recurrence. However, one limitation in previous studies is that people might have experienced difficulties distinguishing their moral emotions such as shame and guilt under certain circumstances. Previous measures assessing these emotions largely depended on participants' subjective rating and are thus problematic in terms of differentiating the moral emotions.

In addition, these measures fail to address the adaptive or maladaptive nature of moral emotions. As proposed by Tangney, moral emotions can be either adaptive and maladaptive, and this difference is possibly determined by an individual's different action tendencies associated with their moral emotions. Action tendencies describe an implicit cognitive and motivational state before an action is taken. It was suggested that adaptive action tendencies, such as feeling like apologizing, were associated with self-blaming emotions such as guilt, and maladaptive action tendencies such as feeling like hiding and creating a distance from oneself were associated with shame. However, an empirical investigation of the associations between action tendencies and self-blaming emotions is lacking. Further investigations of this topic are important for understanding the potential role of action tendencies as a novel measure of self-blame and its association to the vulnerability to MDD. It is important to develop measures of action tendencies with a high ecological validity. In previous studies, our research group has developed a computerised task that measures action tendencies and used it to predict prognosis in MDD. It was found that this task can predict recurrence risk in people with MDD, showing a large effect size (Cohen's d=.96). However, there were two major limitations. First, the task used in a verbal format and included abstract descriptions of scenarios (e.g. "You act stingily towards your friend"), which makes the task dependent on how well participants can imagine the scenarios. Second, the lack of immersiveness of the task made it difficult to engage, which may limit the task's ecological validity.

Virtual reality (VR)-based assessment is a new paradigm for cognitive evaluation compared to the traditional paper-and-pencil or computerized assessment. VR scenarios were suggested to be promising tools for cognitive assessments and have been demonstrated as safe for the assessment of anxiety disorders and depression. Importantly, the interactive and immersive nature of virtual reality makes it possible to develop a cognitive task that is engaging and has a higher ecologically validity, which would be ideal for identifying novel cognitive markers of MDD outcomes. Thus, this study will aim to employ a virtual reality task to measure blame-related action tendencies.

There are three major research questions of this study