It is increasingly acknowledged that cognitive impairment can play an important role in depression vulnerability. Therefore, cognitive remediation strategies, and cognitive control training (CCT) procedures have gained attention in recent years as possible interventions for depression. Recent studies suggest a small to medium effect on indicators of depression vulnerability. Despite initial evidence for the efficacy and effectiveness of CCT, several central questions remain. In this paper we consider the key challenges for the clinical implementation of CCT, including exploration of (1) potential working mechanisms and related to this, moderators of training effects, (2) necessary conditions under which CCT could be optimally administered, such as dose requirements and training schedules, and (3) how CCT could interact with or augment existing treatments of depression. Revisiting the CCT literature, we also reflect upon the possibilities to evolve toward a stratified medicine approach, in which individual differences could be taken into account and used to optimize prevention of depression.

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BackgroundIn recent years, cognitive control training (CCT) has gained momentum as an intervention to remediate cognitive impairments and decrease depressive symptoms. One promising operationalization to train cognitive control is the adaptive Paced Auditory Serial Addition Task (aPASAT). In this systematic review and meta-analysis of aPASAT training, the efficacy of the intervention and potential moderators were examined.MethodThe PsycINFO, MEDLINE, Embase, Web of Science and Cochrane Library electronic databases were searched for studies examining aPASAT training for depressive symptomatology or rumination.ResultsNineteen studies (n=1257) were included, comprising of depressed patients, remitted depressed patients, at-risk, and healthy participants. We found small significant effects directly after training for both depressive symptomatology and rumination, with similar effect sizes at follow- up. Subgroup analyses suggest a significantly higher mean effect of aPASAT training in non- healthy populations for rumination immediately following training, but not for depressive symptomatology. The amount of training sessions did not moderate effects of CCT.ConclusionsaPASAT has a small but significant effect on depressive symptoms, with direct effects immediately after training, as well as sustained long-term effects. It is currently unclear how many sessions are required for sustained effects due to heterogeneity in training dosage and absence of sufficient trials. Our results suggest that aPASAT training may be most effective for at-risk, remitted- and clinically depressed populations. The effect sizes resulting from this meta- analysis could be used to adequately power future research, which could investigate a dose- response relationship and examine potential treatment gains when combining CCT with other antidepressant interventions.

UNSTRUCTURED Depression is a serious and burdensome psychiatric illness that contributes heavily to health expenditures. These costs are partly related to the observation that depression is often not limited to a single episode but can recur or follow a chronic pathway. In terms of risk factors, it is acknowledged that cognitive impairments play a crucial role in depression vulnerability. Within this context, cognitive remediation – among which cognitive control training (CCT) specifically – has shown its effectiveness in reducing risk for recurrence of depression. CCT is low-cost intensive and can be provided online which makes it easy to disseminate. Despite increasing interest in the field, studies examining the cost-effectiveness of CCT in the context of depression are largely missing. Health-economic evaluation (HEE) allows to inform decision makers with evidence-based insights on how to spend limited available (financial) resources in the most efficient way. HEE studies constitute a crucial step to implementing a new intervention in clinical practice. Approaching preventive measures for depression such as CCT from a HEE perspective would be informative to health policy, fostering optimal use of health expenditures. The scope of this review is to inform and guide researchers during the phase of designing HEE studies in the context of CCT for depression. A clear view on CCT cost-effectiveness is paramount to its clinical implementation.