Personal benefits of older adults engaging in a participatory action research (PAR) project.

Participatory action research (PAR) is the process of conducting research with people rather than for them and is perceived as an empowering activity for older adults who participate in it. However, there is little evidence that outlines and explains the reasons why older adults engage in PAR. Thus, the aim of this study was to better understand the personal benefits for older adults participating in PAR. We based our study on the experiences of four older adults who volunteered for CareComLabs, a Swiss-based PAR project, for more than two years. A constructivist grounded theory design was used to explore the benefits of participating in CareComLabs by conducting in-depth, semi-structured interviews. The analysis yielded four categories of personal benefits of participating in CareComLabs: (a) enriching relationships; (b) broadening horizons for older age; (c) keeping in touch with one's profession; and (d) interacting in a nurturing community. Our findings may have implications for policies and frameworks focused on the identification of the potential of participatory action research as a community resource.

Associations between stress, resources, and hair cortisol concentration in teachers.

Challenging interactions are the main source of teacher' stress in the classroom. We investigated the association of chronic stress and characteristics of teacher-student interactions with teachers' Hair Cortisol Concentration (HCC). Forty-one teachers (27 women; Mage = 39.65 ± 12.14 years; Mlesson number = 23.15 ± 3.99 lessons per week; grade: elementary, secondary, high, and vocational school teachers) participated in the present study, with participation lasting over the length of one year. HCC was assessed from a 3 cm hair segment near the scalp. Self-reported chronic stress in the last three months was further assessed using the 'Trier Inventory for Chronic Stress' (TICS). Additionally, four consecutive, same-day lectures of each teacher were videotaped and coded offline in an event sampling procedure by trained external observers. The videos were analyzed for two stressors, i.e., classroom disruptions and total student aggression, as well as two resources, i.e., teacher-student relationship and classroom management. Overall, hair samples were collected M = 120.34 days (SD = 84.39) after the distribution of the questionnaires, and M = 67.63 days (SD = 18.40) prior to the observations. Lesson number, classroom disruptions, as well as total student aggression were all significantly positively correlated with HCC. In addition, both teacher-student relationship and classroom management were significantly negatively related to HCC. With regard to self-rated chronic stress, only the TICS subscale 'Pressure to perform' was positively related to HCC. Exploratory moderation analyses revealed that an increasingly good, observed teacher-student relationship buffered the positive association between lesson number and HCC. Our findings show significant associations between HCC and mainly objectively assessable stress, supporting HCC as a biological indicator of chronic stress. In this association, a good relationship between teachers and students acts as a buffer. While the findings underline the importance of examining objective and behavioral data for better understanding the psychobiology of stress, they also support the importance of boostering teachers' (social) resources to increase their overall resilience.

The impact of integrating emotion focused components into psychological therapy: A randomized controlled trial.

OBJECTIVES: This paper presents a randomized controlled trial on assimilative integration, which is aimed at integrating elements from other orientations within one approach to enrich its conceptual and practical repertoire. Elements from Emotion-Focused Therapy (EFT) were integrated into a form of cognitive behavior therapy: Psychological Therapy (PT). In one treatment condition, EFT was added to PT (+EFT) with the intent to enhance therapists' working with emotions. In the other condition, concepts and interventions based on the socialpsychological self-regulation approach were added to PT (+SR). Our assumption was that the +EFT would lead to greater and deeper change, particularly in the follow-up assessments. METHOD: Patients (n = 104) with anxiety, depression, or adjustment disorders were randomized to the two conditions and treated by 38 therapists who self-selected between the conditions. Primary outcome was symptom severity at 12-month follow-up; secondary outcomes included several measures such as interpersonal problems and quality of life. Variables were assessed at baseline, after 8 and 16 sessions, at posttreatment, and at 6- and 12-month follow-up. RESULTS: Contrary to our hypothesis, no significant between-group effects were found. CONCLUSION: The findings first suggest the difficulty of topping an already very effective approach to psychotherapy. Alternative interpretations were that the EFT training, while corresponding to regular practice in AI, was not sufficient to make a difference in outcome, or that while profiting from the enhancement of abilities for working with emotions, this was outbalanced by negative effects of difficulties related to the implementation of the new elements.

Methods for Measuring and Identifying Sounds in the Intensive Care Unit.

Background: Despite many studies in the field examining excessive noise in the intensive care unit, this issue remains an ongoing problem. A limiting factor in the progress of the field is the inability to draw conclusions across studies due to the different and poorly reported approaches used. Therefore, the first goal is to present a method for the general measurement of sound pressure levels and sound sources, with precise details and reasoning, such that future studies can use these procedures as a guideline. The two procedures used in the general method will outline how to record sound pressure levels and sound sources, using sound level meters and observers, respectively. The second goal is to present the data collected using the applied method to show the feasibility of the general method and provide results for future reference. Methods: The general method proposes the use of two different procedures for measuring sound pressure levels and sound sources in the intensive care unit. The applied method uses the general method to collect data recorded over 24-h, examining two beds in a four-bed room, via four sound level meters and four observers each working one at a time. Results: The interrater reliability of the different categories was found to have an estimate of >0.75 representing good and excellent estimates, for 19 and 16 of the 24 categories, for the two beds examined. The equivalent sound pressure levels (LAeq) for the day, evening, and night shift, as an average of the sound level meters in the patient room, were 54.12, 53.37, and 49.05 dBA. In the 24-h measurement period, talking and human generated sounds occurred for a total of 495 (39.29% of the time) and 470 min (37.30% of the time), at the two beds of interest, respectively. Conclusion: A general method was described detailing two independent procedures for measuring sound pressure levels and sound sources in the ICU. In a continuous data recording over 24 h, the feasibility of the proposed general method was confirmed. Moreover, good and excellent interrater reliability was achieved in most categories, making them suitable for future studies.

The impact of chronic pain on creative ideation: An examination of the underlying attention-related psychophysiological mechanisms.

BACKGROUND: Attentional deficits in patients with chronic pain are common and well studied. Yet, few studies have examined the effects of chronic pain on more complex cognitive abilities that rely on well-functioning attentional systems. With the current study, we aimed to investigate whether the impact of chronic pain on attention affects creative ideation as measured with an adaptation of the alternate uses task (AUT). METHODS: Performance in the AUT was compared between 33 patients suffering from chronic pain and 33 healthy matched controls. While solving the task, EEG was recorded to measure the degree of internally directed attention assessed by means of task-related power (TRP) changes. RESULTS: The results revealed that patients with chronic pain generated less creative ideas than healthy controls. This lack of performance was accompanied by lower event-related synchronization (ERS), especially in right parietal sites. Furthermore, these ERS differences explained one-third of the inter-group variance in AUT performance. CONCLUSIONS: These results suggest that performance decrements in creative ideation in patients with chronic pain may be at least partly attributable to attentional impairments associated with chronic pain. SIGNIFICANCE: Chronic pain negatively affects attention and more complex cognitive abilities. However, the underlying psychophysiological mechanisms and the role of attention as a source of these impairments in more complex abilities are poorly understood. By analyzing task-related power changes in the EEG, the role of internal attention in creative ideation could be determined, revealing the functional relationship between chronic pain, attention, and a more complex cognitive ability.

Association between workaholism, vital exhaustion, and hair cortisol concentrations among teachers: A longitudinal study testing the moderation effect of neuroticism.

Introduction: Workaholism in teachers is characterized by the willingness to work until exhausted and may be associated with various adverse health outcomes as well as high economic costs. The present study examines the association between workaholism, vital exhaustion (VE), and hair cortisol concentration (HCC) as indicators of chronic stress. In addition, this study explores the moderating role of the personality trait neuroticism on the relationship between workaholism and chronic stress indicators, i.e., VE and HCC. Methods: Forty-two Swiss teachers (28 females; M age = 39.66, SD = 11.99) completed questionnaires assessing VE (Maastricht Vital Exhaustion Questionnaire), workaholism (Measure of Coping Capacity Questionnaire), and neuroticism (Big-Five Inventory). Together with VE, HCC was assessed twice, with a one year lag. Results: Both workaholism and neuroticism were positively associated with VE at both time points but not with HCC. Moderation analyses revealed a positive relationship between workaholism and VE in teachers with high neuroticism, while no such association was observed in teachers with low neuroticism. No associations were found between self-reports and HCC. Discussion: These findings emphasize the importance of considering individual characteristics when investigating VE. Further research is necessary to investigate the applicability of HCC as a biomarker of chronic stress in the context of work.

Short and Long Haul Pilots Rosters, Stress, Sleep Problems, Fatigue, Mental Health, and Well-Being.

OBJECTIVE: This research was conducted to compare short haul (SH) and long haul (LH) pilots regarding sleep restrictions and fatigue risks on flight duty, stress, sleep problems, fatigue severity, well-being, and mental health. METHOD: There were 406 international SH and LH pilots who completed the cross-sectional online survey. Pilots sleep restrictions and fatigue-risk profiles (e.g., time pressure, late arrivals, minimum rest), sleep problems, fatigue severity, well-being, and symptoms of depression, anxiety, and common mental disorders (CMD) were measured and compared for SH and LH pilots. RESULTS: Although SH and LH pilots were scheduled for only 51.465.4% of the legally allowed duty and flight hours, 44.8% of SH pilots reported severe fatigue (FSS 4 to 4.9), and an additional 31.7% high fatigue (FSS 5), compared with 34.7% and 37.3% LH pilots. Considerable sleep problems in 8 nights/mo were reported by 24.6% SH vs. 23.5% LH pilots. Positive depression screenings were reported by 18.1% SH and 19.3% LH pilots. Positive anxiety screenings were reported by 9.6% SH and 5% LH pilots. Of all investigated pilots, 20% reported significant symptoms of depression or anxiety, and 7.23% had positive depression and anxiety screenings. LH pilots reported significantly better well-being than SH pilots. CONCLUSIONS: Our results show that even far less duty and flight hours than legally allowed according to flight time limitations lead to high levels of fatigue, sleep problems, and significant mental health issues among pilots. SH pilots were even more affected than LH pilots. Pilots fatigue should be considered an immediate threat to aviation safety and pilots fitness to fly by promoting fatigue and burnout. Venus M, grosse Holtforth M. Short and long haul pilots rosters, stress, sleep problems, fatigue, mental health, and well-being. Aerosp Med Hum Perform. 2021; 92(10):786797.

Differential and shared effects of psychological skills training and mindfulness training on performance-relevant psychological factors in sport: a randomized controlled trial.

BACKGROUND: Mental training intends to support athletes in mastering challenges in sport. The aim of our study was to investigate the differential and shared effects of psychological skills training and mindfulness training on psychological variables relevant to athletic performance (e.g., handling emotions or attention control). We assumed that each approach has its own strengths (e.g., mindfulness has a differential effect on the acceptance of emotions), but for some goals (e.g., attention control), both training forms are expected to be equally successful (i.e., shared effects). METHODS: A total of 95 athletes (Mage = 24.43, SDage = 5.15; 49% female) were randomly assigned into three groups: psychological skills training intervention (PST), mindfulness training intervention (MT), and wait-list control group (WL). Participants completed a questionnaire battery before and after the training (pretest and posttest). We assessed mindfulness, use of mental strategies, handling of emotions, attention in training and competition, as well as the dealing with failure. The two intervention programs each consisted of four 90-min group workshops conducted over a period of 4 weeks. RESULTS: Both interventions passed the manipulation check, that is, PST led to more mental strategies being used (probabilities > 95%), and MT led to an increase in two of three aspects of mindfulness (probabilities > 98%) when compared to WL. Compared to WL, both interventions equally improved in the ability to not let emotions interfere with performance (probabilities > 99%) and in controlling attention in training and competition (probabilities > 89%). To a lesser extend, both interventions showed shared improvements in dealing with failure indicated by more action orientation (probabilities > 82%). We found a differential effect of MT on decreased experiential avoidance: MT decreased compared to WL and PST (probabilities > 92%), whereas PST did not differ from WL. CONCLUSION: We conclude that both forms of mental training lead to improvements in performance-relevant psychological factors, especially concerning the handling of emotions and attention control. The results of our study suggest that different paths may lead to the desired outcomes, and accordingly, both forms of mental training seem justified. TRIAL REGISTRATION NUMBER: ISRCTN11147748 , date of registration: July 11, 2016.

[Long-term consequences of aversive childhood experiences: effects on the incidence of psychiatric illnesses]. / Langzeitkonsequenzen aversiver Kindheitserfahrungen: Auswirkungen auf die Inzidenz psychiatrischer Erkrankungen.

Long-term consequences of aversive childhood experiences: effects on the incidence of psychiatric illnesses Abstract. Early childhood stress experiences through physical, psychological and sexual abuse as well as emotional or physical neglect often lead to permanent changes in the psychological well-being. Clinically, this is shown among other things in an increased incidence of various psychiatric disorders. This narrative survey aims to summarize the current status of existing studies on early childhood stress experiences and related psychiatric consequences. Scientific publications from the online libraries PubMed, PsycINFO and GoogleScholar served as the database. The search was conducted under the keywords Adversive Childhood Events (ACE), Adverse Childhood, Childhood Trauma, Psychiatric Disorders, Health Consequences as well as their German translations. The search resulted in 46 studies to be considered.

[Prevention of aversive childhood experiences: social and health policy consequences]. / Prävention aversiver Kindheitserfahrungen: gesellschaftliche und gesundheitspolitische Konsequenzen.

Prevention of aversive childhood experiences: social and health policy consequences Abstract. Neglect, as well as physical, psychological or sexual abuse increase the risk of developmental disorders and of long-term health consequences in adulthood. The prevention of maltreatment is therefore crucial. In Switzerland, a multi-layered prevention model mainly focuses on supporting the family. An improved social awareness of the importance of adequate childcare is in the interest of each individual as well as of the health care system and society as a whole.

Transcranial magnetic stimulation over the right temporoparietal junction influences the sense of agency in healthy humans.

Background: The sense of agency is an important aspect of motor control. Impaired sense of agency has been linked to several medical conditions, including schizophrenia and functional neurological disorders. A complex brain network subserves the sense of agency, and the right temporoparietal junction is one of its main nodes. In this paper, we tested whether transcranial magnetic stimulation over the right temporoparietal junction elicited behavioural changes in the sense of agency. Methods: In experiment 1, 15 healthy participants performed a behavioural task during functional MRI, with the goal of localizing the area relevant for the sense of agency in the right temporoparietal junction. In the task, the movement of a cursor (controlled by the participants) was artificially manipulated, and the sense of agency was either diminished (turbulence) or enhanced (magic). In experiment 2, we applied transcranial magnetic stimulation in 20 healthy participants in a sham-controlled, crossover trial with excitatory, inhibitory or sham (vertex) stimulation. We measured the summary agency score, an indicator of the sense of agency (lower values correspond to diminished sense of agency). Results: Experiment 1 revealed a peak of activation during agency manipulation in the right temporoparietal junction (Montreal Neurological Institute coordinates x, y, z: 68, -26, 34). Experiment 2 showed that inhibition of the right temporoparietal junction significantly reduced the summary agency score in both turbulence (from -14.4 ± 11.4% to -22.5 ± 8.9%), and magic (from -0.7 ± 5.8% to -4.4 ± 4.4%). Limitations: We found no excitatory effects, possibly because of a ceiling effect (because healthy participants have a normal sense of agency) or noneffectiveness of the excitatory protocol. Conclusion: Our experiments showed that the network subserving the sense of agency was amenable to neuromodulation in healthy participants. This sets the ground for further research in patients with impaired sense of agency. Clinical trial identification: DRKS00012992 (German clinical trials registry).

Anterior cingulate volume predicts response to psychotherapy and functional connectivity with the inferior parietal cortex in major depressive disorder.

In major depressive disorder (MDD), the anterior cingulate cortex (ACC) has been associated with clinical outcome as well as with antidepressant treatment response. Nonetheless, the association between individual differences in ACC structure and function and the response to cognitive behavioral therapy (CBT) is still unexplored. For this aim, twenty-five unmedicated patients with MDD were scanned with structural and resting state functional magnetic resonance imaging before the beginning of CBT treatment. ACC morphometry was correlated with clinical changes following psychotherapy. Furthermore, whole-brain resting state functional connectivity with the ACC was correlated with clinical measures. Greater volume in the left subgenual (subACC), the right pregenual (preACC), and the bilateral supragenual (supACC) predicted depressive symptoms improvement after CBT. Greater subACC volume was related to stronger functional connectivity with the inferior parietal cortex and dorsolateral prefrontal cortex. Stronger subACC-inferior parietal cortex connectivity correlated with greater adaptive rumination. Greater preACC volume was associated with stronger functional connectivity with the inferior parietal cortex and ventrolateral prefrontal cortex. In contrast, greater right supACC volume was related to lower functional connectivity with the inferior parietal cortex. These results suggest that ACC volume and its functional connectivity with the fronto-parietal cortex are associated with CBT response in MDD, and this may be mediated by adaptive forms of rumination. Our findings support the role of the subACC as a potential predictor for CBT response.

Validity of routine clinical diagnoses in acute psychiatric inpatients.

AIM: To examine the validity of diagnoses obtained by clinicians during routine clinical examination on acute psychiatric inpatient wards. METHODS: N=100 inpatients with a broad spectrum of major mental disorders were randomly selected in a mental hospital's department of general psychiatry. Patients were diagnosed by independent assessors within Md = 5 (Range: 1-18) days of admission using the SCID I in order to examine the validity of the diagnoses given by the clinical staff based on routine assessments. RESULTS: The commonly used clinical examination technique had good overall agreement with the SCID I assessments regarding primary diagnoses at the level of ICD-10 main categories (F2, F30-31, F32-F33, F4; κ = 0.65). However, agreement between routine clinical diagnoses and the SCID I diagnoses tended to be low for some specific mental disorders (e.g., depressive disorders) and for secondary diagnoses. CONCLUSIONS: The validity of routine clinical diagnoses established in acute inpatient settings is limited and should be improved.

Identifying relapse prevention elements during psychological treatment of depression: Development of an observer-based rating instrument.

BACKGROUND: Although observer-rated instruments assessing therapist's adherence to relapse-preventive treatments are available, they do not adequately cover specific relapse-preventive elements that focus on implementation of strategies after terminating treatment. This study describes the development of the KERI-D (Kodierbogen zur Erfassung Rückfallprophylaktischer Interventionen bei Depression/Coding System to Assess Interventions of Relapse Prevention in Depression). The KERI-D is a new observer-based rating tool for acute or continuation/maintenance-phase sessions and assesses relapse-prevention elements including implementation into patient's daily routines. METHODS: The development of the KERI-D included iterative steps referring to theoretical, clinical and empirical sources. It consists of 19 content items within four categories (self-care, early warning signs, triggering events/situations, termination of therapy) and one global item. For empirical analyses, videotaped psychotherapy sessions of 36 psychotherapies were rated by three independent observers and analyzed for their psychometric properties. RESULTS: Most items showed moderate to good inter-rater reliability (median ICC = .80) and retest reliability (median ICC = .93). Principal-axis factor analysis revealed three subscales, and first evidence of content validity was demonstrated. No associations with clinical follow-up data were found. LIMITATIONS: Analysis was limited to a relatively small sample of selected psychotherapy sessions. Evaluation of predictive validity is a desirable next step to further examine applicability and scope of the instrument. CONCLUSIONS: The KERI-D is the first observer-based rating instrument measuring specific relapse-prevention strategies in psychotherapy for depression. It may help to identify elements that prove effective in reducing relapse/recurrence in the long-term and thereby help to optimize effect duration of depression treatment.

Resting state brain network function in major depression - Depression symptomatology, antidepressant treatment effects, future research.

The alterations of functional connectivity brain networks in major depressive disorder (MDD) have been subject of a large number of studies. Using different methodologies and focusing on diverse aspects of the disease, research shows heterogeneous results lacking integration. Disrupted network connectivity has been found in core MDD networks like the default mode network (DMN), the central executive network (CEN), and the salience network, but also in cerebellar and thalamic circuitries. Here we review literature published on resting state brain network function in MDD focusing on methodology, and clinical characteristics including symptomatology and antidepressant treatment related findings. There are relatively few investigations concerning the qualitative aspects of symptomatology of MDD, whereas most studies associate quantitative aspects with distinct resting state functional connectivity alterations. Such depression severity associated alterations are found in the DMN, frontal, cerebellar and thalamic brain regions as well as the insula and the subgenual anterior cingulate cortex. Similarly, different therapeutical options in MDD and their effects on brain function showed patchy results. Herein, pharmaceutical treatments reveal functional connectivity alterations throughout multiple brain regions notably the DMN, fronto-limbic, and parieto-temporal regions. Psychotherapeutical interventions show significant functional connectivity alterations in fronto-limbic networks, whereas electroconvulsive therapy and repetitive transcranial magnetic stimulation result in alterations of the subgenual anterior cingulate cortex, the DMN, the CEN and the dorsal lateral prefrontal cortex. While it appears clear that functional connectivity alterations are associated with the pathophysiology and treatment of MDD, future research should also generate a common strategy for data acquisition and analysis, as a least common denominator, to set the basis for comparability across studies and implementation of functional connectivity as a scientifically and clinically useful biomarker.

Altered dynamics of brain connectivity in major depressive disorder at-rest and during task performance.

Major depressive disorder (MDD) has been associated with alterations in several functional brain networks. Previous studies investigating brain networks in MDD during the performance of a task have yielded inconsistent results with the function of the brain at rest. In this study, we used functional magnetic resonance imaging at rest and during a goal-directed task to investigate dynamics of functional connectivity in 19 unmedicated patients with MDD and 19 healthy controls across both experimental paradigms. Patients had spatial differences in the default mode network (DMN), in the executive network (EN), and in the dorsal attention network (DAN) compared to controls at rest and during task performance. In patients the amplitude of the low frequency (LFO) oscillations was reduced in the motor and in the DAN networks during both paradigms. There was a diagnosis by paradigm interaction on the LFOs amplitude of the salience network, with increased amplitude change between task and rest in patients relative to controls. Our findings suggest that the function of several networks could be intrinsically affected in MDD and this could be viable phenotype for the investigation on the neurobiological mechanisms of this disorder and its treatment.

The relationship of self-compassion and depression: Cross-lagged panel analyses in depressed patients after outpatient therapy.

BACKGROUND: Previous cross-sectional studies suggest that self-compassion and depressive symptoms are consistently negatively associated. Although it is often implicitly assumed that (a lack of) self-compassion precedes depressive symptoms, so far no study has tested whether (lack of) self-compassion is a cause or a consequence of depressive symptoms, or both. METHOD: To examine such reciprocal effects, we used data of 125 depressed outpatients after a time limited cognitive-behavioral psychotherapy. We assessed self-compassion and depressive symptoms via self-report measures and the presence of a major depressive episode directly after therapy, as well as 6 and 12 months later. RESULTS: Cross-lagged panel analyses indicated that (lack of) self-compassion significantly predicted subsequent depressive symptoms while controlling for autoregressive effects, whereas depressive symptoms did not predict subsequent levels of self-compassion. This was also the case for the relationship between self-compassion and the presence of a major depressive episode. The same patterns also occurred when we separately tested the reciprocal effects for two composite sub-measures of either positive or negative facets of self-compassion. LIMITATIONS: Causality cannot be inferred from our results. Depressive symptoms and self-compassion could still be causally unrelated, and a third variable could account for their negative association. CONCLUSIONS: These findings support the notions that (a lack of) self-compassion could serve as a vulnerability factor for depression and that cultivating self-compassion may deserve a focus in depression prevention programs or treatments.

Amygdala response to self-critical stimuli and symptom improvement in psychotherapy for depression.

BACKGROUND: Cognitive-behavioural therapy is efficacious in the treatment of major depressive disorder but response rates are still far from satisfactory. AIMS: To better understand brain responses to individualised emotional stimuli and their association with outcome, to enhance treatment. METHOD: Functional magnetic resonance imaging data were collected prior to individual psychotherapy. Differences in brain activity during passive viewing of individualised self-critical material in 23 unmedicated out-patients with depression and 28 healthy controls were assessed. The associations between brain activity, cognitive and emotional change, and outcome were analysed in 21 patients. RESULTS: Patients showed enhanced activity in the amygdala and ventral striatum compared with the control group. Non-response to therapy was associated with enhanced activity in the right amygdala compared with those who responded, and activity in this region was negatively associated with outcome. Emotional but not cognitive changes mediated this association. CONCLUSIONS: Amygdala hyperactivity may lessen symptom improvement in psychotherapy for depression through attenuating emotional skill acquisition.

Preliminary Evidence for a Nexus between Rumination, Behavioural Avoidance, Motive Satisfaction and Depression.

UNLABELLED: The present study tested a theoretically derived link between rumination and depressive symptoms through behavioural avoidance and reduced motive satisfaction as a key aspect of positive reinforcement. Rumination, behavioural avoidance, motive satisfaction and levels of depression were assessed via self-report measures in a clinical sample of 160 patients with major depressive disorder. Path analysis-based mediation analysis was used to estimate the direct and indirect effects as proposed by the theoretical model. Operating in serial, behavioural avoidance and motive satisfaction partially mediated the association between rumination and depressive symptoms, irrespective of gender, medication and co-morbid anxiety disorders. This is the first study investigating the associations between behavioural avoidance, rumination and depression in a clinical sample of depressed patients. The findings are in line with an understanding of rumination in depression as also serving an avoidance function. KEY PRACTITIONER MESSAGE: Rumination, avoidance, motive satisfaction and levels of depressive symptoms were examined in a clinical sample of 160 outpatients with major depressive disorder. Path analysis-based mediation analysis revealed that, operating in serial, avoidance and motive satisfaction partially mediated the link between rumination and levels of depressive symptoms. Findings support an understanding of rumination in depression as serving an avoidance function.