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Metacognitive beliefs in unipolar and bipolar depression: A comparative study G Ö KHAN SARISOY , OZAN PAZVANTO Ğ LU , DENIZ DENIZ Ö ZTURAN , NAILE DILA AY , TUBA YILMAN , SEMA MOR , I Ş IL ZABUN KORKMAZ , Ö MER FARUK KA Ç AR , K Ü BRA G Ü M Ü Ş
Sar ı soy G, Pazvanto ğ lu O, Ö zturan DD, Ay ND, Y ı lman T, Mor S, Korkmaz IZ, Ka ç ar Ö F, G ü m ü ş K. Metacognitive beliefs in unipolar and bipolar depression: A comparative study. Nord J Psychiatry 2013;Early Online:1–7.
Aims: The purpose of this study was to perform a comparative investigation of metacognitive beliefs regarding pathological worry in patients with unipolar and bipolar depressive disorder. Methods: Those subjects with acute depressive episodes among patients diagnosed with major depressive disorder (unipolar) or bipolar disorder on the basis of DSM-IV diagnostic criteria (unipolar n � 51, bipolar n � 45), and healthy controls ( n � 60), were included in the study. Participants were administered the Meta-Cognitions Questionnaire (MCQ-30) in order to determine metacognitive beliefs. The relationship between metacognitive beliefs and anxiety severity, depression severity and self-esteem in the unipolar and bipolar patients groups was then examined. Results: Scores for negative beliefs about worry concerning uncontrollability and danger and for beliefs about the need to control thoughts were higher in both the unipolar and bipolar depression groups than in the healthy controls ( P � 0.05). Lack of cognitive confi dence scores were higher in the bipolar group than in the healthy controls ( P � 0.05). Metacognitive beliefs (to a greater extent in parameters in the bipolar group) were correlated with anxiety level, depression level and self-esteem in both patient groups. Conclusion: In addition to metacognitive beliefs known to be associated with ruminations in unipolar and bipolar depression, metacognitive beliefs can also be seen in association with worry. Worry-associated metacognitive beliefs should be the subject of focus in the identifi cation of metacognitive beliefs in depression patients and in metacognitive therapy in these patients.
• Bipolar, Depression, Metacognition, Unipolar, Worry.
G ö khan Sar ı soy, M.D., Assistant Professor, Psychiatry Department, School of Medicine, Ondokuz Mayis University, T ı p Fak ü ltesi Psikiyatri A.D. Samsun 55139, Turkey, E-mail: [email protected]; Accepted 9 June 2013.
Metacognitions are beliefs concerning the power,
meaning and signifi cance of thoughts, and the need
to control these thoughts (1). They are a psychological
process associated with the interpretation, control and
modifi cation of repetitive negative thinking such as worry
and rumination (2). Nolen-Hoeksama defi nes rumination
as “ behaviors and thoughts that passively focus one ’ s
attention to one ’ s depressive symptoms and on the impli-
cations of these symptoms (3). Worry is a chain of
thoughts and images, negatively affect-laden and rela-
tively uncontrollable; it represents an attempt to engage
in mental problem solving on an issue whose outcome is
uncertain but contains the possibility of one or more neg-
ative outcomes; consequently, worry relates closely to the
fear process ” (4).
According to the Self-Regulatory Executive Function
(S-REF) model, in addition to establishing a general
predisposition to the formation of psychopathologies,
metacognitive beliefs also play an important role in the
progression of psychopathologies. This picture is known
as Cognitive Attentional Syndrome. This syndrome is
characterized by heightened self-focused attention, threat
monitoring, recyclical thinking patterns (rumination and
worry), activation of dysfunctional beliefs and self-
regulation strategies that fail to modify maladaptive
self-knowledge (1). According to the S-REF model,
metacognitive beliefs lead to the development and per-
sistence of psychopathologies by causing maladaptive
response styles (thought suppression, cognitive avoidance
of feared situations, depressive rumination etc., all of
which fail to reduce anxiety or threat) (1, 5). The Meta-
Cognitions Questionnaire (MCQ) was developed in order
to investigate dysfunctional metacognitive beliefs on the
basis of the S-REF model (6, 7). This scale measures
© 2013 Informa Healthcare DOI: 10.3109/08039488.2013.814710
G. SARISOY ET AL.
2 NORD J PSYCHIATRY·EARLY ONLINE·2013
about ruminations. The rumination-metacognition model
in depression is supported in clinical and non-clinical
samples in several studies (19 – 23).
In addition to ruminations, pathological worry is
another frequently seen clinical characteristic seen in
depressive disorder patients (24, 25). Depression studies
in the literature also focus on the relationship between
metacognitive beliefs and rumination. The number of
studies on the relationship between metacognitive beliefs
and pathological worry in these patients is limited (5,
11). To the best of our knowledge, there have been no
previous comparative studies evaluating metacognitive
beliefs and pathological worry in unipolar and bipolar
depression samples.
Aims The fi rst aim of this study was to perform a comparative
determination of metacognitive beliefs regarding patho-
logical worry in unipolar and bipolar depression patients.
The second aim was to examine the relationship between
metacognitive beliefs and depression, severity of anxiety
and self-esteem in both patient groups.
Method Participants and procedures This study was performed at the Ondokuz May ı s Univer-
sity Faculty of Medicine Department of Psychiatry,
Turkey, between February and August 2012, with a total
of 156 subjects – 51 with unipolar depression, 45 with
bipolar depression and 60 healthy volunteers. Patients
undergoing acute depressive episodes from among sub-
jects diagnosed with major depressive disorder and bipo-
lar disorder on the basis of DSM-IV diagnostic criteria
between these dates were included. Healthy controls were
selected from a social sample, particularly friends and
relatives of the authors, and from hospital personnel.
Exclusion criteria for the unipolar and bipolar depressive
group were illiteracy, mental retardation, brain injury or
trauma, neurological disease, depressive episode being of
a psychotic nature and substance abuse. Exclusion crite-
ria for the control group were a continuing psychiatric
disorder, illiteracy, mental retardation, brain injury or
trauma, neurological disease and substance abuse.
Unipolar depression, bipolar depression and control
group socio-demographic data were investigated using a
semi-structured form, and all three groups were adminis-
tered the MCQ-30. Unipolar and bipolar depression
patients were also administered the Beck Depression,
Beck Anxiety and Rosenberg Self-Esteem scales. The
patient groups and control group were compared in terms
of MCQ subscale scores. The relationship between MCQ
subscale scores in each group and anxiety, depression
and self-esteem was investigated.
metacognitive beliefs associated with worry, frequently
seen in anxiety disorder, especially generalized anxiety
disorder (GAD), and other disorders. The scale consists
of fi ve subsections. Three of these inquire into beliefs
about positive beliefs about worry, negative beliefs and
the control of worries. The other two subsections inquire
into cognitive self-consciousness and lack of confi dence
regarding cognitive functions (6, 7).
Metacognitive beliefs have been studied in anxiety
disorders such as obsessive – compulsive symptoms (8, 9),
obsessive – compulsive disorder (OCD) (10 – 13), panic
disorder (PD) (5, 13, 14), GAD (5, 11, 15), social pho-
bia (SP) (5) and post-traumatic stress disorder (PTSD)
(16), and particularly in disorders such as schizophrenia
(12, 14) and hypochondriasis (17).
Studies in the literature regarding metacognitive
beliefs have focused on anxiety disorders, such as OCD,
GAD and PD. Scores for “ negative beliefs about worry
concerning uncontrollability and danger ” and “ beliefs
about the need to control thoughts ” have been shown to
be higher in OCD (10, 12, 13), PD (13, 14) and GAD
(11, 14) patients than in healthy controls. These studies
have suggested that metacognitive beliefs about worry
are correlated with anxiety disorders. Beliefs about the
need to control thoughts have been found to be corre-
lated with obsessive – compulsive symptoms in OCD
patients and have been set out as a potential therapeutic
target in therapy for the reduction of these symptoms
(12, 18). Another fi nding regarding OCD and GAD is
that patients feel a lack of confi dence in cognitive func-
tions such as memory, attention and concentration (8, 10,
11, 13). Increased cognitive self-consciousness has also
been determined in OCD patients (11).
In contrast to the worry-metacognition model in anxi-
ety disorders, a rumination-metacognition model has been
suggested in depression patients. A metacognitive model
has been established as the result of both clinical studies
involving depressive disorder and in non-clinical samples
(19, 20). According to the clinical model hypothesis,
positive metacognitions initiate ruminations. Positive
metacognitions are beliefs concerning ruminations help-
ing to solve problems (reducing discrepancies between
the negative life style) (e.g. “ In order to understand my
feelings of depression I need to ruminate on my prob-
lems ” ). When positive metacognitions are inadequate in
the resolution of problems, negative metacognitions about
ruminations begin to emerge. Negative metacognitions
are beliefs regarding the uncontrollability of ruminations,
and that they are harmful or have negative interpersonal
and social outcomes (e.g. “ Ruminating means I ’ m out of
control ” or “ People will reject me if I ruminate ” ). Negative
metacognitions about ruminations contribute to the devel-
opment and persistence of depression. Additionally,
decreases in confi dence in cognitive functioning contribute
to the development of positive and negative metacognitions
METACOGNITIVE BELIEFS IN DEPRESSION
NORD J PSYCHIATRY·EARLY ONLINE·2013 3
between 0 and 3, and consisting of 21 items (29). The
reliability and validity of the Turkish-language version
was evaluated by Ulusoy et al (30).
The Rosenberg Self-Esteem Scale (RSES) : Developed
by Rosenberg in 1965, the scale consists of 63 multiple
choice questions in 12 sub-categories. The fi rst 10 items
are used to measure self-esteem. We evaluated these fi rst
10 items of the scale. High values indicate high self-es-
teem (31): The relevance-reliability for Turkey was
established by Ç uhadaro ğ lu (32).
Statistics Statistical analysis was carried out using SPSS 16.0 for
Windows. The chi-square test was used to compare cate-
goric variables. Student ’ s t -test was used for comparison
of data for two groups obtained by measurement, and
analysis of variance (one-way ANOVA) was used to
compare three groups. As variances for the post hoc test
were equal, Tukey ’ s test was used. Cohen ’ s method was
used to determine effect size in comparison of two
groups. For this index, cutoffs of 0.2, 0.5 and 0.8 are, by
convention, interpreted as small, medium and large effect
sizes, respectively. Effect size index (as partial eta-
squared, η 2 ) for one-way ANOVA is computed using a
general linear model procedure. For this index, cutoffs of
0.01, 0.06 and 0.14 are, by convention, interpreted as
small, medium and large effect sizes, respectively. Cor-
relation analysis was performed between MCQ subscale
scores and depression, anxiety and self-esteem scale
scores in both the bipolar and unipolar groups (Pearson).
Correlation coeffi cients of 0.30 – 0.49 were regarded as
low, 0.50 – 0.69 as moderate, 0.70 – 0.89 as high and 0.90 –
1.00 as very high (33). The data obtained by measure-
ment were expressed as arithmetical mean � standard
deviation, and those obtained by counting as percentages.
P � 0.05 was regarded as signifi cant.
Results Comparison of groups in terms of socio-demographic characteristics There was no difference between the unipolar depression,
bipolar depression and control groups in terms of age,
gender, marital status, income level, place of residence
and total years in education ( P � 0.005) (Table 1).
Various clinical characteristics of the unipolar and bipolar depression patients Mean number of depressive episodes experienced was
3.29 � 3.97 (Min � 1; Max � 20) in the unipolar group
and 4.48 � 5.00 (Min � 0; Max � 18) in the bipolar group
( t � � 1.69, P � 0.09). Mean number of manic (and
mixed) episodes in the bipolar group was 2.33 � 1.55
Ethical considerations The study protocol was approved by the local ethics
committee, and all patients gave written informed consent.
Measures Socio-demographic and clinical data form : This form
inquired into all participants ’ ages, gender, marital status,
income level, place of residence and total years spent in
education, and these were all recorded. Various clinical
data such as patients ’ past episode types and numbers,
age at onset of disease and duration of disease were
obtained from our mood clinic patient records and
recorded on this form.
The MCQ-30 : developed by Wells & Cartwright-Hat-
ton (7). It consists of fi ve conceptually different but
inter-related factors: (1) positive beliefs about worry (e.g.
“ worrying helps me cope ” , “ worrying helps me to avoid
problems in the future ” ); (2) negative beliefs about worry
concerning uncontrollability and danger (e.g. “ when I
start worrying I cannot stop ” , “ my worrying is danger-
ous for me ” ); (3) beliefs about lack of cognitive confi -
dence (e.g. “ my memory can mislead me at times ” , “ I
have little confi dence in my memory for words and
names ” ); (4) beliefs about the need to control thoughts
(e.g. “ not being able to control my thoughts is a sign of
weakness ” , “ I will be punished for not controlling cer-
tain thoughts ” ); and (5) cognitive self-consciousness (e.g.
“ I pay close attention to the way my mind works ” ,
“ I monitor my thoughts ” ). All factors contain two com-
mon compounds, positive and negative metacognitive
beliefs and metacognitive processes (selective attention,
observation of internal cognitive processes). After read-
ing the statement in each item, participants select the
response most appropriate to them by placing a mark on
a Likert-type classifi cation scale from 1 ( “ I defi nitely
disagree ” ) to 4 ( “ I defi nitely agree ” ). Total possible
scores from the scale range from30 to 120, with higher
scores indicating increased pathological-type metacogni-
tive activity (7). The MCQ-30 has good reliability and
validity. Cronbach coeffi cient alphas for the subscales
range from 0.72 to 0.93. Tosun & Irak investigated the
psychometric characteristics of the scale, adapted it in a
Turkish sample and determined its validity and reliabil-
ity. The Turkish-language version of the form was found
to be valid and reliable (26).
The Beck Depression Inventory (BDI) : This scale was
developed by Beck et al (27) and is widely used in
measuring depression symptom levels. The relevance-
reliability of this scale for Turkey was determined by
Hisli (28).
The Beck Anxiety Scale (BAS) : Developed by Beck
et al., this is a self-evaluation scale used for the purpose
of determining the frequency and intensity of individuals ’
anxiety symptoms. It is a Likert-type scale scored
G. SARISOY ET AL.
4 NORD J PSYCHIATRY·EARLY ONLINE·2013
thoughts ( F � 6.994, P � 0.001, medium effect size � 0.08)
subscale scores. Both subscale scores were higher in the
unipolar and bipolar groups than in the controls. There
was no difference between the unipolar and bipolar
depression groups in terms of these two subscale scores.
However, a difference was determined between the
groups in terms of lack of cognitive confi dence subscale
scores ( F � 4.832, P � 0.009, medium effect size � 0.06).
Lack of cognitive confi dence scores were higher in the
bipolar depression group than in the control group. There
was no difference between the unipolar depression and
control groups. No difference was also determined
between the unipolar and bipolar depression groups. No
difference was also determined between the groups in
terms of positive beliefs about worry and cognitive self-
consciousness subscale scores ( P � 0.05) (Table 2).
Correlation between MCQ subscale scores and depression, anxiety and self-esteem scores in the bipolar and unipolar depression groups In the bipolar depression group, positive beliefs about
worry scores exhibited a low, positive correlation with
anxiety and depression scores. Negative beliefs about
worry concerning uncontrollability and danger scores
(Min � 1; Max � 7) and mean number of hypomanic
episodes was 0.80 � 1.34 (Min � 0; Max � 6).
Age at onset of disease was 33.06 � 12.00 years in
the unipolar group and 28.11 � 9.56 years in the bipolar
group ( t � 2.21, P � 0.03). Duration of disease was
3.26 � 6.02 years in the unipolar group and 11.22 � 10.52
in the bipolar group ( t � � 4.47, P � 0.000).
Mean Beck Depression Scale score was 29.20 � 9.95
in the unipolar group and 30.22 � 9.72 in the bipolar
group ( t � � 0.51, P � 0.61). Mean Beck Anxiety Scale
score was 25.80 � 13.59 in the unipolar group and
28.82 � 14.16 in the bipolar group ( t � � 1.06, P � 0.29).
Mean Rosenberg Self-Esteem Scale score was
15.69 � 5.79 in the unipolar group and 13.13 � 5.17 in
the bipolar group ( t � 2.27, P � 0.03, small effect
size � � 0.59).
Comparison of the unipolar depression, bipolar depression and control groups in terms of MCQ subscale scores The difference was determined between the groups in
terms of negative beliefs about worry concerning uncon-
trollability and danger ( F � 9.772, P � 0.000, medium
effect size � 0.11) and beliefs about the need to control
Table 1. Comparison of groups in terms of socio-demographic characteristics.
Unipolar group Bipolar group Control
( n � 51) % ( n � 45) % ( n � 60) % χ 2 / F P
Age 39.65 � 12.84 39.50 � 12.10 36.63 � 7.54 F � 1.36 0.26
Gender χ 2 � 2.56 0.28
Female 33 35.5 29 31.2 31 33.3
Male 18 28.6 16 25.4 29 46.0
Marital status 15 25.9 25 43.1 χ 2 � 0.88 0.64
Single 18 31.0 30 30.6 35 35.7
Married 33 33.7
Income level χ 2 � 0.24 0.89
Low 10 34.5 9 31.0 10 34.5
Average/high 41 32.3 36 28.3 50 39.4
Residence χ 2 � 3.48 0.17
City 37 29.8 35 28.2 52 41.9
Town/village 14 43.8 10 31.2 8 25.0
Total years spent in education 9.76 � 3.41 9.89 � 4.40 11.00 � 3.89 F � 1.69 0.19
Total 51 100.0 45 100.0 60 100.0
Table 2. Comparison of groups in terms of Meta-Cognitions Questionnaire (MCQ) subscale scores.
Unipolar group (1)
( n � 51)
Bipolar group (2)
( n � 45)
Control group (3)
( n � 60) F P
Effect size
( η 2 )
Post hoc
(Tukey)
Positive beliefs about worry 12.63 � 4.42 13.58 � 4.48 12.22 � 4.26 1.270 n.s.
Negative beliefs about worry concerning
uncontrollability and danger
15.84 � 4.67 17.00 � 3.98 13.43 � 4.07 9.772 0.000 0.11 * 1/3, 2/3
Lack of cognitive confi dence 14.41 � 4.73 15.02 � 4.54 12.40 � 4.52 4.832 0.009 0.06 * 2/3
Beliefs about the need to control thoughts 15.84 � 4.52 16.42 � 4.52 13.53 � 3.81 6.994 0.001 0.08 * 1/3, 2/3
Cognitive self-consciousness 15.06 � 3.73 15.42 � 3.59 16.65 � 4.13 2.617 n.s.
Note: signifi cance P � 0.05, n.s., non-signifi cant, η 2 ; partial eta-squared for ANOVA results.
* Medium effect size.
METACOGNITIVE BELIEFS IN DEPRESSION
NORD J PSYCHIATRY·EARLY ONLINE·2013 5
The fi rst aim of this study was to perform a compara-
tive determination of metacognitive beliefs associated
with pathological worry in unipolar and bipolar depres-
sion patients, because pathological worry is frequently
seen in addition to ruminations in depression patients
(24, 25). The literature contains many studies regarding
the rumination-metacognition correlation in depression
patients (19 – 23), while the number of those regarding
the worry-metacognition correlation is limited (5, 11). In
the fi rst of these studies, Wells & Carter used the MCQ
and showed that metacognition levels in depression
patients were lower compared with GAD patients, simi-
lar to those of PD patients, and higher than those in SP
patients and healthy controls (5). In another study, Brah-
man determined that metacognition levels were higher in
depression, GAD and OCD patients compared with the
control group (11). Furthermore, positive beliefs about
worry levels in depressive patients were higher than
those in OCD patients (11): The primary objective in
these two studies was not to use MCQ to measure the
worry-metacognition relationship in depressive patients,
but to perform a comparison with anxiety disorders. No
distinction was made between bipolar and unipolar
depression in either of these two studies. “ Negative
beliefs about worry concerning uncontrollability and dan-
ger ” and “ beliefs about the need to control thoughts ”
subscale scores in both our bipolar and unipolar depression
groups were higher than those of the healthy controls. Our
results and those of these two studies in the literature show
that in addition to the known rumination-metacognition
relationship in depression patients, metacognitive beliefs
regarding worry may also be signifi cant. Researchers tend
to correlate worry with anxiety disorders (and particularly
GAD), and rumination with depressive disorder. However,
Hong (34) and Hoyer et al. (35) reported in a non-clinical
sample and Goring & Papageorgieu (25) in a clinical
exhibited a low negative correlation with self-esteem
scores, a low positive correlation with depression scores
and a moderate positive correlation with anxiety scores.
Lack of cognitive confidence and cognitive self-
consciousness scores exhibited a low positive correlation
with anxiety scores. Beliefs about the need to control
thoughts scores were moderately negatively correlated
with self-esteem scores, lowly positively correlated with
depression scores and moderately positively correlated
with anxiety scores (Table 3).
In the unipolar depression group, positive beliefs
about worry and cognitive self-consciousness scores
exhibited no correlation with self-esteem, anxiety or
depression scores. Negative beliefs about worry concern-
ing uncontrollability and danger scores exhibited a low
negative correlation with self-esteem scores and a low
positive correlation with anxiety scores. Lack of cogni-
tive confi dence scores were lowly positively correlated
with anxiety scores. Beliefs about the need to control
thoughts scores exhibited a low positive correlation with
depression and anxiety scores (Table 3).
Discussion Unipolar and bipolar patients were enrolled in the study
during their latest depressive episodes. There was no dif-
ference between these two groups in terms of mean num-
ber of depressive episodes experienced. Similarly, no
difference was found between the two groups in terms of
severity of depression and anxiety. Self-esteem was lower
in the bipolar group compared with the unipolar group
(small effect size). These fi ndings suggested that the two
groups were similar in terms of disease severity. Depres-
sive disease onset was later in the unipolar group, while
duration of disease was greater in the bipolar group. This
is an expected fi nding.
Table 3. Pearson correlation analysis between Meta-Cognitions Questionnaire (MCQ) subscales and anxiety, depression and self-esteem scale scores in the bipolar and unipolar depression groups.
Self-esteem Beck depression Beck anxiety
Bipolar depression ( n � 45)
Positive beliefs about worry r � � 0.26 r � 0.33 * r � 0.37 * Negative beliefs about worry concerning
uncontrollability and danger
r � � 0.38 * * r � 0.30 * r � 0.53 * * *
Lack of cognitive confi dence r � � 0.27 r � 0.23 r � 0.32 * Beliefs about the need to control thoughts r � � 0.51 * * * r � 0.34 * r � 0.60 * * * Cognitive self-consciousness r � � 0.15 r � 0.23 r � 0.44 * *
Unipolar depression ( n � 51)
Positive beliefs about worry r � � 0.18 r � 0.13 r � 0.19
Negative beliefs about worry concerning
uncontrollability and danger
r � � 0.43 * * r � 0.28 r � 0.38 * *
Lack of cognitive confi dence r � � 0.25 r � 0.10 r � 0.31 * Beliefs about the need to control thoughts r � � 0.41 r � 0.44 * * r � 0.39 * * Cognitive self-consciousness r � � 0.09 r � 0.08 r � 0.19
* P � 0.05, * * P � 0.01, * * * P � 0.001.
Coeffi cients � 0.30 are shown in bold.
G. SARISOY ET AL.
6 NORD J PSYCHIATRY·EARLY ONLINE·2013
bipolar depression, metacognitive beliefs about worry can
also be seen. Metacognitive beliefs about worry need to
be focused on in the identifi cation of metacognitive
beliefs in depression patients and in the metacognitive
therapy given them.
Acknowledgments This paper has not received funds from any agency. The
authors do not have an affi liation with or fi nancial inter-
est that might pose a confl ict of interest for this paper.
Declaration of interest The authors report no confl icts of
interest. The authors alone are responsible for the content
and writing of the paper.
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sample that worry is correlated with anxiety and depres-
sion while rumination is only correlated with depression.
Barahmand, however, maintains depressive disorder
patients have a greater tendency compared with GAD
and OCD patients to make greater use of worry as a
thought-control strategy in order to control intrusive and
distressing thoughts (11). In the light of these and our
own fi ndings, in addition to metacognitions associated
with depression, it is also important for metacognitions
associated with worry to be evaluated in depression
patients. Lack of cognitive confi dence scores in our bipo-
lar depression patients was higher than those of the
healthy controls. However, we determined no difference
between unipolar and control group scores. In one study
with OCD patients, lack of cognitive confi dence was
correlated, not with severity of OCD, but with depres-
sive symptoms (12). Studies involving larger numbers of
depression patients are needed to investigate the probable
correlation between lack of cognitive confi dence and
depression (particularly bipolar depression).
The second aim of this study was to investigate the rela-
tionship between metacognitions and anxiety, depression
and self-esteem in unipolar and bipolar depression groups.
No studies investigating this were encountered. Negative
beliefs about worry concerning uncontrollability and danger
in the bipolar and unipolar patient groups, and also beliefs
about the need to control thoughts in the bipolar patient
group, were negatively correlated with self-esteem. Meta-
cognitions in both the unipolar and bipolar patient groups
were positively correlated with anxiety and depression lev-
els. It is noteworthy that anxiety level was correlated with
all MCQ subscale scores in the bipolar patient group. One
study with a non-clinical sample reported that negative
metacognitive beliefs about uncontrollability and danger of
worry were a predictor of anxiety and depression indepen-
dently of stressful life events (36). Another study with a
non-clinical sample identifi ed metacognitions as a predictor
of state anxiety (37, 38). Our study fi ndings are important
in showing that metacognitions (concerning worry) are
closely correlated with self-esteem, anxiety and depression
in both groups of depression patients.
The literature contains two different scales evaluating
positive and negative beliefs about ruminations in depres-
sion patients (19, 22). In order to be able to fully evalu-
ate metacognitions in depression patients, an inclusive
scale (as MCQ) evaluating lack of cognitive confi dence,
beliefs about the need to control thoughts and cognitive
self-consciousness is needed in addition to these two
scales. Worry as well as ruminations should be evaluated
in that scale.
Conclusions In conclusion, in addition to rumination-associated meta-
cognitive beliefs that are already known in unipolar and
METACOGNITIVE BELIEFS IN DEPRESSION
NORD J PSYCHIATRY·EARLY ONLINE·2013 7
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G ö khan Sar ı soy, M.D., Assistant Professor, Psychiatry Department, School of Medicine, Ondokuz Mayis University, Samsun, Turkey . Ozan Pazvanto ğ lu, M.D., Assistant Professor, Psychiatry Department, School of Medicine, Ondokuz Mayis University, Samsun, Turkey . Deniz Deniz Ö zturan, M.D., Assistant, Psychiatry Department, School of Medicine, Ondokuz Mayis University, Samsun, Turkey . Naile Dila Ay, M.D., Assistant, Psychiatry Department, School of Medicine, Ondokuz Mayis University, Samsun, Turkey . Tuba Y ı lman, M.D., Assistant, Psychiatry Department, School of Medicine, Ondokuz Mayis University, Samsun, Turkey . Sema Mor, M.D., Assistant, Psychiatry Department, School of Medicine, Ondokuz Mayis University, Samsun, Turkey . I ş ı l Zabun Korkmaz, M.D., Assistant, Psychiatry Department, School of Medicine, Ondokuz Mayis University, Samsun, Turkey. Ö mer Faruk Ka ç ar, M.D., Assistant, Psychiatry Department, School of Medicine, Ondokuz Mayis University, Samsun, Turkey .K ü bra G ü m ü ş , Nurse, Health Services Vocational School, Ondokuz Mayis University, Samsun, Turkey.
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