mental state decoding abilities in clinical depression

www.elsevier.com/locate/jad

Journal of Affective Disord

Research report

Mental state decoding abilities in clinical depressionB

Lisa LeeT, Kate L. Harkness, Mark A. Sabbagh, Jill A. Jacobson

Department of Psychology Queen’s University, Kingston, Ontario, Canada K7L 3N6

Received 10 December 2004; accepted 9 February 2005

Abstract

Background: Depression is associated with profound impairments in social functioning. Past research and theory suggests that

these impairments may be related to a difficulty in the ability of depressed individuals to identify and decode others’ social cues.

However, the nature of this difficulty is equivocal. This investigation is the first to adopt a theory-of-mind framework to

examine unipolar depressed individuals’ ability to identify complex mental states from eye expressions.

Methods: Women with unipolar clinical depression (N =52) and nondepressed controls (N =30) completed the bReading the

Mind in the Eyes TaskQ (Baron-Cohen, S., Wheelwright, S., Hill, J., Raste, Y., Plumb, I., 2001. The bReading the Mind in the

EyesQ test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism. J. Child

Psychol. Psychiatry, 42, 241–251.). All participants also completed self-report measures assessing depressive and anxious

symptoms.

Results: Depressed women were significantly impaired in their ability to identify mental states in the Eyes task compared to

nondepressed participants. This difference remained after controlling for anxiety and was stronger for the affective than the

somatic symptoms of depression.

Limitations: The present study was limited by its sample size, resulting in low power for some comparisons. In addition, the

study is limited by its use of a heterogeneous depressed sample, including outpatients and volunteers from the community, as

well as its use of only female participants.

Conclusions: Our results demonstrate that severely depressed individuals are significantly impaired in their ability to decode

others’ mental states. We suggest that strategies based on improving basic theory-of-mind reasoning could be incorporated into

current therapeutic interventions for depressed individuals to ameliorate their understanding and interpretation of social

information.

D 2005 Elsevier B.V. All rights reserved.

Keywords: Major depression; Theory of mind; Mental state decoding

0165-0327/$ - see front matter D 2005 Elsevier B.V. All rights reserved.

doi:10.1016/j.jad.2005.02.007

B Declaration of interest. None of the authors involved with this

research had financial interest in the investigation.

T Corresponding author. Tel.: +1 613 533 6003; fax: +1 613

533 2499.

E-mail address: [email protected] (L. Lee).

1. Introduction

A primary clinical feature of depression is a

profound impairment in social functioning. Depressed

individuals exhibit reduced social competence

ers 86 (2005) 247–258

L. Lee et al. / Journal of Affective Disorders 86 (2005) 247–258248

(Fisher-Beckfield and McFall, 1982; Levendosky et

al., 1995), have fewer social interactions (Gotlib and

Lee, 1989), and find these encounters less rewarding

and less enjoyable than do nondepressed individuals

(Nezlek et al., 2000). These negative interpersonal

experiences often cause depressed individuals to

isolate themselves, thereby perpetuating their depres-

sion (Rippere, 1980). Because the interpersonal

difficulties of depressed individuals are so pervasive,

it is important to obtain a more detailed understanding

of the cognitive mechanisms that might underlie these

social problems.

One framework that has been used to understand

impaired social functioning in clinical conditions is

btheory of mindQ (e.g., Baron-Cohen, 1989; Langdonet al., 2002; Richell et al., 2003). Broadly construed,

theory of mind refers to the everyday ability to ascribe

mental states (e.g., beliefs, emotions, intentions) to

others to understand and predict their social behavior.

There are two separable aspects of theory of mind: (1)

decoding mental states from perceivable social

information such as tone of voice, body posture, or

facial expression, and (2) reasoning about mental

states by integrating contextual and historical infor-

mation about a person (e.g., idiosyncratic experiences,

knowledge, attitudes) to understand behavior (Sab-

bagh, 2004).

The theory-of-mind framework has proved very

useful in understanding the social deficits associated

with schizophrenia, autism, and psychopathy. For

example, patients with schizophrenia are impaired at

both decoding mental states from pictures of faces

(Craig et al., 2004; Kington et al., 2000; Oguz et al.,

2003) and making judgments about false beliefs or

ambiguous intentions based on contextual information

(Craig et al., 2004; Frith and Corcoran, 1996; Mazza

et al., 2001; Pickup and Frith, 2001; Janssen et al.,

2003; Greig et al., 2004).

However, we know of only two studies that have

applied a theory-of-mind framework to depression. In

one, patients with affective disorders (bipolar- and

unipolar-depressed patients) did not perform differ-

ently from healthy controls on a second-order false

belief task (Doody et al., 1998), thereby suggesting

that individuals with affective disorders may not be

impaired in mental state reasoning. However, a more

recent study has reported poor performance in similar

false belief tasks in a sample of bipolar-depressed and

bipolar-manic patients (Kerr et al., 2003). Given the

conflicting findings of these two studies, it is unclear

whether depressed individuals have difficulty with

theory-of-mind tasks that require reasoning about

mental states.

A wider body of literature may be relevant to

understanding whether patients with unipolar depres-

sion have difficulties with first-order theory-of-mind

tasks that involve decoding mental states. Specifically,

researchers have identified poor facial emotion

recognition as a possible factor underlying depressed

individuals’ social difficulties (e.g., Deldin et al.,

2000). Emotions are a type of mental state and, hence,

emotion recognition may rely in part on mental state

decoding skills. Several studies found that depressed

individuals were impaired at recognizing facial

emotions. These studies required participants to match

a target photograph to one of an array of other

photographs that depicted stereotypical emotions

(Rubinow and Post, 1992) or to determine whether

pairs of faces were the same or different (Feinberg et

al., 1986; Asthana et al., 1998). Intriguingly, however,

Asthana et al. (1998) found that depressed patients

also were impaired at a visuo-spatial pattern-matching

task involving simple non-face patterns. Thus, in these

studies, it is unclear whether depressed individuals are

impaired in their ability to recognize emotional

content, or simply had general deficits in visuo-spatial

pattern matching.

Other studies in this area have found a different

pattern of results. For example, several studies

found that depressed individuals exhibited a bias

to preferentially identify negative emotions (Mandal

and Bhattacharya, 1985; Gur et al., 1992; Bouhuys

et al., 1997; Bouhuys et al., 1999; Hale, 1998).

However, the paradigm employed by the majority of

these studies required participants to recall emotions

from memory or freely label emotion terms,

processes that themselves are associated with

negative biases in depression independent of emo-

tion recognition (Dalgleish and Watts, 1990).

Furthermore, two studies utilizing emotion recog-

nition tasks that did not require either free recall/

labeling or visual–spatial discrimination found no

differences in performance between depressed and

nondepressed participants (Gessler et al., 1989;

Gaebel and Wolwer, 1992). However, in these

studies, both groups performed at near ceiling

L. Lee et al. / Journal of Affective Disorders 86 (2005) 247–258 249

levels, thus limiting the sensitivity of the measure to

detect subtle differences in performance.

This brief review suggests that significant prob-

lems with the methodologies that have been used to

measure facial emotion recognition abilities among

depressed individuals may account for the conflicting

findings of these studies. It is thus an open question as

to whether patients with unipolar depression have

difficulties decoding others’ mental states.

In the current study we assess mental state

decoding using the bReading the Mind in the EyesQtask (bEyes taskQ; Baron-Cohen et al., 2001). The

Eyes task was developed as a test of adult theory-of-

mind abilities and involves the identification of a

wide range of complex mental states. Across 36

trials, participants are shown a picture of the eye

region of the face (from the nose to the brow)

surrounded by four mental state terms (e.g., reflec-

tive, irritated, confident, ashamed). Participants select

from the four terms the one that best matches the

mental state portrayed in the picture. This task has

been used in a large number of studies investigating

mental state decoding skills in patients with autism

or Asperger’s syndrome (Dorris et al., 2004; Klein-

man et al., 2001; Rutherford et al., 2002), schizo-

phrenia (Craig et al., 2004; Kelemen et al., 2003),

psychopathy (Richell et al., 2003), dementia (Greg-

ory et al., 2002), and dysphoria (Harkness et al., in

press).

The Eyes task has two main strengths that make it

an excellent method for assessing mental state

decoding in depression. First, it is quite difficult.

The information carried by the eyes, while reliable, is

quite subtle and difficult to interpret when information

about other features of the face are not available

(Ekman and Friesen, 1978). Previous studies with the

Eyes task showed that healthy adults perform at about

70% accuracy (Baron-Cohen et al., 2001), thereby

allowing for detection of subtle group differences.

Second, the Eyes task is procedurally simple and

imposes very little demand on peripheral cognitive

systems that may be collaterally affected in depression

(i.e., free recall, visuo-spatial matching).

1.1. Goals and hypotheses

The first goal of the current investigation is to

examine differences in theory-of-mind decoding

between clinically depressed and nondepressed indi-

viduals using the Eyes task. Based on previous studies

with other clinical groups, we predict that individuals

with depression will be impaired in their ability to

decode others’ mental states in relation to nonde-

pressed individuals.

Our second goal is to examine whether individual

differences in the severity and specific symptoms of

depression differentially predict mental state decoding

abilities among depressed individuals. First, we

predict that those who are severely depressed will be

more impaired on the Eyes task than those with a mild

to moderate level of depression. Second, we predict

that certain symptoms will drive the negative associ-

ation between depression severity and theory-of-mind

performance. In particular, we predict that the

affective symptoms of depression, such as anhedonia,

low motivation, and hopelessness will be more

strongly related to performance on this social skill

than somatic symptoms, such as insomnia, loss of

appetite, and low energy.

2. Method

2.1. Participants

Clinically depressed adult women were referred

from the outpatient Mood Disorders Unit of the

Providence Continuing Care Centre-Mental Health

Services (PCCC, MHS) or the Adult Psychiatry

Outpatient Unit of Hotel Dieu Hospital (HDH) or

were recruited from the wider community. Nonde-

pressed adult women were recruited from the

community. Community recruitment was accom-

plished via radio and newspaper advertisements,

posted fliers, and referrals from private practitioners.

All depressed participants recruited from the com-

munity took part in a brief interview by telephone

to determine eligibility for the study. This interview

involved the bmajor depressive disorderQ module of

the Structured Clinical Interview for DSM-IV Axis I

Disorders (SCID-I/P; First et al., 1995), as well as

questions regarding the presence of comorbid exclu-

sionary diagnoses. To be included in the clinically

depressed group, women had to be over 18 years of

age and have a primary diagnosis of current

unipolar major depression. Women who had a

Fig. 1. Sample items from: (a) Eyes task (panicked is the target, or

correct, answer), (b) Animal task (ferocious is the target), and (c)

Gender task (female is the target).


current or past diagnosis of a psychotic disorder,

bipolar disorder, substance dependence or a serious

medical condition that could cause depression (e.g.,

hypothyroidism) were excluded. These potential

comorbid conditions were excluded to increase the

internal validity of the study. In particular, our aim

is to investigate the specific relationship of theory-

of-mind skills to unipolar major depression. Hence,

it was necessary to exclude individuals who

suffered from comorbid conditions that may, them-

selves, be causally related to their depression.

To be included in the nondepressed control group,

women had to be over 18 years of age and have no

psychiatric history. Nineteen participants were

excluded based on the phone screen, leaving 67

depressed and 34 nondepressed women. These

women participated in the study at an on-campus

laboratory, or at PCCC, MHS if they were patients at

this facility.

At the appointment, all participants were assessed

with the SCID-I/P. This structured interview derives

diagnoses according to Diagnostic and Statistical

Manual for Mental Disorders criteria (DSM-IV;

American Psychiatric Association, 1994). SCID

interviews were conducted by the second author (a

clinical psychologist with extensive training and

experience with the SCID) or the first author, an

advanced graduate student who was trained to bgoldstandardQ reliability status by the second author (see

Grove et al., 1981 for details on achieving bgoldstandardQ status). Five women in the depressed

group were excluded at this stage because they did

not meet criteria for current major depression, and

10 were excluded because they had a history of

mania, psychosis, or substance dependence. Four

women in the control group were excluded because

they had a history of psychiatric illness. Thus, the

final sample comprised 52 women who met DSM-

IV criteria for major depression and 30 nonde-

pressed women.

2.2. Experimental tasks

2.2.1. Eyes task

The task consists of 36 black-and-white photo-

graphs (15 cm�6 cm) of the eye region of faces from

just above the eyebrows to halfway down the bridge

of the nose (Sample items are presented in Fig. 1).

Participants selected the one of four mental state

adjectives (three distracters and the correct adjective)

that described the person’s mental state. The task was

presented on a laptop computer screen. The photo-

graph was centered on the screen, and the four

descriptive adjectives were placed at the four corners

of the photograph equally spaced from the center of

the screen. Participants responded by pressing one of

four keys on the keyboard (i.e., S, X, K, M) identified

by colored stickers. These keys were chosen because

they are spatially analogous to the location of the

adjectives at the corners of the picture. Participants’

responses and response times were digitally recorded.

For some analyses, the 36 eyes stimuli were classified

into three valence categories: 12 negative (e.g.,

bupsetQ), 8 positive (e.g., bfriendlyQ), and 16 neutral

(e.g., breflectiveQ) based upon pilot research (see

Harkness et al., in press).

We developed two control tasks to help ensure that

any differences found between the groups on the Eyes

task could not be attributed to peripheral differences

in task demands or low-level perceptual processing:

(1) Animals task: 12 black-and-white pictures of


different animals were presented in a similar fashion

as the pictures of eyes, and participants selected the

best adjective (out of four) that described the animal;

and (2) Gender task: 12 pictures from the Eyes task

were randomly selected and presented with the words

bmaleQ and bfemaleQ at the bottom corners of the

picture. Again, participants were asked to select the

appropriate adjective.

2.3. Measures

2.3.1. Demographic interview

This information sheet contained questions regard-

ing sex, age, education level attained, occupational

status, number of children, and treatment status.

2.3.2. Depression severity measures

The 21-item Hamilton Rating Scale for Depression

interview (HRSD; Hamilton, 1960) and the 21-item

self-report Beck Depression Inventory (BDI-II; Beck,

1996) were administered to determine the presence

and severity of depression symptoms. Both measures

are widely used in the study of depression, and

considerable evidence supports their strong psycho-

metric properties (Beck et al., 1988; Rehm and

O’Hara, 1985).

2.3.3. Mood and Anxiety Symptom Questionnaire

(MASQ; Watson and Clark, 1991)

This 90-item self-report questionnaire yields

indexes of specific anxious and depressive symp-

toms. The instrument is shown to have good

convergent and discriminant validity (Watson et al.,

1995). Studies have indicated that more than 50% of

individuals with major depression suffer from a

comorbid anxiety disorder (e.g., Dobson and

Cheung, 1990) and an even larger percentage

experience significant anxiety symptoms. Anxiety

has been associated with poor social functioning and

negative interpersonal experiences (Weary and

Edwards, 1994). Furthermore, anxious participants

are more accurate in the identification of negative

facial emotions than are non-anxious participants

(Lundh and Ost, 1996; Veljaca and Rapee, 1998; Foa

et al., 2000). Thus, the MASQ allowed us to control

for the effect of anxiety symptoms in examining the

relation of depression to mental state decoding

abilities.

2.3.4. Procedure

After a complete description of the study, partic-

ipants provided written informed consent. All partic-

ipants were administered the demographic

questionnaire, the SCID-I/P, and the HRSD. Then

participants completed the experimental tasks, which

were combined and presented in a single block (60

trials total), and trials were randomly selected from

among all tasks. Following the experimental tasks,

participants completed the self-report measures of

mood. Participants were then debriefed, and those

recruited from advertisements were paid $10. The

protocol for this study was approved by the IRB at

Queen’s University.

3. Results

3.1. Preliminary item analyses

Accuracy on each of the three experimental tasks

was defined as the percentage of items on which

participants selected a designated target adjective

(see Baron-Cohen et al., 2001). To confirm the

validity of each item, we conducted a series of

Bonferonni-corrected binomial tests comparing the

proportion of participants who selected the target

adjective to the proportion that would be expected

by chance ( p =0.25 for the Eyes and Animal tasks

and p=0.50 for the Gender task). For the 36 eyes

stimuli, more participants selected the target than

would be expected by chance for all but one item

(at least 23/52 depressed participants and 16/30

nondepressed participants, binomial test, p b0.0013).

The same results were obtained for the 12 stimuli

used in the Animal task (at least 22/52 depressed

and 15/30 nondepressed participants, binomial test,

pb0.0041) and the 12 stimuli in the Gender task (at

least 16/52 depressed and 23/30 nondepressed

participants, binomial test, p b0.0041). Thus, after

deleting the invalid items, the Eyes, Animal, and

Gender tasks consisted of 35, 11, and 11 items,

respectively.

3.2. Demographic and clinical differences

We examined three groups based on depression

severity (Beck et al., 1988): (1) mildly/moderately


depressed: women meeting DSM-IV criteria for major

depression with BDI scores between 10 and 23

(n =15); (2) severely depressed: women meeting

DSM-IV criteria for major depression with BDI scores

above 23 (n =37); and (3) nondepressed: participants

with no history of psychiatric illness (n =30).

The demographic and clinical characteristics by

group are presented in Table 1. Significant differences

were obtained across the groups for age,

F(2,79)=6.14, p =0.003, and education, F(2,79)=

3.18, p =0.04. The nondepressed group was signifi-

cantly older than the mildly/moderately depressed and

severely depressed groups, t(43)=2.63, p =0.01 and

t(65)=2.97, p=0.004, respectively. In addition, the

nondepressed group was significantly more highly

educated than the severely depressed group,

t(65)=2.52, p =0.01. However, neither age nor years

of education emerged as significant covariates in the

primary analyses, p’sN0.38. Therefore, results of the

uncontrolled analyses are reported below. Depressed

participants recruited from the community did not

Table 1

Demographic and clinical characteristics of the sample by group

Mild/moderate depression group (n =15)

VARIABLE N % M S.D.

Age 37.5 12.7

Marital status: married 6 40.0

Divorced, widowed 2 13.4

Never married 7 46.7

Education: grade 8 or less 0 0

Grade 9–12 1 6.7

Part college 7 46.7

Graduated college 2 13/3

Graduate degree 5 33.3

Occupation: unemployed 4 26.7

Homemaker 1 6.7

Professional 3 20.0

Sales, service 5 33.3

Student 2 13.3

Treatment: therapy 1 6.7

Medication 0 0

Both 11 73.3

No treatment 3 20.0

Age of onset 25.3 10.6

Previous episodes 5.1 6.3

Anxiety disorder 10 66.7

BDI score 16.6 5.1

HRSD score 11.7 5.4

AA score 29.1 9.6

differ on the experimental tasks from those referred

from outpatient clinics ( p’sN0.10), thus these groups

were examined together.

3.3. Overall accuracy analyses

Fig. 2 shows percent accuracy on the three tasks

(i.e., Eyes, Animal, and Gender tasks) for depressed

and nondepressed groups. Percent accuracy on the

Gender task was examined separately because it is a

statistically easier task (i.e., it involves choosing

between two answers as opposed to four). An analysis

of covariance (ANCOVA) was conducted with group

as the between-subjects factor (severely depressed vs.

mild/moderately depressed vs. nondepressed) and

percent accuracy on the Gender task as the dependent

measure. Total score on the Anxious Arousal (AA)

index of the MASQ was entered as a covariate. The

analysis revealed no significant effect of depression

group on the Gender task, F(2,74)=2.03, p =0.13. As

well, level of anxiety was not a significant covariate,

Severe depression group (n =37) Control group (n =30)

N % M S.D. N % M S.D.

39.9 12.5 50.6 17.1

17 45.9 14 46.7

7 18.9 9 30.0

13 35.1 7 23.3

1 2.7 0 0

9 24.3 0 0

6 16.2 9 30.0

18 48.6 16 53.3

3 8.1 5 16.7

21 56.8 10 33.3

3 8.1 1 3.3

0 0 7 23.3

11 29.7 5 16.7

2 5.4 7 23.3

7 18.9

4 10.8

23 62.2

3 8.1

20.7 10.4

6.2 9.7

18 48.6

36.5 6.7 3.2 4.5

17.4 6.6 1.0 1.8

37.7 12.6 20.5 4.6

Task

Eyes Animals Gender

Per

cent

Acc

urac

y

60

70

80

90

100 ControlsMild/Moderate DepressionSevere Depression

Fig. 2. Means for percent accuracy on Eyes, Animal, and Gender

task for depressed and nondepressed groups.


F(1,74)=2.39, p =0.13. These null results were

expected given that the Gender task served as a

control for mental state decoding abilities.

Next, a 3�2 (group� task) mixed-design

ANCOVA was conducted, with group (severely

depressed vs. mild/moderately depressed vs. nonde-

pressed) as the between-subjects factor, task (Eyes

task vs. Animal task) as the within-subjects factor, and

percent accuracy on the task as the dependent

measure. Total score on AA was entered as a

covariate. The main effect of task was significant,

F(1,74)=5.01, p =0.03, such that, across groups, the

Animal task was easier than the Eyes task. The main

effect of group was not significant, F(2,74)=1.14,

p =0.33. However, a significant group by task

interaction was found, F(2,74)=3.28, p =0.04. Con-

sistent with hypotheses, the severely depressed group

was significantly less accurate than was the nonde-

pressed group on the Eyes task, t(65)=2.24, p=0.03,

but these two groups did not significantly differ on the

Animal task, t(65)=1.36, p =0.18. Similarly, the mild/

moderately depressed group was less accurate than the

nondepressed group at a trend level on the Eyes task,

t(43)=1.66, p=0.10, but did not differ significantly

from the nondepressed group on the Animal task,

t(43)=0.41, p=0.69. The two depressed groups did

not differ significantly on either the Eyes or the

Animals tasks, t(50)=0.02, p =0.98 and t(50)=0.72,

p =0.48, respectively.

The anxiety covariate was significant, F(1,74)=

6.79, p =0.01, such that increasing anxiety predicted

poorer performance on both the Eyes and Animal

tasks. However, the interaction between the anxiety

covariate and task was not significant, F(1,74)=0.36,

p =0.55. Thus, the effect of severe depression

remained a significant predictor of poor performance

on the Eyes task over and above the effect of

anxiety.

3.4. Response time (RT) analyses

To ensure that the difference in accuracy on the

Eyes task between severely depressed and nonde-

pressed groups was not solely attributable to differ-

ences in RT, a 3�2 (group� task) mixed-design

ANCOVA was conducted with group as the between-

subjects factor, task (Eyes task vs. Animal task) as the

within-subjects factor, and the mean RT on the task as

the dependent measure. Total score on AA was

entered as a covariate. Only the main effect of task

was significant, F(1,74)=8.40, p =0.005. That is,

collapsed across groups, participants spent more time

on the Eyes task (M =8390.82, S.D.=3732.05) than

on the Animal task (M =6195.88, S.D.=2792.73).

There were no other main or interaction effects,

p’sN0.70. Thus, the severely depressed group’s

decreased performance on the Eyes task relative to

the nondepressed group was not due to differences

between groups in RT.

3.5. Mental state valence analyses

We next examined whether the valence of the

mental state expressed in the eyes influenced perform-

ance across the groups (see Fig. 3). A mixed model

ANCOVA was conducted with valence (negative vs.

positive vs. neutral) as the within-subjects factor,

group (severely depressed vs. mild/moderately

depressed vs. nondepressed) as the between-subjects

factor, and percent accuracy on the Eyes task as the

dependent measure. Neither the main effect of valence

nor the valence by group interaction was significant,

F(2,73)=0.74, p =0.48, and F(4,148)=1.03, p =0.39,

respectively. Thus, collapsed across group, accuracy

did not differ across negative, positive, and neutral

mental states, nor did accuracy differ among groups

across negative, positive, and neutral mental states. In

Emotional Valence

Negative Positive Neutral

Per

cent

Acc

urac

y

60

70

80

90

100 Controls Mild/Moderate Depression Severe Depression

Fig. 3. Means for percent accuracy on negative, positive, and neutral

eyes items of the Eyes task for depressed and nondepressed groups.


addition, anxiety was not a significant covariate,

F(2,73)=0.84, p =0.43.

3.6. Depression symptom analyses

Contrary to the first part of our second hypothesis,

no relation was found between depression severity

and performance on the Eyes task within the

depressed groups. That is, among those who were

depressed, those with a severe depression were not

more impaired on the task than those with a milder

level of depression. However, while quantitative

differences in the overall level of depression severity

did not predict differences in theory-of-mind reason-

ing, it may still be the case that qualitative differences

in specific symptom profiles may have differential

relations to theory-of-mind performance. To test this

hypothesis we derived two summary scores, based on

previous factor analytic study of the HRSD (Steer et

al., 1987): (1) affective depression: This factor

comprised the summed scores for the HRSD symp-

toms of depressed mood, guilt, suicide, work and

activities, and retardation; and (2) somatic depression:

This factor comprised the summed scores for the

HRSD symptoms of early, middle, and late insomnia,

anxiety-somatic, somatic-gastrointestinal, somatic-

general, genital symptoms, hypochondriasis, and

weight loss.

We performed a hierarchical linear regression with

accuracy on the Eyes task as the criterion. Scores on

affective depression and somatic depression were

entered together as a block. (Entering reaction time

on the Eyes task to the model as a covariate did not

change the pattern of results and, thus, the non-covaried

findings are presented.) The overall model was

significant, R2=0.14, F(2,46)=3.43, p =0.04. Consis-

tent with hypotheses, affective depression was signifi-

cantly negatively related to Eyes task performance

among the depressed women (b =�0.38, p =0.01),

while somatic depression was not (b =0.24, p =0.12).

4. Discussion

The main goal of the present study was to

investigate mental state decoding abilities in women

with unipolar major depression. Consistent with our

predictions, we found that severely depressed women

were significantly less accurate in identifying complex

mental states from pictures of eyes than were nonde-

pressed women across the range of positively,

negatively, and neutrally valenced mental states. Our

findings are the first to show a deficit in mental state

decoding in patients with unipolar depression. In

addition, they are in line with several studies reporting

an impairment in more general facial emotion

recognition (Feinberg et al., 1986; Zuroff and Colussy,

1986; Persad and Polivy, 1993; Rubinow and Post,

1992; Asthana et al., 1998). More importantly, our

findings suggest that depressed individuals’ impair-

ment in this area may be independent of more general

cognitive and perceptual deficits because these

women did not differ from nondepressed individuals

on the control tasks, which were matched with respect

to surface cognitive and perceptual demands.

A compelling interpretation of the present findings

is that patients with clinical depression have a specific

impairment in the theory-of-mind ability to recognize

and decode others’ mental states. Yet, one alternative

explanation that we cannot entirely rule out is that

depressed individuals have a more general cognitive or

perceptual deficit in the ability to process facial

stimuli. We attempted to control for this explanation

by including the two control tasks and, indeed, no

evidence was found for significant differences among

the groups on these tasks. For example, in the Gender


task depressed individuals were not significantly

impaired in their ability to process the physical

features of the eyes stimuli and organize them into

male and female categories. However, all groups

performed at near ceiling levels, thus limiting the

ability of the task to discriminate performance among

groups and raising the possibility that depressed

participants showed impaired performance on the Eyes

task because it was cognitively the most difficult of the

three experimental tasks. Perhaps with a gender-

discrimination task that was more difficult, depressed

individuals would have shown impairment on this task

as well. In support of this possibility, a recent study has

shown that the characteristic brain electrophysiolog-

ical response to face stimuli appears to be abnormal in

patients with depression (Deldin et al., 2000).

The question of why patients with depression have

difficulties decoding mental states is one of clear

importance and requires more research. In particular,

future research that includes other theory-of-mind

tests (such as the false belief task) will be helpful in

validating the present findings and confirming their

specificity to theory-of-mind reasoning. Nonetheless,

these issues do not cast doubt on our main claim. That

is, irrespective of its root cause, patients with clinical

depression clearly do have difficulties decoding

mental states of others based on subtle visual

information.

Our second goal was to investigate whether

individual differences in depression severity and the

specific affective vs. somatic symptom factors of

depression predict differences in mental state decoding

among depressed individuals. In terms of our first

hypothesis, contrary to predictions, performance on

the Eyes task did not vary as a function of depression

severity. Indeed, mean accuracy on the Eyes task was

identical for both the mild/moderate and severe

depression groups (i.e., 70% accuracy for both

groups). However, the difference between the mild/

moderate depression group and the nondepressed

control group failed to reach statistical significance

due to increased variability in the scores of these

depressed participants on the Eyes task (i.e.,

S.E.=0.03 for the mild/moderate depression group

and S.E.=0.01 for the severe depression group).

Interestingly, the results of the present study run

counter to those obtained in a recent study from our

lab in which mental state decoding was examined in

dysphoric individuals (i.e., individuals with elevated

levels of depression symptoms, but who did not meet

DSM-IV criteria for a major depressive episode;

Harkness et al., in press). In this study, dysphoric

individuals (mean BDI=17.7) performed significantly

better on the Eyes task than a non-dysphoric control

group. This effect persisted in two independent

replications and was robust after controlling for

demographic variables, anxiety symptoms, and reac-

tion time. By contrast, the exact opposite pattern of

performance was obtained in the present study even

among those with mild/moderate depression who

exhibited roughly the same level of depression

severity (mean BDI=16.6) as those in our previous

study, but who did meet DSM-IV criteria for major

depression.

While there may be several reasons for this

dissociation, one intriguing possibility is that there is

a fundamental qualitative difference between the

ddysphoriaT of our non-clinical sample and the

diagnosis of major depression in the clinical sample,

despite similar quantitative levels of depression

severity. That is, the presence of depressive symptoms

is qualitatively quite different from having the

syndrome of depression. This qualitative difference

may underlie a difference in the way social informa-

tion is processed by clinically depressed vs. dysphoric

individuals.

This suggestion is consistent with the results

bearing on the second part of our second hypothesis,

in which we found that performance on the Eyes task

was particularly impaired among those who scored

high on the affective symptoms of depression. These

symptoms include depressed mood, guilt, anhedonia,

retardation, and suicidality, and are very similar to the

symptoms that comprise the subtype of hopelessness

depression (HD; Abramson et al., 1989). HD is

associated with an overwhelming sense that negative

life events are likely to occur, that they will have a

devastating impact, and that they are entirely uncon-

trollable (Abramson et al., 1989). HD has been

associated with a lack of interest in others and poor

social problem-solving (Bonner and Rich, 1988;

Reinecke et al., 2001). In effect, individuals experi-

encing HD may have essentially bgiven upQ in trying

to rectify negative circumstances and thus are unlikely

to allocate cognitive resources to attending to and

processing social information.


These latter results are intriguing, as they

suggest that not all forms of depression are

associated with poor theory-of-mind reasoning

skills. In particular, regardless of the level of global

depression severity, the presence of specific affec-

tive symptoms may indicate a clinical subtype of

depression particularly likely to be associated with

compromised mental state decoding. Future research

examining the specific symptoms and symptom

clusters associated with theory-of-mind ability

across the full spectrum of non-clinical and clinical

depression severity is required to fully address this

issue.

4.1. Limitations and future directions of research

The present study was limited by its sample size,

resulting in low power for some comparisons. In

particular, low power may have limited our ability

to find an effect of depression on accuracy in the

Eyes task across mental states of a negative,

positive, and neutral emotional valence. In addition,

the study is limited by its use of a heterogeneous

depressed sample, including outpatients and volun-

teers from the community. However, the use of

such a sample may also be seen as a strength as it

increases the generalizability of the findings in

comparison to more homogenous samples. Impor-

tantly, preliminary analyses revealed no differences

in accuracy on the Eyes task between the two types

of referrals. Nevertheless, our sample may differ in

important ways from a non-referred epidemiological

sample. Furthermore, the present study was limited

by its use of only women participants; thus future

study with a mixed sample is required to ensure

generalizability to men with depression.

Future research also is required to determine

whether impaired theory-of-mind decoding in

depressed individuals is a stable trait-like phenom-

enon, or whether this deficit is state-dependent.

Preliminary results using second-order theory-of-

mind reasoning tasks suggest that deficits on a false

belief task are observed even during remission,

suggesting that impaired theory of mind may

represent a trait-like vulnerability for psychopathol-

ogy (Inoue et al., 2004). Similar studies are now

required to generalize this finding to the founda-

tional skill of theory-of-mind decoding.

5. Conclusions

Severe depression, and specifically the affective

symptoms of depression, was associated with signifi-

cant impairment in the ability to decode others’

mental states. Intact mental state decoding supports

everyday social interactions. A breakdown in the

ability to pick up on others’ subtle nonverbal cues

may be a critical factor in understanding the profound

social difficulties experienced by depressed individu-

als. This compromised ability may lead depressed

individuals to respond inappropriately, eliciting neg-

ative reactions from others and potential rejection.

Given the important role of nonverbal cues in human

communication, the findings of this investigation have

potentially important clinical implications. For exam-

ple, research into the theory-of-mind deficits of

individuals with autism have led to major clinical

advances such as the development of techniques for

early diagnosis (Baird et al., 2000) and interventions

that aim to improve their understanding and inter-

pretation of social information (Swettenham et al.,

1996). Strategies could also be incorporated into

current therapeutic interventions for depressed indi-

viduals to improve their day-to-day social functioning.

Acknowledgements

This research was supported by a grant from the

Canada Foundation for Innovation to Kate Harkness

and Mark Sabbagh, and was part of Lisa Lee’s

Master’s thesis. We are grateful to Roumen Milev,

Michela David, Amarendra Singh, and Eva Barnett-

Cowan for supplying patient referrals. We also wish to

thank Tina Chen, Erin Cordingley, James Lackie,

Lynne Lamarche, and Veronica Legnini for their help

with data coding and data management. Finally, we

thank Simon Baron-Cohen for graciously providing

us with stimulus materials.

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