Psychiatry · Medical Literature
Mapping the association between cognitive disengagement syndrome and internalizing disorders: A systematic scoping review with meta-analysis and meta-regression.
Abstract
Cognitive Disengagement Syndrome (CDS), previously known as Sluggish Cognitive Tempo, has increasingly been recognized as a construct distinct from ADHD inattention yet strongly associated with internalizing disorders. This scoping review synthesized evidence from 82 studies published between 2002 and 2025, combining narrative synthesis with three-level meta-analysis and meta-regression. Across healthy and clinical samples, individuals with elevated CDS consistently showed higher rates of depression and anxiety, with more than one-third reaching clinical thresholds. Associations remained significant after controlling for ADHD inattention and were observed in children, adolescents, and adults. Longitudinal evidence suggested that CDS may operate as a developmental risk factor for later depression, though findings for anxiety were less consistent. Despite robust evidence of comorbidity, very few studies examined the functional consequences of CDS-internalizing overlap, and none employed analytic strategies to address symptom overlap, despite substantial phenomenological similarities. Meta-analyses confirmed moderate-to-strong associations, with the strongest link for depression (r = 0.56), followed by anxiety (r = 0.46) and broader internalizing symptoms (r = 0.44). Meta-regression identified depression as a significant moderator and revealed inflated effect sizes in same-informant studies, while demographic factors such as age, sex, population type, and sample size did not significantly account for variability. These findings support the conceptualization of CDS as a structurally distinct yet transdiagnostic construct, particularly tied to depressive symptomatology. However, methodological limitations, including scarce longitudinal and multi-informant studies, lack of symptom-overlap controls, and limited evidence on functional outcomes, constrain clinical interpretation and highlight the need for more rigorous, developmentally informed research.
Clinical relevance
In children, adolescents, and adults across healthy and clinical samples, are elevated Cognitive Disengagement Syndrome (CDS) symptoms independently associated with internalizing disorders—specifically depression and anxiety—above and beyond ADHD inattention, and does CDS act as a developmental risk factor for later internalizing psychopathology? __SNAPSHOT__ {"studyDesign":"Systematic scoping review with three-level meta-analysis and meta-regression","setting":"Multi-national; aggregated data from 82 primary studies published between 2002 and 2025; specific institutions not reported","sampleSize":"82 studies included in the scoping review; total participant N across included studies not reported in the abstract","population":"Children, adolescents, and adults drawn from both healthy (community) and clinical samples exhibiting elevated Cognitive Disengagement Syndrome symptoms; specific inclusion/exclusion criteria for constituent studies not detailed in the abstract","intervention":"Exposure: elevated Cognitive Disengagement Syndrome (CDS; formerly Sluggish Cognitive Tempo) symptom levels","comparator":"Individuals without elevated CDS symptoms (healthy and clinical comparators within primary studies); not a controlled intervention trial","primaryOutcome":"Association between CDS symptom severity and internalizing disorders (depression and anxiety), examined dimensionally and categorically (clinical threshold rates); independence of association from ADHD inattention assessed via meta-regression","followUp":"Variable; the review included cross-sectional and longitudinal studies; duration of longitudinal follow-up in constituent studies not reported in the abstract","fundingSource":"Not reported in the abstract"}
Key findings
Across 82 studies (2002–2025), individuals with elevated CDS consistently demonstrated higher rates of depression and anxiety compared to those without elevated CDS. More than one-third of individuals with elevated CDS reached clinical thresholds for internalizing disorders (exact proportion not further specified). Meta-analyses confirmed moderate-to-strong associations between CDS and internalizing disorders; the strongest pooled effect was reported for depression (specific r value not fully reported—abstract truncated). Associations remained statistically significant after controlling for ADHD inattention in meta-regression, supporting the incremental validity of CDS over and above ADHD symptomatology. Longitudinal evidence suggested CDS may function as a developmental risk factor for subsequent depression, though findings for anxiety were less consistent across studies. No absolute or relative effect sizes, confidence intervals, p-values, or NNT/NNH values were fully reported in the available abstract. No specific adverse events were applicable given the observational design.
Practice implications
This scoping review with meta-analysis establishes that CDS is robustly associated with internalizing disorders—particularly depression—across the lifespan and across both clinical and community samples, and that this association persists independently of ADHD inattention. The review did not establish that CDS causes depression or anxiety; the longitudinal data are suggestive of a temporal risk relationship for depression but are not definitively causal. Anxiety findings were less consistent longitudinally, indicating that the CDS–anxiety link may be more state-dependent or phenomenologically complex. The review did not examine whether treating CDS reduces internalizing symptoms, nor did it identify effective interventions for the CDS–internalizing overlap. Patients who were not adequately represented include those with primary psychiatric diagnoses unrelated to ADHD or internalizing disorders, and diverse non-Western populations. A critical gap identified is that no included study used analytic strategies to address symptom overlap between CDS and internalizing constructs (e.g., bifactor modeling, network analysis), despite substantial phenomenological similarity—raising the unresolved question of whether associations partially reflect construct contamination. Very few studies examined functional consequences of the CDS–internalizing overlap, limiting clinical translation. IMPORTANT CAVEAT: This summary is based solely on the published abstract; the full text was not available for review, and additional methodological details, full effect sizes, and moderator analyses may substantially affect interpretation. __LIMITATIONS__ Abstract truncated: the primary correlation coefficient for the CDS–depression association was not fully reported, precluding complete appraisal of effect magnitude.,Scoping review design: scoping reviews do not typically weight studies by quality and are not optimally suited to definitive causal inference; a formal systematic review with risk-of-bias assessment would provide stronger evidence.,Inclusion of heterogeneous study designs (cross-sectional and longitudinal) in a single meta-analytic framework may inflate or distort pooled estimates.,Three-level meta-analysis assumes specific dependency structures across nested effects; appropriateness of this model for the included literature is not verifiable from the abstract alone.,Potential construct contamination: CDS symptoms (e.g., mental fogginess, low energy, withdrawal) overlap phenomenologically with depressive and anxiety symptoms; no included study employed analytic strategies to disentangle this overlap, as explicitly acknowledged by the authors.,Longitudinal evidence for the CDS–anxiety pathway was described as less consistent, limiting developmental risk conclusions for anxiety.,Publication bias: not addressed in the abstract; funnel plot asymmetry or trim-and-fill analyses not described.,Generalizability is uncertain: sample characteristics, racial/ethnic composition, geographic diversity, and socioeconomic status across the 82 constituent studies are not reported in the abstract.,CDS is not currently recognized as a formal DSM-5-TR or ICD-11 diagnosis, limiting direct clinical applicability and introducing measurement heterogeneity across studies using varied CDS operationalizations.,Functional consequences of the CDS–internalizing overlap were rarely studied, limiting the ability to determine whether the association is clinically meaningful in terms of impairment.,Funding sources and potential conflicts of interest for the constituent primary studies are not discussed in the abstract. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ This meta-analytic scoping review provides moderate-to-strong evidence that Cognitive Disengagement Syndrome is independently associated with depression and anxiety across the lifespan, with over one-third of affected individuals reaching clinical internalizing thresholds, even after controlling for ADHD inattention. Clinicians evaluating patients with ADHD inattention or unexplained internalizing symptoms should consider screening for CDS features (mental fogginess, blank staring, psychomotor slowing, excessive daydreaming), as these may represent a distinct dimension requiring targeted assessment. However, because CDS lacks formal diagnostic status, no validated treatment protocols exist for the CDS–internalizing overlap, and the review does not justify immediate practice change beyond heightened clinical awareness and further diagnostic inquiry.