Psychiatry 74(1) Spring 2011

Psychodynamic Approaches to Depression Luyten and Blatt

Psychodynamic Approaches to Depression: Whither Shall We Go?

Patrick Luyten and Sidney J. Blatt
The resurgence of interest in psychodynamic approaches to depression is evident by a steady increase of both basic (Blatt, 2004; Taylor, 2009; Watt and Panksepp, 2009) and outcome (Abbass et al., 2006; Driessen et al., 2010; Leichsenring & Rabung, 2008) research. Yet, many researchers and clinicians are relatively unfamiliar with these developments, and handbooks and even some treatment guidelines often disregard the growing empirical evidence supporting psychodynamic approaches to depression. This special section addresses these issues by bringing together some of the most prominent researchers in this area, with the aim of fostering basic research concerning the psychodynamics of depression as well as to further the dissemination and implementation of evidencebased psychodynamic treatments for depression. Given the major advances in the fields of psychiatric genetics and neuroscience, this special section starts with a thought-provoking review by Panksepp and Watt of basic neuroscience findings concerning depression, bringing new light to long-standing psychoanalytic assumptions about depression (Blatt & Luyten, 2009a) by suggesting that depression is the consequence of a cascade of neurobiological disturbances set in motion by experiences of loss and rejection. Papers by Schattner and Shahar and by Luyten and colleagues address another series of long-standing psychodynamic hypotheses, namely the role of depression in patients suffering from chronic pain and fatigue. Schattner and Shahar, congruent with object relations theory, present evidence that chronic pain patients tendency to personify chronic illness in terms of a bad inner object is associated with elevated levels of depression, increased levels of illness intrusiveness, and pain-related distress. Luyten and colleagues, in turn, report that self-critical perfectionism in patients suffering from chronic fatigue syndrome is related to increased stress sensitivity as well as to the active generation of stress in the daily flow of life, explaining in part elevated levels of depression in these patients. From a clinical perspective, both self-critical perfectionism and the tendency to personify chronic illness may be important targets for therapeutic intervention, particularly as they may be associated with negative treatment outcome (Blatt et al., 2010). The paper by Besser and Priel points to the importance of distortions in meaning-making processes in the causation of depression associated with different depressive personality styles. Together, these four papers illustrate the potential of basic research to inform clinical practice and the need to translate these findings to treatment guidelines and techniques. While the findings of these papers suggest considerable overlap with theoretical views that are the basis of both cognitive behavioral therapy and interpersonal therapy for depression, the focus on developmental and dynamic issues seems to

Patrick Luyten is affiliated with the Department of Psychology at the University of Leuven, in Leuven, Belgium, and with the Yale Child Study Center, Yale University, New Haven, Connecticut. Sidney J. Blatt is affiliated with the Departments of Psychiatry and Psychology at Yale University. 2011 Guilford Publications, Inc.

Psychodynamic Approaches to Depression

be a distinguishing feature of psychodynamic approaches. The final three papers in this special section address treatment issues more directly. Lemma, Target, and Fonagy describe the development and preliminary evidence supporting Dynamic Interpersonal Therapy (DIT), a novel brief psychodynamic treatment that is currently being rolled out on a large scale in the United Kingdom as part of the Improving Access to Psychological Therapies (IAPT) initiative. DIT, based in object relations theory and attachment and mentalizing approaches, emphasizes the importance of interpersonal problems and associated mentalizing impairments in depression, echoing Panksepp and Watts emphasis on the importance of interpersonal issues in depression. The paper by Taubner and colleagues addresses the potential role of mentalization in the long-term psychodynamic treatment of depression. Certainly their results should be interpreted with caution given the small sample size. Yet, their most important finding is that mentalization impairments in depression may be specifically related to issues of loss and rejection. This finding urges clinicians to assess specific, idiosyncratic mentalizing impairments and problems, rather than

assuming that depression is associated with general interpersonal problems and mentalizing impairments. Finally, a meta-analysis by Abbass and colleagues provides evidence that brief psychodynamic treatment may also be effective in patients with comorbid personality disorder, even at long-term followup. Their finding that more than 40% of the patients recovered after brief psychodynamic treatment, and even more patients obtained clinically significant changes, is impressive given that these were depressed patients with marked personality problems. More carefully conducted, high quality studies of psychodynamic treatments of depression that are rooted in extant knowledge of the causation of depression are needed (Blatt and Luyten, 2009b; Luyten et al., 2011). Gerber and colleagues recently advanced a number of quality criteria in this context that may also be used by granting agencies (Gerber et al., in press). In the meantime, the evidence supporting the efficacy of a range of psychodynamic treatments for depression should not be neglected and governments and health care organizations should consider the broader dissemination and implementation of psychodynamic treatments for depression.

References Abbass, A.A., Hancock, J.T., Henderson, J., & Kisely, S.R. (2006). Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews: Reviews, 4 18:CD004687. Blatt, S.J. (2004). Experiences of depression: Theoretical, clinical and research perspectives. Washington, DC: American Psychological Association. Blatt, S.J., & Luyten, P. (2009a). Depression as an evolutionary conserved mechanism to terminate separation-distress: Only part of the biopsychosocial story? [Commentary on Watt & Panksepp]. Neuropsychoanalysis, 11, 52-61. Blatt, S.J., & Luyten, P. (2009b). A structuraldevelopmental psychodynamic approach to psychopathology: two polarities of experience across the life span. Development & Psychopathology, 21, 793-814. Blatt, S.J., Zuroff, D.C., Hawley, L.L., & Auerbach, J.S. (2010). Predictors of sustained therapeutic change. Psychotherapy Research, 20, 37-54. Driessen, E., Cuijpers, P., de Maat, S.C.M., Abbass, A.A., de Jonghe, F., & Dekker, J.J.M. (2010). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis. Clinical Psychology Review, 30, 25-36. Gerber, A.J., Kocsis, J.H., Milrod, B.L., Roose, S.P., Barber, J.P., Thase, M.E., et al. (2011). A quality-based review of randomized controlled

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trials of psychodynamic psychotherapy. American Journal of Psychiatry. Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association, 300, 1551-1565. Luyten, P., Fonagy, P., Lemma, A., & Target, M. (in press). Mentalizing and depression. In A. Bateman & P. Fonagy (Eds.), Mentalizing in mental health practice. Washington, DC: American Psychiatric Association.

Taylor, D. (2009). Special issue: Depressive disorders in the life cycle: Biology, environment and internal world [Guest Editorial]. Psychoanalytic Psychotherapy, 23, 172-175. Watt, D.F., & Panksepp, J. (2009). Depression: An evolutionarily conserved mechanism to terminate separation distress? A review of aminergic, peptidergic, and neural network perspectives. NeuroPsychoanalysis, 11, 7-51.

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