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THE THEORY AND TREATMENT OF DEPRESSION
TOWARDS A DYNAMIC INTERACTIONISM MODEL
FIGURES OF THE UNCONSCIOUS 5

Editorial Board

J. CORVELEYN, P. MOYAERT, PH. VAN HAUTE,

W. VER EECKE, R. BERNET
 The Theory and Treatment of Depression:
Towards a Dynamic Interactionism Model

Edited by

Jozef Corveleyn
Patrick Luyten
Sidney J. Blatt

Published jointly by

LEUVEN UNIVERSITY PRESS LAWRENCE ERLBAUM ASSOCIATES

BELGIUM MAHWAH, NEW JERSEY, LONDON
Copyright © 2005 by

Leuven University Press

Lawrence Erlbaum Associates, Inc.

All rights reserved. No part of this book may be reproduced in any form, by photostat,
microform, retrieval system, or any other means, without the prior written permission of the
publishers.

Published 2005 by

Leuven University Press

Europahuis
Blijde-Inkomststraat 5
B 3000 Leuven

ISBN 90 5867 425 8

0/2005/1869/5
NUR: 777

and

Lawrence Erlbaum Associates, Inc.

10 Industrial Avenue
Mahwah, New Jersey 0 7430

Library of Congress Cataloging-in-Publication Data

The theory and treatment of depression: towards a dynamic interactionism model 1 edited by
Jozef Corveleyn, Patrick Luyten, Sidney J. Blatt.
p.cm.
Includes bibliographical references and index.
ISBN 0-8058-5669-2 (alk. paper)
1. Depression, Mental. 2. Depression, Mental-Treatment. 1. Corveleyn, Jozef. II. Luyten,
Patrick. III. Blatt, Sidney J. (Sidney Jules), 1928-

RC537.T4782005
616.85'2706-dc22 2005040632

Design Cover: Lejon Tits

Printed in Belgium
 About the editors

Jozef Corveleyn, PhD, is Professor of Psychology, Department of Psychology,

Faculty of Psychology and Educational Sciences at the Catholic University of
Leuven (Belgium) and part-time professor, Faculty of Psychology and Educational
Sciences at the Free University of Amsterdam (The Netherlands), psychoanalyst
(Belgian School of Psychoanalysis), and clinical psychologist. He teaches courses
on psychoanalysis, psychodynamic psychology, qualitative research methodology
and clinical psychology of religion. Professor Corveleyn is also Profesor Honorario
of the Universidad de Lima (Peru) and of the Universidad Nacional Mayor de San
Marcos (Lima, Peru), and Honorary member of the Center for Psychoanalytic
Psychotherapy of Lima, Peru. His main research interests concern psychodynamic
approaches of psychosis, moral emotions and religious psychopathology.

Patrick Luyten, PhD, is Postdoctoral Fellow of the Fund for Scientific Research-
Flanders (FWO) (Belgium) at the Center for Research in Psychoanalysis and
Psychodynamic Psychology (Department of Psychology, University of Leuven,
Belgium). He is particularly interested in empirical research of psychodynamic
concepts and theories and in the interface between psychodynamic, cognitive-
behavioral, and neurobiological research. Currently, his main research interest
focuses on the relationship between personality, life stress, and depression. Other
research interests include psychotherapy research, emotion research, Chronic
Fatigue Syndrome, eating disorders, and the (clinical) psychology of religion.

Sidney J. Blatt, PhD, is Professor of Psychiatry and Psychology at Yale University

and Chief of the Psychology Section in the Department of Psychiatry at the Yale
University School of Medicine. He is also a member of the faculty of the Western
New England Institute of Psychoanalysis in New Haven, Connecticut (USA). His
primary interests are in the psychological development of mental representations,
or cognitive-affective schemas, of self and significant others; the differential
impairments of these representations in various forms of psychopathology (espe-
cially schizophrenia and depression); and the differential change in the content and
cognitive organization of these representations in the therapeutic process. In addi-
tion to his interest in mental representation in individual psychological develop-
ment, Professor Blatt is also interested in the cultural development of mental repre-
sentation, particularly the development in Western Civilization of the capacity to
represent a three-dimensional reality on a two-dimensional surface in the develop-
ment of art. Dr. Blatt is the recipient of awards for Distinguished Scientific
Contributions from The Association of Medical School Professors of Psychology
(1995); and from two divisions of the American Psychological Association -
Division of Psychoanalysis (2000) and the Division of Clinical Psychology (2004).

v
 List of contributors

Sidney J. Blatt, PhD, Departments of Psychiatry and Psychology, Yale University,

New Haven, Connecticut (USA)
Stephan .T. Claes, MD, Department of Molecular Genetics, Flanders
Interuniversity Institute for Biotechnology (VIB); Department of Psychiatry,
University of Antwerp, Antwerpen (Belgium)
Gaston Cluckers, PhD, Department of Psychology, University of Leuven, Leuven
(Belgium)
Jozef Corveleyn, PhD, Department of Psychology, University of Leuven, Leuven
(Belgium)
Jurgen De Fruyt, MD, Department of Psychiatry, St.-Jan Hospital, Brugge
(Belgium)
Koen Demyttenaere, MD, Department of Psychiatry, University Hospital
Gasthuisberg, Leuven (Belgium)
Paul Eelen, PhD, Department of Psychology, University of Leuven, Leuven
(Belgium)
Dirk Hermans, PhD, Department of Psychology, University of Leuven, Leuven
(Belgium)
Patrick Luyten, PhD, Postdoctoral Fellow of the Fund for Scientific Research-
Flanders (FWO) (Belgium), Department of Psychology, University of Leuven,
Leuven (Belgium)
Patrick Meurs, PhD, Department of Psychology, University of Leuven, Leuven
(Belgium)
Charles B. Nemeroff, MD, PhD, Department of Psychiatry, Emory University,
Atlanta, Georgia (USA)
Filip Raes, Research Assistant of the Fund for Scientific Research-Flanders (FWO)
(Belgium), Department of Psychology, University of Leuven, Leuven (Belgium)
Golan Shahar, PhD, Department of Psychiatry, Yale University School of
Medicine, New Haven, Connecticut (USA); and Department of Behavioral
Sciences, Ben Gurion University of the Negev, Israel

Lukas Van Oudenhove, MD, Research Assistant of the Fund for Scientific
Research-Flanders (FWO) (Belgium), Department of Psychiatry, University
Hospital Gasthuisberg, Leuven (Belgium)

Nicole Vliegen, Department of Psychology, University of Leuven, Leuven

(Belgium)

VII
 Contents

Foreword (Robert S. Wallerstein) 5

Introduction (Patrick Luyten, Sidney J. Blatt, & Jozef Corveleyn) 5
Chapter 1 17
The life cycle of depression (Koen Demyttenaere, Lukas Van Oudenhove,
& Jiirgen De Fruyt)
Chapter 2 43
Mood and memory: A cognitive psychology perspective on maintenance of
depressed mood and vulnerability for relapse (Dirk Hermans, Filip Raes,
& Paul Eelen)

Chapter 3 67
The convergence among psychodynamic and cognitive-behavioral theories
of depression: Theoretical overview (Patrick Luyten, Sidney J. Blatt, & Jozef
Corveleyn)
Chapter 4 95
The convergence among psychodynamic and cognitive-behavioral theories
of depression: A critical review of empirical research
(Patrick Luyten, Jozef Corveleyn, & Sidney J. Blatt)

Chapter 5 137
A dialectic model of personality development and psychopathology:
Recent contributions to understanding and treating depression
(Sidney J. Blatt and Golan Shahar)
Chapter 6 163
'Closed doors and landscapes in the mist' I.
Childhood and adolescent depression in developmental psychopathology
(Nicole Vliegen, Patrick Meurs, & Gaston Cluckers)
Chapter 7 189
'Closed doors and landscapes in the mist' 2. Depression in psychodynamic
developmental psychopathology: From single track models to complex
developmental pathways
(Patrick Meurs, Nicole Vliegen, & Gaston Cluckers)
Chapter 8 227
Corticotropin releasing factor (CRF) and major depression: Towards an
integration of psychology and neurobiology in depression research
(Stephan J. Claes and Charles B. Nemeroff)

IX
Epilogue 253
Towards integration in the theory and treatment of depression?
The time is now (Patrick Luyten, Sidney J. Blatt, & Jozef Corveleyn)

Author I Subject index 285

x
 Foreword

Robert S. Wallerstein, MD

Depression, in its various manifestations, is the chief symptom, and complaint,

that brings its sufferers into the mental health care system. In this it is the
counterpart of physical pain, which plays the same central role in propelling
individuals into the general medical care system. But what is made very clear in this
impressively comprehensive volume about the totality of the depressive phenomena
and the depressive experience, from the most subtle subclinical dispositions to the
most profoundly crippling and even life-threatening illness pictures, is that we have
been living in a world of vastly insufficient and even misleading understandings of
this major symptom and character complex, as well as of insufficient awareness of
the conceptual, diagnostic, and therapeutic implications of the chronic, recurrent,
and often progressive, nature of so much depressive illness.
An implicit message of this volume is that the chief basis for these
misunderstandings and skewed conceptualizations has been the dominance over
these past several decades of the a-theoretical and a-etiological framework imposed
upon diagnosis and therapy recommendations within the realm of mental and
emotional disorders by the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM). Valuable as that compendium has
been for categorization for statistical (epidemiological) purposes, and for reliability
and comparability in empirical research study, DSM has, by its insistence on
precision in compartmentalized categorization of distinct entities, as created by
number counts and intensities of symptom clusters, but devoid of meanings or
conditions of onset and development in the individual patients, has led, by this
insistence, to grossly inadequate understandings of depression, and in many ways
has rendered more difficult the kind of study and research needed to truly enhance
our knowledge of the conditions of onset and development, and the most effective
treatment of depression, in all its variant forms.
What this volume so convincingly demonstrates by its multi-pronged and
dynamic interactional consideration of epidemiological, psychodynamic (psycho-
analytic), cognitive-behavioral, developmental, psychopathological and neurobio-
logical factors, is that depression, in its predispositions and in its various overt
expressions, is profoundly dimensional, not categorical, in nature. Its various
features and manifestations are intertwined and mutually interactive, not
orthogonally separated as distinctive entities. And it is above all the outcome of a
long developmental process, in which in-built (genetic) vulnerabilities and quality
of life circumstance, most profoundly in the earliest mother-infant caregiver
relationship, but also throughout the lifetime developmental trajectory, further
accentuated by the traumata, losses and disappointments that can impact any life,
all lead together in dialectically and recursively interacting ways to the significant
distortions and deviations in the normal developmental process. These distortions
can be expressed - even early in life, if severe enough - as a depressive personality
disposition, or as mild or transient depressive symptomatic episodes in response to
readily identifiable life crisis and distress (such as loss, illness, work failures or
disappoint-ments, etc.). Alternatively, these distortions can also be expressed as
more severe, and at times, recurrent, chronic, and progressive severe-enough
depressive illness outbreaks, often of increasing intensity and diminishing interval
states, or all the way to what have been classically designated as major unipolar or
bipolar de-pressions. In later years, involutional melancholias may result, with
profound disruptions in life functioning, necessary hospitalizations, and marked
suicidal propensities that need to be vigorously guarded against.
A major theoretical organizing framework for this volume has been provided by
the work of Sidney Blatt of Yale University, one of the co-editors, as well as one of
the co-authors of chapters in this volume, and has been further developed and then
brought together in all its ramifying and mutually interacting expressions by a
gifted and dedicated group of clinicians and researchers headed by Professor Jozef
Corveleyn of the University of Leuven in Belgium, chief editor and also co-author
of chapters in this volume, with most but not all contributing authors members, of
his strongly psychoanalytically-informed research group at the Department of
Psychology, including his chief collaborator in this overall enterprise, Patrick
Luyten, the third co-editor and co-author. The very persuasive conceptual frame-
work, elaborated and brought together by this whole cooperating group, is based on
that developed originally by Blatt and his many collaborators at Yale, over an entire
professional lifetime, and recently brought together in comprehensive and compel-
ling exposition in Blatt's own 2004 magisterial volume, Experiences ofDepression:
Theoretical, Clinical, and Research Perspectives.
What is the originating essence of this elaborated organizing framework? It is
simply and fundamentally that clinical depression and/or the depressive character
formation do not represent a unitary, coherent, illness and character pattern. Rather,
both out of his clinical psychoanalytic experience, and his thirty years of empirical
research study (along with an array of gifted colleagues), Blatt separated out
two significantly different depressive diatheses, designated by him anaclitic and
introjective, differing in their character attributes and in their presenting
symptomatology, differing in the formative early life experiences that create their
predispositions, and differing in the implications for prognosis and for psychothera-
peutic course.

2
 The anaclitic (or dependent) depression is marked by interpersonal issues of care
and connectedness and relatedness. A central fear is of abandonment and loss, and
of a state of helplessness as a consequence. There is a desperate need to maintain
supporting and nurturant links, and to ward off feelings of being unwanted and
unloved. At its life threatening extremes in infancy and toddlerhood, it can be
manifested as hospitalism and marasmus, as has been chronicled by Spitz and the
Robertsons. And it occurs more frequently in females, who are declared to be more
oriented to issues of relatedness than are males. Blatt locates the infantile proto-
types of this disorder in the deformative experiences of the earliest, oral, develop-
mental stage.
Contrariwise, the introjective (self-critical) depression is marked by issues of
self-definition, separateness, and autonomy, with often a coercive characterological
perfectionism. The central concerns are with self-criticism, self-worth, and self-
doubt. There is a profound fear of failure to measure up to one's own exalted
standards (internally felt, or presumably externally imposed), with consequent guilt
and either self blame or blame aggressively projected onto one's most important
objects. In the Engel-Schmale formulations, this engenders a feeling of hopeless-
ness. This species of depression occurs more frequently in males, who are declared
to be more oriented to issues of self-definition, ambition, and achievement. And it
is located by Blatt at a higher developmental level, built around the deviant
experiences of Mahler's separation-individuation phase, and then the superego
issues of guilt and blame.
Given this originating theoretical frame, the overall thrust of this volume by
Corveleyn and his many colleagues is not to explore further the many similarities
and differences between these two variant forms of depression, nor the linkages to
intermediate states which partake of both and border on both, but rather to explore
them as alternative deviations from the normal developmental path with, in each
instance, an abnormal preoccupation with the issues and conflicts of one or the
other side of this dichotomy (and possibly a concomitant excessive avoidance of, or
defense against, the issues and conflicts of the other side), and then to set all of
these etiological and developmental considerations that can give rise to the variant
expressions of the depressive experience and illness, conceptualized thus
psychoanalytically, into conjunction with, and in dialectical interaction with, all the
other realms of accruing knowledge of the depressive condition already mentioned,
the epidemiological, the cognitive-behavioral, the developmental, the psychopatho-
logical, and the neurobiological - each of these developed very comprehensively
and convincingly, in each instance by a chapter co-authored by experts in that arena,
mostly Belgian co-authors, but also with two cooperating American workers
beyond Blatt, Golan Shahar at Yale (now at Ben Gurion University in Israel), and
Charles Nemeroff at Emory University in Atlanta.
The treat awaiting the reader of this volume is to witness the unfolding interplay
of these multiple considerations of the many-sided complexity of the totality of the
depressive experience, as illuminated from these many disparate vantage points,
variously clinical or empirical, psychosocial or neurobiological, nomothetic or
idiosyncratic, etc., as they are all mutually interacting, and at each moment exist at
various points of convergence or divergence. Examples abound and recur, through-

3
out the text, for example, the various convergences seen among psychological
theoretical perspectives grounded in seemingly antithetical assumptions about the
nature of mental activity, like the quite classically psychoanalytic perspectives of
Blatt, the behavioral theory perspectives of Beck, the attachment formulations of
Bowlby, and the interpersonal propositions of Arieti and Bemporad; or like the
inner-outer interplay of a depressive character disposition (itself an outcome of the
interplay of genetic vulnerabilities and adverse developmental life experience) and
its "depressogenic" impact in shaping continuing environmental contingency in
ways that reinforce the depressive outlook and confirm the depressive character
expectation.
Perhaps the best conclusion to this foretelling to the readers is to quote from the
very last paragraph of this volume. Overall, "an etiologically-based, dynamic
interactionism view of depression, emphasizing interactions among genetics, early
adversity, current life stress, and relatively stable cognitive-affective schernas or
personality dimensions, emerges as a model that may facilitate the integration of
various theoretical, methodological, and clinical approaches to depression. At the
same time, much work remains to be done." The entire volume propounds very
convincingly all the evidence that buttresses this conclusion, all the work done by
so many that has brought us to this point, and that points enticingly to all the many
opened avenues of continuing clinical and research endeavor awaiting our
collective attention. As such, it is a tribute to this group of primarily Belgian
clinicians and researchers who have collaboratively written it. Reading it should be
a journey of pleasure and of widening perspective. Bon voyage!

4
 Introduction

Patrick Luyten, Sidney l. Blatt, & Jozef Corveleyn

Depression: Changing Views

Depression, with a lifetime prevalence of approximately 15% (Blazer, Kessler,

McGonagle, & Swartz, 1994), is one of the most prevalent disorders worldwide
(NIMH, 2001). By the year 2020, depression is expected to be the second most
serious disorder with respect to global disease burden (Murray & Lopez, 1996). The
personal and social costs associated with this disorder are immense. Depression
seriously affects both intrapersonal and interpersonal functioning (Beach, 2000,
not only for those suffering from depression, but also for those in their immediate
environment. Moreover, these negative effects are not limited to an episode of
depression, but may extend over years, as is for instance shown by the fact that
children of depressed parents are at elevated risk for psychopathology in later life
(Blatt & Homann, 1992; Goodman & Gotlib, 2002). In addition, depression has
also a serious economic cost. For instance, the National Institute of Mental Health
estimated the total cost of depression in the U.S.A. to be $30-44 billion annually
(NIMH, 1999).
Until recently, it was believed that depression, though prevalent, was a relatively
"benign" disorder, because it was thought to be associated with a good prognosis,
even when untreated. Depression therefore was often called the "common cold" of
psychopathology. However, over the past two decades, our view on the natural
course and the treatment of depression has dramatically changed (Costello et aI.,
2002; Hollon et aI., 2002). Research concerning the natural course of depression
has made increasingly clear that depression is a recurrent and for a considerable
number of patients even a chronic disorder (Frank et aI., 2002; Segal, Pearson, &
Thase, 2003). Recent estimates suggest relapse rates after a first episode of 20-30%
within 3 years, and 70-80% within the same period in subjects who have had three
depressive episodes or more (Judd, 1997; Segal et al., 2003; Solomon et al., 20(0).
The risk for at least one other episode after a first episode is estimated at almost
90% (Kupfer & Frank, 2001), and the average depressed patient, during their life
time, will experience four episodes, each of about 20 weeks duration (Judd, 1997).
Also, research has shown that with each new episode, the time between two next
episodes shortens (Solomon et aI., 2000). Moreover, in about 10% to 30% of the
cases, depression becomes chronic (Verheul, 2003). Finally, adding to the growing
realization that depression is not a relatively benign and isolated disorder, research
indicates that comorbidity of depression with other Axis I and especially Axis II
disorders is the rule rather than the exception. Estimates of comorbitity between
depression and personality disorders, for instance, vary in psychiatric populations
between 50-60% (Klein & Hayden, 2000; Mulder, 2002). And it is now well
established that comorbid Axis I and Axis II disorders have a negative impact on
the prognosis and treatment of depression (Mulder, 2002; Westen, Novotny, &
Thompson-Brenner, 2004).

This leads us to a second domain in which our view of depression has

dramatically changed. The treatment of depression by both psychotherapeutic and
pharmacological means has proved much more difficult and less successful then
once was hoped for. In the 1980's, many researchers and clinicians believed that
depression could be effectively treated with short-term (standardiz.ed)
psychotherapeutic treatments, such as Cognitive-Behavioral Therapy (CBT) or
Interpersonal Therapy (IPT), and/or pharmacological treatment (e.g., see Dobson,
1989; APA, 2000).
This optimism has been seriously tempered. A growing body of research has
shown important limitations of these brief treatments for many depressed patients
(Hollon et al., 2002; Luyten, Lowyck, & Corveleyn, 2003; Parker, Roy, & Eyers,
2003; Rush & Thase, 2002; Westen & Morrison, 2001; Westen et aI., 2004). For
instance, in what is probably the most prestigious and extensive Randomised
Clinical Trial (RCT) to date, the National Institute of Mental Health (NIMH)-
sponsored Treatment of Depression Collaborative Research Program (TDCRP;
Elkin, Parloff, Hadley, & Autry, 1985), only about half of the patients that received
16 weeks of treatment with either Cognitive-Behavioral Therapy (CBT),
Interpersonal Therapy (lPT), or antidepressant medication (Imipramine plus
Clinical Management; IMI-CM), met criteria for remission at termination (Elkin et
aI., 1989) and only about 20% of the patients were considered as fully recovered
(remission without relapse) at a follow-up assessment conducted 18-months after
the termination of treatment (Shea et aI., 1992).
Westen and Morrison (2001) estimated from well-designed randomized clinical
trials (RCTs) of so-called Empirically Supported Treatments (ESTs) of depression,
such as Cognitive-Behavioral Therapy (CBT) and Interpersonal Therapy (lPT), that
only about 50% of depressed patients who completed such treatments showed
improvement. For the Intent-To-Treat (ITT) sample, this figure was only 37%.
Moreover, because of high exclusion rates in outcome studies, patients in routine
practice might show even less response to these treatments. Congruent with this

6
hypothesis, Westen and Morrison (200 I) found that there was a high correlation
between outcome and exclusion criteria (r=.4I), indicating that the more stringent
the exclusion criteria (the greater the exclusion rate), the more likely it was for the
study to have a greater number of patients who showed improvement. In addition,
it is important to note that the average patient who shows improvement after these
brief treatments, remains symptomatic and thus does not show full recovery
(Westen & Morrison, 200 I; see also Elkin et al., 1989; Shea et al., 1992).
Besides these modest effects of short-term treatments at termination, there is also
a lack of controlled studies on the long-term effects of ESTs of depression. Westen
and Morrison (2001), for instance, could locate only 4 studies published in the
1990's in which the long-term effects (from 12 to 18 months) of ESTs of depression
were investigated. The average percentage of patients showing no relapse after
12-18 months was 36.6%. For instance, in the NIMH TDCRP-study, at follow-up
after 18 months, only 20% of the patients were fully recovered (Blatt, Zuroff,
Bondi, & Sanislow, 2000; Shea et al., 1992). Westen and Morrison (2001) could
only locate one study with follow-up data of 2 years or more. The results of this
study demonstrated that as little as 27% of the patients who were in treatment and
8% of all patients initially screened, showed no relapse. Westen and Morrison
(2001, p. 886) rightfully conclude from these and similar findings: "By any
standards, it is difficult to construe these data as evidence for the hypothesis that
these treatments show genuine efficacy for the treatment of depressive disorders".
Similar response rates of about 50% (compared to 30-35% placebo response)
have been reported for the pharmacotherapeutic treatment of depression (e.g.,
Williams et al., 2002). More critical reviews, which also include non-published
negative studies, have even claimed that drug-placebo differences are minimal
and "of questionable clinical significance" (Kirsch & Sapirstein, 1998; Kirsch,
Moore, Scoboria, & Nicholls, 2002; see also Khan & Khan, 2003). In addition,
a recent meta-analysis has shown that approximately 40 years of research on
drug treatment of depression has only led to progression concerning the side effects
of medication, but not concerning its efficacy (Barbui & Hotopf, 200 I). Thus,
so-called "older" antidepressants are at least as effective as "newer" ones, but
they show more side effects. And although research has shown that the long-
term treatment of depression with antidepressants leads to a significant reduction
in relapse rates (e.g., see Kupfer & Frank, 2001), there is no relationship be-
tween the duration of drug treatment and the probability of relapse after
discontinuation of the drug (Viguera, Baldessarini, & Friedberg, 1998; see also
Fava, 2002).

The Search for More Effective Treatments

and the Need for Integration in Research on Depression

The findings just reviewed clearly suggest that further research on depression, its
origins, the factors influencing its course, and particularly its treatment, are

7
important future tasks from a scientific, clinical, as well as from a national mental
health perspective. We clearly have an important responsibility to find better
treatments for this disabling disorder, and also to develop primary and secondary
prevention strategies. Moreover, these prevention and treatment strategies need to
be made more available to the public because research has shown that very few
depressed persons - estimates vary between 19-37% - ever seek treatment (Grote
& Frank, 2003). In addition, the modal patient who does seek treatment, either is
not treated or inadequately treated or drops out early from treatment (Grote &
Frank,2003).
Not surprisingly, these findings concerning the recurrent and often chronic
course of depression, the high rates of comorbidity of depression with personality
disorders, and the growing awareness of the limits of brief treatments of depression,
have led to a renewal of interest in theories and techniques that are based on long-
term treatments of depression, such as psychodynamic theories (Jones & Pulos,
1993; Kwon, 1999; Shapiro et al., 1994), and especially in theoretical models that
focus on the relationship between personality and depression (Gunderson,
Triebwasser, Philips, & Sullivan, 1999; Klein, Kupfer, & Shea, 1993; Kupfer &
Frank, 2001; Verheul, 2003).
The convergence among psychodynamic and more recent cognitive-behavioral
theories of depression plays an important role in this evolution (Blatt, 2004; Blatt
& Maroudas, 1992; Robins, 1993). Most research in this domain has concentrated
on the psychodynamic conceptions of Sidney J. Blatt (Yale University) and the
cognitive-behavioral formulations of Aaron T. Beck (University of Pennsylvania).
Both Blatt (e.g., Blatt, 1974, 1998,2004; Blatt, D'Afflitti, & Quinlan, 1976; Blatt,
Quinlan, Chevron, McDonald, & Zuroff, 1982) and Beck (e.g., Beck, 1983, 1999)
have proposed that two personality dimensions, i.e., interpersonal dependency or
sociotropy and self-critical perfectionism or autonomy, are vulnerability factors for
clinical and nonclinical forms of depression. According to Blatt and Beck, these
personality dimensions are associated with different personality structures, a
different relational and attachment style, a vulnerability for specific life events (loss
vs. failure), a different clinical presentation, and a different response to psycho-
therapy and pharmacotherapy. Moreover, Blatt has proposed that these personality
dimensions are also associated with different developmental factors and biological
vulnerabilities (Blatt & Homann, 1992; Blatt, Cornell, & Eshkol, 1993). Support
for these formulations has come from three decades of empirical research (Blatt,
2004; Blatt & Zuroff, 1992; Clark & Beck, 1999). Yet, this research is often little
known, even among experts in research on depression.
This is only one example that shows that the field of research on depression is
still relatively fragmented. Different theoretical and research traditions concerning
depression have often developed separately from each other. The time seems
overdue to bring these different views together with the aim of developing a more
comprehensive theoretical framework for depression. It is our firm conviction that
only then more effective treatments of this serious and disabling disorder can be
developed and implemented. This has also been recognized recently by the National
Institute of Mental Health Strategic Plan for Mood Disorders Research (NIMH,
2003). This Strategic Plan, which will guide the NIMH's research initiatives in the

8
coming years, identified several routes and barriers towards integration among
approaches towards depression with the aim of enhancing both theoretical insights
in depression and treatment strategies. Although this initiative from the NIMH
deserves utmost praise, in our view it misses out on some important developments
in mood disorders research (Luyten et aI., 2003). This is in part due to the
fragmented state of research in this field, but also to different theoretical and
research traditions within the U.S.A., and between the U.S.A. and other parts of the
world, especially in Europe.

This led us to the idea of organizing a conference on depression, inviting several

scholars from a wide variety of different fields in depression research. Professor
Sidney J. Blatt (Yale University, New Haven, USA), who was, at that time, Visiting
Professor at the University of Leuven (Belgium), was invited as the main speaker.
The aim of this conference was not only to present a "state of the art" of depression
research, but also, and perhaps more importantly, to formulate possible avenues for
integration between different approaches of depression. In addition, it seemed
crucial to identify important barriers towards integration among various
psychological and biological approaches of depression. Subsequently, on March
14, 2003, a conference on the integration of psychological and biological
approaches towards depression was held at the St. Jozef University Psychiatric
Clinic in Kortenberg (Leuven), Belgium.
The chapters in this book are based on the presentations at this conference.
However, most chapters have been rewritten based on the interactions and
discussion among the participants. In preparing their chapter for this volume, we
asked the authors (I) to review the current state of research in their area and (2) to
also identify possible routes and barriers towards the integration among different
approaches in depression research. In the epilogue, we have made an attempt at an
"integration of the integration", summarizing possibilities and barriers towards
integration, spelling out future lines of investigation, and discussing clinical
implications of the recent research on depression from the various perspectives
presented in this volume.

Overview of the Book

The first chapter by Demyttenaere, Van Oudenhove and De Fruyt sets the stage
for this volume by summarizing and discussing recent epidemiological studies,
including the recent European Study on Mental Disorders (ESEMeD), which have
dramatically changed our view of depression. Among the many interesting findings
they discuss, two seem particularly important. First, recent epidemiological studies
do not support the categorical view of depression promulgated by the Diagnostic

9
and Statistic Manual for Mental Disorders (DSM; APA, 1994). Instead, a
dimensional view appears to more adequately fit to the data. Second, these
epidemiological studies also clearly show that depression is not an isolated, state-
like disorder, but a recurrent disorder that becomes chronic in a considerable
amount of patients, and one that can lead to considerable and lasting changes in
functioning, even on the neurobiological level.
In the second chapter, Hermans, Raes and Eelen review recent developments in
cognitive behavioral theory and research on depression. Their contribution is
noteworthy in many respects, including their emphasis on the need for more
experimental research to inform research on depression. In this context, they
emphasize the relevance of cognitive psychological research on memory in general
and on autobiographical memory in particular for understanding depression. In
addition, this chapter is also an excellent example of how fundamental experimental
research can inform clinical practice. Hermans and colleagues, for example,
demonstrate how research on mood congruent encoding and recall might help
understand the vicious cycles of negative thoughts typical of depressed patients.
Equally important is their emphasis on relapse prevention. They note that the fact
that depression tends to be a recurrent disorder should lead to a focus in both
research and treatment on the prevention of future relapses. In this context,
Hermans and colleagues discuss the integration between cognitive research on
(autobiographical) memory and more recent cognitive-behavioral treatments for
depression such as Mindfulness-Based Cognitive Therapy (MBCT; Segal,
Williams, & Teasdale, 2002).
The next three chapters are devoted to the convergence among psychodynamic
and cognitive-behavioral theories of depression. In Chapter 3, Luyten, Blatt and
Corveleyn provide an overview of the convergence in psychodynamic and
cognitive-behavioral theorizing concerning depression. In particular, they focus on
the conceptualizations of Sidney J. Blatt and Aaron T. Beck concerning
Dependency/Sociotropy and Self-Critical Perfectionism/Autonomy as primary
vulnerability factors for depression. As this overview shows, there are many
similarities and thus much common ground between psychodynamic and cognitive-
behavioral theories of depression. However, at the same time, Luyten and
colleagues note that there are also some important barriers towards further
integration because of major differences in the underlying view of human nature in
these two models.
In Chapter 4, Luyten, Corveleyn and Blatt review empirical research concerning
the three most central assumptions of the theories of Blatt and Beck as well as
research concerning the clinical implications of these theories. The review in this
chapter demonstrates that the central assumptions of Blatt and of Beck have
received considerable empirical support. However, Luyten and colleagues also
identify several areas for further research. Their review also shows that Blatt's and
Beck's views have not only led to considerable integration between psychodynamic
and cognitive-behavioral formulations, but also between psychodynamic and
cognitive-behavioral theories and research in the fields of personality, social
psychology, developmental psychology, and neurobiology, clearly illustrating the
vitality of these theoretical models in generating integrative research.

10
 Subsequently, in Chapter 5, Blatt and Shahar address recent developments in
research on Dependency/Sociotropy and Self-Critical Perfectionism/Autonomy. In
particular, Blatt and Shahar argue that depression should be situated within a
general theory of personality development. Depression should not be viewed
categorically as a disease, but as a distortion of normal personality development. In
addition, a dynamic interactionism model is proposed that involves reciprocal
interactions between adaptive and maladaptive dimensions of self-definition
(identity) and interpersonal relatedness, life stress, social support, and depression.
According to this dynamic interactionism model, individuals are not just the passive
recipients of their stressful environment, but actively, though often unwittingly,
interpret and generate, in part, their own (social) environment. Finally, Blatt and
Shahar also discuss recent research exploring the dynamics of patients showing
mixed dependent and self-critical characteristics.
Whereas until recently many even doubted whether children could experience
depression, today the question is rather how many adults have their first onset of
depression in childhood (Costello et aI., 2002). Developmental research on
depression is therefore a most important task for the future. In Chapter 6, Vliegen,
Meurs and Cluckers review research in developmental psychopathology on
depression in childhood and adolescence. This research has not only shown that
depression in childhood and adolescence is not uncommon, but that developmental
factors appear to play an important role in the etiology and pathogenesis of
depression. Moreover, Vliegen, Meurs and Cluckers also stress the need for broad,
comprehensive, developmentally-based theories of depression in childhood and
adolescence. Such comprehensive theories are needed to develop prevention
programs and treatments strategies that are developmentally sensitive. The next
chapter, Chapter 7, provides the outlines for such an overarching, psychodyna-
mically inspired developmental psychopathological framework to understand the
origins of depression. In particular, in this chapter, Meurs, Vliegen and Cluckers
delineate several developmental tasks and stages that might be involved in the
development of depression. Their views are illustrated by a detailed discussion of
excerpts of the treatment of a depressed boy.
Chapter 8 by Claes and Nemeroff addresses what can be considered to be the
greatest future challenge for research on depression and perhaps psychopathology
in general, namely the integration between biological and psychological
approaches. This integration is of high relevance for both researchers and clinicians
alike. From a research perspective, with each new study, it becomes increasingly
clear that genes, neurobiological processes, psychological, and environmental
factors constantly interact, and that any theory that assumes a neat distinction
between "nature" and "nurture" is incapable of capturing these intrinsic and
recursive interactions between biological, psychological, and social factors.
Clinicians, in turn, are faced with difficult questions such as the decision on
whether and how they should combine pharmaceutical and psychotherapeutic
treatments of depression. At present, no theoretical rationale that is firmly grounded
in empirical research exists for such decisions. Hence, the need for integrative
research and theories is clear and urgent. According to Claes and Nemeroff, such
integrative research has already begun in the domain of neurobiological research on

11
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