Treatment-resistant depression at different developmental levels : the anaclitic and introjective depression assessment

Individuals with long-term and relapsing forms of depression are at a serious disadvantage due to the shortage of research evidence guiding their clinical management. Moreover, differences in responsiveness to treatment might result as a function of the interactions between patients' pre-treatment personality characteristics and various aspects of the therapeutic process. This PhD takes the Two-Configurations model developed by Blatt and collaborators as its starting point. In order to circumvent well-known biases of self-report questionnaires as well as difficulties of available instruments to assess issues of dependency and self-criticism at different developmental levels reliably, the aim was to develop a viable alternative following a person-centred approach. After introducing the conceptualisation of treatment-resistant depression from four angles (the psychiatric, the psychoanalytic, the private, and Blatt's integrative approach), the development and preliminary validation of the Anaclitic Introjective Depression Assessment (AIDA) is presented. This observer-rated measure was developed using expert consensus rating and Q-methodology. Psychometric properties, preliminary reliability, and validity were established using a sample of 128 patients diagnosed with treatment-resistant depression from a randomised controlled trial investigating the effectives of psychoanalytic psychotherapy (the TADS study). Using Q-Factor analysis, four naturally occurring clusters of patients representing concerns with relatedness and self-definition were identified. Anaclitic and introjective issues of severe depression appear to be expressed at different developmental levels. Whether and to what extent the four factors of depressed patients differed was investigated by testing their relations to expert anaclitic/introjective prototypes, developmental adversity, and various functioning indices. Finally, using multi-level modelling, their differential response to psychoanalytic treatment compared with treatment-as-usual was investigated. Overall, findings provide preliminary evidence for the reliability and validity of the new measure and evidence that anaclitic and introjective concerns are hierarchically organised among individuals with severe depression. Limitations, and implications for future research and clinical practice are discussed.