Change and sustained recovery in defense mechanisms and depression in a pilot study of antidepressant medications plus up to 18 months of psychotherapy for recurrent major depression

Treatment studies of major depression commonly focus on symptoms rather than changes in psychological risk factors. This pilot study examines the relationship between changes in eight defenses specifically related to depression, called depressive defenses, and depressive symptoms. Thirty adults with acute, recurrent major depression were given antidepressant medications (ADM) and randomized to up to 18 months of either cognitive behavioral therapy (CBT), dynamic, or supportive psychotherapy and followed for 4.5 years. Defenses were assessed using the observer-rated Defense Mechanism Rating Scales (DMRS) at intake and 18 months. The Hamilton Rating Scale for Depression-17 item version (HRSD-17) and the Beck Depression Inventory-2nd version (BDI-II) assessed depression periodically. Depressive symptoms decreased significantly on both the HRSD-17 (effect size [ES]=-1.03) and BDI (ES=-1.90). Overall defensive functioning (ODF) increased significantly (ES=.85), improving in 76% of participants. Similarly, the mean proportion of depressive defenses decreased significantly by termination (ES=-.62), although the overall mean remained above that generally seen in healthy adults. Twenty-four percent of participants attained this threshold at termination. After controlling for initial levels, at termination depressive defenses correlated significantly with HRSD-17 (rs=.44, p=.02), and BDI (rs=.33, p=.095). Although causal relationships were not established, depressive defenses were consistently related to changes in depressive symptoms, suggesting that they are promising mediators of treatment effects for major depression. Clinically, defenses are readily identifiable and can serve as important foci in treatment. Finally, levels of depressive defenses that exceed healthy norms may reflect a continuing level of risk for current or future depressive symptoms or episodes.