Models of Development and Mental Health

1. Models of Development and Mental Health Lecture 6: Object Relations Model: Depression

2. Depression • Low Mood Vs Clinical Depression • Major Depressive Disorder; Manic Depression (primary mood disorders) Vs depressive symptomatology as secondary feature • Unipolar (Depression) – Bipolar (Manic Depression) • Reactive Vs Endogenous • Co-morbidity: highest rates between Anxiety Disorders and Major Depressive Disorders; also high rates between Depression and Conduct Disorder, Oppositional Defiant Disorder, ADHD, Substance Abuse Disorders and Eating Disorders Rosaleen McElvaney, Phd

3. Prevalence Adapted from Phares, 2003 Rosaleen McElvaney, Phd

4. Developmental Course Preschoolers and younger children: • irritability and somatic complaints rather than dysphoric mood or hopelessness • less likely to have sleep disturbances, compared with adolescents • Developmental constraints, such as language, cognition, memory and self-understanding may compromise the accuracy of assessment of MDD in children (Cicchetti & Toth, 1998) • Assessment tool: Childhood Depression Inventory Adolescents: • more likely to report depressed mood, feelings of hopelessness, and low self esteem. The older the individual, the lower self esteem tends to be in clinical samples. Adults: • Sleep, eating, mood, activity levels, suicidal ideation and behaviour Rosaleen McElvaney, Phd

5. Risk of suicidal behaviour • Approx one third of children with MDD and/or dysthymia at risk for a first suicide attempt by age 17 years (Kovacs et al., 1993) • 25%-34% of depressed children and adolescents had attempted suicide Ryan et al. (1987); Approx 50% of those who make one suicide attempt make further attempts (Kovacs et al., 1993; Pfeffer et al., 1991) • Fatal suicide in young people linked with MDD. Chance of having MDD 27 times higher among those who committed suicide than among case controls (Brent et al., 1993; Shaffer et al., 1996) • ‘Developmental Costs’ (Kovacs, 1997) • during depressive episode children are removed from normal social experiences that serve developmental function of building social-cognitive and interpersonal skills. • Attachment may be disrupted. Depressed children show lack of reciprocity (or negative reciprocity) in interpersonal interactions. May elicit negative parental responses and undermine affective bonds. Rosaleen McElvaney, Phd

6. Aetiology • Genetics • Approx 50% of variance due to genetic influences. Children of depressed parents are more likely to develop depression even if children are raised by non-depressed adoptive parents (Rutter et al., 1999) • Monozygotic twins, even when raised apart, have higher concordance for major depression than dyzygotic twins or siblings (Hammen, 1991) • Environmental • Children’s outcomes depend on presence or absence of parental conflict (Downey and Coyne, 1990) high inter-parental conflict associated with externalising problems (CD, ODD) low levels of parental conflict associated with internalising problems, e.g. depression and anxiety Rosaleen McElvaney, Phd

7. Assessment Tool Houghton, S., McConnell, M. O’Flaherty, A. (1998), The use of the Children’s Depression Inventory in an Irish context, Irish Journal of Psychology, 19, 2-3, pp313-331. Compared Irish sample to norms, differences in age and gender Rosaleen McElvaney, Phd

8. Assessment Tool 2 • Houghton, F.Cowley, H., Meehan, F. & Houghton, S., Kelleher, K. (2006). The short 4-item Center for Epidemiological Studies Depression Scale for Children (CES-DC) in Ireland, Irish Journal of Psychology, 27, 3-4, pp183-190 Rosaleen McElvaney, Phd

9. National Institute for Health and Clinical Excellence • NICE Guidelines – Depression in children and adolescents (September, 2005) • http://www.nice.org.uk • See quick reference guide (word & pdf) • Depression (December, 2004) Rosaleen McElvaney, Phd

10. Object Relations Model • Freud • Importance of the unconscious & Defense mechanisms • Depression - Object loss: • Those with depressive personality can be identified by their object loss & distinctive object relations (Huprich, 2001) • Melanie Klein • Paranoid-Schizoid phase • Depressive phase • Defenses of introjection, splitting and projective identification in both normal and abnormal development Rosaleen McElvaney, Phd

11. Donald Winnicott • The facilitating environment • The transitional object • Illusions of omnipotence to gradual disillusionment Rosaleen McElvaney, Phd

12. Therapeutic Intervention • Emphasis on relationships • Change occurs within the context of the therapeutic relationship • The meaning of symptoms • Karon, B.P. (2005) Recurrent psychotic depression is treatable by psychoanalytic therapy without medication, Ethical Human Psychology and Psychiatry, 7,1. Rosaleen McElvaney, Phd

13. Object Relations & Attachment • Murray, L. (1991). Intersubjectivity, object relations theory and empirical evidence from mother-infant interactions, Infant Mental Health Journal, 12,3 • Study of postnatal depression – linking attachment theory with OR Rosaleen McElvaney, Phd

14. Effectiveness • The outcome measures used to determine treatment effectiveness generally reflect changes in behaviour or perceived mental health as opposed to more basic enduring changes in personality structure.(Peleikis & Dahl, 2005) Rosaleen McElvaney, Phd

15. OR & Outcomes • Van, Henricus et al. (2008). Predictive value of object relations for therapeutic alliance and outcome in psychotherapy for depression: An exploratory study. Journal of Mental and Nervous Diseases, 196,9,pp655-662 Rosaleen McElvaney, Phd

16. OR & Research • When is transference work useful in dynamic psychotherapy? Gabbard, G. (2006). American Journal of Psychiatry, 163, 10, pp1667-1669 (commentary on below article) • Hoglend et al., (2006) Analysis of the patient–therapist relationship in dynamic psychotherapy: An experimental study of transference interpretations (Rct study) Rosaleen McElvaney, Phd

17. OR & Research • Cramer, P. (2002). Defense mechanisms behavior and affect in young adulthood, Journal of Personality, 70, 1. Rosaleen McElvaney, Phd

18. Cramer’s study • “The findings show that men and women who rely on the immature defense of denial at age 23 showmultiple signs of behavioral immaturity, as well as anxiety. In contrast, extensive use of projection was related to a suspicious, hyperalert personality style, including anxiety and depression, in men, but to a sociable, nonwary, nondepressed style in women. The use of the mature defense ofidentification, by women, was related to behavior characterized by maturity, social competence, and the absence of depressive symptoms.” (Cramer, 2002 – abstract) Rosaleen McElvaney, Phd