Enduring deficits after remissions of depression: A test of the scar hypothesis

doi:10.1016/0005-7967(88)90114-3

Behaviour Research and Therapy

Volume 26, Issue 2, 1988, Pages 151-158

https://doi.org/10.1016/0005-7967(88)90114-3 Get rights and content

Abstract

People who have recovered from an episode of clinical depression have an elevated risk for developing a new episode of depression compared with those not previously depressed. One possible explanation for this finding is that depression may leave ‘scars’—enduring psychological changes resulting from depression. This hypothesis was examined for a set of interpersonal variables which measured self-perceptions, behavior observed in dyadic and group interactions, and ratings by peers and coders based on those interactions. The ‘scar’ pattern was defined as a deficit observed during depression which remained after the depressive episode ended. Data for 21 patients who improved during psychotherapy, 20 patients who did not improve, and 80 nondepressed participants were examined. No variables fit the ‘scar’ pattern. Seven variables were identified as concomitants of depression. Nine variables provided predictive information, in that patients who subsequently improved in treatment significantly differed at pre-test from patients who subsequently failed to improve. The failure to support the scar hypothesis is discussed, along with alternative explanation for the higher risk for a new depressive episode seen in the previously depressed. The importance of the finding that some measures of interpersonal behavior predict response to treatment is also discussed.

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While previous studies suggest that self-esteem and depression are related, the direction of causal effects between them remains contested (Johnson et al., 2016; Orth & Robins, 2013; Sowislo & Orth, 2013). Low self-esteem increases depression (Beck, 1967; Butler et al., 1994; Metalsky et al., 1993; Roberts & Monroe, 1992), while depressive episodes may decrease self-esteem (Coyne & Whiffen, 1995; Rohde et al., 1990; Zeiss & Lewinsohn, 1988). Most longitudinal studies investigating the relationship between self-esteem and depression provide stronger support for the vulnerability model (i.e., low self-esteem predicts depression) than for the scar model (i.e., depression predicts low self-esteem; Orth & Robins, 2013).
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This study takes a life course perspective to examine the long-term effect of negative school experiences during early adolescence on depressive affect in middle adulthood. The study uses a prospective longitudinal panel dataset that spanned nearly three decades with three waves: when respondents were at 7th grade (Time 1, mostly 12–13 years of age), young adulthood (Time 2, in their 20 s), and middle adulthood (Time 3, in their mid-30 s to early 40 s). The OLS regression models yielded results demonstrating that early negative school experiences were contemporaneously associated with depressive affect at Time 1, which endured through Time 2 and Time 3. Furthermore, independently of Time 1 control variables and the stability effects of depressive affect at Time 1 and Time 2, early negative school experiences still exerted a direct effect on depressive affect in middle adulthood. Ad hoc analysis demonstrated that this significant direct effect was mediated by the economic attainment of the respondents in middle adulthood net of the stability effects of depressive affect. Apparently, part of the influences of early negative school experiences on depressive affect in middle adulthood may be explained by its impeding economic attainment in adulthood, which in turn was associated with depressive affect.
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In particular, it is unclear whether set-shifting is impaired prior to MDD onset, as prior findings have been mixed (Papmeyer et al., 2015; Stange et al., 2016). If set-shifting is only impaired in current and remitted MDD, it may be a consequence, or ‘scar,’ of MDD rather than an intermediate process involved in its pathophysiology (Zeiss and Lewinsohn, 1988). For example, it is possible that symptoms of depression may cause lasting damage to neural structures such as the prefrontal cortex, which subsequently contribute to deficits in executive functioning domains such as set-shifting.
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Affect dynamics reflect individual differences in how emotional information is processed, and may provide insights into how depressive episodes develop. To extend prior studies that examined affect dynamics in currently depressed individuals, the present study tested in 68 non-depressed young adults whether three well-established risk factors for major depressive disorder (MDD) – (a) past episodes of MDD, (b) family history of MDD, and (c) reduced neurophysiological responses to reward – predicted mean levels, instability, or inertia (i.e., inflexibility) of positive affect (PA) and/or negative affect (NA). Momentary PA and NA were assessed up to 6 times per day for 14 days (mean number of surveys completed = 45.89). MDD history and family history of MDD were assessed via semi-structured interview, and neurophysiological responses to reward were indexed using the Reward Positivity, an event-related potential related to depression. After adjusting for current depressive symptoms, results indicated that (a) past episodes of MDD predicted higher mean levels of NA, (b) family history of MDD predicted greater PA inertia, and (c) blunted reactivity to reward predicted greater NA inertia. Collectively, these results suggest that elevated mean levels of NA and inflexibility of PA and NA may be potential mechanisms that confer risk for depression.
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The significant public health burden associated with late-life depression (LLD) is magnified by the high rates of recurrence. In this manuscript, we review what is known about recurrence risk factors, conceptualize recurrence within a model of homeostatic disequilibrium, and discuss the potential significance and challenges of new research into LLD recurrence. The proposed model is anchored in the allostatic load theory of stress. We review the allostatic response characterized by neural changes in network function and connectivity and physiologic changes in the hypothalamic-pituitary-adrenal axis, autonomic nervous system, immune system, and circadian rhythm. We discuss the role of neural networks’ instability following treatment response as a source of downstream disequilibrium, triggering and/or amplifying abnormal stress response, cognitive dysfunction and behavioral changes, ultimately precipitating a full-blown recurrent episode of depression. We propose strategies to identify and capture early change points that signal recurrence risk through mobile technology to collect ecologically measured symptoms, accompanied by automated algorithms that monitor for state shifts (persistent worsening) and variance shifts (increased variability) relative to a patient's baseline. Identifying such change points in relevant sensor data could potentially provide an automated tool that could alert clinicians to at-risk individuals or relevant symptom changes even in a large practice.
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Citation Excerpt :
Fifth, we measured hopelessness in patients who already had a depressive disorder. Hence, we were unable to conclude whether trait hopelessness represents a characteristic existing before a first depressive episode, as Abramson et al (1989) suggested, or a “scars” phenomenon (Zeiss and Lewinsohn, 1988). We showed that patients with depressive disorder demonstrate both state and trait characteristics of hopelessness during the five-year follow-up.
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No treatment effects were controlled.
Hopelessness varies markedly over time both within and between patients with depression; it is both state- and trait-related. Concurrent depressive and anxiety symptoms and low social support explain both state and trait variance, whereas high Neuroticism and low Extraversion explain only trait variance of hopelessness. These variations influence the utility of hopelessness as an indicator of suicide risk.

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Enduring deficits after remissions of depression: A test of the scar hypothesis

Abstract

An investigation into the observed sex differences in prevalence of unipolar depression

J. abnorm. Psychol.

Biomedical Aspects of Depression

Toward an interactional description of depression

Psychiatry

A diagnostic interview: The Schedule for Affective Disorders and Schizophrenia

Arch. gen. Psychiat.

The Phenomena of Depression

Design and Analysis: A Researcher's Handbook

Do negative expectancies, irrational beliefs, and positive and negative thoughts predict improvement in cognitive-behavioral therapy?

Manual of instructions for the behavior ratings used for the observation of interpersonal behavior: Revised version

A prospective study of risk factors for unipolar depression

An integrative theory of depression

The measurement of expectancies and other cognitions in depressed individuals

Cogn. Ther. Res.

Social competence and depression: the role of illusory self-perceptions

J. abnorm. Psychol.