Differentiating early-onset chronic depression from episodic depression in terms of cognitive-behavioral and emotional avoidance

Abstract

Background

Although chronic depression is associated with lower global functioning and poorer treatment response than episodic depression, little is known about the differences between these two forms of depression in terms of psychological factors. Thus, the present study aimed at differentiating chronic and episodic depression regarding cognitive-behavioral and emotional avoidance that have been proposed as important risk factors for depression and promising targets for the treatment of depression.

Methods

Thirty patients with early onset chronic depression were compared with 30 patients with episodic depression and 30 healthy, never-depressed controls in terms of self-reported cognitive-behavioral (social and non-social) and emotional avoidance.

Results

Chronically depressed patients reported more avoidance than healthy controls in each of the measures. Moreover, they reported more cognitive-nonsocial and behavioral-nonsocial as well as behavioral-social and emotional avoidance (in the form of restricted emotional expression to others) than patients with episodic depression. This kind of emotional avoidance also separated best between chronically and episodically depressed patients. Furthermore, general emotion avoidance and behavioral-social avoidance were positively correlated with levels of depression in chronically depressed patients.

Limitations

The results are based on self-report data and should thus be interpreted with caution. Additionally, the cross-sectional design limits any causal conclusions.

Conclusions

The findings underscore the relevance of cognitive-behavioral and emotional avoidance in differentiating chronic from episodic depression and healthy controls and advocate a stronger focus on maladaptive avoidance processes in the treatment of chronic depression.

Introduction

Chronic depression is defined by the persistence of depressive symptoms for at least two years (Klein, 2008). As much as 20% of all depressed patients experience such a chronic course of the disorder (Keller et al., 1992). Compared to episodic depression, chronic depression is associated with higher hospitalization rates, poorer treatment response, lower social-vocational functioning, and an increased socio-economic burden (Evans et al., 1996, Gilmer et al., 2005, Klein et al., 2000, Thase et al., 1994). However, surprisingly little is known about potential differences between chronic and episodic depression in terms of psychological factors such as avoidance. To fill this gap, the present study examines several facets of cognitive-behavioral and emotional avoidance in patients with chronic and episodic depression.

Several authors have emphasized the importance of maladaptive avoidance processes and mechanisms in the development and maintenance of depression and of chronic depression in particular (Barnhofer et al., 2009; McCullough, 2003, Moore and Garland, 2003, Ottenbreit and Dobson, 2008, Trew, 2011). In line with these theoretical accounts, there is growing evidence for a consistent association between depression and cognitive-behavioral (Brockmeyer et al., 2014, Krieger et al., 2013, Moulds et al., 2007, Ottenbreit and Dobson, 2004, Röthlin et al., 2010) as well as emotional avoidance (Brockmeyer et al., 2013, Brockmeyer et al., 2012, Campbell-Sills et al., 2006, King and Emmons, 1990, King and Emmons, 1991). Whereas cognitive-behavioral avoidance refers to decreased attention towards unpleasant thoughts and withdrawal from supposedly uncomfortable activities (Ottenbreit and Dobson, 2004), emotional avoidance refers to a diminished acceptance and expression of emotions and reduced attention towards them (Kennedy-Moore and Watson, 1999, Maio and Esses, 2001, Williams et al., 1997). Both kinds of avoidance have been assumed to contribute to the development and maintenance of depression through disturbed emotion regulation (Brockmeyer et al., 2012, Campbell-Sills et al., 2006, Gohm, 2003), poor emotional processing (Watkins and Moulds, 2007), increased access to formerly suppressed, aversive cognitions (Kircanski et al., 2008, Wenzlaff and Wegner, 2000, Wenzlaff et al., 1991), and a loss of social support and positive reinforcement (Carvalho and Hopko, 2011, Ferster, 1973, Hooley and Teasdale, 1989).

Chronic depression is assumed to be particularly associated with a pronounced avoidance of interpersonal conflict and a disconnection from the environment (McCullough, 2003, Moore and Garland, 2003, Pettit and Joiner, 2006). However, there is a lack of empirical studies examining avoidance processes in chronic depression. One of the few studies in this upcoming research domain found that patients with chronic depression report more socially avoidant behavior than those with episodic depression (Ley et al., 2011). In addition, several studies demonstrated a higher prevalence of comorbid avoidant personality disorder in chronic than in non-chronic depression (Garyfallos et al., 1999, Sanderson et al., 1992). Furthermore, in a study on the effectiveness of the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for chronic depression, an avoidant coping style was found to be associated with a less favorable treatment outcome (Blalock et al., 2008).

Based on the literature outlined above we hypothesized that chronically depressed patients would report more cognitive-behavioral and emotional avoidance than patients with episodic depression and healthy controls. In order to examine whether chronic depression is associated with abnormal increases in cognitive-behavioral and emotional avoidance and thus whether these facets of avoidance are clinically relevant factors in chronic depression, patients with chronic depression were compared to healthy, never-depressed controls. To further examine whether such abnormalities in cognitive-behavioral and emotional avoidance are specific for chronic depression, chronically depressed patients were also compared with non-chronically depressed patients. Hereby, we aimed to contribute to the knowledge on specific causes and maintenance factors in chronic depression. In line with previous studies on avoidance in depression, we further expected a positive relationship between levels of avoidance and levels of depressive symptoms in chronically depressed patients. In addition, we were interested in identifying those avoidance facets that discriminate best between patients with chronic versus episodic depression and healthy controls.