Experiences of Depression: Theoretical, Clinical, and Research Perspectives

Working in the Yale Psychology Department, Sidney Blatt has tenaciously pursued a formulation of depression for more than 30 years. This book captures his journey and charts the development of the model from personal sources (early wrestling with Freud’s “Mourning and Melancholia” [1] and analytic observations), through years of applied research, to this proposal of an integrated model.

The model argues for two types of depression but is not the classic binary (i.e., endogenous versus neurotic/reactive) one. In essence, Blatt argues for developmentally determined “anaclitic” or dependent depression (where the depressed individual’s preoccupations involve themes of abandonment and loss) and “introjective” depression (typified by punitive and harsh self-criticism), with differential developmental factors creating the shared vulnerability to depression. As acknowledged by Blatt, the model overlaps with views of other theorists, including Bowlby and Beck (the latter used concepts of “sociotropy” and “autonomy”).

The model is multilayered. The two types are held to reflect developmental disturbances in early parent-child relationships, frame the experiential world of those who develop depression, involve a stress-diathesis congruency model linking contextual stressful events with depression onset, direct treatment approaches, and allow “depression” to be modeled parsimoniously. The last issue is perhaps the most worrisome plank in Blatt’s argument. Arguing first that depressive subtyping has failed to be achieved by use of symptoms and that “depression” is a continuum ranging from “transient dysphoric” responses to “serious distortions of reality” (p. 29), Blatt then argues for his dichotomous model as providing a “major subtyping of depression” that is both reliable and has “demonstrated validity” (p. 30). Such claims are not supported by appropriately designed or definitive analyses. Reviewed analyses seek to affirm the model rather than refine it by refutability studies.

Where are the twin studies to consider the genetic and environmental contribution to such personality styles? Why two constructs as against at least four factors of the Big Five model? Is “anaclitic” not a component domain of neuroticism and, as measured, weighted to the well-researched but here essentially ignored facet of rejection sensitivity? If Blatt’s continuum model is valid, how necessary and sufficient are the constructs to distinguish psychotic from melancholic depression as well as the depressions experienced by psychology students from those of resilient control subjects? In chapter 8 (“Therapeutic Implications”), how does the model extrapolate to the world of clinical psychiatry (e.g., the perfectionistic individual with a psychotic depression)? Here it would appear that psychotherapy is viewed as necessary and sufficient.

There can be little doubt that developmental experiences and personality styles increase the risk to certain depressive disorders, shape the clinical picture to some degree, and have some differential impact on varying treatment modalities, and that Blatt’s contribution to developing such a matrix has and will continue to be distinctive. However, his exposition in this book posits the model as all-explanatory and has Procrustean overtones.