Further exploration of the relationship between depression and dependence

Journal ofAffectiL)e Disorders, 22 (1991) 221-233 0 1991 Elsevier Science Publishers B.V. 0165-0327/91/$03.50 ADONIS 0165032791001110

221

JAD 00822

Further exploration of the relationship between depression and dependence John Birtchnell

‘, Martin Deahl

2 and Jan Falkowski

3

’ MRC Social and Community Psychiatry Unit, Institute of Psychiatry, ’ Department of Psychological Medicine, St. Bartholomew’s Hospital and 3 Department of Psychiatry, St. George’s Hospital Medical School, London, U.K. (Received 20 February 1991) (Revision received 23 April 1991) (Accepted 2 May 1991)

Summary Two instruments, the Self Rating Questionnaire and the Interpersonal Dependency Inventory, were used to examine further the relationship between dependence and depression. Dependence scores on both measures correlated highly with scores on measures of neuroticism, self-esteem, depressive cognition and depression. Dependence scores were significantly higher in samples of depressed subjects than in samples of non-depressed subjects. The scores of depressives who fully recovered dropped, but those of depressives who remained depressed or who only partially recovered remained high. In non-depressed subjects there was no relationship between dependence and gender. There was no support for the use of subscales of dependence.

Key words: Dependence;

Depression;

Questionnaire;

Introduction This study aims to introduce a new measure of dependence and related constructs, to compare this with the Interpersonal Dependence Inven-

Address for correspondence: John Birtchnell, MRC Social and Community Psychiatry Unit, Institute of Psychiatry, London, U.K.

Gender;

Recovery

tory of Hirschfeld et al. (1977) and to explore further, with both these measures, the association between dependence and (1) gender and (2) depression. The association of dependence with depression This issue has been dealt with in previous publications (Birtchnell, 1984, 1987a, 1988a, 1991a). A number of theories exist to explain why dependent people may be prone to depression. These all concern interactions between the de-

222

pendent person and what has come to be known as ‘the powerful other’ with whom he/she is considered commonly to relate. Writers such as Bemporad (1971, 1980), Nemiah (1975), Coyne (19761, Millon (1981) and Kiesler (1986) maintain that the dependent person strains the tolerance of the powerful other by repeated demands for reassurance and forgiveness and that this leads to his/her inevitable rejection. Others such as Feldman (1976), Price and Sloman (1987) and Price (1988) consider that the powerful other plays a more actively dominating and suppressive role. A common theme (Rado, 1968; Chodoff, 1972) is that the dependent person relies excessively upon the powerful other for his/her self-esteem. Hirschfeld et al. (1976) proposed that depression-prone people have a chronically low selfesteem and that a fall in self-esteem heralds the onset of clinical depression. McCranie (1971) believed that depressive affect is a direct response to the lowering of self-esteem and Beck (1967) observed that common precipitants of depression are situations which are likely to lower selfesteem. More recent studies have cast doubt upon these theories by showing that whilst both current depressives (Pilowsky and Katsikitis, 1983; Hirschfeld et al., 1983a) and recovered depressives (Hirschfeld et al., 1983b, 1989) have dependence scores which are higher than those of non-depressed or never depressed subjects, high dependence scores in currently non-depressed subjects are not predictive of the future onset of depression (Andrews and Brown, 1988; Rossmann, 1988; Hirschfeld et al., 1989). This suggests that dependence is a concomitant of depression rather than a precursor to it. An alternative theory is that pathological dependence is simply part of a more general factor of psychopathology. The Millon Clinical Multiaxial Inventory (Millon, 1982) incorporates measures of all the major personality disorders (including dependence) and all the major clinical syndromes. Factor-analytic studies (e.g., Choca et al., 1986) reveal a large, first, general factor which extends across personality disorders and across symptoms, accounting for a high percentage of the variance. A similar factor has been demonstrated in factor-analytic studies of the MMPI (e.g., Kassebaum et al., 1959).

The measurement

of dependence

The measurement of dependence has been reviewed by Birtchnell (1991a). Currently, the most widely used measure is the Interpersonal Dependency Inventory of Hirschfeld et al. (lY77) Though the paper introducing this was preceded by a theoretical review (Hirschfeld et al., 1976), the theoretical basis upon which it was constructed was never described, and whilst it was stated that it was derived from a subjective grouping of items into 19 categories, these categories were never published. It is a 48-item self-administered questionnaire with three subscales called Emotional Reliance upon Another Person ( 17 items), Lack of Social Self Confidence (17 items) and Assertion of Autonomy (14 items). The third scale was intended to be a measure of the denial of dependence, based upon the assumption that certain dependent people claim to be excessively independent. In practice, it is impossible to distinguish between the denial of dependence and true independence. In the present study, a new instrument will be introduced which is intended to be a measure both of dependence (43 items) and of what may be considered to be two contrasting forms of independence called directiveness, the tendency to direct, influence and control from a position of strength (21 items), and detachment, the tendency to avoid or withdraw from people (27 items). The dependence measure is based upon a previously published definition (Birtchnell, 1984) which proposes the existence of three components: affectional, concerning doubts about approval and acceptability (15 items); ontological, concerning a poor sense of purpose and lack of direction (15 items); and deferential, concerning excessive humility, deference and respectfulness (13 items). A more detailed description of directiveness and detachment is given in Birtchnell (1987b). The study will be concerned with (1) the psychometrics of the new instrument, (2) its relationship to the measure of Hirschfeld et al. (1977), (3) the relationship of both these measures to measures of neuroticism, self-esteem and depressive cognition, (4) their relationship to gender and (5) the application of the new measure to a number of depressed and non-depressed samples.

223

Method Data will be drawn from a range of studies in which the new instrument (the Self Rating Questionnaire, SRQ) has been used. Brief accounts of these studies will be given, but more detailed information is available from previous reports. In some studies a companion, Partner Rating Questionnaire (Birtchnell, 1988b, 1991b) was used, but this will not be considered here. The items and scoring of the SRQ are provided in the Appendix. Housing estate study All young, married women on a south London housing estate were screened for depression by their general practitioners, using the Depression Screening Instrument (DSI) (Birtchnell et al., 1989). Fifty women with very high scores (> 16) and 40 with very low scores (< 5) were selected for detailed investigation (Birtchnell, 1988~). The presence or absence of depressive symptoms was confirmed by the Present State Examination (Wing et al., 1974). The DSI was also administered to the women’s husbands. For 46 of the high scorers and all of the low scorers, the SRQ was completed (as a self-report only) by both the women and their husbands. Since only four of the husbands had DSI scores in the very high (> 16) range, the husbands were divided into two groups: the 64 with very low scores (< 5), who were comparable with the very low scoring women, and the remaining 22 who had a mean DSI score of 10.4 (SD 6.6). Territorial Army study The DSI was sent, by post, to 477 members of the Territorial Army about to embark upon a week of practice manoeuvres. During the week, a subsample of 119 (72 men and 47 women> was selected for more detailed study. Of these, 31 (eight men and 23 women> had DSI scores of 14 or more and represented 41% of all who were depressed. The plan originally was to include a group who considered they might have had a previous depressive episode. This proved impractical, but this group is included among the remaining 88. Members of the subsample were invited to complete, besides the Self Rating Ques-

tionnaire, the interpersonal Dependence Inventory (Hirschfeld et al., 19771, the Eysenck Personality Questionnaire (Eysenck and Eysenck, 19751, the Rosenberg Self-Esteem Scale (Rosenberg, 1965; Carmines and Zeller, 1979) and the Depressive Affect Scale, Form A (Beck, 1976; Dobson and Shaw, 1986). During a further week of manoeuvres, 2 years later, members of the subsample again completed the DSI and the same battery of tests. Unexpectedly, 25 of the original 31 depressives (80.6%) still had DSI scores of 14 or more. Only one member moved from the nondepressed to the depressed category (DSI 9 to DSI 17) over the 2-year period. Depressed psychiatric in-patients The DSI and SRQ are being administered, before the commencement of treatment, to a series of psychiatric patients, at a London teaching hospital, who are taking part in a trial of antidepressant medication. An entry requirement for the trial is that patients should have a DSM-III major depressive episode and score 17 or more on the Hamilton Rating Scale (Hamilton, 1960). When possible, the measures are being repeated on completion of treatment. To date, 38 women and 20 men have been admitted to the trial, but only nine men and 12 women have been tested on completion of treatment. Elderly community subjects The SRQ was administered to a series of 30 depressed (19 women and 11 men) and 48 nondepressed (25 women and 23 men> elderly subjects (mean ages 67 and 65 respectively) as part of a small community survey. All subjects were interviewed in their own homes. The depressives were a mixture of Maudsley Hospital out-patient attenders and patients receiving treatment for depression by their general practitioners. As a further check on their depression, all subjects completed both the DSI and the Beck Depression Inventory (Beck et al., 1961). Marriage guidance clients The SRQ was administered to a series of 63 couples attending marriage guidance counsellors as part of a study of marital quality (Birtchnell, 1988b). The couples were required to be, in the

224

opinion of the counsellor, experiencing serious marital difficulties. No assessment of depression was made. Community sample The SRQ was administered to a sample of 38 couples from the general population. This was a heterogeneous sample accumulated from a number of sources. Whilst no test of depression was administered, neither partner showed evidence of depression. Sample sizes The sizes of the samples in some of the comparisons were unavoidably small. This was particularly so for the depressed men and the recovered depressives. The samples were retained for completeness, but the results of these comparisons should be viewed with caution. Results Internal psychometrics of the SRQ A pool of 424 subjects (212 men and 212 women), comprising 89 housing estate couples, 63 marriage guidance couples, 38 community sample couples and 22 elderly couples, was used to determine the factorial structure of the SRQ. A criterion for inclusion in this pool (which was not accumulated specifically for the present study) was that both marital partners had completed both the self-rating and the partner-rating questionnaire. An oblimin rotated principal components analysis yielded a 3-factor pattern matrix which accounted for 21% of the variance. Counting only those items with a factor loading of 0.3 or above, of the 31 items in factor 1, 29 were Dependence items; of the 20 in factor 2, 17 were Detachment items; and of the 19 in factor 3, 15 were Directiveness items. A 4-factor solution had the effect of splitting mainly the Detachment items into a denial of closeness factor (18 items) and a self-sufficiency factor (10 items). Pearson correlation coefficients for factor 1 were 0.96 with Dependence and less than 0.15 with the other two scales; for factor 2 were 0.90 with Directiveness, 0.37 with Detachment and 0.02 with Dependence; for factor 3 were 0.67 with Detachment and - 0.16 with the other two scales; and for

factor 4 were 0.52 with Detachment, 0.10 with Directiveness and - 0.11 with Dependence. Neither the 3- nor the 4-factor solution supported the division of the Dependence items into the Affectional, Ontological and Deferential subscales. With the same pool of 424 subjects the cy coefficients for the SRQ scales were Dependence 0.87, Directiveness 0.72 and Detachment 0.77. Within Dependence, the coefficients for the three subscales were 0.72 for Affectional, 0.79 for Ontological and 0.64 for Deferential. The correlations for men and women were comparable. Interscale Pearson correlation coefficients were Direct/ Detach 0.25, Depend/ Direct - 0.12 and Depend/ Detach - 0.02. Within Dependence they were Affec/Ontol 0.63, Affec/Defer 0.45, and Ontol/Defer 0.56. Thus, although the three main scales were reasonably discrete, there was considerable overlap between the Dependence subscales. The internal psychometrics of the IDI The Interpersonal Dependency Inventory (IDI) of Hirschfeld et al. (1977) was completed by 113 members of the Territorial Army subsample. The intention is to compare the SRQ with the ID1 but, before this is done, the psychometrics of the ID1 within this sample will be examined. The cy coefficients for the three subscales were 0.90 for Emotional Reliance on Another Person (ERP) and Lack of Social Self-Confidence (LSS) and 0.39 for Assertion of Autonomy (AA). The interscale correlation coefficients were ERP/LSS 0.80, ERP/AA - 0.04 and LSS/AA 0.21. These arc higher than the originally published ones (Hirschfeld et al., 1977) of 0.41, 0.42 and 0.62; -0.23, 0.10 and 0.18; and -0.08, 0.16 and 0.34 (ranging between three separate samples). They indicate that there is little justification for considering the ERP and the LSS as separate scales, but that the AA scale, while psychometrically distinct, has a low internal consistency. The relationship of the SRQ and IDI measures to gender Since dependence (if not directiveness and detachment) is related to depression, it is necessary, when considering the relationship of the SRQ

225 TABLE

1

CORRELATIONS SCALES

BETWEEN

SRQ

AND

IDI

SUB-

ID1

SRQ Dependence

Directiveness

Detachment

ERP LSS AA Total

0.83 * * * 0.83 * * * 0.02 0.85 ***

0.06 0.05 0.21 * 0.09

0.20 0.15 0.45 * * * -0.15

* * * P < 0.001; * * P < 0.01; * P < 0.05 (two-tailed).

measures to gender, to exclude the effect of depression. Two samples in which this was possible were the Territorial Army servicemen and -women and the men and women from the housing estate survey who, on the basis of the DSI, and, for the women only, the PSE, were shown to be free of depressive symptoms. From Table 4 it will be seen that the servicemen and -women were more directive than the men and women from the housing estate. The mean Dependence scores for the housing estate men and women were practically identical but the mean Directiveness and Detachment scores were significantly higher for the men (Direct t = 3.16, P < 0.005; Detach t = 3.62, P < 0.0011. For the Territorial Army subsample, there were no significant differences between the mean scores, for the men and the women, on any of the three measures, at either the first or the second time of testing. The IDI was administered only to the Territorial Army subsample. To make gender comparisons, again it is necessary to consider only the non-depressed group. From Table 5, it will be seen that on all three scales the mean scores were higher for men than for women, the difference

TABLE

significant

for

Comparing the IDI with the SRQ Pearson correlation coefficients between the ID1 and the SRQ scores are given in Table 1. As would be expected, the total ID1 score showed a high correlation with the Dependence score of the SRQ (and with those of each of its subscales) but a low correlation with its Directiveness and Detachment scores. The SRQ Dependence score showed a high correlation with both the ERP and the LSS score but a low correlation with the AA score. The AA score however showed a fairly high correlation with the SRQ Detachment score and a fairly low correlation with the Directiveness score. If therefore it represents a denial of dependence, such denial is more concerned with avoiding involvement than with inviting the dependence of others. Comparing the SRQ and the IDI with measures of neuroticism, self-esteem and depresskle affect The Eysenck Personality Questionnaire (EPQ), the Rosenberg Self-Esteem Questionnaire (RSEQ) and the Depressive Affect Scale (DAS) were also administered to the Territorial Army sample. From Table 2 it will be seen that the dependence measures of the SRQ and the ID1 (with the exception of the AA scale) were highly correlated with neuroticism, low self-esteem and depressive affect. These three measures were also highly intercorrelated (EPQ-N/RSEQ - 0.63, EPQ-N/DAS - 0.71, RSEQ/DAS - 0.62), which suggests that they represent overlapping constructs. Apart from a low correlation between Detachment and neuroticism, there were no sig-

2

CORRELATIONS DAS

BETWEEN

THE SUBSCALES

OF THE SRQ AND THE

ID1 AND THE EPQ-N.

THE

RSEQ

AND THE

ID1

SRQ

EPQ-N RSEQ DAS

being significant for LSS, weakly ERP and not significant for AA.

Depend

Direct

Detach

ERP

LSS

AA

089 *** -0:71 *** 0.79 ***

0.01 - 0.04 0.17

0.23 * 0.02 0.40

0.79 * * * -0.65 *** 0.66 ***

0.79 * * * -0.74 *** 0.71 ***

0.11 ~ 0.00 0.20

* * * P < 0.001; * * P < 0.01; * P < 0.05 (two-tailed).

226

nificant correlations between either Directiveness or Detachment and these three measures. The link between the SRQ and IDI measures and depression From Table 3 it will be seen that the DSI correlated highly with the Dependence scale of the SRQ and with the ERP and LSS scales of the IDI but not with the Directiveness and Detachment scales of the SRQ or with the AA scale of the IDI. Table 4 shows the mean SRQ scores for a number of female and male samples. These results indicate a highly significant association

TABLE MEAN

(k SD) SRQ SCORES

Dependence: Directiveness: Detachment: All two-tailed.

MEAN

3

CORRELATIONS BETWEEN THE SUBSCALES SRQ AND THE IDI AND THE DSI ID1

SRQ

DSI

OF THE

Depend

Direct

Detach

ERP

LSS

AA

0.74 ***

0.19

0.08

0.60 ***

0.69 ***

0.11

** * P < 0.001: ** P i 0.01; * P < 0.05(two-tailed).

between depression and dependence. The difference between the scores of the depressed and the non-depressed subjects was most striking for the

4a FOR VARIOUS

Depressed psychiatric patients Depressed housing estate women Depressed Territorial Army women Depressed elderly women Marriage guidance wives Community women Depression-free housing estate women Non-depressed Territorial Army women Non-depressed elderly women

TABLE

TABLE

SAMPLES

OF WOMEN

N

Depend

Direct

Detach

38 46 23 19 63 38 40 24 25

26.1 k 6.5 24.7k 6.6 32.6+ 4.1 27.8k 6.2 22.8k 6.6 19.5k 5.8 15.5* 5.5 13.6i 6.9 21.7+ 10.4

11.5k3.9 11.2i3.6 12.6-t 1.7 8.9i4.1 11.1+3.1 9.8 k 3.6 8.0+ 3.2 12.7 + 2.9 10.0 i 4.4

9.5 + 3.4 9.2 f 2.9 7.9 k 2.9 6.1 k3.7 8.3 k 4.6 6.5 * 2.6 6.1 k3.1 8.6+3.5 6.8+5.0

Patients/community t = 4.65, P < 0.001;Housing estate dep/dep-free t = 7.08. P < 0.001; dep/non-dep I = 11.42, P < 0.001; Elderly dep/non-dep t = 2.25, P < 0.05. Patients/community I = 1.45, NS; Housing estate dep/dep-free t = 4.37, P < 0.001. Patients/community f = 4.13, P < 0.001; Housing estate dep/dep-free t = 4.61, P < 0.001.

Territorial

Army

4b ( f SD) SRQ SCORES

FOR

VARIOUS

SAMPLES

OF MEN

N

Depend

Direct

Detach

Depressed psychiatric patients Depressed Territorial Army men Depressed elderly men Housing estate men with DSI score > 4 Marriage guidance husbands Community men Depression-free housing estate men Non-depressed Territorial Army men

20 8 11 22 63 38 64 62

Non-depressed

23

26.25 5.2 30.6k 5.3 23.6+ 11.1 20.X* 7.2 19.7* 7.5 16.8f 6.8 15.3+ 6.2 15.8k 5.7 14.9* 6.6

9.6 k 4.2 14.7* 1.9 9.1 k4.4 11.8k3.1 12.2 k 3.8 10.753.6 10.2 * 4.0 13.2+2.4 12.8k5.0

11.5k5.3 Y.7 + 2.6 6.5 +5.3 10.6 + 4.2 10.5 * 4.3 8.5 + 3.6 Y.l k4.5 9.5 + 2.5 11.5k5.5

Dependence: Directiveness: Detachment: All two-tailed.

elderly men

Patients/community r = 5.45, P < 0.001; Housing estate DSI > 4/DSI < 5 / = 3.64. dep/non-dep t = 7.13, P < 0.001; Elderly dep/non-dep t = 2.87, P < 0.01. Patients/community t = 1.09, NS. Patients/community t = 2.55, P < 0.02.

P i 0.001: Territorial

Army

227

Territorial Army men and women, but was also apparent for the housing estate men and women, and the elderly men and women. The psychiatric patient scores were significantly higher than those of the community sample, the most appropriate comparison group. For the housing estate women, but not for the Territorial Army women or the elderly women, the directiveness and detachment scores were significantly higher in the depressed than in the non-depressed and their directiveness and detachment scores were strikingly similar to those of the psychiatric patients. Table 5 shows that, for the IDI, in the Territorial Army subsample, there was a correspondingly significant association between ERP and LSS scores and depression, but not between AA scores, and depression. Do high dependence scores fall on recoueyy from depression? Although all 21 psychiatric patients tested at the end of treatment revealed a substantial drop in their DSI score (mean drop 17.0, SD 8.21, only those 11 whose score dropped to below 10 showed a corresponding drop in the SRQ Dependence score. Their mean scores were 27.2, SD 5.6 before treatment and 18.3, SD 6.5 after treatment (t = 3.43, P < 0.005). The mean scores for the remaining 10 patients were 26.4, SD 6.3, and 25.9, SD 7.2 respectively. The mean Dependence score of the six Territorial Army depressives who recovered over the 2-year period dropped from 33.2, SD 4.1 to 20.4, SD 7.3 (t = 3.63, P < O.OOS>,

TABLE MEAN

but the mean scores for the 25 who remained depressed also dropped, from 31.9, SD 4.5 to 27.6, SD 5.7 (t = 2.8, P < 0.01). The mean scores for those who remained not depressed were, at the two times of testing, 15.2, SD 6.1 and 15.2, SD 6.0. Because these numbers are small the finding should be accepted with some caution. They do suggest, however, that recovery from depression is accompanied by a substantial drop in the Dependence score. The score for the patients dropped to around that for non-depressed subjects, but that for the Territorial Army subjects remained higher. Discussion The nature and composition of pathological dependence On theoretical grounds, dependence appears to be a complex construct (Birtchnell, 1984, 1988a, 19911, yet in the present study, attempts to identify discrete components of it proved unsuccessful. The three proposed components of affectional, ontological and deferential dependence did not emerge from the factor analysis. This may simply mean that, though they may be valid components of dependence, they co-exist to a high degree. Whilst the original paper on the ID1 (Hirschfeld et al., 1977) provided statistical justification for the existence of three scales, in the present paper the evidence suggests that the ERP and LSS scales are so highly intercorrelated that there is no advantage in considering them sepa-

5 (&SD)

IDI SCORES

FOR

DEPRESSED

AND NON-DEPRESSED

TERRITORIAL

ARMY

MEN AND WOMEN

ERP

LSS

AA

Depressed men (n = 8) Non-depressed men (n = 62) I P (two-tailed)

53.9k6.3 43.7k6.6 4.15 < 0.001

41.8*8.3 32.0 k 4.9 4.90 < 0.001

31.8+3.6 30.8 + 3.5 0.65 NS

Depressed women (n = 23) Non-depressed women (n = 21) t P (two-tailed)

60.0 +_7.4 40.0 & 7.0 9.29 < 0.001

47.0+8.7 28.lk5.4 8.79 < 0.001

31.7+4.3 29.8 4 4.2 1.46 NS

2.29 < 0.025

3.21 < 0.005

1.14 NS

Non-depressed

P (two-tailed)

men/women:

1

228

rately. Both scales also correlated highly with the Dependence scale of the SRQ. The AA scale, on the other hand, appears not to be a measure of dependence at all. It does not correlate with the other two scales or with the Dependence scale of the SRQ. Also, unlike the other scales, it does not correlate with the DSI, the Neuroticism scale of the EPQ, the Rosenberg Self-Esteem scale or the DAS. It does, however, correlate significantly with the Detachment scale of the SRQ and would appear therefore to be more a measure of independence. In the Territorial Army sample at least, in contrast with the other two ID1 scales, it shows a low level of internal consistency. Comparison of the two measures of dependence Though the IDI was developed in 1977, the SRQ was developed quite independently of it. The number of dependence items in the two measures is similar, 48 and 43, but the 14 items of the Assertion of Autonomy scale are of doubtful usefulness. Even though the assumed components of dependence differ, the scores on the two measures correlate highly and both, with the exception of the AA scale, correlate highly with scores on the other measures used. Spurious correlations of the two scales with gender may result from the greater tendency for women to become depressed. Once the effect of depression is eliminated, there is no correlation with gender using the SRQ, but surprisingly, men tend to be more dependent than women using the IDI. The SRQ has the advantages that it also incorporates measures of directiveness and detachment and has a companion partner-rating questionnaire (Birtchnell, 1988b, 1991b). The relationship of dependence to depression The present study reveals that the constructs of depression (DSI), depressive cognition (DAS), low self-esteem (RSEQ), neuroticism (EPQ-N) and pathological dependence (SRQ, Depend; IDI, ERP and LSS) are highly intercorrelated. This means either that they are a number of discrete entities which happen to be closely related or that they all represent facets of one general factor. If the latter is the case, then our usual way of thinking about these concepts may need to be changed. Dependence, for example,

may come to be seen more as a component of depression. To date, it has generally been assumed that pathological dependence is a personality disorder and depression is a psychiatric illness. In the DSM-III classification for example, Dependence belongs to axis II and depression belongs to axis I. The main distinction between a personality disorder and a psychiatric illness is that a personality disorder is stable over time and is resistant to therapeutic intervention and a psychiatric illness is episodic and responsive to therapeutic intervention. It is commonly assumed that certain forms of personality disorder carry an increased vulnerability to certain psychiatric illnesses and that the illness episodes become superimposed upon the continuous personality disorder. This has been the understood relationship between dependence and depression. One of the implications of this model is that individuals diagnosed as having a dependent personality disorder would be expected to have more future depressive episodes than other individuals. Andrews and Brown (1988) showed this not to be so. In the Territorial Army study, it was hoped to show that proportionally more of the non-depressed subjects with high dependence scores at the first time of testing would develop depressive symptoms at the second time of testing. Of 1.5 non-depressed subjects with first scores of 22 or more only one later developed depressive symptoms. Boyce et al. (1990) compared recovered endogenous and neurotic depressives and observed that dependence scores were significantly higher in the neurotic group. Hirschfeld et al. (1983a) compared the mean scores of recovered female depressives with those of the female relatives of the depressives who had, and had not, had a previous depressive episode. The mean scores of both recovered groups were similar, but both were significantly higher than that of the never depressed group. Since they did not have the premorbid scores of either of the recovered groups they were unable to say whether the higher scores indicated an underlying dependent personality or were the lingering effects of the depressive episode. In a later study (1989) they administered the IDI to 438 never ill relatives of patients with depressive disorders and followed them up

over a 6-year period. For 15 subjects aged 17-30, who later developed a major depressive disorder, the original ID1 scores were no different from those of the subjects who remained well. For 11 subjects aged 31-41 who did, the original scores were significantly higher. In the younger group therefore, there was no evidence of an underlying dependent personality, but in the older group there was. The mean scores of the first-onset subjects when they were depressed were not given, but it can be assumed that they were high. If dependence is simply part of the depressed state then (1) depressed subjects should have higher dependence scores than non-depressed ones and (2) dependence scores should go up when subjects become depressed and drop when they recover. In the present study, in a number of samples, mean dependence scores were significantly higher in those who were depressed. In the patient sample the dependence scores dropped only when the DSI score dropped substantially. In the Territorial Army sample, there was a very considerable drop in the dependence scores of the small number whose DSI score dropped substantially, but there was also a significant drop in the scores of those who remained depressed. Is this a regression to the mean effect or does this represent an adjustment to the depressed state? Rossmann (19881 observed dependence scores rising and falling with depressed state in a series of 342 conscripts, during the first 4 weeks of compulsory military service, but the changes in dependence and depression were not great. Hirschfeld et al. (1983b) compared the mean entry and follow-up IDI scores of recovered and unrecovered depressives. The entry scores were markedly higher than the scores of the (1983a) never depressed relatives. The entry and followup scores of the unrecovered remained the same, but the follow-up scores of the recovered were significantly lower than the entry scores. Does the experience of a period of depression have a lasting effect upon dependence? Because the dependence scores of recovered patients were higher than those of the relatives of first-onset patients and also of never depressed relatives Hirschfeld et al. (1989) concluded that it does. This could, however, mean either that the premorbid level of dependence was higher in the

recovered depressives or that they had not entirely recovered from their depression. The findings of the present study were conflicting. The scores of the depressed patients who fully recovered (to below a DSI score of 10) did appear to have dropped to the level of general population subjects. Those of the Territorial Army subjects who recovered (by the same criterion) remained higher than those of the non-depressed Territorial Army subjects. Possibly, it depends upon the length of the period of depression. The relationship of the other SRQ scales to depression The depressives in the housing estate sample were not only more dependent; they were also more directive and more detached. The scores of the depressed patients were strikingly similar to those of the housing estate depressives, and with a different control group, the patients would have shown this effect more convincingly. It was not apparent, however, with the Territorial Army or the elderly depressives. It might be expected, on the basis of the aetiological theories examined in the Introduction, that directiveness and detachment would be higher in the marital partners of depressives, but the evidence in favour of this is conflicting (Birtchnell, 1991b). The chronicity of depression A striking finding of the study was that the proportion of identified depressives in the Territorial Army subsample who were still depressed (with a DSI score of at least 12) after an interval of 2 years was extremely high (80.6%). In the entire Territorial Army sample, the proportion of identified depressives (n = 75) with a DSI score of at least 10 (there were none in the subsample with scores of 10 or 11) at the time of follow-up was 74.6%. Dropping to below 10 is a reasonable criterion for recovery. Of the depressed housing estate women, 44% considered that they had been depressed for 2 years or more (Birtchnell, 1988~). These figures suggest that depression identified in non-clinical samples is a relatively chronic condition which comes more closely to resemble a personality disorder. Its overlap with dependence becomes more plausible, but the concept of the depression-prone personality be-

230

comes more dubious. In their more recent paper, Hirschfeld et al. (1989) speculate on this point, and ask ‘Do individuals have abnormal personality features (personality disorders perhaps) or do they have chronic (subsyndromal) affective states? Does it make any difference? At this point we have no answer to these vexing problems’. Towards

a

general

factor

of

depressice

psy-

chopathology

The findings reported here concerning dependence and depression mirror previously reported findings concerning neuroticism and depression. Katz and McGuffin (1987) measured neuroticism (using the EPQ) in the first-degree relatives of depressed patients who had and had not had previous depressive episodes and who were and were not currently depressed. They concluded that, when current symptomatology is taken into account, neuroticism does not indicate disposition to depression, but is strongly associated with the state of being depressed. They further concluded that almost any level of symptomatology, including subclinical depression, influences the

neuroticism score and that there is a direct linear relationship between neuroticism and level of current symptoms. This similarity of findings might lead one to conclude that dependence is simply a variant of neuroticism. Whilst the study has shown a high degree of correlation between the two constructs, an important difference between them is that neuroticism is more intrapersonal and dependence is more interpersonal. It seems probable that similar findings will emerge concerning the relationship between both selfesteem and depressive cognition and depression, and that eventually this set of interrelated constructs will be understood to be facets of one broad factor of depressive psychopathology.

Acknowledgements Data for the elderly subjects were collected by Sandra Heathcote. Dr Peter Fonagy contributed to the data processing of the Territorial Army sample. Dr Chris Evans provided valuable statistical assistance.

Appendix Items and scoring of the SRQ

For each item the response may be ‘True’, ‘Not sure’ or ‘Not true’. All contributory responses (indicated by a T or an N) carry a score of 1 and all not sure responses carry a score of 0.5. In the questionnaire, the items are distributed randomly. Dependence Affectional

I’m not very good at solving my own problems (T) I am always afraid that someone I am fond of will lose I have a dread of being rejected (T) I am inclined to be very jealous and possessive (T) I like to feel in the safe hands of another person (T) I don’t like to rely on other people (N) I do not like being left on my own (T) I like to be made a fuss of (T) When I’m in trouble I usually run to someone for help I can never convince myself that people really love me I can never be sure that people approve of me (T) It worries me if the person I am close to has too much I’m not inclined to ask people to help me (N)

interest

in me (T)

(T) (T) freedom

(T)

231

When people I like go away I long for their return I like people to look after me CT)

CT)

Ontological Even the slightest criticism can affect me for hours (T) I pride myself on having a mind of my own (N) I don’t feel I have very much to offer in life CT) It is easy for other people to change my mind (T) When another person is depressed it tends to make me depressed (T) I am not very sure where I am going in life CT) I like to feel that I know what the person I feel close to is thinking (T) I am inclined to follow or imitate other people CT) I am not much affected by what others say about me (N) My opinions can easily be influenced by what others say to me CT) I am very much affected by other people’s moods CT) I have no very clear cut aims in life (T) I prefer it when others make decisions for me CT) It disturbs me if the person I feel close to keeps things from me CT) It takes a lot to unsettle me (NJ Deferential When things go wrong I am all too ready to assume it’s my fault (T) I have a tendency to admire or even idolise other people CT) I don’t like another person to have too much influence over me (N) I like to look at myself in the mirror (N) I am inclined to do what I am told (T) Looking up to someone comes naturally to me (T) I have no difficulty telling another person what to do (N) I am very bad at standing up for myself (T) I am always grateful for whatever comes my way (T) I am well pleased with myself (N) I usually find it easiest to abide by the rules (T) I have a tendency to look up to others (T) I don’t like to push myself forward (T) Directiveness I feel more comfortable in a relationship when I’m the one who makes the decisions CT) In a relationship I like to be the one in control (T) I mostly have a good idea what the person I feel close to needs to do (T) I often make hurtful remarks which I later regret (T) I feel in a relationship a responsibility not to let things get out of hand CT) I sometimes find it necessary to take someone in hand and put them right (T) I find I am inclined to form a relationship with someone who is weaker than me (T) I find that people tend to rely on me a great deal CT) I worry that the person I feel close to doesn’t do things right CT) I have noticed I can sometimes be very critical of someone I like CT) In a relationship I find I am usually the one who decides what to do (T) In a relationship I tend to be the dominant partner CT)

232

I sometimes feel I know better than other people what would be best for them (T) I am sometimes inclined to put someone down with an unkind remark (T) I have sometimes felt that if I don’t take control in a relationship things could go wrong (T) I have at times been accused of being bossy (T) It disturbs me when people will not do what I expect of them (T) I like making a fuss of other people (T) I feel protective towards someone less able than myself (T) Other people tend to look to me for guidance (T) I feel I need to keep a close eye on the person I am close to (T) Detachment I am inclined to be intolerant of other people’s faults (T) I find it pleasant to spend long periods on my own (T) It gives me pleasure to be kind to someone else (N) I find it easy to be affectionate to the person I am close to (N) I don’t concern myself too much with other people’s worries (T) I often praise and encourage the person I feel close to (N) I do not like to get too involved with people (T) I find my own ideas more interesting than other people’s (T) I respond readily to the distress of others (N) When I am upset I try not to show it (T) I prefer things to people because they don’t let you down (T) I take a great interest in the well being of the person I feel close to (N) I believe in staying cool and unruffled at all times (T) I find it necessary to get away from people sometimes (T) I enjoy giving things to others (N) I find it easy to be caring towards another person (N) I would rather people didn’t bother me with their problems (T) When someone is down I like to help them to get back on their feet (N) I prefer to go my own way (T) When people get too close to me it makes me feel uneasy (T) I find it a pleasure to be needed by someone else (N) In conversation I prefer to talk about my own ideas (T) When someone is upset I want to reach out to them (N) I prefer to keep my feelings to myself (T) I get very bound up in whatever job I take on (T) I follow the fortunes of a person I like (N) I always like to be as helpful as I can (N)

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