title: Adult attachment representation moderates psychotherapy treatment efficacy in clinically depressed inpatients.
abstract: BACKGROUND
  We explored in a sample of clinically depressed patients the influence of attachment security and unresolved trauma on psychotherapeutic outcome as well as changes in attachment representation through psychotherapeutic intervention.
  
  
  METHODS
  The sample consisted of 85 women (aged 19-52), 43 clinically depressed patients from a psychosomatic inpatient unit, and 42 healthy control subjects matched for age and education. Average length of hospitalization in the patient group was eight weeks. Attachment representations were assessed with the Adult Attachment Interview at the time of admission (baseline) and at discharge. Depressive symptoms were measured using the PHQ-9 at T1 and T2.
  
  
  RESULTS
  Insecure attachment representations were overrepresented in depressed patients. Treatment effects were moderated by baseline attachment representation: patients with higher attachment security scores at admission benefited more from the inpatient treatment and were less depressed at time of discharge than less secure patients (η(2)=.07). Generally, attachment security increased (η(2)=.19) and depressive symptoms decreased (η(2)=.23) after inpatient psychotherapy treatment in the patient group. No significant effects for unresolved symptoms were found.
  
  
  CONCLUSIONS
  The study is not a randomized controlled study, but used a quasi-experimental matched control group design with female subjects only.
  
  
  CONCLUSIONS
  Our results suggest that attachment representations play a major role in both the development and treatment of clinical depression. Baseline attachment security may influence psychotherapeutic outcome, perhaps through relational factors such as therapeutic working alliance. Inpatient psychotherapy may also need to address psychological issues associated with depression such as attachment insecurity.
authors.affiliation: University Medical Center Mainz, Department of Psychosomatic Medicine and Psychotherapy, Untere Zahlbacher Str. 8, 55131 Mainz, Germany. Electronic address: iris.reiner@unimedizin-mainz.de.
authors.forename: I
authors.initials: I
authors.lastname: Reiner
authors.affiliation: Center for Child and Family Studies, Rommert Casimir Institute for Developmental Psychopathology, Leiden University, P.O. Box 9555, 2300 RB Leiden, The Netherlands.
authors.forename: M J
authors.initials: MJ
authors.lastname: Bakermans-Kranenburg
authors.affiliation: Center for Child and Family Studies, Rommert Casimir Institute for Developmental Psychopathology, Leiden University, P.O. Box 9555, 2300 RB Leiden, The Netherlands.
authors.forename: M H
authors.initials: MH
authors.lastname: Van IJzendoorn
authors.affiliation: Clinic for Child Psychiatry, Psychosomatic and Psychotherapy, Universitätsstraße 84, 93053 Regensburg, Germany.
authors.forename: E
authors.initials: E
authors.lastname: Fremmer-Bombik
authors.affiliation: University Medical Center Mainz, Department of Psychosomatic Medicine and Psychotherapy, Untere Zahlbacher Str. 8, 55131 Mainz, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Beutel
mesh_terms: D000328:Adult; D000367:Age Factors; D003866:Depressive Disorder / Q000523:psychology* / Q000628:therapy*; D005260:Female; D006801:Humans; D007297:Inpatients; D007902:Length of Stay; D008875:Middle Aged; D009483:Neuropsychological Tests; D009769:Object Attachment; D011613:Psychotherapy / Q000379:methods*; D016896:Treatment Outcome; D055815:Young Adult
keywords: AAI; Adult attachment; Coherence; Depression; In-patients; Psychotherapy