Does attachment lead recovery from severe depression
- In a preregistered secondary analysis of the OPTIMA trial, 198 adults with acute, severe major depression received seven weeks of schema therapy (n = 97) or CBT (n = 101) in inpatient and day-clinic care at the Max Planck Institute of Psychiatry in Munich.
- Avoidant attachment (RSQ fear of closeness) went from 2.70 at baseline to 2.64 after treatment and 2.45 at six months; anxious attachment (RSQ fear of separation) from 2.89 to 2.75 and 2.63. BDI-II scores fell from 31.3 to 16.23 and 15.21.
- The two therapies did not differ in their effect on attachment, reappraisal or suppression. Earlier change in these four did not predict later symptom change (BF01 = 4.98 to 38.46) and did not mediate the treatment effect.
- The reverse order appeared for emotion regulation: lower depression at mid-treatment preceded better reappraisal at the end of treatment (BF10 = 9.77), and lower depression at the end of treatment preceded less suppression at six months (BF10 = 6.70).
Attachment work is often framed as the deep layer of depression treatment: change how a person holds relationships, and mood follows. A Munich group tested that order in inpatients and day patients with severe depression, and the data ran the other way or not at all.
Two therapies, four candidate mechanisms
The OPTIMA trial randomised 198 adults with acute, severe major depression to schema therapy (97) or CBT (101). Treatment lasted seven weeks inside an intensive programme: two 100-minute group sessions and two 50-minute individual sessions a week. 52.5% were women; mean age was 42.75.
Attachment came from two subscales of the Relationship Styles Questionnaire, fear of closeness (avoidant) and fear of separation (anxious), taken at baseline, at the end of treatment and at six months. Reappraisal and suppression came from the Emotion Regulation Questionnaire, depression from the BDI-II. This is a preregistered secondary analysis of a trial built to compare effectiveness.
Improvement without a leader
Everything moved. Avoidant scores went from 2.70 to 2.64 and then 2.45; anxious scores from 2.89 to 2.75 and 2.63. The BDI-II fell from 31.3 to 16.23 and 15.21. Schema therapy and CBT did not differ on any of the four mechanisms.
The authors looked at sequence. Earlier change in attachment, reappraisal or suppression did not predict later change in symptoms, and none of the four mediated the effect of treatment. For reappraisal and suppression, the drop in depression came first. For attachment, no reliable link turned up in either direction.
My reading for the ward: in the acute phase of severe depression, do not stake the first weeks on reworking attachment. Fear of closeness and fear of separation eased over six months, but here they did not lead symptom change. Work on mood first – activation, daily structure, medication where it is prescribed – and plan the attachment work for when the person is less depressed and can use it. Attachment is not dropped. It is scheduled.
In severe depression, attachment eased alongside recovery but did not lead it, so the question becomes when to work on attachment, not whether.
The authors note that the intensive multimodal setting, with medication, group and individual therapy and occupational therapy running together, may have masked effects specific to each psychotherapy. Intervals between measurements were unequal, attachment was not measured at mid-treatment, and seven weeks may be too short for schema techniques to shift the mechanisms. The sample is small for the model; the preregistered estimation failed, and the authors moved to Bayesian estimation. The findings apply to an acutely and severely depressed inpatient and day-clinic sample.