Articles
2025: Online Advance Publication
Change and sustained recovery in defense mechanisms and depression in a pilot study of antidepressant medications plus up to 18 months of psychotherapy for recurrent major depression
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Published: 2 February 2026
0
Views
0
Downloads
Authors
Treatment studies of major depression commonly focus on symptoms rather than changes in psychological risk factors. This pilot study examines the relationship between changes in eight defenses specifically related to depression, called depressive defenses, and depressive symptoms. Thirty adults with acute, recurrent major depression were given antidepressant medications (ADM) and randomized to up to 18 months of either cognitive behavioral therapy (CBT), dynamic, or supportive psychotherapy and followed for 4.5 years. Defenses were assessed using the observer-rated Defense Mechanism Rating Scales (DMRS) at intake and 18 months. The Hamilton Rating Scale for Depression-17 item version (HRSD-17) and the Beck Depression Inventory-2nd version (BDI-II) assessed depression periodically. Depressive symptoms decreased significantly on both the HRSD-17 (effect size [ES]=−1.03) and BDI (ES=−1.90). Overall defensive functioning (ODF) increased significantly (ES=.85), improving in 76% of participants. Similarly, the mean proportion of depressive defenses decreased significantly by termination (ES=−.62), although the overall mean remained above that generally seen in healthy adults. Twenty-four percent of participants attained this threshold at termination. After controlling for initial levels, at termination depressive defenses correlated significantly with HRSD-17 (rs=.44, p=.02), and BDI (rs=.33, p=.095). Although causal relationships were not established, depressive defenses were consistently related to changes in depressive symptoms, suggesting that they are promising mediators of treatment effects for major depression. Clinically, defenses are readily identifiable and can serve as important foci in treatment. Finally, levels of depressive defenses that exceed healthy norms may reflect a continuing level of risk for current or future depressive symptoms or episodes.
Downloads
Download data is not yet available.
Citations
American Psychiatric Association (1994). Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). American Psychiatric Press, Washington, D.C.
American Psychiatric Association (2000). Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR). American Psychiatric Press, Washington, D.C.
Arieti, S., & Bemporad, J. Severe and Mild Depression. Basic Books, New York, 1978.
Babl, A., Holtforth, M. G., Perry, J. C., Schneider, N., Dommann, E., Heer, S., Staehli, A., Aeschbacher, N., Eggel, M., Eggenberg, J., Sonntag, M., Berger, T., & Caspar, F. (2019). Comparison and change of defense mechanisms over the course of psychotherapy in patients with depression or anxiety disorder: Evidence from a randomized controlled trial. Journal of Affective Disorders, 252, 212-220. doi: 10.1016/j.jad.2019.04.021
Babl, A. Berger, T., Holtforth, M.G., Taubner, S., Caspar, F., & Gomez Penedo, J.M. (2020). Disentangling within- and between-patient effects of defensive functioning on psychotherapy outcome using mixed models. Psychotherapy Research, 30(8), 1088-1100. doi: 10.1080/10503307.2019.1690714
Beck, J. S. (1995). Cognitive Therapy: Basics and Beyond. New York: Guilford.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). BDI-II: Beck Depression Inventory Manual, second ed. Psychological Corporation, San Antonio, TX, 1996.
Beck, S. & Perry, J.C. (2008). The measurement of interview structure in five types of psychiatric and psychotherapeutic interviews. Psychiatry: Interpersonal and Biological Processes, 71, 219-233. doi: 10.1521/psyc.2008.71.3.219
Békés, V., Perry, J. C., Starrs, C. J., Prout, T., Conversano, C., & Di Giuseppe, M. (2023). Defense Mechanisms Are Associated with Mental Health Symptoms Across Six Countries. Research in Psychotherapy: Psychopathology, Process and Outcome, 26(3), 729-737. doi: 10.4081/ripppo.2023.729
Biesheuvel-Leliefeld, K. E., Kok, G. D., Bockting, C. L., Cuijpers, P., Hollon, S. D., Van Marwijk, H. W., & Smit, F. (2015). Effectiveness of psychological interventions in preventing recurrence of depressive disorder: meta-analysis and meta-regression. Journal of Affective Disorders, 174, 400-410. doi: 10.1016/j.jad.2014.12.016
Bloch, A. L., Shear, M. K., Markowitz, J. C., Leon, A. C., & Perry, J. C. (1993). An empirical study of defense mechanisms in dysthymia. American Journal of Psychiatry, 150, 1194-1194. https//doi.org/10.1176/ajp.150.8.1194
Casacalenda, N., Perry, J. C., & Looper, K. (2002). Remission in major depressive disorder: a comparison of pharmacotherapy, psychotherapy, and control conditions. American Journal of Psychiatry, 159(8), 1354-1360. doi: 10.1176/appi.ajp.159.8.1354
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates.
Cramer, P. (2006). Protecting the self: Defense Mechanisms in Action. Guilford Press, NY.
Cuijpers, P., Hollon, S. D., Van Straten, A., Bockting, C., Berking, M., & Andersson, G. (2013). Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ Open, 3(4), e002542. doi: 10.1136/bmjopen-2012-002542
Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Papola, D., Ebert, D., & Karyotaki, E. (2023). Psychological treatment of depression: A systematic overview of a Meta-Analytic Research Domain (2023). Journal of Affective Disorders, 335, 141-151. doi: 10.1016/j.jad.2023.05.011
DeFife, J. A., & Hilsenroth, M. J. (2005). Clinical Utility of the Defensive Functioning Scale in the assessment of depression. The Journal of Nervous and Mental Disease, 193(3), 176-182. doi: 10.1097/01.nmd.0000154839.43440.35
DeRubeis, R. J., Webb, C. A., Tang, T. Z., & Beck, A. T. (2001). Cognitive Therapy. In K.S. Dobson (Eds.). Handbook of Cognitive-Behavioral Therapies, Guilford Press, New York.
Di Giuseppe, M., Perry J.C., Lucchesi, M., Michelini, M., Vitiello, S., Piantanida, A., Fabiani, M., Maffei, S., & Conversano, C. (2020). Preliminary reliability and validity of the DMRS-SR-30, a novel self-report measure based on the Defense Mechanisms Rating Scales. Frontiers in Psychiatry, 11, 1-11. doi: 10.3389/fpsyt.2020.00870
Di Giuseppe, M., Lo Buglio, G., Cerasti, E., Boldrini, T., Conversano, C., Lingiardi, V., & Tanzilli, A. (2024). Defense mechanisms in individuals with depressive and anxiety symptoms: A network analysis. Frontiers in Psychology, 15, 146-5164.
Driessen, E., Hegelmaier, L. M., Abbass, A. A., Barber, J. P., Dekker, J. J., Van, H.L., Jansma, E. P. & Cuijpers, P. (2015). The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis, update. Clinical Psychology Review, 41, 1-15. doi: 10.1016/j.cpr.2015.07.004
Fiorentino, F., Lo Buglio, G., Morelli, M., Chirumbolo, A., Di Giuseppe, M., Lingiardi, V., & Tanzilli, A. (2024). Defensive functioning in individuals with depressive disorders: A systematic review and meta-analysis. Journal of Affective Disorders, 357, 42-50.
Fowler, J. C., & Perry, J. C. (2005). Clinical techniques of the dynamic interview. Psychiatry: Interpersonal and Biological Processes, 68, 316-336. doi: 10.1521/psyc.2005.68.4.316
Frank, E., Prien, R. F., Jarrett, R. B., Keller, M. B., Kupfer, D. J., Lavori, P. W., Rush, A. J., & Weissman, M. M. (1991). Conceptualization and rationale for consensus definitions of terms in major depressive disorder: remission, recovery, relapse, and recurrence. Archives of General Psychiatry, 48(9), 851-855. doi: 10.1001/archpsyc.1991.01810330075011
Freud, S. (1894/1962). The Neuro-psychoses of Defense. In Strachey, J., (Ed. & Trans.). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 3. Hogarth Press, London.
Fukumori, M., Kikuchi, T., Zhou, Y., Hatton, S., & Kudo, T. (2024). Network meta-analysis of the effectiveness of psychotherapies with or without medication for treating adult depression. Acta Neuropsychiatrica, 36(6), 423-437. doi: 10.1017/neu.2024.45
GBD, Disease and Injury Collaborators (2018). Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet, 392(10159), 1789-1858. doi: 10.1016/S0140-6736(18)32279-7
Gilman, S. E., Sucha, E., Kingsbury, M., Horton, N. J., Murphy, J. M., & Colman, I. (2017). Depression and mortality in a longitudinal study: 1952–2011. Canadian Medical Association Journal, 189(42), E1304-E1310. doi: 10.1503/cmaj.170125
Grimm, I., Perry, J. C., & Jäger, M. (2016). The Psychotherapy Process Q-Sort and change in defense and coping mechanisms and depression over psychotherapy for recurrent major depression. Paper presented at the 47th Annual Meeting of the Society for Psychotherapy Research (SPR), Jerusalem, Israel.
Guidi, J., & Fava, G. A. (2020). Sequential combination of pharmacotherapy and psychotherapy in major depressive disorder: a systematic review and meta-analysis. JAMA Psychiatry, 78(3), 261-269. doi: 10.1001/jamapsychiatry.2020.3650
Johansen, P. Ø., Krebs, T. S., Svartberg, M., Stiles, T. C., & Holen, A. (2011). Change in defense mechanisms during short-term dynamic and cognitive therapy in patients with cluster C personality disorders. The Journal of Nervous and Mental Disease, 199(9), 712-715. doi: 10.1097/NMD.0b013e318229d6a7
Judd, L. L., Akiskal, H. S., Maser, J. D., Zeller, P. J., Endicott, J., Coryell, W., Paulus, M. P., Kunovac, J. L., Leon, A. C., Mueller, T. I., & Rice, J. A. (1998). A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders. Archives of General Psychiatry, 55(8), 694-700. doi: 10.1001/archpsyc.55.8.694
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56-62. doi: 10.1136/jnnp.23.1.56
Hersoug, A. G., Bøgwald, K. P., & Høglend, P. (2005). Changes of defensive functioning. Does interpretation contribute to change?. Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice, 12(4), 288-296. doi: 10.1002/cpp.444
Høglend, P. & Perry, J. C. (1998). Defensive functioning predicts improvement in major depressive episodes. The Journal of Nervous and Mental Disease, 186(4), 238-243.
Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology, 3, 1–27. https://dx.doi.org/10.1146/annurev.clinpsy.3.022806.091432
Keller, M. B., Lavori, P. W., Mueller, T. I., Endicott, J., Coryell, W., Hirschfeld, R. M., & Shea, T. (1992). Time to recovery, chronicity, and levels of psychopathology in major depression: a 5-year prospective follow-up of 431 subjects. Archives of General Psychiatry, 49(10), 809-816. doi: 10.1001/archpsyc.1992.01820100053010
Kessler, R. C. (2012a). The costs of depression. Psychiatric Clinics of North America, 35, 1-14. doi: 10.1016/j.psc.2011.11.005
Kessler, R. C., & Bromet, E. J. (2013). The epidemiology of depression across cultures. Annual Review of Public Health, 34, 119-138. doi: 10.1146/annurev-publhealth-031912-114409
König, H., König, H.-H., & Konnopka, A. (2020). The excess costs of depression: a systematic review and meta-analysis. Epidemiology and Psychiatric Sciences, 29, e30, 1–16. doi: 10.1017/S2045796019000180
Kramer, U., Despland, J. N., Michel, L., Drapeau, M., & de Roten, Y. (2010). Change in defense mechanisms and coping over the course of short‐term dynamic psychotherapy for adjustment disorder. Journal of Clinical Psychology, 66(12), 1232-1241. doi: 10.1002/jclp.20719
Kraemer, H. C., Wilson, G. T., Fairburn, C. G., & Agras, W. S. (2002). Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry, 59(10), 877-883. doi: 10.1001/archpsyc.59.10.877
Leichsenring, F., Luyten, P., Hilsenroth, M. J., Abbass, A., Barber, J. P., Keefe, J. R., Leweke, F., Rabung, S., & Steinert, C. (2015). Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria. The Lancet Psychiatry, 2(7), 648-660. doi: 10.1016/S2215-0366(15)00155-8
Luborsky, L. L., & Crits-Christoph, P. (1990). Understanding Transference: The Core Conflictual Relationship Theme Method. New York: Basic Books.
Luborsky, L. L., Diguer, L., Cacciola, J., Barber, J. P., Moras, K., Schmidt, K., & DeRubeis, R. J. (1996). Factors in outcomes of short-term dynamic psychotherapy for chronic vs. nonchronic major depression. The Journal of Psychotherapy Practice and Research, 5(2), 152-159.
Luborsky, L. L., Mark, D., Hole, A. V., Popp, C., Goldsmith, B., & Cacciola, J. (1995). Supportive-expressive dynamic psychotherapy of depression: a time-limited version. In Barber, J. P., Crits-Cristoph, P. (Eds.). Dynamic Therapies for Psychiatric Disorders (Axis I). Basic Books, New York.
Martin-Joy, J. S., Malone, J. C., Cui, X.-J., Johansen, P.-O., Hill, K. P., Rahman, M. O., Waldinger, R. J., & Vaillant, G. E. (2017). Development of Adaptive Coping From Mid to Late Life: A 70-Year Longitudinal Study of Defense Maturity and Its Psychosocial Correlates. The Journal of Nervous and Mental Disease, 205, 685-691.
Minges, M. V., Solomonov, N., & Barber, J. P. (2017). What Makes Psychodynamic Psychotherapy Work? A Review of Five Perspectives. Psychoanalytic Inquiry, 37, 191-201. doi: 10.1080/07351690.2017.1285188
Mueller, T. I., Leon, A. C., Keller, M. B., Solomon, D. A., Endicott, J., Coryell, W., Warshaw, M., & Maser, J. D. (1999). Recurrence after recovery from major depressive disorder during 15 years of observational follow-up. American Journal of Psychiatry, 156(7), 1000-1006. doi: 10.1176/ajp.156.7.1000
Novalis, P. N., Rojcewicz, S. J., & Peele, R. (1993). Clinical Manual of Supportive Psychotherapy. American Psychiatric Press, Washington, DC.
Perry, J. C. (1990). Defense Mechanism Rating Scale. Cambridge, MA: Harvard School of Medicine.
Perry, J. C. (1992). Problems and considerations in the valid assessment of personality disorders. The American journal of psychiatry, 149(12), 1645-1653. doi: 10.1176/ajp.149.12.1645
Perry, J. C. (1993). The study of defense mechanisms and their effects. In N. Miller, N., L. Luborsky, L., Barber, J., & Docherty, J. (Eds.) Psychodynamic Treatment Research: A Handbook for Clinical Practice. New York, Basic Books.
Perry, J. C., Banon, E., & Bond, M. (2020). Change in defense mechanisms and depression in a pilot study of combined antidepressive medications plus 20-sessions of psychotherapy for recurrent major depression. Journal of Nervous and Mental Disease, 208, 261-268. doi: 10.1097/NMD.0000000000001112
Perry, J. C. & Bond, M. (2009). The sequence of recovery in long-term dynamic psychotherapy. Journal of Nervous and Mental Disease, 197, 930-937. doi: 10.1097/NMD.0b013e3181c29a0f
Perry, J. C. & Bond, M. (2012). Change in defense mechanisms during long-term dynamic psychotherapy and five-year outcome. American Journal of Psychiatry, 169, 916-925. doi: 10.1176/appi.ajp.2012.11091403
Perry, J. C., Constantinides, P., & Simmonds, J. (2017). Dynamic conflicts in recurrent major depression: Does combined short-term psychotherapy and antidepressive medication lead to healthy dynamic functioning? Psychoanalytic Psychology, 34(1), 3–12. doi: 10.1037/pap0000058
Perry, J. C., & Cooper, S. H. (1989). An empirical study of defense mechanisms: I. Clinical interview and life vignette ratings. Archives of General Psychiatry, 46, 444-452. doi: 10.1001/archpsyc.1989.01810050058010
Perry, J. C., & Fowler, J. C. (2021). A naturalistic study of time to recovery in adults with treatment-refractory disorders. Psychiatry: Interpersonal and Biological Processes, 84(3): doi: 10.1080/00332747.2021.1907869
Perry, J. C., Fowler, J. C. & Semeniuk, T. T. (2005). An investigation of the tasks and techniques of the dynamic Interview. The Journal of Nervous and Mental Disease, 193(2), 136-139. doi: 10.1097/01.nmd.0000152785.19644.6d
Perry, J. C., Metzger, J., & Sigal, J. J. (2015). Defensive functioning in women with breast cancer and community controls. Psychiatry: Interpersonal and Biological Processes, 78(2), 156-169. doi: 10.1080/00332747.2015.1051445
Pole, N., Ablon, J. S., & O’Connor, L. E. (2008). Using psychodynamic, cognitive behavioral, and control mastery prototypes to predict change: A new look at an old paradigm for long-term single-case research. Journal of Counseling Psychology, 55(2), 221-232. doi: 10.1037/0022-0167.55.2.221
Prout, T. A., Di Giuseppe, M., Zilcha-Mano, S., Perry, J. C. & Conversano, C. (2022). Psychometric properties of the Defense Mechanisms Rating Scales-Self-Report-30 (DMRS-SR-30): Internal consistency, validity and factor structure. Journal of Personality Assessment, 104(6), 833-843. doi: 10.1080/00223891.2021.2019053
Richter, P., Werner, J., Heerlein, A., Kraus, A., & Sauer, H. (1998). On the validity of the Beck Depression Inventory: A review. Psychopathology, 31(3), 160-168. doi: 10.1159/000066239
Roy, C. A., Perry, C. J., Luborsky, L., & Banon, E. (2009). Changes in defensive functioning in completed psychoanalyses: The Penn Psychoanalytic Treatment Collection. Journal of the American Psychoanalytic Association, 57(2), 399-415. doi: 10.1177/0003065109333357
Solomon, D. A., Leon, A. C., Endicott, J., Mueller, T. I., Coryell, W., Shea, M. T., & Keller, M. B. (2004). Psychosocial impairment and recurrence of major depression. Comprehensive Psychiatry, 45(6), 423-430. doi: 10.1016/j.comppsych.2004.07.002
Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: as efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry, 174(10), 943-953. doi: 10.1176/appi.ajp.2017.17010057
Tidemalm, D., Langstrom, N., Lichtenstein, P., & Runeson B. (2008). Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up, British Medical Journal, 337, a2205. http://doi.org/10.1136/bmj.a2205
Vaillant, G. E. (1993). The Wisdom of the Ego. Harvard University Press, Cambridge, Massachusetts.
World Health Organization (2017). Depression and other common mental disorders. In Global Health Estimates. Available at: https://www.who.int/publications/i/item/depression-global-health-estimates
How to Cite
Change and sustained recovery in defense mechanisms and depression in a pilot study of antidepressant medications plus up to 18 months of psychotherapy for recurrent major depression. (2026). Research in Psychotherapy: Psychopathology, Process and Outcome. https://doi.org/10.4081/ripppo.2025.885
Copyright (c) 2026 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.