Hidden Scars in Depression? Implicit and Explicit Self-Associations Following Recurrent Depressive Episodes Hermien J. Elgersma, Klaske A. Glashouwer, and Claudi L. H. Bockting University of Groningen Brenda W. J. H. Penninx VU University Medical Centre and Leiden University Medical Centre Peter J. de Jong University of Groningen To help explain the recurrent nature of major depressive disorder, we tested the hypothesis that depressive episodes and/or the duration of depressive symptoms may give rise to persistent dysfunctional implicit and/or more explicit self-associations, which in turn may place people at risk for the recurrence of symptoms. We therefore examined, in the context of the Netherlands Study of Depression and Anxiety, whether the strength of self-depressed associations at baseline was related to the number of past episodes (retrospective analysis; n  666), and whether the duration of symptoms between baseline and follow-up predicted self-depressed associations at 2-year follow-up (prospective analysis; n  726). The lifetime Composite International Diagnostic Interviews and Life Chart Interview were used to index the number of depressive episodes; the Implicit Association Test and its explicit equivalent were used to index self-associations. Consistent with the hypothesis that self-depressed associations strengthen fol- lowing prolonged activation of negative self-associations during depressive episodes, individuals’ im- plicit and explicit self-depressed associations correlated positively both with the number of prior depressive episodes at baseline and with the duration of depressive symptoms between baseline and 2-year follow-up. There was evidence that these relationships held, particularly in the prospective study, even when controlling for neuroticism and current depressive symptoms, whereas the retrospective relationship between number of episodes and implicit self-associations fell just short of significance. Keywords: longitudinal study, implicit self-depressed associations, explicit self-depressed associations, depression, recurrence Major depressive disorder (MDD) causes suffering in the indi- vidual and his or her environment, and contributes to high societal and health care costs (Ormel et al., 2008; Smit et al., 2006). In 2030, MDD is expected to be at the top of the list for the World Health Organization in terms of burden of disease. Notably, its recurrent nature contributes to the disability and health care costs of MDD (Mathers & Loncar, 2006). The chance of recurrence reaches 90% in patients with three or more episodes (Mueller et al., 1999; Judd et al., 1998). Consequently, it is very important to obtain a better understanding of the processes that increase vul- nerability to relapse and recurrence in depression. Cognitive models emphasize the relevance of dysfunctional attitudes toward the self in the onset and recurrence of depressive episodes (Clark, Beck, & Alford, 1999). Dual-process models point to the importance of distinguishing between more explicit and more automatic (implicit) attitudes in this respect (e.g., Gawronski & Bodenhausen, 2006; Haeffel et al., 2007). To help explain the onset, course, and recurrence of depression, Beevers (2005) applied this dual-process perspective to the cognitive vul- nerability to depression. He proposed that, in response to a stress- ful life event, two sets of processes determine how that event will be evaluated. First, by default, the implicit processing system is Hermien J. Elgersma, Klaske A. Glashouwer, and Claudi L. H. Bockting, Department of Clinical Psychology, University of Groningen, Groningen, The Netherlands; Brenda W. J. H. Penninx, Department of Psychiatry/EMGO Institute, VU University Medical Centre, Amster- dam, The Netherlands, Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands; and Peter J. de Jong, De- partment of Clinical Psychology, University of Groningen, Groningen, The Netherlands. Supported by ZonMw (OOG) (Grant 100000 –2035) and Accare Dren- the/Overijssel. Netherlands Study of Depression and Anxiety infrastructure supported by the Netherlands Organisation for Health Research and De- velopment (Grant 10-000-1002) and by participating universities and men- tal health care organizations (VU University Medical Center, GGZ in- Geest, Arkin, Leiden University Medical Center, GGZ Rivierduinen, University Medical Center Groningen, University of Groningen, Lentis, GGZ Friesland, GGZ Drenthe, Scientific Institute for Quality of Health Care [IQ Health Care]), Netherlands Institute for Health Services Research [NIVEL], and Netherlands Institute of Mental Health and Addiction [Trim- bos]). We thank Bert Hoekzema for technical support, and Maggie Stroebe for her helpful comments and suggestions. Correspondence concerning this article should be addressed to Hermien J. Elgersma, Department of Clinical Psychology, University of Groningen, Grote Kruisstraat 2/1, 9712 TS Groningen, The Netherlands. E-mail: h.j.elgersma@rug.nl This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Journal of Abnormal Psychology © 2013 American Psychological Association 2013, Vol. 122, No. 4, 951–960 0021-843X/13/$12.00 DOI: 10.1037/a0034933 951