Implicit self-esteem in recurrently depressed patients Anne K. Risch a, * , Astrid Buba b , Uwe Birk a , Nexhmedin Morina c , Melanie C. Steffens a , Ulrich Stangier d a Department of Psychology, University of Jena, Humboldtstr.11, 07743 Jena, Germany b International Max Planck Research School, University of Jena, Bachstraße 18k, 07743 Jena, Germany c Department of Clinical Psychology, University of Amsterdam, Roeterstraat 15,1018 WB Amsterdam, The Netherlands d Department of Psychology, University of Frankfurt, Varrentrappstr. 40–42, 60486 Frankfurt, Germany article info Article history: Received 16 April 2008 Received in revised form 4 January 2010 Accepted 5 January 2010 Keywords: Self-esteem Implicit attitudes Recurrent depression Implicit Association Test abstract Negative self-esteem is suggested to play an important role in the recurrence of depressive episodes. This study investigated whether repeated experiences of a negative view of the self within a recurrent course of depression might cause implicit self-esteem to be impaired and negative self-attributes to even be chronically activated beyond remission. We measured implicit self-esteem using an Implicit Association Test. The sample consisted of N ¼ 24 currently depressed patients with first-onset depressive episode, N ¼ 28 currently depressed patients with recurrent depressive episodes, N ¼ 33 currently remitted patients with recurrent depressive episodes, and N ¼ 34 controls with no history of depression. In line with cognitive theories, results revealed significantly lower implicit self-esteem in current depressive patients than in healthy controls but no significant differences in implicit self-esteem between remitted recurrent depressive patients and healthy controls. However, remitted depressive patients with three or more depressive episodes showed a significantly lower implicit self-esteem than those with less than three depressive episodes. The current findings underline the necessity of relapse prevention treatments which not only enhance self-esteem at an explicit but also at an implicit level as well as emphasizing the need for evaluations of treatment efficacy to focus upon both implicit and explicit levels of self-esteem. Ó 2010 Elsevier Ltd. All rights reserved. 1. Introduction The recurrent nature of depression chiefly contributes to the total burden of the disease (Murray & Lopez, 1997). However, the cognitive mechanisms on which recurrence is based are not yet clear. Numerous studies have shown that acute-phase major depression is associated with specific cognitive distortions such as increased negative thinking, enhanced accessibility of negative information, and biased information processing (for a review, see Ingram, Miranda, & Segal, 1998). According to the self-schema model of depression (Clark, Beck, & Alford, 1999), recovered indi- viduals continue to exhibit dysfunctional self-related schemas, which are hypothesised to lie dormant until activated. When acti- vated in vulnerable individuals, these schemas may provide access to an associative network of self-related negative content and patterns of biased information processing which increase the risk of both maintenance and recurrence of unipolar depression (Williams, Watts, MacLeod, & Mathews, 1997). In his model of differential activation, Teasdale (1988) proposed that an association between negative self-relevant attributes and negative mood is established during first-onset depression. In subsequent states of negative mood following this first episode, negative self-relevant attributes are automatically activated. The strengthening of these associations may contribute to an increased risk of recurrence with each subsequent episode. In line with this model, a prospective study showed that first onset of depression was predicted by the number of negative life events, whereas recurrences were predicted by states of dysphoric mood (Lewinsohn, Allen, Seeley, & Gotlib, 1999). It may, however, also be the case that the repeated activation of negative self-evaluation in recurrent episodes increases negative self-esteem. During acute depression, negative self-relevant attri- butions may be more powerful in patients with multiple recurrences and thereby provoke a relapse or the maintenance of depression. Furthermore, the association between self and negative attributes may become chronic even after remission and thus increase the risk of recurrence. This corresponds with the notion that the repeated activation of positive self-evaluations developed early in life may become an integral part of the ‘‘automatic’’ self which is chronically activated (Paulhus, 1993). So far, a number of studies have demon- strated persistent cognitive deficits in the domains of memory and attention following remission from depressive episodes (Frasch et al., 2000). Moreover, remitted depressive patients with three or * Corresponding author. Tel.: þ49 3641 945173; fax: þ49 3641 945172. E-mail address: anne.katrin.risch@uni-jena.de (A.K. Risch). Contents lists available at ScienceDirect Journal of Behavior Therapy and Experimental Psychiatry journal homepage: www.elsevier.com/locate/jbtep 0005-7916/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbtep.2010.01.003 J. Behav. Ther. & Exp. Psychiat. 41 (2010) 199–206