Often, there is improvement in family functioning as the depression remits. Nonetheless, families with a member who is depressed still report worse family functioning at remission of the depression than do control families (Keitner et al., 1995). Family functioning is also related to the likelihood of maintaining wellness or relapsing. High levels of criticism toward the patient are associated with a greater likelihood of relapse (Vaughn and Leff, 1976). In addition to perceived criticism, marital distress is also strongly related to the tendency to relapse.
We do not know the causal sequence between depression and problematic family functioning. It is likely that there are mutually reinforcing patterns of interactions between a patient's vulnerability to depression and the family's ways of coping with the illness (Figure) (Due to copyright concerns, this Figure cannot be reproduced online. Please see p40 of the print edition--Ed.). A patient's vulnerability to depression may include genetic predisposition, early life experiences, personality variables, current life events and/or persistent family conflicts. Regardless of the etiology of the episode, the patient's family and/or significant others have to respond to and deal with the depression. If the family and social support system respond effectively, the depressive illness may be relatively brief and may remit more readily. If the family is unable to respond adequately to the patient's illness because of the family's own difficulties, then the illness may be more prolonged, with the patient less likely to recover and more likely to relapse into subsequent episodes. Pharmacotherapy and psychotherapy may be helpful in dealing with genetic vulnerability, early life experiences and current life stresses, while family intervention can reinforce the family's competence in responding to the illness (Keitner and Miller, 1990).
Methods of Assessing Family Functioning
A number of self-reported and interview-based family assessment instruments have been developed and described. Many of these family assessment tools were designed for research purposes. They are standardized and provide numerical summaries of various aspects of family functioning that can then be more systematically analyzed. Some may be adapted for clinical use.
Self-report scales, which are cost effective to administer, provide information on how family members evaluate their own functioning. The Dyadic Adjustment Scale (DAD), for example, is a 32-item measure of marital quality and marital adjustment. Four subscales measure marital satisfaction, cohesion, consensus and affective expression. The Family Environment Scale (FES) is a 90-item true/false measure assessing how family members perceive their family environment along the three domains of relationships, personal growth and system maintenance. The Family Questionnaire (FQ) is a brief measure of perceived criticism and overinvolvment. The Family Assessment Device (FAD) is a 60-item scale that assesses the six dimensions of the McMaster Model of Family Functioning (communications, problem solving, affective responsiveness, affective involvement, roles and behavior control) in addition to having a general functioning subscale. The FAD has high levels of internal consistency, acceptable levels of test-retest reliability, low correlations with social desirability and good discriminative validity.
Interview-based family assessment instruments are more labor intensive and require rater training. They provide an outside perspective on how a family functions compared to other families. The Camberwell Family Interview requires extensive training and is used to assess levels of criticism and overinvolvment. The Five Minute Speech Sample is a brief method of assessing expressed emotion in relatives of patients with psychiatric disorders. The McMaster Clinical Rating Scale (MCRS) is based on a family interview conducted by a rater, and it assesses the same six dimensions of family functioning as the FAD in addition to assessing the overall health/pathology of a family. The MCRS has acceptable interrater and test-retest reliability as well as concurrent and discriminative validity. The family assessment interview can take from 45 to 90 minutes depending on the experience of the rater.
Marital/Family Therapy for Depression
Marital and family therapies share very similar therapeutic principles and can be considered the same for the purpose of this article. There are many schools of marital/family therapy (e.g., strategic marital therapy, behavioral marital therapy, cognitive marital therapy, the problem-centered systems therapy of the family, inpatient family, inpatient family intervention). None have been shown superior to the others. Studies of marital/family therapy for depression are faced with the same limitations that other treatment studies face, making comparisons between different types of therapies very difficult. These limitations include differences in patient group studied (diagnosis, severity, chronicity, gender, level of marital distress) and designs used (with or without controls, different comparison groups, variable number of therapy sessions, length of follow-up evaluations).
