In spite of these limitations, a number of studies testing a variety of marital therapy approaches to patients with depression have been undertaken and reviewed (Beach, 2003; Kung, 2000). Behavioral marital therapy appears to be comparable to individual therapy in improving depressive symptoms and better than individual therapy in improving marital functioning. Family therapy may be particularly helpful when family distress is present as a component of the depression. Wives who are depressed and are in maritally distressed relationships were randomly assigned to behavioral marital therapy (BMT), cognitive therapy (CT) or a wait-list control condition. In reducing depressive symptoms, BMT and CT were equally effective (and better than the wait-list condition), but BMT was significantly better at reducing the wife's marital distress than was CT (Beach and O'Leary, 1992).
In a randomized, controlled trial, 77 couples, of which one partner had mild-to-moderate depression, were assigned to either antidepressant medication or couples therapy (Leff et al., 2000). Both groups were treated for one year, at which point treatment was discontinued and participants were followed for an additional year. Couples therapy was much more acceptable to the participants in this trial than medication, with a dropout rate of 57% from the drug treatment and 15% from the couples therapy. Both treatment groups improved during the first year, although patients who received couples therapy showed a greater improvement on the Beck Depression Inventory (BDI) than did the couples on medication. The advantage for couples therapy was maintained over the second year after treatments had been discontinued. The Hamilton Rating Scale for Depression (HAM-D) did not differentiate between the two groups. In this study, couples therapy was found to be at least as efficacious as antidepressant drugs for both the treatment and the prevention of relapse of depression.
Another study randomly assigned 121 patients with more severe depression, recruited from the inpatient or partial hospital units of a hospital, to pharmacotherapy alone; combined pharmacotherapy and cognitive therapy; combined pharmacotherapy and family therapy; or combined pharmacotherapy, cognitive therapy and family therapy (Miller et al., in press). The family therapy provided was the Problem Centered Systems Therapy of the Family (PCSFT), which is based on the McMaster Model of Family Functioning. The PCSFT is a structured, short-term family systems intervention that is based on the following principles: an emphasis on "macro" stages of treatment (assessment, contracting, treatment, closure) as opposed to the idiosyncratic "micro" moves of each therapist; emphasis on assessment; inclusion of the entire family; active collaboration between therapist and family members; open, direct communication with the family; focus on the family's responsibility for change; emphasis on current problems; focus on behavioral change; time-limited nature. Compared to no family therapy treatment, the addition of family treatment to pharmacotherapy and/or cognitive therapy led to greater proportions of patients who improved and to significant reductions in interviewer-rated depression and suicide ideation.
Family therapy can be provided in a multifamily group format (Keitner et al., 2002). This format combines family therapy and psychoeducational group therapy and is complementary to pharmacotherapy. In addition to obtaining information and dealing with their own issues, families in a group format not only learn from each other, but also experience an additional important source of social support from others who understand their concerns. The multifamily group format also has the potential to be more cost effective.
Principles for Connecting With Families
Some general principles may be useful to consider when meeting with families of patients with depression (Table 1). Meet with all available/interested family members. One never knows which family member is most involved in the care of the patient and most in need and open to outside support. It is important to be supportive and nonjudgmental. Many families have had the experience of being blamed for their loved one's depression, thus making them defensive and less likely to join in a collaborative effort to deal with ongoing problems. A thorough assessment of the family is important. This is best achieved by listening to all perspectives and by exploring a broad range of family functions, including how they communicate, solve problems, allocate roles and responsibilities, engage emotionally with each other, and set rules and expectations (Ryan et al., 2005). It is helpful to try to identify a major problem/conflict area as opposed to trying to deal with every issue that the family may bring up.
Sharing information about the illness, its treatment, and the early signs and symptoms of relapse, as well as the impact of residual symptoms, can be very helpful for families. A discussion of illness characteristics and available treatments should lead to an emphasis on compliance. The more family members know about the depression and the more they feel like collaborative partners in the management of the illness, the more likely they are to support ongoing treatment efforts with their loved one.
One of the most difficult tasks that a family has is to find a balance between not pushing the member with depression beyond their capability versus passively accepting the negative outlook and self-doubt of the family member who is depressed. A therapist can be very helpful in guiding the family to recognize the realistic limitations that a person with depression may experience in terms of being able to concentrate or having sufficient energy or motivation to carry out more complicated tasks, while at the same time helping to determine the kinds of positive steps that the person with depression can take in terms of reconceptualizing their illness and making small changes that can help to minimize feelings of hopelessness and helplessness.
