Psychiatric Times October 2005
The current most commonly used model for the understanding and treatment of depression is a biomedical one that emphasizes symptom resolution. The mainstay of contemporary psychiatric treatment is pharmacotherapy, and of contemporary psychological treatment, cognitive-behavioral therapy. Both pharmacotherapy and psychotherapy can be effective treatments for depression, but, in spite of their efficacy, a significant minority of patients with depression do not respond well and continue to experience problematic residual symptoms (Hirschfeld et al., 2002; Thase et al., 2001). Double-blind, controlled trials for outpatients with mild-to-moderate depression have reported remission rates of 46% for medications, 46% for psychotherapy and 24% for control conditions (Casacalenda et al., 2002), leaving up to 50% of patients with some degree of persistent symptoms.
A biopsychosocial model that draws attention to the social environment in which the depressive episode evolves may be a more helpful way of approaching the management of major depression. There are many reasons to pay attention to the social context of depression in addition to the generally insufficient effectiveness of biological and/or psychological treatments by themselves.
The Interpersonal Context of Depression
More than half of patients with major depression experience distressing and problematic family functioning (Coyne et al., 2002; Keitner et al., 1995). Families of patients with chronic forms of depression experience similar levels of family dysfunction as patients with acute depression (Keitner et al., 2003). Changes in the social environment and the level of social support have a clear association with depression (Paykel and Cooper, 1992). Marital difficulties, especially arguments, are the most frequently reported events prior to the onset of depression (Paykel et al., 1969). Lack of support and inability to confide in a spouse can in itself increase the risk for depression (Parry and Shapiro, 1986). Even within a maritally distressed group of subjects, couples comprised of one partner with depression tended to have the lowest level of marital cohesion (Beach et al., 1988). During interactions between people with depression and their spouses, both parties experience their partners as more negative, hostile, mistrusting and detached than controls (Kahn et al., 1985). Patients who are depressed exert aversive control over their spouses' behaviors (Nelson and Beach, 1990; Schmaling and Jacobson, 1990). Conflicted social interactions are associated with depression, and depression may lead to family stresses and burdens.
Family Functioning and the Course of Depression
Interpersonal stress is not only a precursor to depression, but marital/family dysfunction during the acute phase of a depressive episode is common and often leads to difficulties in multiple family domains. Communication, problem solving and role functioning are particular areas of family life that are disrupted (Keitner et al., 1995). There is significant family burden with financial worries, a sense of social isolation, loss of status, chronic tension and fears of recurrence (Fadden et al., 1987; van Wijngaarden et al., 2004). Problematic family functioning during the acute episode is not only distressing for the family but also has an impact on the course of the depression. Patients who are depressed and have marital distress show slower responsiveness to treatment (Rounsaville et al., 1979). Poor family functioning has a negative impact on both short- and long-term recovery from depression (Keitner et al., 1997, 1995). However, the depression may last for a shorter period of time in those families who are able to improve their family functioning (Keitner et al., 1987).