When a family member is diagnosed with depression the whole family is affected. Additional family and marital stresses imposed on the patient with depression can add to the severity of depression and affect long-term remission rates. In order to ensure the best possible success in treatment, the therapist should integrate the family into the patient’s treatment.
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).
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).
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.
Not all families of patients with depression need family therapy, but all can benefit from the opportunity of meeting together with a mental health professional (Table 2). At the minimum, useful information can be exchanged, potential difficulties identified, and plans can be made for addressing agreed-upon problems. Families can be encouraged to become knowledgeable about the illness, to learn about local mental health laws, to recognize prodromal and residual symptoms, to establish an ongoing collaborative relationship with health care providers, to support treatment compliance, to reach out for help early in the onset of an episode, and to become familiar with local support groups.
A comprehensive, biopsychosocial approach, which combines a judicious use of pharmacotherapy, psychotherapy and family intervention, may not only provide a good likelihood of positive response to acute and maintenance treatment of depression, but can also help patients and families cope with those depressive symptoms that may persist in spite of optimal treatment.
Dr. Keitner is professor of psychiatry at Brown University and director of adult psychiatry and the Mood Disorders Program at Rhode Island Hospital.
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