Marital therapy: a viable treatment for depression and marital discord

Individual mental health and couple functioning following couple relationship education participation: Exploring prospective cross-lagged influences among changes

Limited research on couple relationship education (CRE) programs explores the relationships among potential outcomes over time. This study conducted tests of processes of change in CRE participants' mental health and couple functioning, based on previous evidence of concurrent benefit in these domains following CRE participation. Using a diverse sample of 926 men and women we first tested the stress generation model (Journal of Abnormal Psychology, 1991, 100(4), 555-561) assumptions that individual functioning influences relational functioning. We found support for immediate changes in mental health predicting changes in couple functioning 6 months later. However, a full cross-lagged prospective model comparatively testing the stress generation model and the marital discord model (Depression in marriage: A model for etiology and treatment. Guilford, 1990), which emphasizes relational functioning impacts on individual well-being over time, revealed the stronger directional link for both men and women was from immediate changes in couple functioning to later changes in individual mental health. Practical implications and future research directions are suggested.

Randomized Controlled Trial of the Marriage Checkup: Depression Outcomes

The association between relationship functioning and depressive symptoms is well established. This study examined the effects of the Marriage Checkup, a brief two-session Assessment and Feedback relationship intervention, on depressive symptoms. Two hundred and nine married couples participated in the Marriage Checkup and were randomized into Treatment (N = 108) and Waitlist-Control Conditions (N = 101). Compared to the control condition, intervention participants reported significant improvements in depressive symptoms (d = 0.55), with an even greater effect for those who were reporting more severe baseline depression symptoms (d = 0.67). These outcomes are comparable to those within long-term individual psychotherapy, couple therapy, and pharmacology trials, making this the briefest intervention to date to demonstrate significant improvements in depressive symptoms. Clinical implications are discussed.

Marital Problems among Partners of Patients with Bipolar Affective Disorder

BACKGROUND

Partners of patients with bipolar affective disorder (BPAD) have problems with their marital life. Identification of these problems is important to develop strategies to solve them for improving quality of life.

AIMS

To identify marital distress and problem areas in their marital life among the partners of patients with BPAD.

MATERIALS AND METHODS

A cross-sectional descriptive design was used to collect data from 125 participants, 59 males and 66 females, who were partners of patients with BPAD. The study was done in outpatient clinics of Community Mental Health Clinics of District Mental Health Program. Tools used for data collection included a semi-structured interview schedule to collect socio-personal data of partners of patients with BPAD and clinical data of the patient, Couple Satisfaction Index (CSI), and Problem Areas Questionnaire (PAQ). Purposive sampling technique was used.

RESULTS

Majority of the participants (male - 55.9%, female -54.5%) expressed marital distress on CSI. Handling family finances and career/job decisions were the most problematic areas for male participants, whereas household tasks, handling finances, and career/job decisions were the most problematic areas for female participants.

CONCLUSION

A significant proportion of spouses of BPAD patients have marital distress in important areas of life, with a potential for long-term consequences in their lives.

The Role of Dyadic Discord in Outcomes in Acute Phase Cognitive Therapy for Adults With Recurrent Major Depressive Disorder

Major depressive disorder (MDD) and relationship discord between cohabiting partners frequently co-occur, with bidirectional effects established. As relationship quality influences understanding and treatment of MDD, the current analyses clarified the relations of pretreatment dyadic discord with outcomes during and at the end of acute phase cognitive therapy (CT) for adults with recurrent MDD. Married or cohabiting patients (n = 219) completed the Dyadic Adjustment Scale (DYS) before and after a 16-20 session, 12-14 week CT protocol. Lower levels of dyadic adjustment indicated higher levels of dyadic discord. Response to CT was defined as the absence of a major depressive episode and ≤ 12 on the 17-item Hamilton Rating Scale for Depression. Pretreatment dyadic discord, whether defined as a continuous or categorical variable (using DYS cutoff score of 97), was not associated with treatment completion or response but was positively associated with levels of depressive symptoms at the end of acute phase CT. Furthermore, CT was associated with declines in dyadic discord, with 23.3% of initially discordant couples moving to nondiscordant status at the end of CT. Depressive symptoms did not significantly mediate changes in dyadic discord. Finally, pre- (but not mid-) treatment dyadic discord was associated with subsequent changes in depressive symptoms, suggesting limited mediation. These findings replicate prior research indicating that individual CT is associated with reductions in depressive symptoms and dyadic discord while clarifying that lower pre-treatment dyadic discord may predict initial improvement in depressive symptoms.

Treatment and Prevention of Depression

Depression is one of the most common and debilitating psychiatric disorders and is a leading cause of suicide. Most people who become depressed will have multiple episodes, and some depressions are chronic. Persons with bipolar disorder will also have manic or hypomanic episodes. Given the recurrent nature of the disorder, it is important not just to treat the acute episode, but also to protect against its return and the onset of subsequent episodes.

Several types of interventions have been shown to be efficacious in treating depression. The antidepressant medications are relatively safe and work for many patients, but there is no evidence that they reduce risk of recurrence once their use is terminated. The different medication classes are roughly comparable in efficacy, although some are easier to tolerate than are others. About half of all patients will respond to a given medication, and many of those who do not will respond to some other agent or to a combination of medications. Electro-convulsive therapy is particularly effective for the most severe and resistant depressions, but raises concerns about possible deleterious effects on memory and cognition. It is rarely used until a number of different medications have been tried.

Although it is still unclear whether traditional psychodynamic approaches are effective in treating depression, interpersonal psychotherapy (IPT) has fared well in controlled comparisons with medications and other types of psychotherapies. It also appears to have a delayed effect that improves the quality of social relationships and interpersonal skills. It has been shown to reduce acute distress and to prevent relapse and recurrence so long as it is continued or maintained. Treatment combining IPT with medication retains the quick results of pharmacotherapy and the greater interpersonal breadth of IPT, as well as boosting response in patients who are otherwise more difficult to treat. The main problem is that IPT has only recently entered clinical practice and is not widely available to those in need.

Cognitive behavior therapy (CBT) also appears to be efficacious in treating depression, and recent studies suggest that it can work for even severe depressions in the hands of experienced therapists. Not only can CBT relieve acute distress, but it also appears to reduce risk for the return of symptoms as long as it is continued or maintained. Moreover, it appears to have an enduring effect that reduces risk for relapse or recurrence long after treatment is over. Combined treatment with medication and CBT appears to be as efficacious as treatment with medication alone and to retain the enduring effects of CBT. There also are indications that the same strategies used to reduce risk in psychiatric patients following successful treatment can be used to prevent the initial onset of depression in persons at risk. More purely behavioral interventions have been studied less than the cognitive therapies, but have performed well in recent trials and exhibit many of the benefits of cognitive therapy.

Mood stabilizers like lithium or the anticonvulsants form the core treatment for bipolar disorder, but there is a growing recognition that the outcomes produced by modern pharmacology are not sufficient. Both IPT and CBT show promise as adjuncts to medication with such patients. The same is true for family-focused therapy, which is designed to reduce interpersonal conflict in the family. Clearly, more needs to be done with respect to treatment of the bipolar disorders.

Good medical management of depression can be hard to find, and the empirically supported psychotherapies are still not widely practiced. As a consequence, many patients do not have access to adequate treatment. Moreover, not everyone responds to the existing interventions, and not enough is known about what to do for people who are not helped by treatment. Although great strides have been made over the past few decades, much remains to be done with respect to the treatment of depression and the bipolar disorders.

The Effectiveness of Couple and Individual Relationship Education: Distress as a Moderator

Current literature yields mixed results about the effectiveness of relationship education (RE) with low-income participants and those who experience a high level of individual or relational distress. Scholars have called for research that examines whether initial levels of distress act as a moderator of RE outcomes. To test whether initial levels of relationship and/or individual distress moderate the effectiveness of RE, this study used two samples, one of couples who received couple-oriented relationship education with their partner (n = 192 couples) and one of individuals in a relationship who received individual-oriented RE by themselves (n = 60 individuals). We delivered RE in a community-based setting serving primarily low-income participants. For those attending with a partner, there was a significant interaction between gender, initial distress, and time. Findings indicate that women who were relationally distressed before RE reported the largest pre-postgains. Those who attended an individual-oriented RE program reported significant decreases in individual distress from pre to post, but no significant relationship gains. Findings also suggest that initial levels of distress did not moderate the effectiveness of individual-oriented RE.

The Affectionate Bond

The role of empathy in promoting emotional closeness between two individuals has been well established. It is a significant component of various forms of individual psychotherapy and has also been recognized as important to promoting growth in parent-child, teacher-student, manager-staff, and other relationships. The authors have incorporated this conceptualization of empathy into a couple-centered approach to relationship difficulties. Reciprocal empathy promotes emotional disclosure, which leads to increased intimacy and an affectionate bond between partners.

Attributional Models of Depression and Marital Distress

The authors compare the attributional models presented in depression and marital literatures by examining simultaneously their prediction of depressive symptoms and marital distress. A total of 150 married couples completed the Attribution Style Questionnaire (ASQ), the Relationship Attribution Measure (RAM), and measures of depression and marital distress. For both husbands and wives, a full model that included paths from depressogenic and distress-maintaining marital attributions to both depressive symptoms and marital distress provided a better fit to the data than a model that omitted paths from distress-maintaining attributions to each outcome. The theoretical implications of these findings are discussed.

Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression

Combination treatment with psychotherapy and antidepressant medication can be provided from the initiation of treatment, sequentially after nonremission with a single-modality treatment or sequentially after remission to buttress the patient's recovery to prevent recurrence. Combination treatment from the initiation of care is best reserved for patients with high depression severity. Sequential addition of treatments, particularly psychotherapy after nonremission to antidepressant medication, is the best supported method of combination, improving remission rates and reducing relapse and recurrence in the long term. However, uncertainty persists around the optimal form of psychotherapy to combine with antidepressant medication for maximizing long-term gains. Better outcomes from combination treatment have been strongest in clinical trials that limited pharmacotherapy to a single antidepressant; benefits of combination treatment have been substantially smaller in trials that allowed flexible use of multiple antidepressant classes. Patients with recurrent major depressive disorder who benefit from combination treatment have better long-term outcomes if an active treatment component is maintained during recovery.

Parental Depression and Child Behaviour Problems: Implications for Behavioural Family Intervention

This report explores the role of parental depression in the adjustment of children and discusses its implications for behavioural family intervention. Within a social interactional perspective, depression is conceptualised as a class of behaviours that is under the control of the social environment and at the same time operates as a context for other social agents. The presence of this class of behaviours in parents is postulated to precipitate developmentally determined psychological problems, that is based on a child's age and sex, such that younger boys and adolescent girls would be most at risk. The results of two longitudinal studies are presented showing a significant relation between fluctuations in mothers' depressive symptoms and similar symptoms in their adolescent daughters. Weaker effects are seen between fathers' and sons' depressive levels. The implications for behavioural family therapy are discussed in relation to depression in adolescent girls.

Perceptions of partners' attributions for depression in relation to perceptions of support and conflict in romantic relationships

People's attributions for their own psychological problems are linked to their interpersonal behaviors and attitudes. However, depressed individuals' inferences about their romantic partners' attributions for their depressive symptoms have yet to be studied in relation to their perceptions of relationship quality. This study examined perceived support from and conflict with partners in relation to perceptions of partners' attributions for depression in 165 individuals experiencing at least mild depressive symptoms. After controlling for relevant demographic characteristics, perceived internal/controllable psychological attributions were related to greater perceived conflict and lower perceived support, and perceived controllable biological attributions were related to greater perceived conflict. Perceived external/uncontrollable psychological and uncontrollable biological attributions were unrelated to perceived support and conflict. Findings suggest that perceived attributions may help explain the link between depression, support, and conflict in romantic relationships.

Mechanisms of change in brief couple therapy for depression

The goal of the present study was to investigate potential mechanisms of previously documented treatment effects for a brief, 5-session, problem-focused couple therapy for depression in a sample of 35 depressed women and their nondepressed husbands. The primary treatment effects were reducing women's depressive symptoms and their husbands' psychological distress and depression-specific burden. Secondarily, treatment resulted in increased relationship satisfaction for both partners. Given these significant treatment changes observed in 5 sessions, we sought to examine the mechanisms of change by testing the following three factors as potential mediators: (a) negative behaviors and attitudes toward depression, (b) support provision, and (c) empathic communication towards the depressed female partners. Women's depression and husbands' depression-specific burden were alleviated by positive changes in their illness-related attitudes and behaviors. Improvements in women's marital satisfaction were also mediated by positive change in their illness-related attitudes and behaviors, along with perceptions of increased positivity and support from their husbands. Findings highlight the importance of targeting specific treatment agents in a brief couple therapy for depression such as psychoeducation about depression and support-building to increase partners' understanding and acceptance of the illness, and teaching communication skills to reduce negative behaviors and criticism that are replaced by more empathic communication towards the depressed individual.

A Framework for Intentional Cultural Change

We present a framework for a pragmatic science of cultural evolution. It is now possible for behavioral science to systematically influence the further evolution of cultural practices. As this science develops, it may become possible to prevent many of the problems affecting human wellbeing. By cultural practices, we refer to everything that humans do, above and beyond instinctual or unconditioned behaviors: not only art and literature, but also agriculture, manufacturing, recreation, war making, childrearing, science-everything. We can analyze cultural practices usefully in terms of the incidence and prevalence of individual behavior and group and organization actions. An effective science of intentional cultural evolution must guide efforts to influence the incidence and prevalence of individuals' behaviors and the actions of groups and organizations. In this paper, we briefly sketch advances in scientific understanding of the influences on individual behavior. Then we describe principles that could guide efforts to influence groups and organizations. Finally, we discuss legitimate concerns about the use and misuse of a science for intentional cultural change.

The Role of Relationships in Understanding the Alexithymia–Depression Link

Alexithymia is associated with increased depressive symptoms in both clinical and community samples. One way that alexithymia may lead to depression is through its impact on interpersonal relationships. Individuals with alexithymia report lower perceived social support, intimacy, and relationship satisfaction. Furthermore, poor relationship functioning is a clear risk factor for depressive symptoms. Given the established alexithymia–depression link and marital dysfunction–depression link, a logical next step is to examine whether relationship dysfunction (low social support, intimacy, negative relationship behaviours, and relationship dissatisfaction) mediates the association between alexithymia and depressive symptoms. The hypothesized mediation model was assessed in a sample of 104 community couples with two analytical approaches—first with cross–sectional measures using path analysis and second with daily diary measures collected over a seven–day period using a multilevel modelling approach. Poor relationship functioning mediated the association between alexithymia and depressed mood in the daily diary data and partially mediated that association with the cross–sectional measures. These results identify alexithymia as an important variable in understanding the marital functioning–depression association, and this finding has implications for treatment. Copyright © 2012 European Association of Personality Psychology

Marital functioning and psychological distress among older couples over an 18-month period

Many authors have underlined the existence of a negative association between marital functioning and psychological distress. However, little is known about the direction of this association over time among older couples. This study examined the relation over time between psychological distress and marital functioning among 394 community-dwelling couples. The authors conducted dyadic data analyses to determine whether marital functioning at baseline (T1) predicted psychological distress 18 months later (T2), and inversely. The results for women suggested that marital and psychological functioning may each predict the other. The results for men showed that marital problems lead to more psychological distress. The authors found some significant partner effects: In both genders, the marital functioning of one spouse influenced the marital functioning of the other. Men's marital functioning at baseline significantly predicted women's psychological distress at T2. The authors conducted analyses also to determine how 6 patterns of change in marital functioning between times were associated with changes in psychological distress, and inversely. Changes characterized by an increase in psychological distress over time in at least 1 spouse were associated with a decrease in marital functioning. These findings underlined the importance for clinicians and researchers to pay closer attention to the association between these variables.

Marriage as a perceived panacea to mental illness in India: Reality check

Marriage is a consensual and contractual relationship recognized by law. In India, there is a tremendous social and cultural pressure to marry. It is of paramount importance to discuss the relationship between marriage and mental illness in Indian scenario as marriage is perceived to be a panacea to mental illness by many. This review aims to explore whether marriage contributes to mental-health problems; whether it has a protective role; what effect it has on pre-existing mental illnesses and its outcome in major mental illnesses.

Contribution of spontaneous improvement to placebo response in depression: a meta-analytic review

OBJECTIVES

It is unknown to what degree spontaneous improvement accounts for the large placebo response observed in antidepressant trials for Major Depressive Disorder (MDD). The purpose of this study was to estimate the spontaneous improvement observed in treatment-seeking individuals with acute MDD by determining the symptom change in depressed patients assigned to wait-list controls in psychotherapy studies.

METHOD

The databases PubMed and PsycINFO were searched to identify randomized, prospective studies randomizing outpatients to psychotherapy or a wait-list control condition for the treatment of acute MDD. Standardized effect sizes calculated from each identified study were aggregated in a meta-analysis to obtain a summary statistic for the change in depression scores during participation in a wait-list control.

RESULTS

Ten trials enrolling 340 participants in wait-list control conditions were identified. The estimated effect size for the change in depression scores during wait-list control was 0.505 (95% CI 0.271-0.739, p < 0.001), representing an average improvement of 4 points on the Hamilton Rating Scale for Depression.

DISCUSSION

Depressed patients acutely experience improvement even without treatment, but spontaneous improvement is unlikely to account for the magnitude of placebo response typically observed in antidepressant trials. These findings must be interpreted in light of the small number wait-list control participants available for analysis as well as certain methodological heterogeneity in the psychotherapy studies analyzed.

Distressed behavior and its context

Behavior that is commonly labeled as indicating distress may have an important function in certain clinical problems. Evidence suggests that "distressed" behavior is displayed more frequently by persons who are depressed or experiencing chronic pain. Such behavior includes nonverbal facial expressions and body postures which are typically labeled as "sad," and verbal responses involving self-denigration or complaints. Such behaviors appear to form a functional response class which has a unique impact on others. The behavior appears to be more likely among persons who are receiving aversive stimulation. Recipients of distressed behavior are more likely to experience negative emotion, yet be solicitous toward the person who displays distressed behavior. Under circumstances where distressed behavior is unsuccessful in reducing aversive stimulation, the behavior may be shaped and maintained by the fact that it temporarily reduces the probability of others behaving aggressively toward the person displaying distress. Thus, the development of a pattern of high rates of distressed behavior that characterizes clinically depressed persons and persons in chronic pain may be partly a result of the unique social contingencies that surround this behavior.

Treating Anorexia Nervosa in the Couple Context

Anorexia nervosa is a serious mental illness that affects women and men of all ages. Despite the gravity of its chronic morbidity, risk of premature death, and societal burden, the evidence base for its treatment-especially in adults-is weak. Guided by the finding that family-based interventions confer benefit in the treatment of anorexia nervosa in adolescents, we developed a cognitive-behavioral couple-based intervention for adults with anorexia nervosa who are in committed relationships that engages both the patient and her/his partner in the treatment process. This article describes the theoretical rationale behind the development of Uniting Couples in the treatment of Anorexia nervosa (UCAN), practical considerations in delivering the intervention, and includes reflections from the developers on the challenges of working with couples in which one member suffers from anorexia nervosa. Finally, we discuss future applications of a couple-based approach to the treatment of adults with eating disorders.

Uniting Couples (in the treatment of) Anorexia Nervosa (UCAN)

OBJECTIVE

To describe the development of a novel couple-based cognitive-behavioral intervention for adult anorexia nervosa (AN) called Uniting Couples (in the treatment of) Anorexia Nervosa (UCAN).

METHOD

We review the state of the science for the treatment of adult AN, the nature of relationships in AN, our model of couple functioning in AN, and the development of the UCAN intervention.

RESULTS

We present the UCAN treatment for patients with AN and their partners and discuss important considerations in the delivery of the intervention.

DISCUSSION

With further evaluation, we expect that UCAN will emerge to be an effective, acceptable, disseminable, and developmentally tailored intervention that will serve to improve both core AN pathology as well as couple functioning.

A randomized clinical trial of a brief, problem-focused couple therapy for depression

The aim of this study was to evaluate a brief couple therapy for depression targeted for mildly discordant or nondiscordant couples struggling with the negative impact of depression. Subjects included women with major depression or dysthymia who had husbands without clinical depression. Thirty-five couples were randomly assigned to the 5-week intervention (n=18) or a waitlist control group (n=17), and followed up 1 and 3 months later. Results showed a significant effect of treatment in reducing women's depressive symptoms, with 67% of women improved and 40% to 47% recovered at follow-up, compared to only 17% improved and 8% recovered among women in the control group. Treatment was also effective in secondarily improving women's marital satisfaction, reducing husbands' levels of psychological distress and depression-specific burden, and improving both partners' understanding and acceptance of depression. The treatment was implemented in five 2-hour sessions, representing an efficient, cost-effective approach. Findings support the growing utility of brief, problem-focused couple interventions that simultaneously target depression, relational functioning, and psychological distress experienced by the loved ones of depressed persons.

A review of empirically supported psychological therapies for mood disorders in adults

BACKGROUND

The mood disorders are prevalent and problematic. We review randomized controlled psychotherapy trials to find those that are empirically supported with respect to acute symptom reduction and the prevention of subsequent relapse and recurrence.

METHODS

We searched the PsycINFO and PubMed databases and the reference sections of chapters and journal articles to identify appropriate articles.

RESULTS

One hundred twenty-five studies were found evaluating treatment efficacy for the various mood disorders. With respect to the treatment of major depressive disorder (MDD), interpersonal psychotherapy (IPT), cognitive behavior therapy (CBT), and behavior therapy (BT) are efficacious and specific and brief dynamic therapy (BDT) and emotion-focused therapy (EFT) are possibly efficacious. CBT is efficacious and specific, mindfulness-based cognitive therapy (MBCT) efficacious, and BDT and EFT possibly efficacious in the prevention of relapse/recurrence following treatment termination and IPT and CBT are each possibly efficacious in the prevention of relapse/recurrence if continued or maintained. IPT is possibly efficacious in the treatment of dysthymic disorder. With respect to bipolar disorder (BD), CBT and family-focused therapy (FFT) are efficacious and interpersonal social rhythm therapy (IPSRT) possibly efficacious as adjuncts to medication in the treatment of depression. Psychoeducation (PE) is efficacious in the prevention of mania/hypomania (and possibly depression) and FFT is efficacious and IPSRT and CBT possibly efficacious in preventing bipolar episodes.

CONCLUSIONS

The newer psychological interventions are as efficacious as and more enduring than medications in the treatment of MDD and may enhance the efficacy of medications in the treatment of BD.

Dyadic discord at baseline is associated with lack of remission in the acute treatment of chronic depression

BACKGROUND

Dyadic discord, while common in depression, has not been specifically evaluated as an outcome predictor in chronic major depressive disorder. This study investigated pretreatment dyadic discord as a predictor of non-remission and its relationship to depressive symptom change during acute treatment for chronic depression.

METHOD

Out-patients with chronic depression were randomized to 12 weeks of treatment with nefazodone, the Cognitive Behavioral Analysis System of Psychotherapy or their combination. Measures included the Marital Adjustment Scale (MAS) and the Inventory of Depressive Symptomatology - Self Report (IDS-SR30). Of 681 original patients, 316 were partnered and 171 of these completed a baseline and exit MAS, and at least one post-baseline IDS-SR30. MAS scores were analysed as continuous and categorical variables ('dyadic discord' v. 'no dyadic discord' defined as an MAS score >2.36. Remission was defined as an IDS-SR30 of 14 at exit (equivalent to a 17-item Hamilton Rating Scale for Depression of 7).

RESULTS

Patients with dyadic discord at baseline had lower remission rates (34.1%) than those without dyadic discord (61.2%) (all three treatment groups) (chi2=12.6, df=1, p=0.0004). MAS scores improved significantly with each of the treatments, although the change was reduced by controlling for improvement in depression. Depression remission at exit was associated with less dyadic discord at exit than non-remission for all three groups [for total sample, 1.8 v. 2.4, t(169)=7.3, p<0.0001].

CONCLUSIONS

Dyadic discord in chronically depressed patients is predictive of a lower likelihood of remission of depression. Couple therapy for those with dyadic discord may increase remission rates.

Overperception of spousal criticism in dysphoria and marital discord

Depression and marital discord are related to feeling criticized by others, especially by spouses (e.g., Hooley, J. M., & Teasdale, J. D. 1989). This study evaluated the extent to which criticism was overperceived in relation to "actual" spousal critical comments, with actual critical comments being established by independent observers and by criticizing spouses themselves. Using dyadic interaction and questionnaire data from 72 married couples, signal detection and regression analyses suggested that both dysphoria and marital discord were associated with a general bias towards feeling criticized. Marital discord's association with criticality bias subsumed dysphoria's, but dysphoria's did not subsume marital discord's. Criticality bias also accounted for a significant proportion of perceived spousal criticism. A common cognitive process may underlie established associations among perceived criticism, dysphoria, and marital discord.

Generalized anxiety disorder and entry into marriage or a marriage-like relationship

Previous studies have suggested that individuals with generalized anxiety disorder report significantly higher levels of marital distress and are at a greater risk for divorce than those without generalized anxiety disorder. Studies also showed that relationship difficulties among those with generalized anxiety disorder predict poor treatment response and long-term outcome. In this study, the relation between a lifetime diagnosis of generalized anxiety disorder and marital history was examined with the data from the National Comorbidity Survey (NCS). Respondents were grouped into those who have no mental disorder, those who have only generalized anxiety disorder, and those who have generalized anxiety disorder and a lifetime history of at least one of the 16 DSM-III-R diagnoses assessed in the NCS. Generalized anxiety disorder was significantly associated with the likelihood of entry into a marriage-like relationship. The results support the continued investigation into the association between couple functioning and the onset, course, and treatment of generalized anxiety disorder, and suggest that couples intervention could be an untapped resource for generalized anxiety disorder treatment.

Treating emotion dysregulation in a couples context: a pilot study of a couples skills group intervention

This article reports the development of a couple-based intervention in which at least one partner had experienced chronic difficulties in emotion regulation, operationalized as having participated in a yearlong dialectical behavior therapy (DBT) skills training group. Integrating dialectical behavior therapy and cognitive-behavioral couple therapy, this group intervention taught couples emotion regulation, communication, and problem-solving skills, and led them through an exploration of how strong feelings affect and are affected by their relationship. The effects of treatment were evaluated in terms of relationship satisfaction and individual well-being. Sizeable treatment effects were found in several domains, including a reduction in DBT graduates' depressive symptoms and emotion dysregulation, and an increase in their partners' relationship satisfaction and confidence in their graduate spouses' ability to regulate emotions.

Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects

Relapse and recurrence following response to acute-phase treatment for major depressive disorder (MDD) are prevalent and costly. In a meta-analysis of 28 studies including 1,880 adults, the authors reviewed the world's published literature on cognitive-behavioral therapies (CT) aimed at preventing relapse-recurrence in MDD. Results indicate that after discontinuation of acute-phase treatment, many responders to CT relapse-recur (29% within 1 year and 54% within 2 years). These rates appear comparable to those associated with other depression-specific psychotherapies but lower than those associated with pharmacotherapy. Among acute-phase treatment responders, continuation-phase CT reduced relapse-recurrence compared with assessment only at the end of continuation treatment (21% reduction) and at follow-up (29% reduction). Continuation-phase CT also reduced relapse-recurrence compared with other active continuation treatments at the end of continuation treatment (12% reduction) and at follow-up (14% reduction). The authors discuss implications for research and patient care and suggest directions, with methodological refinements, for future studies.

Cognitive and behavioral therapies for depression: overview, new directions, and practical recommendations for dissemination

Cognitive-behavioral therapy (CBT) is a nonpharmacologic strategy for depression treatment that has received considerable empirical support. This article provides an overview of the history and core techniques of CBT and discusses recently developed techniques and augmentations to CBT for depression. It reviews empirical studies comparing the relative efficacy of CBT and antidepressant medication as well as their combination. Studies highlighting the relapse-prevention properties of CBT are reviewed also. The article concludes with a discussion of practical recommendations for integrating CBT into a depression treatment plan.

Impairment and distress associated with relationship discord in a national sample of married or cohabiting adults

The clinical importance of relationship discord was examined through evaluating the association between relationship discord and multiple measures of impairment and psychological distress in a population-based sample of married and cohabiting adults (N=2,677). In comparison to people that were not in discordant relationships, individuals in discordant relationships reported greater social role impairment with relatives and friends and greater work role impairment. They also reported higher levels of general distress and poorer perceived health and were more likely to report suicide ideation. With the exception of suicide ideation, the associations between relationship discord and impairment and psychological distress remained significant when controlling for current mood, anxiety, and substance use disorders, suggesting that relationship discord is incrementally related to impairment and psychological distress over and above the effects of psychiatric disorders.

Cognitive-behavioral depression treatment for mothers of children with attention-deficit/hyperactivity disorder

An adaptation of the Coping With Depression Course (CWDC) was evaluated in mothers of children with attention-deficit/hyperactivity disorder (ADHD), a population at risk for depression. Mothers were randomly assigned to receive the CWDC either immediately following an intensive summer treatment program targeting their child's behavior or after a wait-list period. Measures of maternal functioning, cognitions about child behavior, parent-child and marital relationship quality, child behavior, and ADHD-related family impairment were obtained at pretreatment, posttreatment, and 5-month follow-up. The CWDC resulted in improvements in maternal depressive symptoms, maternal self-esteem, child-related cognitions, and family impairment at posttreatment compared to a wait-list control group that were maintained at follow-up. Findings suggest that the CWDC is a promising intervention for mothers of children with ADHD, particularly those with current depressive symptomatology.

Methodologically sound, cost-effective research on the outcome of couple therapy

Because of its potential to answer pressing applied questions about what treatments to use with which couples as well as its potential to answer basic questions about couple functioning, outcome research on couple therapy is vital to the field. This article describes the primary methodological issues that an investigator faces in conducting outcome research during treatment development, efficacy testing, and effectiveness evaluation. Descriptions of what has been done in the past are integrated with recommendations about what should be done in the future. Mindful of the potential expense of outcome research, the authors suggest ways in which questions can be investigated cost effectively.

Alcohol-focused spouse involvement and behavioral couples therapy: evaluation of enhancements to drinking reduction treatment for male problem drinkers

This study evaluated the effects of alcohol-focused spouse involvement and behavioral couples therapy (BCT) in group drinking reduction treatment for male problem drinkers. Sixty-four male clients and their female partners were randomly assigned to 1 of 3 conditions: treatment for problem drinkers only (PDO), couples alcohol-focused treatment, or the latter combined with BCT. Clients whose partners were included in treatment evidenced fewer heavy drinking days and more abstinent/light drinking days in the year following treatment, relative to PDO clients. The combination of alcohol-focused spouse involvement and BCT yielded no better outcomes than alcohol-focused spouse involvement alone. Drinking consequences, spouse behavioral support for drinking reduction, and relationship satisfaction showed no effects of treatment condition.

Effects of Behavioral Marital Therapy: A Meta-Analysis of Randomized Controlled Trials

This meta-analysis summarizes results from 30 randomized experiments that compare behavioral marital therapy with no-treatment control with distressed couples. Results showed that behavioral marital therapy is significantly more effective than no treatment (d=.585). Although behavioral marital therapy research studies tend to be conducted under conditions that are less clinically representative than other samples of studies, representativeness was not significantly related to outcome. However, evidence also suggested that publication bias may exist in this literature whereby small sample studies with small effects are systematically missing compared with other studies. This bias may inflate the effects of behavioral marital therapies reported in previous meta-analyses, though we also explore a number of alternative explanations for this small sample bias.

Relations of husbands and wives dysphoria to marital conflict resolution strategies

This study investigated relations between spouses' dysphoria and constructive and destructive emotions and tactics displayed by husbands and wives throughout marital conflicts. Behavioral observations were made of 267 couples' interactions during marital conflict resolution tasks. Husbands' and wives' dysphoria levels were related to particular negative marital conflict expressions and the absence of positive strategies, even after taking into account couples' marital satisfaction and their partners' levels of dysphoria. Moreover, in comparison with wives' dysphoria, husbands' dysphoria was associated with more pervasive impairments in couples" conflict strategies evident in multiple contexts of conflict resolution, including discussion of relatively minor sources of disagreement. Implications for the treatment of depressed or maritally discordant couples are discussed.

The effects of life events and social relationships on the course of major depression

Concern about the accuracy of risk factor and mental status assessments argues for the need for more experimental research design studies on social factors in the course of depression. Gender and the history of disorder may need to be taken into account in examining the effects of adversity, interpersonal relationships, and social support on the future course of depression. This insight may be particularly critical in relation to intervention studies in which the group targeted may determine the potential for effectiveness so that negative results are not wrongly generalized to wider populations that could potentially benefit if studied. Interventions to improve mental health by providing social support have generally failed to show the enduring benefits suggested by observational studies. However, interventions that modify interpersonal functioning, which may improve the way persons perceive and value support from others, appear more promising.

Implementing evidence-based practices for people with severe mental illness

Persons with severe mental illnesses (SMI) often lack access to effective treatments. The authors describe the Implementing Evidence-Based Practices (EBPs) Project, designed to increase access for people with SMI to empirically supported interventions. The EBP Project aims to improve access through development of standardized implementation packages, created in collaboration with different stakeholders, including clinicians, consumers, family members, clinical supervisors, program leaders, and mental health authorities. The background and philosophy of the EBP Project are described, including the six EBPs identified for initial package development: collaborative psychopharmacology, assertive community treatment, family psychoeducation, supported employment, illness management and recovery skills, and integrated dual disorders treatment. The components of the implementation packages are described as well as the planned phases of the project. Improving access to EBPs for consumers with SMI may enhance outcomes in a cost-effective manner, helping them pursue their personal recovery goals with the support of professionals, family, and friends.

Antecedents and consequences of negative marital stressors

Many couples seeking therapy report the occurrence of severe, negative marital stressors (e.g., infidelity, threats of marital dissolution). In addition, existing research has demonstrated that these marital stressors precipitate Major Depressive Episodes and psychological symptoms. This longitudinal study examines the antecedents and consequences of negative marital stressors to help clinicians and researchers develop interventions that might prevent these stressors and their outcomes. Forty-one women completed a semistructured interview and measures of marital discord and depressive symptoms within one month after experiencing a marital stressor (baseline) and at a 16-month follow up. The results indicate that baseline marital discorded contributes to the occurrence of additional marital stressors during the follow-up period. Although baseline depressive symptoms do not predict additional marital stressors, depressive symptoms along with marital discord predict future depressive symptoms. Finally, baseline marital discord and additional marital stressors contribute to future marital dissolution. Clinical and research implications are discussed.

Marital quality, coping with conflict, marital complaints, and affection in couples with a depressed wife

This study compared three groups of women--outpatient depressed, inpatient depressed, and community control--and their husbands on a range of variables including marital functioning and styles of coping with conflict. Outpatient depressed couples reported greater marital distress and more destructive and less constructive tactics for resolving conflict than did community control couples. They also were more likely to have been previously married and to express regrets about having married their current husbands. There were smaller and less consistent differences for couples with inpatient depressed spouses, although inpatient couples with younger wives were similar to outpatient depressed couples. Both groups of depressed women and their husbands reported fewer expressions of affection and more complaints about the marriage than did control couples. Results are discussed in terms of interpersonal perspectives on depression.

Untreated short-term course of major depression: a meta-analysis of outcomes from studies using wait-list control groups

INTRODUCTION

While the short-term response rates to antidepressant medication and placebo are well established, very little is known about the short-term course of untreated depression. Knowledge of the course of untreated depression can serve as a benchmark for assessing the true benefits of active treatment.

METHOD

A meta-analysis was performed analyzing the outcomes of all psychotherapy studies that randomized adult outpatients with major depressive disorder to a wait-list control group.

RESULTS

Nineteen studies involving 221 subjects were reviewed. The mean decrease in Hamilton Rating Scale for Depression scores over 2-20 weeks was 11.9%, while the mean decrease in Beck Depression Inventory scores was 15.7%. Using a subsample of studies that reported individual outcomes, we estimated that 15 of 76 subjects (19.7%) improved to a degree comparable to what would be considered a positive response in antidepressant trials.

CONCLUSIONS

In the short-term, depressive symptomatology can be expected to decrease by about 10-15% on average without treatment. As many as 20% of subjects who participate in a short-term antidepressant trial may experience a spontaneous remission.

The London Depression Intervention Trial. Randomised controlled trial of antidepressants v. couple therapy in the treatment and maintenance of people with depression living with a partner: clinical outcome and costs

BACKGROUND

Relapse of depression is associated with a criticising attitude of the patient's partner.

AIMS

To compare the relative efficacy and cost of couple therapy and antidepressant drugs for the treatment and maintenance of people with depression living with a critical partner.

METHOD

A randomised controlled trial of antidepressant drugs v. couple therapy. The subjects were 77 people meeting criteria for depression living with a critical partner.

RESULTS

Drop-outs were 56.8% [corrected] from drug treatment and 15% from couple therapy. Subjects' depression improved in both groups, but couple therapy showed a significant advantage, according to the Beck Depression Inventory, both at the end of treatment and after a second year off treatment. Adding the costs of the interventions to the costs of services used showed there was no appreciable difference between the two treatments.

CONCLUSIONS

For this group couple therapy is much more acceptable than antidepressant drugs and is at least as efficacious, if not more so, both in the treatment and maintenance phases. It is no more expensive overall.

Marital Satisfaction and Pain Severity Mediate the Association between Negative Spouse Responses to Pain and Depressive Symptoms in a Chronic Pain Patient Sample

OBJECTIVE

The current study investigated marital satisfaction and pain severity as mediators of the relationship between spouse responses to pain and depressive symptoms. The study also investigated possible gender differences in these relationships.

PATIENTS AND SETTING

This study included 165 married patients with chronic pain who were evaluated and treated at a comprehensive pain and rehabilitation center.

DESIGN

Patients completed several questionnaires, including the West Haven-Yale Multidimensional Pain Inventory, Beck Depression Inventory, and the Marital Adjustment Test.

RESULTS

Analyses were conducted separately for male and female patients. Correlational analyses revealed several gender differences in the associations among marital functioning, pain severity, and depressive symptoms. In addition, path analyses suggested that more frequent negative spouse responses to pain were associated with increased pain severity and decreased marital satisfaction, which were linked to increased depressive symptoms. Similar results were found for male and female chronic pain patients in terms of multivariate relationships.

CONCLUSIONS

The current results suggest that marital therapy aimed at improving communication and coping skills may be an appropriate treatment for depression and pain in married chronic pain patients, regardless of sex.