Marital
Therapy:
for Depression
A Viable
Treatment
and Marital
Discord
K. Daniel O’Leary, Ph.D.,
Thirty-six maritally discordant couples with depressed wives were randomly assigned to marital thenapy, cognitive therapy, or a waiting-list control condition. The women given marital or cognitive therapy showed significant and clinically meaningful reductions in their depression. The women given marital therapy showed greater increases in marital satisfaction than did those given cognitive therapy or no thenapy; these differences were maintained at 1-year follow-up. These findings suggest that marital therapy may be the most effective and appropriate treatment for clinically significant marital discord with coexisting clinically significant depression. (Am J Psychiatry 1990; 147:183-186)
M
arital discord is the most common life stressom that is a precursor to depression (1). Relapses of depression following acute depressive episodes and following pharmacological treatment of depression are often precipitated by marital disruption (2, 3). Given the association between depression and marital discord, and given the fact that in more than 50% of maritally discordant couples at least one spouse is depressed (4), we compared two well-developed treatments-behavioral marital therapy (5, 6) and cognitive behavioral
therapy
(7-9)-in
the
treatment
of
such
couples. In a pilot study with eight women who were depressed and whose marriages were discordant, behaviomal marital therapy led to a reduction in both depression and marital discord, whereas cognitive therapy for the women was associated only with a significant reduction
vides
in depression
a more
complete
(10).
The
comparison
present
study
of the clinical
pro-
effi-
Received Sept. 8, 1988; revisions received May ii and July 25, 1989; accepted Aug. 11, 1989. From the State University of New York at Stony Brook. Address reprint requests to Dr. O’Leary, State University of New York, Stony Brook, NY 11794-2500. Supported in part by NIMH grant MH-38390.
The authors thank Dr. Evelyn Sandeen, one of the therapists, who coordinated the second half of this project following Dr. Beach’s move to Georgia; the other therapists, A. Cantos and C. Newman; Jean Malone, who conducted the data analyses; and Dr. D.N. Klein, who commented on an earlier version of the manuscript. Copyright
Am
J
C 1990
Psychiatry
American
147:2,
Psychiatric
February
Association.
1990
and
Steven
cacy apy
R.H.
of behavioral in reducing
Beach,
Ph.D.
marital therapy depression and
and cognitive themincreasing marital
satisfaction.
Behavioral marital therapy for depression places emphasis on increasing feelings of closeness, open sharing of thoughts and concerns, positive interchanges, and effective problem-solving strategies for resolving manital
disputes.
Cognitive
behavioral
therapy
places
em-
phasis world,
on increasing positive beliefs about the self, the and the future and on decreasing negative cog-
nitive
distortions
and
selective
memories
for
negative
events.
METHOD As part of an ongoing treatment outcome study, 36 couples were randomly assigned to individual cognitive therapy for the depressed wife (N= 12), conjoint marital therapy for the depressed wife and her spouse (12 couples), or a 15-week waiting list (12 couples). Subjects were recruited by means of announcements in newspapers for a depression-marital therapy treatment program. All subjects provided informed consent to participation in the study after its nature had been explained to them. Both behavioral marital therapy and cognitive thenapy lasted for 15-16 weeks. The couples in behavioral marital therapy and the women in cognitive therapy were seen on a weekly basis. The therapy protocol allowed for up to 2 hours of emergency phone consultation for the 16 weeks if such help were needed. To be included in the study, the women had to meet DSM-III diagnostic criteria for major depression or dysthymic disorder. Ten women in individual cognitive therapy, 1 1 women in marital therapy, and 11 women in the waiting-list control group were diagnosed as having major depression, single episode. Two women in individual therapy, one woman in marital therapy, and one woman in the control group did not meet criteria for major depression and were diagnosed as having dysthymic disorder. All of the women were interviewed with the Structured Clinical Interview for DSM-III (SCID) (1 1), a standard diagnostic interview. Approximately half of the women in each of the three groups received a second diagnosis in addition to de-
183
MARITAL
THERAPY
pression. The women had to have a Beck Depression Inventory scone of 14 or more (12, 13). Women who were actively suicidal were not included in the main portion of this study because they could not be randomly assigned to the waiting-list control condition (unpublished 1987 paper of K.D. O’Leary et al.). One on both partners in the marriage had to have a score of 100 on less (significantly maritally discordant) on the Dyadic Adjustment Scale (14). Subjects also had to describe themselves as maritally discordant on as having substantial marital problems during the marital interview. Three couples in the marital therapy group and three women in the individual therapy group dropped out of treatment before five sessions. Their data are not included here. No subjects were receiving medication for depression. The average age ofthe women was 39.3 years (range= 28-59). The average number of children per family was 2.5 (range=0-7), and the average educational level of the women was 13.9 years (range=9-21). Three therapists provided both cognitive therapy and marital
level
therapy.
psychologists
student
in
clinical
Two
and
of the
one
psychology.
therapists
was
were
a fifth-year All
doctoral
graduate
therapists
had
at
least 4 years of full-time graduate training in clinical psychology in a program nationally recognized for training in behavior therapy. All therapists had panticipated in a one-semester behavioral marital therapy seminar and an associated year-long practicum. They had also participated in a year-long intervention course and associated year-long practicum emphasizing cognitive behavior therapy. In preparation for this clinical research, the therapists were trained for 30 hours in each of the two treatments by nationally necognized experts before seeing patients (cognitive thenapy: Dr. Craighead, Duke University, and Dr. Epstein, University of Maryland; marital therapy: Dr. Baucom, University of North Carolina, and Dr. O’Leary, State University of New York, Stony Brook). Before any of the patients were seen, the therapists had to be judged by the experts as competent service providers of the two therapies. In addition, the recognized experts provided periodic clinical supervision to the therapists.
RESULTS
Both behavioral marital therapy and cognitive mdividual therapy were effective in reducing depressive symptoms in the women given these therapies (figure 1). The Beck Depression Inventory scones for the 24 subjects
in these
groups
went
from
the
moderately
de-
pressed mange (mean=25; mange=14-.38) to the nondepressed range (mean=9; range=0-23). Three-quantens of the women experienced changes that led them to report Beck scores less than 14 after therapy. There was a significant difference in the women’s depression scores after treatment across the three groups (F6.46, df=2, 33, p=O.0O4), and the women in both the marital therapy group (F=11.67, df=1, 21, p=O.Ol7) and
184
in Depression Scores in Women Cognitive Therapy and Women
FIGURE 1. Changes
Therapy or Individual List Control
Given Marital in a Waiting-
Group
0 I p F
I 0
n n V S
30
/Z
25
20 15 10
n t 0 F
5
/
y
#{182}7
-
Follow-up
Post-ThSrspy
PrS-Th.Fapy
Marital
(N#{149}12)
IndiVidual (N#{149}12)
EJ wait
List
(P4.12)
the individual therapy group (F=S.23, df= 1, 21, p=0.O32) had significantly lower depression scores than the women in the waiting-list control group. The depression scores of the women in marital therapy and in individual therapy did not differ significantly from each other after therapy (F=1.23, df=1, 22, p= 0.278). Analyses of variance (ANOVAs) indicated that there were significant differences in marital satisfaction across the three groups after treatment (F=S.13, df=2, 33, p=O.Ol2). The women given marital therapy had significantly higher marital satisfaction scores after therapy than did the women given cognitive therapy (F=8.65, df=1, 22, p=O.0O8) and the women in the waiting-list control group (F=7.65, df=1, 22, p=0.Oll). However, the marital satisfaction scores of the women in individual therapy did not differ from those of the women in the waiting-list control group (F=0.42, df= 1, 22, p=O.526). Despite some numerical differences on the Dyadic Adjustment Scale and the Beck Depression Inventory, the three groups of women did not differ significantly on these measures before treatment. Furthermore, an analysis of covamiance, controlling for pretreatment differences, yielded the same results pre- to posttreatment for both the Dyadic Adjustment Scale and the Beck Depression Inventory. ANOVAs indicated that the women given marital therapy did not have lower depression scores at follow-up than the women given cognitive therapy (F=1.84, df=1, 22, p=O.l88). However, as shown in figure 2, the marital therapy patients had significantly higher marital satisfaction scores at follow-up (F= 5.41, df=1, 22, p=0.03O). Within-group correlations of Beck Depression Inventory scones before and after treatment showed that an initially higher level of depression did not significantly predict higher scores after treatment for either therapeutic modality (r= -0.28, N= 12, n.s., for cognitive therapy and r=0.26, N=12, n.s., for behavioral
Am
J
Psychiatry
147:2,
February
1990
K. DANIEL
O’LEARY
AND
in Marital Satisfaction Scores in Women Given Therapy or Individual Cognitive Therapy and Women in a Waiting-List Control Group
The correlations of Beck scores before and after treatment
0
related to outcome in this sample ately depressed women. However,
FIGURE 2. Changes Marital
y
a
tial
level
of severity
d
ity of marital
C
come: only those showed consistent
A d
faction.
U 5
prove
m
penencing
S
expect marital women
n t
S C
initial Post-Therapy
PFS-TheFapy
S
-
Marital
(N12)
marital
therapy).
Follow-up
Individual (P4-12)
However,
EJ
Wait
List
(N12)
in
the
absence
of
treat-
ment, there was a significant association between Beck Depression Inventory scores before and after treatment (m=0.S2, N= 12, p
Therapy:
for Depression
A Viable
Treatment
and Marital
Discord
K. Daniel O’Leary, Ph.D.,
Thirty-six maritally discordant couples with depressed wives were randomly assigned to marital thenapy, cognitive therapy, or a waiting-list control condition. The women given marital or cognitive therapy showed significant and clinically meaningful reductions in their depression. The women given marital therapy showed greater increases in marital satisfaction than did those given cognitive therapy or no thenapy; these differences were maintained at 1-year follow-up. These findings suggest that marital therapy may be the most effective and appropriate treatment for clinically significant marital discord with coexisting clinically significant depression. (Am J Psychiatry 1990; 147:183-186)
M
arital discord is the most common life stressom that is a precursor to depression (1). Relapses of depression following acute depressive episodes and following pharmacological treatment of depression are often precipitated by marital disruption (2, 3). Given the association between depression and marital discord, and given the fact that in more than 50% of maritally discordant couples at least one spouse is depressed (4), we compared two well-developed treatments-behavioral marital therapy (5, 6) and cognitive behavioral
therapy
(7-9)-in
the
treatment
of
such
couples. In a pilot study with eight women who were depressed and whose marriages were discordant, behaviomal marital therapy led to a reduction in both depression and marital discord, whereas cognitive therapy for the women was associated only with a significant reduction
vides
in depression
a more
complete
(10).
The
comparison
present
study
of the clinical
pro-
effi-
Received Sept. 8, 1988; revisions received May ii and July 25, 1989; accepted Aug. 11, 1989. From the State University of New York at Stony Brook. Address reprint requests to Dr. O’Leary, State University of New York, Stony Brook, NY 11794-2500. Supported in part by NIMH grant MH-38390.
The authors thank Dr. Evelyn Sandeen, one of the therapists, who coordinated the second half of this project following Dr. Beach’s move to Georgia; the other therapists, A. Cantos and C. Newman; Jean Malone, who conducted the data analyses; and Dr. D.N. Klein, who commented on an earlier version of the manuscript. Copyright
Am
J
C 1990
Psychiatry
American
147:2,
Psychiatric
February
Association.
1990
and
Steven
cacy apy
R.H.
of behavioral in reducing
Beach,
Ph.D.
marital therapy depression and
and cognitive themincreasing marital
satisfaction.
Behavioral marital therapy for depression places emphasis on increasing feelings of closeness, open sharing of thoughts and concerns, positive interchanges, and effective problem-solving strategies for resolving manital
disputes.
Cognitive
behavioral
therapy
places
em-
phasis world,
on increasing positive beliefs about the self, the and the future and on decreasing negative cog-
nitive
distortions
and
selective
memories
for
negative
events.
METHOD As part of an ongoing treatment outcome study, 36 couples were randomly assigned to individual cognitive therapy for the depressed wife (N= 12), conjoint marital therapy for the depressed wife and her spouse (12 couples), or a 15-week waiting list (12 couples). Subjects were recruited by means of announcements in newspapers for a depression-marital therapy treatment program. All subjects provided informed consent to participation in the study after its nature had been explained to them. Both behavioral marital therapy and cognitive thenapy lasted for 15-16 weeks. The couples in behavioral marital therapy and the women in cognitive therapy were seen on a weekly basis. The therapy protocol allowed for up to 2 hours of emergency phone consultation for the 16 weeks if such help were needed. To be included in the study, the women had to meet DSM-III diagnostic criteria for major depression or dysthymic disorder. Ten women in individual cognitive therapy, 1 1 women in marital therapy, and 11 women in the waiting-list control group were diagnosed as having major depression, single episode. Two women in individual therapy, one woman in marital therapy, and one woman in the control group did not meet criteria for major depression and were diagnosed as having dysthymic disorder. All of the women were interviewed with the Structured Clinical Interview for DSM-III (SCID) (1 1), a standard diagnostic interview. Approximately half of the women in each of the three groups received a second diagnosis in addition to de-
183
MARITAL
THERAPY
pression. The women had to have a Beck Depression Inventory scone of 14 or more (12, 13). Women who were actively suicidal were not included in the main portion of this study because they could not be randomly assigned to the waiting-list control condition (unpublished 1987 paper of K.D. O’Leary et al.). One on both partners in the marriage had to have a score of 100 on less (significantly maritally discordant) on the Dyadic Adjustment Scale (14). Subjects also had to describe themselves as maritally discordant on as having substantial marital problems during the marital interview. Three couples in the marital therapy group and three women in the individual therapy group dropped out of treatment before five sessions. Their data are not included here. No subjects were receiving medication for depression. The average age ofthe women was 39.3 years (range= 28-59). The average number of children per family was 2.5 (range=0-7), and the average educational level of the women was 13.9 years (range=9-21). Three therapists provided both cognitive therapy and marital
level
therapy.
psychologists
student
in
clinical
Two
and
of the
one
psychology.
therapists
was
were
a fifth-year All
doctoral
graduate
therapists
had
at
least 4 years of full-time graduate training in clinical psychology in a program nationally recognized for training in behavior therapy. All therapists had panticipated in a one-semester behavioral marital therapy seminar and an associated year-long practicum. They had also participated in a year-long intervention course and associated year-long practicum emphasizing cognitive behavior therapy. In preparation for this clinical research, the therapists were trained for 30 hours in each of the two treatments by nationally necognized experts before seeing patients (cognitive thenapy: Dr. Craighead, Duke University, and Dr. Epstein, University of Maryland; marital therapy: Dr. Baucom, University of North Carolina, and Dr. O’Leary, State University of New York, Stony Brook). Before any of the patients were seen, the therapists had to be judged by the experts as competent service providers of the two therapies. In addition, the recognized experts provided periodic clinical supervision to the therapists.
RESULTS
Both behavioral marital therapy and cognitive mdividual therapy were effective in reducing depressive symptoms in the women given these therapies (figure 1). The Beck Depression Inventory scones for the 24 subjects
in these
groups
went
from
the
moderately
de-
pressed mange (mean=25; mange=14-.38) to the nondepressed range (mean=9; range=0-23). Three-quantens of the women experienced changes that led them to report Beck scores less than 14 after therapy. There was a significant difference in the women’s depression scores after treatment across the three groups (F6.46, df=2, 33, p=O.0O4), and the women in both the marital therapy group (F=11.67, df=1, 21, p=O.Ol7) and
184
in Depression Scores in Women Cognitive Therapy and Women
FIGURE 1. Changes
Therapy or Individual List Control
Given Marital in a Waiting-
Group
0 I p F
I 0
n n V S
30
/Z
25
20 15 10
n t 0 F
5
/
y
#{182}7
-
Follow-up
Post-ThSrspy
PrS-Th.Fapy
Marital
(N#{149}12)
IndiVidual (N#{149}12)
EJ wait
List
(P4.12)
the individual therapy group (F=S.23, df= 1, 21, p=0.O32) had significantly lower depression scores than the women in the waiting-list control group. The depression scores of the women in marital therapy and in individual therapy did not differ significantly from each other after therapy (F=1.23, df=1, 22, p= 0.278). Analyses of variance (ANOVAs) indicated that there were significant differences in marital satisfaction across the three groups after treatment (F=S.13, df=2, 33, p=O.Ol2). The women given marital therapy had significantly higher marital satisfaction scores after therapy than did the women given cognitive therapy (F=8.65, df=1, 22, p=O.0O8) and the women in the waiting-list control group (F=7.65, df=1, 22, p=0.Oll). However, the marital satisfaction scores of the women in individual therapy did not differ from those of the women in the waiting-list control group (F=0.42, df= 1, 22, p=O.526). Despite some numerical differences on the Dyadic Adjustment Scale and the Beck Depression Inventory, the three groups of women did not differ significantly on these measures before treatment. Furthermore, an analysis of covamiance, controlling for pretreatment differences, yielded the same results pre- to posttreatment for both the Dyadic Adjustment Scale and the Beck Depression Inventory. ANOVAs indicated that the women given marital therapy did not have lower depression scores at follow-up than the women given cognitive therapy (F=1.84, df=1, 22, p=O.l88). However, as shown in figure 2, the marital therapy patients had significantly higher marital satisfaction scores at follow-up (F= 5.41, df=1, 22, p=0.03O). Within-group correlations of Beck Depression Inventory scones before and after treatment showed that an initially higher level of depression did not significantly predict higher scores after treatment for either therapeutic modality (r= -0.28, N= 12, n.s., for cognitive therapy and r=0.26, N=12, n.s., for behavioral
Am
J
Psychiatry
147:2,
February
1990
K. DANIEL
O’LEARY
AND
in Marital Satisfaction Scores in Women Given Therapy or Individual Cognitive Therapy and Women in a Waiting-List Control Group
The correlations of Beck scores before and after treatment
0
related to outcome in this sample ately depressed women. However,
FIGURE 2. Changes Marital
y
a
tial
level
of severity
d
ity of marital
C
come: only those showed consistent
A d
faction.
U 5
prove
m
penencing
S
expect marital women
n t
S C
initial Post-Therapy
PFS-TheFapy
S
-
Marital
(N12)
marital
therapy).
Follow-up
Individual (P4-12)
However,
EJ
Wait
List
(N12)
in
the
absence
of
treat-
ment, there was a significant association between Beck Depression Inventory scores before and after treatment (m=0.S2, N= 12, p
