Marital therapy for depression
Abstract
Background
Marital therapy for depression has the two‐fold aim of modifying negative interaction patterns and increasing mutually supportive aspects of couple relationships, thus changing the interpersonal context linked to depression.
Objectives
1. To conduct a meta‐analysis of all intervention studies comparing marital therapy to other psychosocial and pharmacological treatments, or to non‐active treatments.
2. To conduct an assessment of the internal validity and external validity.
3. To assess the overall effectiveness of marital therapy as a treatment for depression.
4. To identify mediating variables through which marital therapy is effective in depression treatment.
Search methods
CCDANCTR‐Studies was searched on 5‐9‐2005, Relevant journals and reference lists were checked.
Selection criteria
Randomised controlled trials examining the effectiveness of marital therapy versus individual psychotherapy, drug therapy or waiting list/no treatment/minimal treatment for depression were included in the review. Quasi‐randomised controlled trials were also included.
Data collection and analysis
Data were extracted using a standardised spreadsheet. Where data were not included in published papers, two attempts were made to obtain the data from the authors. Data were synthesised using Review Manager software. Dichotomous data were pooled using the relative risk (RR), and continuous data were pooled using the standardised mean difference (SMD), and 95% confidence intervals (CIs) were calculated. The random effects model was employed for all comparisons. A formal test for heterogeneity, the natural approximate chi‐squared test, was also calculated.
Main results
Eight studies were included in the review. No significant difference in effect was found between marital therapy and individual psychotherapy, either for the continuous outcome of depressive symptoms, based on six studies: SMD ‐0.12 (95% CI ‐0.56 to 0.32), or the dichotomous outcome of proportion of subjects remaining at caseness level, based on three studies: RR 0.84 (95% CI 0.32 to 2.22). In comparison with drug therapy, a lower drop‐out rate was found for marital therapy: RR 0.31 (95% CI 0.15 to 0.61), but this result was greatly influenced by a single study. The comparison with no/minimal treatment, showed a large significant effect in favour of marital therapy for depressive symptoms, based on two studies: SMD ‐1.28 (95% CI ‐1.85 to ‐0.72) and a smaller significant effect for persistence of depression, based on one study only. The findings were weakened by methodological problems affecting most studies, such as the small number of cases available for analysis in almost all comparisons, and the significant heterogeneity among studies.
Authors' conclusions
There is no evidence to suggest that marital therapy is more or less effective than individual psychotherapy or drug therapy in the treatment of depression. Improvement of relations in distressed couples might be expected from marital therapy. Future trials should test whether marital therapy is superior to other interventions for distressed couples with a depressed partner, especially considering the role of potential effect moderators in the improvement of depression.
PICOs
Plain language summary
Marital therapy for depression
Marital therapy has been suggested as a treatment for couples with a depressed spouse on the basis of the strong association between depressive symptoms and marital distress; the role played by marital negative factors on onset and maintenance of depressive disorders; and the possible buffering effect of interpersonal support and enhanced intimacy on depressive symptoms. Therefore, marital therapy has the two‐fold aim of modifying negative interactional patterns and increasing mutually supportive aspects of couple relationships. This review aimed to provide an overall assessment of the role of marital therapy among psychological treatments for depression. The meta‐analysis showed that there was no evidence to consider marital therapy as more or less effective than individual psychotherapy, either reducing depressive symptoms or the proportion of participants who remained depressed at caseness level (persistence of depression). The absence of a significant difference also held true when only distressed couples were included. However, in comparison to no/minimal treatment, the outcome for depressive symptoms and persistence of depression was better in the marital therapy group. There were no significant differences in the number of dropouts between the marital therapy group than in the individual psychotherapy group, this was also true when only distressed couples were analysed. Marital distress was significantly lower and persistence of marital distress significantly less frequent in the marital therapy group than in the individual treatment group. This effect was enhanced when distressed couples were considered separately. In comparison with drug therapy only data from two studies about dropout rates were available, showing significant relative risk in favour of marital therapy. All the results should be regarded in light of the methodological limitations of the studies, which, in general, are affected by small sample sizes; assessments at the end of treatment or short follow‐up; unclear sample representation; and loss of patients at follow‐up. The mediating role of other variables, such as improvement in marital satisfaction, could not be adequately tested. Although there is no evidence to consider marital therapy as more or less effective than individual psychotherapy or drug therapy for depression, the evidence for improvement in couple relationships due to marital therapy may favour the choice of marital therapy when marital distress is perceived as a major problem. Otherwise, the choice rests on patient preference and availability of specific resources.
