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.

Avoidance may be bad for the heart: a comparison of dyadic initiator tendency in cardiac rehabilitation patients and matched controls.

The psychophysiologic model of marital distress proposes that demand/withdraw dyadic communication activates cardiovascular reactivity in the withdrawing partner, which eventually leads to cardiac illness. Thirty-one patients (23 men and 8 women) in a cardiac rehabilitation program were matched to community controls. Participants completed the Initiator Style Questionnaire, a measure of a person's tendency to initiate relationship problem discussions. As hypothesized, cardiac rehabilitation patients (M = 42.53, 95% CI 37.6-47.5) reported being less likely to initiate relationship problem discussions than did community controls (M = 60.79, 95% CI 54.7-66.8). Consistent with the model, cardiac patients rated themselves as less initiating (M = 39.12, 95% CI 32.96-45.28) than they rated their partners (M = 45.94, 95% CI 38.98-52.90); in contrast, matched controls rated themselves as more initiating (M = 63.04, 95% CI 57.36-68.70) than they rated their partners (M = 58.54, 95% CI 42.98-67.78). Further analysis found that female patients accounted for this finding. The results add further support for the psychophysiologic model.

Cortisol suppression index: a further evaluation.

The cortisol suppression index (CSI) is the ratio of pre- to postdexamethasone plasma cortisol concentrations. The 8 a.m. CSI was previously found to identify 66% of a sample of psychiatric inpatients with major depression. In the present study, a 4 p.m. CSI identified 71% of psychiatric inpatients with major depression, in contrast to 53% when using DST criteria alone. This finding adds further validation to the CSI. Further studies of the utility of the CSI are suggested to help improve the detection of major depression.

Dsm-iii-R and the family therapist: ethical considerations.

DSM-III-R has gained popularity in many segments of the mental health field. Family therapists have generally not found its approach to assessing problems to be helpful in the planning of therapy, yet, are often forced to use it due to the requirements of third-party payers. This raises several ethical and practical concerns, e.g., the incompatibility of orientations between DSM-III-R and family therapy, the stigma associated with diagnosing, being asked to misrepresent diagnoses to third-party payers, and the competency of some family therapists to make DSM-III-R diagnoses. Short- and long-term strategies to deal with these ethical dilemmas are also presented.

Use of the DSM in marriage and family therapy programs: current practices and attitudes.

The DSM has largely become the common language of behavioral health which its authors intended. Although family systems theory resulted in part from the study of major mental illness, it later became distanced from considerations of individual psychopathology. No studies have assessed current practices and views within the field of family therapy on teaching students the use of the DSM. Member training programs of the Education and Training Council of the American Association for Marriage and Family Therapy were surveyed regarding their practices in teaching the DSM. Seventy-nine of 177 surveys (45%) were returned. Ninety-one percent of these programs offered training in the DSM, and in 93% of those such training was mandatory. Written comments indicated that pragmatic concerns about students being able to speak a common language with other behavioral health providers were among the primary reasons for teaching the DSM.

The role of marital status in health services expenditures for psychiatric outpatients.

This study tested the hypothesis that married psychiatric outpatients would have lower total health services expenditures than divorced or separated patients. Chart review of the 471 individuals attending an academic medical center outpatient psychiatric clinic during 1994 identified 131 married, 40 separated, and 93 divorced patients. Separated men had significantly higher average total charges ($16,890) than married ($5,279) or divorced ($5,539) men by one-way ANOVA (p < .05). The nonparametric Mann-Whitney test also showed that separated men had higher charges than married or divorced men. There were no differences between marital status groups for women.

A randomized trial of emotion-focused therapy for couples in a training clinic.

Forty married couples participated in a randomized trial comparing 8 weekly sessions of emotion-focused therapy (EFT) for couples to a group of couples who were placed on an 8-week waiting list. A composite marital satisfaction score was created from scores on the Dyadic Adjustment Scale, Positive Feelings Questionnaire, and Personal Assessment of Intimacy in Relationships scale. Controlling for pretest scores, participants in the treatment group had significantly higher levels of marital satisfaction after 8 weeks than wait-list participants. Supplementary analyses identified variables associated with gains in therapy and with dropping out of the study.

Association of interpersonal cognitive complexity with communication skill in marriage: moderating effects of marital distress.

Little research has examined the influence of social cognition on communicative behaviors that spouses exhibit in conversational interactions. The present study examined the associations between interpersonal cognitive complexity and three marital communication skills: communication effectiveness (generating messages that have the desired outcome), predictive accuracy (anticipating accurately the effects of a message on a receiver), and perceptual accuracy (correctly inferring the intent of a message source). The study also evaluated whether marital distress moderated associations between cognitive complexity and communication skills. Participants (60 couples) discussed a problem from their own marriage and a vignette from the Inventory of Marital Conflicts (Olson & Ryder, 1970) using the communication box. Cognitive complexity was moderately associated with perceptual accuracy, weakly associated with communication effectiveness, and not associated with predictive accuracy. Subsidiary analyses revealed that associations between cognitive complexity and the communication skills were generally stronger in the subsample of distressed couples than in the subsample of nondistressed couples.

Cardiovascular reactivity and initiate/avoid patterns of marital communication: a test of Gottman's psychophysiologic model of marital interaction.

Gottman's (1990, 1991; Gottman and Levenson, 1988) psychophysiologic model of marital interaction was tested in 60 married couples. Participants were classified as avoiders or initiators of relationship problem discussions by trained coders observing videotaped semistructured interviews. Blood pressure (BP) and heart rate reactivity was assessed during the cold pressor test, during a mental math test, while watching a marital argument on video, and during a conjoint interview. As hypothesized, avoiders had significantly greater systolic BP reactivity during the interview. Additionally, husbands who interacted with avoider wives had significantly greater diastolic and systolic BP reactivity than did husbands of initiator wives. Initiator husbands, in particular, who were married to avoider wives had greater systolic BP reactivity. These results both support Gottman's psychophysiologic model and suggest modifications of it.