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Systemic Family and Couple Therapy for Mood Disorders

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Systemic family and couple therapy for mood disorders
Behaviourally-inspired couple therapy approaches have been used for some time and have proved to be effective with patients suffering from depression. A number of RCTs of marital therapy as a treatment for depression have been conducted (e.g. O'Leary & Beach, 1990; Jacobson et al, 1991; Emanuels-Zuurveen & Emmelkamp, 1996; Baucom et al, 1998). Interpersonal systems therapy (Gottlieb & Colby, 1987) and conjoint interpersonal therapy (Klerman et al, 1984) have also been shown to be effective with couples when one of the partners has depression. At the more severe end of the spectrum, family interventions, in addition to ongoing traditional treatments, have been found to significantly reduce relapse rates of patients suffering from bipolar disorder (Miklowitz & Goldstein, 1990), confirming similar findings by Clarkin et al (1990). A recent RCT (Leff et al, 2000) has confirmed the efficacy of systemic couple therapy with people with depression living with a partner. This study, with an unusually long 2-year follow-up, is described in more detail below.
The London Depression Intervention Trial (Leff et al, 2000) was set up to compare the effectiveness of antidepressants, individual CBT and systemic couple therapy. Patients diagnosed by psychiatrists as having depression and who were in a stable relationship with a partner were randomly assigned to one of these three treatment modalities. The trial involved an initial baseline assessment of patients with depression and their partners, followed by an intervention (treatment) phase. Patients were assessed at the end of treatment and again after a period of no treatment lasting 12–15 months. The treatment phase consisted of a maximum of 9 months or 20 sessions for couple therapy and CBT and 1 year for antidepressant medication. Patients allocated to one of the treatments were not permitted to receive any other treatment simultaneously. Patients had to meet criteria for depression as measured by the Present State Examination (Wing et al, 1974), Hamilton Depression Rating Scale (Hamilton, 1960) and the Beck Depression Inventory (BDI) (Beck et al, 1961). Partners were assessed on the BDI and the Camberwell Family Interview (Vaughn & Leff, 1976), and patients and partners were assessed on the Dyadic Adjustment Scale (Spanier, 1976).
The subjects who were included met the psychiatric criteria for significant depressive illness. Patients allocated to the different treatments were matched on all relevant characteristics, such as age of patient and partner, gender of patient, chronicity and severity of depression.
The first result of the London Depression Intervention Trial (Leff et al, 2000) was that the CBT arm of the trial had to be stopped at an early stage, above all because of a high drop-out rate (8 out of the first 11 cases). It is likely that the specific characteristics of the patients recruited to the study, above all their high levels of comorbidity and chronicity, were atypical of those patients with depression that tend to respond well to CBT. The final comparison, therefore, was between drug therapy and systemic couple therapy and involved 88 subjects. Here the major finding was that people with depression seen in systemic couple therapy did significantly better than those treated with antidepressant medication. Moreover, patients receiving antidepressant medication dropped out at a much more significant rate (56.8%) than those in couple therapy (15%). This finding in itself shows that drug treatment was far less acceptable to the patients in the study than was couple therapy. A health economic analysis demonstrated that antidepressant treatment is no cheaper than systemic couple therapy.

Outlook
The emerging evidence base of systemic therapy strengthens its claim to be considered as one of the major psychological treatment modalities in the field of psychological medicine. It has been demonstrated that systemic therapy can be effective for a wide range of child- and adult-focused conditions and problems (see Box 2⇓). Systemic therapy can be used both on its own as well as in combination with other treatments. Detailed treatment manuals have been developed for an increasing number of family interventions (e.g. Klerman et al, 1984; Jones & Asen, 2000; Kuipers et al, 2002). This allows not only a more detailed study of which interventions work and why, but also serves to encourage clinicians to undertake further research and to replicate existing findings.
Box 2
Conditions with evidence of response to systemic therapy
Psychotic disorders
Mood disorders
Eating disorders in adolescents
Drug and alcohol misuse
Conduct problems in children
Marital distress

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