The impact of an uncaring partner on improvement in non-melancholic depression

Jourtzal of Affectire Disorders, 25 (1992) 147-160 0 1992 Elsevier Science Publishers B.V. All rights reserved 016S-0327/92/$05.00

147

JAD 00905

ei

er on improve

Ian Hickie

and Gordon

Parker

Mood Disorders Unit. School of Psychiatry, Unkrrsity of New South Wales, Sydney, Australia

(Received 13 September 1991) (Revision received 28 February 1992) (Accepted 10 March 1992)

Summary Interpersonal characteristics of the intimate partners of patients with non-melancholic depressive disorders were evaluated as potential predictors of outcome in an eighteen-month, longitudinal study. The short-term reduction in depressive symptoms was predicted most significantly by the patient’s perception of the partner’s care (as measured by the Intimate Bond Measure). The longer-term reduction in depressive symptoms was predicted by two components of the intimate relationship (the perceived care of the intimate and a briefer relationship) and was more likely in younger patients. Those who separated from an uncaring partner reported a distinct improvement in depressive symptoms. The patterns of improvement for patients who separated from uncaring partners and for patients who remained in caring relationships were similar, and distinctly superior to the pattern for those who remained with a partner who was perceived as uncaring.

Key words: Uncaring intimate partner; Separation;

Introduction An association between marital dysfunction and depressive disorders is accepted, with Weissman (1987) proposing that a noor marriage constitutes one of the few ‘firm risk factors’ to major depression. Others (Birtchncl; 1988, 1991) have

Correspondence to: Ian Hickie, Mood Disorders Unit, Division of Psychiatry, Prince Henry Hospital, Sydney, Australia. 2036. Fax: (611-2-661 4329.

Non-melancholic

depression

suggested a more cautious interpretation of this association, noting the possibility that certain personality characteristics (e.g. depcrldence, interpersonal sensitivity) may predispose the individual both to an increased risk of depression and to dysfunctional intimate relationships. Further, a range of personality and interpersonal factors may have differential relevance, whereby certain factors predispose to onset, while others impair recovery (Boyce et al., 1991). An interpersonal perspective proposes that the characteristics of close affectional relationships play a critical role

148

independently of personality or genetic vuhrerability, both in terms of increasing the risk to onset and in determining the course of depressive disorders (Coyne. 1976a,b; Bowlby, 1988). Previous studies examining the relevance of interpersonal factors to the outcome of depressive disorders have provided variable results (Rounsaville et al., 1979; Surtees, 1984; Hirschfeld et al., 1986). In most studies, broad ‘structural’ aspects of social relationships or ‘resources’ (e.g. married, separated, single) have been emphasised. Counterintuitively, ‘being married’ (which is usually regarded as positive evidence of ‘social support’), has emerged as a strong predictor of poor outcome following a major depressive episode (Keller et al., 1986; George et al., 1989). Such a finding is unlikely to reflect the categorical status of ‘being married’, and argues for clarification of the ‘functional’ (or, here, ‘dysfunctional’) components of the marital interaction. Previous research has suggested a link between dysfunctional marital interactions and a poor outcome for depressive disorders. Various aspects of the marital relationship have been measured across studies with debate concerning the relative merits of self-rating scales completed by the patient and/or the spouse, direct interview of the patient and spouse separately and/or conjointly and direct behavioural observation of the coupie’s interaction (see Birtchnell, 1991). Rounsaville et al., (1980) established that, in married women. marital characteristics predicted depressive outcome and that improvement in marital relationships over time was associated with recovery from depression. Both Vaughn and Leff (1976) and Hooley et al., (1986), utilising the notion of ‘expressed emotion’, demonstrated that patients with ‘depressive neuroses’ relapsed rapidly if they returned to live with a critical spouse. In their studies, the interpersonal characteristics of the spouse were determined on the basis of direct interview of the partner. In an extended follow-up study of a more heterogeneous sample, George et al., (1989) established that both the actual size of the social network and the extent of the subjectively-judged support by that network predicted resolution of depressive symptoms. They noted, however, that ‘the subjective social support measure exhibited the

strongest and most complex relationship’ with outcome. Similarly, Goering et al., (1992) have reported that recovery from a major depressive episode in wcmen at six months follow-up was predicted by the wife’s ratings of the current marital relationship but not by the husband’s level of expressed criticism or his ratings of the current relationship. These latter findings require clarification and extension over prolonged followup periods. Measurement of the characteristics of the intimate partner

In rating ‘functional’ aspects of the intimate or marital relationship, an emphasis has been put on characteristics such as care, empathy, support and control (Sheldon and West, 1989; Wilhelm and Parker, 1988). A difficulty arises in assessing such characteristics. That is, who should rate such characteristics (e.g. the patient, their spouse or an independent third party) and how (e.g. on the basis of independent or conjoint interviews)? Each method has potential strengths and empirical studies examining the variable intercorrelations between methods has highlighted the inherent conceptual and measurement problems (Birtchnell, 1991). Previous empirical studies have suggested that it is the patient’s perception of such characteristics which may best predict outcome (Henderson et al., 1981; George et al., 1989; Goering et al., 1992). Assessments based on the partner’s perception of their own characteristics have not proved useful (Goering et al., 1992). Interview methods may allow the reliable observation of behavioural characteristics and, therefore, permit some validation of questionnairebased assessments. Such interviews may themselves be limited by the intrusion of the rater whose presence may promote socially-desirable responses and who does not have access to the private interactions of the couple nor their pattern of interaction prior to the depressive episode. The relative merits of various methods of rating interpersonal characteristics may be best determined, however, by their independence from other measures of personality and severity of current depressive symptoms and by their predict ive capacity. Wilhelm and Parker (1988) developed a 24-

item questionnaire, the Intimate Bond Measure (IBM), to assess interpersonal attitudes and behaviours of the intimate to the respondent over recent times. That is, the respondent completes the questionnaire concerning the characteristics of their partner. The IBM has two scales labelled ‘care’ and ‘control’. ‘Care’ scale scores have been shown to correlate with ‘care’ ratings generated by experienced clinicians and marital therapists (r = 0.43-0.68, P < 0.001, Wilhelm and Parker, 1988) and an alternative interview-based rating system (r = 0.68, P < 0.001, Hickie et al., 19911, suggesting that IBM ‘care’ scores probably reflect ‘actual’ and not just ‘perceived’ levels of care. Similarly, IBM care scores were found to be negatively correlated with chronic marital difficulties as assessed by the relevant sections of the Life Events and Difficulties Schedule (Brown and Harris, 1978). Most importantly, the IBM ‘care’ scale has been shown to be relatively unaffected by varying levels of depressed mood (Wilhelm and Parker. 1988; Hickie et al., 1991) and to be little influenced by levels of ‘neuroticism’ (Hickie et al., 1991), of relevance when the latter has been held to reflect a ‘plaintive set’ bias (Henderson et al., 1981). Birtchnell (1991) has been particularly critical of such partner-rating questionnaires suggesting that both parties tend simply to complete such instruments in a ‘generally positive or generally negative way’. We have suggested that perceived dysfunctional interpersonal characteristics, as assessed by IBM ‘care’ scores, are associated with a three to five times increased risk to onset of nonmelancholic depression (Hickie et al., 1990, 1991). Further, this risk seems selective to nonmelancholic but not melancholic depressive disorders (Hickie et al., 1990). By contrast, the IBM ‘control’ scores do appear to be more influenced by current depressive symptoms and to reflect a less relevant risk factor to depressive disorders (Hickie et al., 1991). Importantly, IBM care scores appear relatively stable over time (Hickie et al., 1990), consistent with our hypothesis that they reflect enduring interpersonal characteristics of the partner, rather than just the negative view of a depressed spouse or brief epochs of dysfunctional relating that may be a consequence of aversive interactions with a depressed partner.

Dysfunctional partners or dysfunctional personaiity? Given the empirical evidence suggesting the

salience of ‘perceived’ characteristics of the intimate partner, the question arises as to the extent that any association between such perceptions and depressive onset or course is actually explained by personality characteristics of the patient, rather than actual characteristics of the relationship. Such features as neuroticism (Rounsaville et al., 1980) interpersonal dependency (Hirschfeld et al., 19861, interpersonal sensitivity (Boyce and Parker, 1989; Boyce et al., 1990) and dependence (Birtchnell et al., 1991) have been evaluated in regard to depressive disorders. As with each of the methods of assessment of relationships, difficulties have been experienced differentiating the personality characteristics of the patient from the distorting effects of current mood state. For example, as a consequence of their failure to differentiate dependence clearly from neuroticism, self-esteem, depressive cognitions or depressive symptoms, Birtchnell et al. (1991) concluded that while ‘neuroticism is more intrapersonal and dependence is more interpersonal.. . eventually this set of interrelated constructs will be understood to be facets of one broad factor of depressive psychopathology’. Our approach to these difficulties has emphasised the use of multiple methods of measurement of personality characteristics (neuroticism, interpersonal sensitivity-see [Boyce et al., 1991]), interpersonal characteristics (IBM and observer rating, see Hickie et al., [1991]) and depressive symptoms (self-rated Zung scales and observerrated Hamilton scale). This methodology has allowed the intercorrelations between measures to be assessed and does not assume the primacy of stability of measures of either personality or interpersonal characteristics, regarding these instead as questions for empirical evaluation (Hickie et al., 1991; Boyce et al.. 1991). In this report we seek to examine the releVance of key ‘functional’ aspects of intimate relationships, as assessed by patient’s ratings of the interpersonal characteristics of their partner and by an independent observer of a conjoint interview, to the outcome of non-melancholic depressive disorders. Further, we comprrre such factors

150

with ‘structural’ aspects of the relationships (e.g. duration) and a more behaviouraiiy-based questionnaire of marital quality (the Dyadic Adjustment Scale [Spanier, 19761). Given the potential conceptual and predictive importance of personality characteristics, neuroticism, as assessed by self-rating (Eysenck Personality Inventory [Eysenck and Eysenck, 19641) was also evaluated. The study investigates primarily the role of the patient’s perception of low care by the partner as it appears to be the critical risk factor to disorder (Hickie et al., 1990, 19911, is relevant theoretically (Henderson, 1974; Coyne, 1976a,b; Bowlby, 1988), and, as measured by the IBM, is consistent with previous measures utilised (Rounsaviiie ct al., 1980; George et al.. 19891 and appears uninfluenced by depressed state or neuroticism (Hickie et al., 1991). Methods Sixty-nine subjects with an episode of nonmelancholic depression (greater than two weeks of depressive symptoms associated with functional impairment) of less than 12 months duration were enrolled. ail being required to have been in an intimate relationship (e.g. marriage, engaged to be married, common law marriage) at the time they became depressed. As outlined in a previous report which examined in detail the psychcmetric properties of the IBM and established its Lort-term predictive validity in this same sample (Hickic et al., 19911, a numher of strategies were used to restrict the sample to patients presenting for treatment of nonmelancholic, primary affective disorders (i.e. by exclusion of those patients with alcohol or drug disorders or depression secondary to another major psychiatric disorder). No recommendations concerning clinical management were made by the authors to the treating physicians. Initinl assessment of depression

Each patient was assessed initially to establish current DSM-III diagnoses, as well as the number of past episodes of affective disorder. Patients judged to be ‘cases’ of depression had ail experienced at least two continuous weeks of depressive symptoms. Importan:iy, ail patients

were seeking treatment for their disorder and were experiencing significant impairment. The 17-item Hamilton depression scale (Hamilton, 1960) was completed by the same interviewer (I.H.) for all patients to assess severity of depressive symptoms. Possible cases of melancholic/ endogenous depression were excluded by not enrolling patients who: met DSM-III criteria for melancholia; had a Newcastle diagnostic scale (Carney et al., 1965) score greater than five; had a past history of bipolar disorder; or were prescribed EC? for the current episode. Patients with depressive disorders of greater than 12 months duration were excluded from the study as we sought also to assess life events and relationship characteristics prior to the onset of the depressive episode (Hickie et al., 1991). We judged that the accuracy of such reports may be seriously distorted by a chronic depressive process. Assessment of the intimate partner

At the commencement of the intake interview, patients were asked to complete the IBM, rating their intimate as perceived currently. In addition, 46 (67%) of the patients were interviewed conjointly with their partner (by I.H.) to assess the convergent validity of both subscales of the IBM self-report measure (Hickie et al., 1991). For the risk factor analyses described previously (Hickie et al., 1991), patients were matched with an independent sample of non-clinical subjects who had generated normative data for the IBM scale (Wilhelm and Parker, 1988). These subjects were not followed up in this study. For between-group analyses, an IBM ‘care’ score greater than one standard deviation below the mean IBM ‘care’ score of the normal reference group (i.e. !ess than 20) was used in this study to define an intimate partner’s perceived interpersonal characteristics as categorically ‘dysfunctional’. At completion of the individual assessment interview, patients were asked to complete the Zung state depression scale (Zung, 19651, and the Eysenck Personality Inventory (Eysenck and Eysenck, 1964) to assess ‘neuroticism’, as well as Spanier’s Dyadic Adjustment Scale (SDAS; Spanier, 1976) to measure current marital satisfaction.

Patients were reviewed at six weeks, six months and 18 months after the initial assessment and the interviewer (1.H.) again completed the i74tem Hamilton scale to reassess depression severity. Patients completed the Zung depression scale after the interview. In addition, five patients who were unable to attend in person were contacted by telephone and asked to detail type and duration of current depressive symptoms so that their depression status could be determined at eighteen months. These patients returned Zung selfreport depression scales by post. Patients who remained in the initial relationship were asked to recomplete that IBM at six weeks and six months, though the SDAS and conjoint interview were not readmiuistered. We have detailed previously (Hickie et al., 1991) the stability of IBM ‘care’ scores in this sample over the six-month period. Assessing outcome of depression As the most appropriate method for assessing outcome in depression remains a matter of debate (Coryell and Zimmerman, 19841, we utilised two main strategies, namely, percentage improvement in Hamilton and Zung depression scores and categorical assignment of ‘caseness’ using the same criteria as at intake (i.e. greater than two weeks of symptoms associated with impairment of function). Percentage improvement in Zung ([time l-time 2]/[time l-201 X 100) and Hamilton ([time l-time 2]/time 1 x 100) depression scores were calculated, as the predictive value of any variable should be tested after adjusting the dependent variable for initial depression severity (George et al., 1989). Kaiser (1989) has suggested that a measure of response which has been properly adjusted for baseline severity will show no concomitant variation with baseline. If the outcome measure and any putative predictor variable both covaty with the baseline score then significant correlations may be generated between the two sitnply as a result of this association with the third, higher-order variable, namely, baseline severity of depression. Consequently, in the presence of such associations, the predictive capacity of the ‘independent’ variable cannot be assumed. In this case, IBM scale scores can only be assumed to have predictive value if it can be demonstrated that baseline depression severity

and the outcome depression measures do not covary. Thus, the independence of each continuous measure of depressive improvement was tested by determination of the correlation with the baseline score. A correlation approaching zero would suggest that an independent measure of outcome had been derived. Each method of assessing outcome from the depressive episode is based OD L number of cross-sectional assessments and so provides only indirect evidence of the course of the depressive episode between follow-up points. It has the advantage, however, of being based on the clinical and self-rated depressive symptoms at multiple time points over an extended period rather than being based on the patient’s retrospective account of the course of their depression. Statistical analyses T-tests (two-tailed) were used for comparison of dimensional data and chi-square analyses for categorical data. In the univariate analyses testing relationships between individual predictor variables and depressive outcome, Pearson correlations (two-tailed) were utilised. For the multivariate analyses, stepwise multiple regression analyses were utihsed to determine the relative contributions to outcome of specific subsets of the independent predictor variables. Mu!tivariate analyses of variance (MANOVA) were utilised to compare the patterns of reduction in depressive symptoms over time between specified subgroups of patients. Patient characteristics There were 45 female and 24 male patients with a mean age of 40.3 (SD = 13.5; range 20-78) years. The mean length of their intimate relationship was 15.1 (SD = 12.4; range 1-55) years. At initial assessment, 28 subjects were inpatients of general hospital psychiatric units, while 41 were outpatients of those units or associated consultation-liaison services. The mean duration of the current depressive episode was 16.0 (SD = 14.8) weeks. The mean depression scores of the sample were 19.8 (SD = 5.0) on the Hamilton depression scale and 55.3 (SD = 8.9) on the Zung scale, indicating that depressive episodes were of moderate severity and comparable to other studies

evaluating similar patient populations (Weissman et al.. 1976; Elkin et al.. 1989). However. criterion -A’ of the DSM-111 definition of ‘major depression’ was :tpplicd strictly (‘dysphoric mood OF IOSS of interestor plcasure in all or almost all usual activities or pastimes’) so that only 67% (46/69) of cases wcrc assigned that diagnosis. The remainder were. therefore, classed as cases of atypical depression or adjustment disorder with depressed mood. Importantly, all cases had expcrienced depressive symptoms filr at least two weeks which were associated with functional impairment. and had presented for psychiatric asscssment. Patients with ‘m-or depression’ acre oldel (44.3 vs 32.4 years, t = 3.76. P < 0.001). were more likely to be inpatients (35/36 vs 3/23. x’ = 9.2. P < 0.01). had higher Hamilton depression scotcs (21.4 vs 16.7, t = 4.0, P< 0.0011, but had only marginally higher Zung depression scores (56.3 vs 53.3. t = 1.3 1. NS). There was no difference between the neuroticism scores of these two groups (15.9 vs 15.4, t = 0.42. NS). As not all patients could be interviewed in person at each follow-up, the number of Zung self-rated scores and observer-rated Hamilton scores differ marginally (for Zung: [60/6Y] 87% at six weeks, [64/69] 931% at six months. z~d [61/69] 88% at 18 months respectively while for Hamilton: [62/69] 90%. [56/69] 8 1%. 2nd [54/69] 78%, respectively). Depressive status (case/noncase) could be determined in 86% (59/69) of the patients at eighteen months. Over the course of this naturalistic study, a number of individuals separated from their partner (of those contacted at each point: 3/60 at six weeks. 12/64 at six months, IO/61 at eighteen months). Specifically. of those who perceived their partner as uncaring initially. 8/38 had separated by eighteen months compared with 2/23 of those who perceived their partner as caring (x2 = 1.6. NS). Of those who were still living with the uncaling partner, 25/29 were still perceived as uncaring at six weeks and 17/27 at six months (i.c., IBM ‘care’ score less than 20). In terms of both change in mean IBM care scores (paired t-tests: baseline 17.8 [10.8] vs SLYweeks 18.4 [10.7]. t = 1.02. NS; baseline 17.6 [ 10.51 vs six months 19.1 [lO.Sl, i = 1.6, NSJ and correlations between ini-

tial and follow-up care scores (baseline and six weeks: r = 0.91, P < ~.OOl; and baseline and six months: r = 0.83, P < 0.001) there was substantial stability of scores across time. Initial IBM care scores and the SDAS measure were positively correlated (u = 0.65, P < 0.000, indicating that both measures tap some similar constructs, while IBM control scores demonstrated only a small but significant relationship (r = -0.27, P < 0.05). Results I~tdeperuiertceof measwes of outcome

To test formally whether the procedure of deriving percentage improvement in Zung anji Hamilton depression measures had resulted in outcome measures which were independent of baseline depression severity, correiations between each measure at each time point and baseline depression scores were examined. For both the Zung (r = 0.02,0.03,0.04) and the Hamiiton scales (r = -0.05, 0.06, -0.12) the appropriate correlations for the six week, six month and eighteen month follow-ups approximated zero, confirming the utility of percentage improvement outcome measures. Utaii*nriaterrrtn1yse.s

Inter-correlations between each of the initial predictor variables and percentage reduction in depressive symptoms longitudinally (Table la) demonstrate clearly the predictive importance of aspects of the intimate relationship (higher perceived care and shorter duration). The predictive validity of the IBM care score is supported by results obtained with the interview-derived measure of the partner’s ‘care’ and Spanier’s SDAS. The capacity of all three relationship measures to predict reduction in Zung scores at eighteen months suggests the clinical importance of the overall construct of marital dysfunction, irrespective of the actual form of measurement. Sex of the patient, neuroticism and length of the depressive episode were not suggested as important determinants of depressive course, while older subjects tended io have a worse outcome. (Age showed no association with It:cgth of the depressive episode [r = -0.061, though, as expected, there was a small association between increasing

IS3

TABLE 1A Correlations (N=69)

between predictor variables and depressive symptoms at six weeks, six months and eighteen months in all patients

Predictor variables

Percentage improvement in depressiun measures Zung self-report six weeks (N=tmO)

Hamilton observer rating Six months .(N=64)

Eighteen months (N=61)

Six weeks (N = 62)

Six months (N=56)

Eighteen months t!V = 54)

IBM Care Control Interview-derived ‘care’ SDAS Duration of intimate

0.47 *** -0.14 0.29 0.27 *

0.16 - 0.04 0.16 0.36 **

0.31 * - 0.23 0.36 * 0.29 *

0.31 * - 0.0 0.12 0.18

0.20 -0.14 0.30 0.30 *

0.18 -0.29 * 0.26 0.24

relationship Past history of depression Length of the depressive

-0.12 -0.16

-0.11 -0.17

-0.42 *** - 0.24

- 0.25 0.05

-0.31 * - 0.23

-0.40 ** -.I9

episode Neuroticism Age Sex

0.12 - 0.07 - 0.13 0.13

- 0.02 - 0.07 O.til 0.00

- 0.20 0.04 -0.30 * 0.04

0.06 0.19 - 0.23 - 0.06

-0.12 -0.12 -0.16 0.05

- 0.07 0.06 - 0.25 - 0.08

* * * P < 0.001 ‘** P < 0.01 * P < 0.05: ‘SDAS’ = Spanier’s dyadic adjustment scale.

age and the past number of depressive episodes [r = 0.30, P < 0.051). As characteristics of the intimate relationship are clearly most relevant to those who remain

with their partner, we repeated the univariate correlational analyses limiting consideration to that group (Table lb). The results highlight the importance of the perceived and actual character-

TABLE 1B Correlations between predictor variables and depressive symptoms at six weeks, six months and eighteen months in patients who remained with their partner Predictor variables

Percentage improvement in depression measures Hamilton observer rating

Zung se&-report

IBM Care Control Intemiew-deri,ved ‘care’ SDAS Duration of relationship Past episodes of depression Length of the depressive episode Neuroticism Age Sex

Six weeks (N=57)

Six months (N = 52)

Eighteen months (N=51)

Six weeks (N=SS)

Six months (N=46)

Eighteen months (N = 45)

0.47 *** -0.16 0.29 0.27 -0.10

0.18 - 0.08 0.21 n.55 *** - 0.05

0.40 -0.19 0.46 0.38 -0.35

0.31 * - 0.03 0.12 0.18 -0.21

0.22 - 0.08 0.25 0.47 ** - 0.24

0.28 - 0.27 0.37 * 0.36 * -0.38 **

-0.19

-0.16

- 0.23

0.03

- 0.24

-0.14

0.13 - 0.08 -0.11 0.09

- 0.05 - 0.22 0.06 - 0.05

- 0.23 0.05 - 0.25 0.09

- 0.05 0.17 - 0.20 - 0.09

-0.10 - 0.22 - 0.04 0.07

-0.12 0.01 - 0.25 0.0s

** ** * *

* * * P < 0.001 * * P < 0.01 * P < 0.05; ‘SDAS’ = Spanier’s dyadic adjustment scale.

TABLE

2A regression analyses of depressive outcome z:t six weeks, six months and eighteen months in all patients

Multiple

Percentage l,f valiance due to predictor variables

Predictor variables

Percentage improvement

Percentage improvement

in Zung score

in Hamilton

score

Six

Six

Eighteen

Six

Six

Eighteen

weeks _-

months

months

weeks

months

months

lcr

19m ,L *

9%

14%

17% *

x5

2jTc

16%

1.5r,

19%

1. Structural 45

factors + 2. IBM Care

235

scores I. ‘Structural 2. IBM

factors’ = age. sex, duration of the relationship

care scores - indicates

structural *

*

the percentage

and past number of depressive episodes.

of the variance explained

once IBM

care scores have been added

to the four

factors.

P < 0.05.

istics of intimate relationships in predicting short-, and longer-term reduction in depressive symptoms. Significant results were largely obtained with regard to reduction in self-rated Zung rather than observer-rated Hamilton depression scores. This might suggest that some general factor accounts for the association between the two questionnaires completed by the patient (such as depressive severity determining a general response bias). Alternatively, it may reflect the fact that the Hamilton depression scale (which has been used principally to assess changes in vegetative symptoms associated with antidepressant drug response) is less suited to the measurement of change in depressive symptoms in patients with nun-melancholic disorders. TABLE Multiple

Multir*aviate analyses

Multiple regression analyses were performed to determine the principal predictors of percentage improvement in self-report and observerrated depression severity. As above, two analyses are reported; firstly, for all patients (Table 2a); and, secondly, for those patients remaining with their original intimate (Table 2b). In each analysis, relevant ‘structural’ (age, sex, number of previous depressive episodes and duration of the relationship) factors were forced to enter the regression equation first. Subsequently, IBM care scores were entered and the increase in the percentage of the variance in outcome as a result of this ‘functional’ assessment of the intimate partner was then tabulated (Tables La and b). The

2B regression analyses of depressive outcome in patients who remained

Predictor variables

with the partner

Percentage of *,ariance due to predictor variables Percentage improvement

Percentage improvement

in Zung score

Hamilton

in

score

Six

Six

Eighteen

Six

Six

Eighteen

weeks

months

months

weeks

months

months

7%

144°C

6%

14%

16%

10%

24% *

147r

16%

20%

I. Structural factors +

45

2. IBM Care scores

23?c *

1. ‘Structuralfactors’= age. sex. duration of the relationship and past number of depressive episodes. 2. IBM care scores - indicates the percentage of the variance explained once IBM care scores have been_ added structural factors. *

P < 0.05.

to the four

improvement in the predictive power of the regression equation as a result of the addition of IBM care scores was greatest for short-term reduction in symptoms (e.g. 4-23% of the explained variance in the percentage reduction in Zung scores), though the same pattern was evident at eighteen months. As our principal hypothesis concerned the predictive capacity of IBM care scores, we did not enter the other correlated relationship measures (SDAS, conjoint interview scores) into the regression analyses. An alternative method of assessing outcome is to assess predictors of ongoing depressive ‘caseness’. In a similar fashion to the multiple regression analyses, discriminant function equations based on the ‘structural’ hciuls alone wtre compared, in terms of additional reduction in Wilk’s Lambda, with those derived after IBM care scores were added. The analyses were conducted in the whole sample (3a) and then in those who had remained with their partner at each follow-up point (3bj. In the first set of analyses, 78% (49/63) of patients were still cases (that is, reported more than two weeks of depressive symptoms associated with impairment) at six weeks, 45% (26.158) at six months and 48% (28/59) at cightzen months. For the analyses of patients who had remained with their originai partner, 79% (46/58) were current ‘cases’ of depression at six weeks, 50% (24/4S) at six months and 49% (24/49) at eighteen months. As with the multiple regression analyses, the discriminant function equations utilizing IBM care scores were more powerful, at all follow-up points, than those based on the ‘structural’ factors alone. Associations with separation Using the definition of a dysfunctional partner derived from IBM care scores (IBM care < 20). we compared the patterns of outcome in three clinically important groups: (a) those in relationships perceived as ‘functional’ initially and who stayed together; (b) those in relationships perceived as ‘dysfunctional’ initially but who separated over The course of the study; and (c) those in relationships perceived as ‘dysfunctional’ initially and who stayed together. Each specific contrast was evaluated (a vs c; b vs c; a vs b) to determine both the importance of separation and

60

!?

H

-

60

5

35

I ii $ P

40

r3

30 0

I

I

I

I

I

I

.

-I

9

18

27

36

46

64

63

72

Time In weeks

Fig. 1. Reduction in Zung depression scores over 18 months in patients who (a) remained in ‘functional’ relationships, (b) separated from ‘dysfunctional’ relationships and (c) remained in ‘dysfunctional’ relationships. MANOVA of (a) vs (c) for cub c trend in differences. F = 15.9. P < 0.001.

of an initial dysfunctional relationship. Specifically, (see Fig. 1) the MANOVA contrasting ‘a vs c’ (thereby. contrasting those who stayed in functional vs dysfunctional relationships) showed a significant cubic trend (F = 15.9, P -=I0.001) in the pattern of differences in the reduction in depressive symptoms over time, while the MANOVA contrasting ‘b vs c’ (thereby, contrasting those who separated against those who remained in dysfunctional relationships) showed a significant linear trend in the pattern of differences in symptom reduction (F = 7.38, P < 0.01). The MANOVA contrasting ‘a vs b’ (remained in functional relationship vs separated from dysfunctional relationship) also showed a linear, though smaller trend in the pattern of differences in reduction in depressive symptoms (F = 5.88, P < 0.09, with the former having a more rapid reduction in symptoms over time. As cutlined in Table 4, the specific comparisons of percentage reduction in depression scores at each follow-up point detail the differences evident in the overall MANOVAs. In summary, differential outcomes were evident, with those remairsing in relationships perceived as dysfunc-

156 TABLE

TABLE

3A

Discriminant function analyses of depressive ‘caseness’ weeks. six months and eighteen months in all patients

3B

Discriminant function and analyses of depressive patients who remained with their partner

at six

in

Wilk’s lambda

Wilk’s lambda

1. Structural factors + 2. IBM Care scores

‘caseness’

Six weeks

Six months

Eighteen months

0.83 *

0.71 ***

0.76 * *

0.78 *

0.59 :g**

0.72 **

1. Structural factors + 2. IBM Care scores

Six weeks

Six months

Eighteen months

0.83 *

0.74 *

0.75 *

0.79 *

0.56 ***

0.64 * *

* P < o.n5. 1. ‘Structural factors’ = age. sex, duration of the relationship and past number of depressive episodes. 2. IBM care scores - indicates the reduction in Wilk’s lambda once IBM care scores have been added to the four structural factors. NB: A further reduction in Wilk’s lambda from 1.0 after addition of IBM care scores to the discriminant function indicates that the latter combination is a more powerful predictor of outcome than the structural factors alone.

tional (‘c’) being slowest to recover from the depressive episode and experiencing less overall reduction in symptoms over time. Of particular interest was the superior outcome for those who separated from a relationship which had been perceived as dysfunctional initially (‘b’). Although their initial improvement was slow, their longterm recovery approximated that seen in those who remained in relationships perceived as functional initially (‘a’). Of the ten patients separated from their original partner at the 1%month follow-up, only three

had initiated or actively sought the dissolution. Those ten who were separated (five females and five males) did not differ from those (N = 49)

TABLE -1 Comparisons (ANOVA) of improvement in depression at six weeks. six months and eighteen months between; Patients reporting IBM care scores greater than 20 (functional relationships) who stayed toge;her (‘A’): patients reporting IBM care scores less than 20 (dysfunctional relationships) who separated (‘B’l: and those in dysfunctional relationships who stayed together (‘C’I Mean percentage Functional relationships ‘a’ 1. Six Weeks Zung

3. Eighteen Zung

relationships

F value

9.1 ***

‘61

10% (N = 33) 24% (N=32)

51% (N=22) 67% (N= 19)

45% (N=9) 62% (N=8)

33% (N=30) 539 (N= 27)

2.6

54% (N=21I

63% (N=&I 69% (N=7)

32% (N = 30) 5*;i_

5.0 **

4.3 *

1.7

months

: Iamilton

7!7.

(N= ***

Dysfunctional

33% (N=3) 45% (N=3I

46%

Hamilton

depression

Intact lc’

(N= 2. Six months Zung

in

Separated ‘b’

42G (N = 24)

Hamilton

improvement

P
**p
*p
16)

lN=29)

!.9

who remained with their partners on levels of initial neuroticism (17.0 [3.4] vs 14.9 [5.3], t = 1.2, NS) or baseline depression (Zung: 57.9 [10.7] vs 55.1 [8.4], t = 0.93, NS; Hamilton: 19.7 [3.9] vs 20.2 [5.2], t = 0.29, NS), nor was there any differernce in the number of previous depressive episodes (1.3 [0.9] vs 1.6 [ 1.11, t = 0.92, NS) or in social class (Congalton score: 4.0 [1.5] vs 4.0 [1.3], t = 0.00, NS). They tended, however, to be younger (36.2 [ 13.11 vs 42.1 [ 13.91 years, t = 1.2, NS) and, perhaps as a corollary, to have had briefer relationships (10.8 [9.8] vs 17.3 [12.6] years, t = 1.54, NS). IBM care scores were not significantly different (17.0 E8.31vs 17.4 110.31, t = 0.11, NS). Only two of the 10 patients who were separated at 18 months and were assessed had initially rated their partner’s interpersonal characteristics as ‘functional’ (i.e. IBM care > 20). Discmsion In this naturalistic study we examined whether key aspects of intimate relationships predicted the reduction in depressive symptoms following an episode of non-melancholic depression. Henderson (1974) has suggested that non-psychotic psychiatric disorders are best conceptualised as abnormal forms of cart-eliciting behaviour. Consequently, a depressive syndrome may be perpetuated, or the patient placed at increased risk of further new episodes, if their intimate partner is perceived as providing insufficient care. Similarly, Coyne (1976a) proposed that the depressive syndrome represents an active attempt by the patient to reinvolve key persons but, as depressive behaviour is both aversive to, and guilt-inducing in others, the desired caring response may not be elicited. That is, the interactive process between the depressed patient and their partner may prevent resolution of the depressive syndrome. This study highlights the key role of the ‘functional’ characteristics of the intimate partner, notably liriiv care, in predicting the course of nonmelancholic depressive syndromes. Our findings are consistent with other reports (Kerr et al., 1974; George et al., 1989; Frank et al., 1989; Goering et al., 1992) suggesting that the interpersonal environment of depressed patients may be a major determinant of outcome.

Birtchnell (1991) and Birtchnell et al. (1991) have suggested more cautious interpretations of such studies, noting the possibility that a personality factor such as ‘dependency’ or a ‘broad factor of depressive psychopathology’ might account for observed associations between such predictor variables and reduction in depressive symptoms. Further, it is likely that an alternative process may operate whereby depressed subjects generate dysfunctiona marriages as a consequence of their aversive behaviour and concurrent inability to elicit caring responses from their spouse. In this situation, a depressed patient may rate their partner as uncaring, but the perceived lack of care is hypothesised to be a consequence of their own behaviour and their own cognitive set. This longitudinal aspect of this study suggests that irrespective of the contribution to onset made by the patient as compared with the spouse, once the spouse is uncaring (in either the eyes of the patient or of the independent observer) the longterm outcome is poor. The ability of a simple self-report measure, the IBM ‘care’ score, to account for a major proportion of the variance in depressive outcome requires further examination. Self-report measures of social relationships risk judgement of limited utility if they more reflect ‘perceived’ rather than ‘actual’ characteristics of any relationship (Birtchneil, i341) and, potentially, may be distorted by state effects such as depressed mood or ‘personality’ characteristics such as trait neuroticism. The advantages of the IBM care scale are that: scores are little influenced by either of these possible biases (Wilhelm and Parker, 1988; Hickie et al., 1991); scores correspond with independent observations of the characteristics of intimate relationships (Wilhelm and Parker, 1988; Hickie et al., 1991); and, as demonstrated in this study, the scale has predictive utility. Birtchnell (1991) has suggested that measures of aspects of marital relationships should encompass a wider spectrum of measurement including self-rating scales, partner-rated scales and observer-rated instruments. While conceptually this may allow a more diverse range of views to be considered, the current literature emphasises the predictive validity of the patient’s perception of the relationship (George et al., 1989; Goering et

al., 1992). Birtchnell et al’s concern that all such factors, including the interpersonal factors evaluated here, simply represent manifestations of the depressive syndrome is not consistent with the evidence (Hickie et al., 1991) that IBM care scores are not strongly linked to depressive state or neuroticism (both of which are strongly linked to dependence [Birtchnell et al. 19911). In the future, however, it may be useful to test the predictive capacity of other views, including the spouse’s view of themself and their partner and the patient’s view of his/her own interpersonal characteristics. A longer duration of the intimate relationship also predicted poorer long-term outcome though this may have been due, in part. to its association with lower IBM care scores (r = -0.25. P < 0.05; Hickie et al., 1991). Alternatively, given that those who separated tended to have been in briefer it may indicate that as the relationships, ‘honeymoon’ phase of a relationship passes, some patients become entrapped progressively in increasingly dysfunctional relationships. Such entrapment then contributes to, and predicts failure to recover from depressive episodes. Consistent with Henderson’s (1974) hypothesis. such palielttb would be expected to remain depressed until they elicit a sufficiently caring response from key others. As patients with lower IBM care scores are presumed to be in relationships where care from their partner is deficient. they would be expected to experience greater ongoing depressive morbidity. The findings are consistent with Coyne’s (1976b) notion that the partner’s current ability to respond to the depressed patient (despite the aversive nature of the patient’s behaviour) may be the most important factor in determining outcome. Rounsaville et al., (1980) have highlighted previously the improvement in depression which may accompany separation from a dysfunctional relationship. Debate has developed, however, as to whether such improvement can he interpreted as evidence of the causal role of dysfunctional relationships or whether it is indicative of some other factor (notably better pre morbid personahty) which may lead independently to both improvement in symptoms and the decision to separate from a destructive relationship (Birtchnell and

Kennard, 1983). In this study, patients who separated tended not to initiate the process and were indistinguishable from those who remained with their original partner in terms of neuroticism, depression severity and past depressive history. This finding is supportive of the hypothesis that dysfunctional relationships cause ongoing depressive morbidity. This issue requires more detailed assessment in future studies, however, to evaluate the possibility that other personality and/or coping styles may be acting as higher-order variables. The trends towards separation in younger patients and in patients with shorter duration of their intimate relationships suggest that a cohort effect may be operative with younger patients being less willing to stay in relationships which have become dysfunctional. It is possible that older patients are mo; 1 reluctant to leave dysfunctional relationships despite the deleterious effects on their mental health. The lower separation rates and lower IBM care scores in our older subjects did not appear to be the consequence of more chronic depression, as the groups did not differ in terms of the past number of depressive episodes, nor were they due to social class effects. Th/s btudy supports the notion that deficient care from an intimate partner, as reported by the patient OT as observed by an independent rater, is strongly predictive of ongoing depressive morbidity. The predictive capacity of both ‘perceived’ and ‘actual’ measures of the characteristics of the intimate partner support a causal or circular hypothesis whereby deficits in the interpersonal behaviour of the spouse contribute directly to a poor prognosis for patients with non-melancholic depressive disorders. This does not preclude the possibility that the depressed patients own behaviour (which is often aversive) OT the patient’s personality (particularly their intrinsic and perhaps excessive need for overt cart and support) do not also have causal or circular implications. An alternative hypothesis, namely that of ‘social selection’ suggests that patient-based personality variables determine both the impaired characteristics of the partner and, independently, any vulnerability to psychiatric disorder. That is, acutal partner characteristics make no significant contribution. Our finding that separation from a dysfunctional partner was associated with a re-

1.59

turn to the pattern of recovery observed in patients with partners perceived as ‘functional’ is more consistent, however, with a ‘social bond’ hypothesis whereby aspects of current social relationships (in this case partner characteristics) are themselves held to be of aetiological and prognostic significance. Acknowledgements Dr Hickie was funded by the NSW Institute Psychiatry. The authors wish to thank Mr Hadzi-Pavlovic and Drs H. Brodaty, P. Boyce, Wilhelm and P. Mitchell and MS K. Eyers reviewing earlier versions of this report.

of D. K. for

eferences Birtchnell. J. and Kennard. J. (1983) Does marital maladjustment lead to mental illness? Sot. Psychiatry 18, 79-88. Birtchnell. J. (1988) Depression and family relationships. Br J Psychiatry 153, 758-769. Birtchnell. J. (1991) Negative modes of relating, marital quality and depression. Br. J. Psychiatry 158. 648-657. Birtchnell. J., Deahl. M. and Falkowski. J. (1991) Further exploration of the relationship between depression and dependence. J. Affect. Disord. 22, 221-233. Bowlby. J. (1988) Developmeiital psychiatry comes of age. Am. J. of Psychiatry 145, l-10. Boyce. P. and Parker. G. (1989) Development of a scale to measure interpersonal sensitivity. Aust. and N.Z. J. Psychiatry 23. 341-351. Boyce. P.. Parker, G., Kickie. 1.. Wilhelm. K.. Brodaty. K. and Mitchell. P. (1990) Personality differences between patients with remitted melancholic and non-melancholic depression. Am. J. Psychiatry 147. 1476-1483. Boyce. P.. Kickie. I. and Parker. G. (1991). Parents. partners or personality? Risk factors for post-natal depression. J. Affect. Disord. 21. 245-255. Brown, G.W. and Harris. T. (197X). The social origins of depression. Tavistock. London. Carney. M.W.P., Roth. M. and Garside. R.F. (1965) The diagnosis of deprecsive symptoms and the prediction of ECT response. Br. J. Psychiatry I I I. 6SY-74. Coryell, W. and Zimmerman, M. (1984) Outcome following ECT for primary unipolar depression: a trbt for newly proposed response predictors. Am. J. Psychiatry 141. X62867. Coyne. J.C. (1976a) Toward an interactionai description of depression. Psychiatry 39, 14-27. Coyne. J.C. (1976b) Depression and the response of others. J. Abnorm. Psychol. 85. 186-193. Elkin. I.. Shea, M.T., Watkins, J.T., lmber. S.D.. sotsky. S.M.. Collins, J.F.. Glass. D.R.. Pilkoms. P.A.. Leber. W.R.. Dacherty. J.P.. Fiester, S.J. and Parloff. M.B. (1989) Na-

tional Institute of Mental Health treatment of depression collaborative research program: general effectiveness of treatments. Arch. Gen. Psychiatry 46. 971-982. Eysenck, K.J. and Eysenck, S.B. (1964) Manual of the Eysenck PersOnahtY Inventory. Kodder and Stoughton, London. Frank, E., Kupfer, D.J. and Perel. J.M. (1989) Early recurrence in unipolar depression. Arch. Gen. Psychiatry 46, 397-400. George, L.K., Blazer. D.G.. Kughes. D.C. and Fowler, N. (198% Social support and the outcome of major depression. Br. J. Psychiatry 154, 478-485. Goering, P.N.. Lancee, W.J. and Freeman, J.J. (1992) Marital support and recovery from depression. Br. J. Psychiatry 160, 76-82. Hamilton, M. (1960) A rating scale for depression. J. Neural.. Neurosurg. Psychiatr. 23. 56-62. Henderson. S. (1974) Care-eliciting behaviour in man. J. Nerv. Ment. Dis. 159. 172-181. Henderson. A.S.. Byrne, D.G. and Duncan-Jones, P. (1981) Neurosis and the Social Environment. Academic Press. Sydney. Hickie, I.. Wilhelm, K.. Parker, G.. Boyce, P.. Kadzi-Pavlovic. D.. Brodaty, H. and Mitchell, P. (1990) Perceived dysfunctional intimate relationships: a specific association with the non-melancholic depressive sub-type. J. Affect, Disord. 19. 99- 107. Hickie. I., Parker. G.. Wilhem, K. and Tennant, C. (1991) Perceived interpersonal risk factors to non-endogenous depression. Psychol. Med. 21, 399-412. Kirschfeld, R.M.A., Klerman. G-L., Andreasen. N.C.. Clayton, P.J. and Keller, M.B. (1986) Psychosocial predictors of chronicity in depressed patients. Br. J. Psychiatr. 148. 64X-654. Kooley, J.M.. Orley, J., Teasdale, J.D. (1986) Levels of expressed emotion and relapse in depressed patients. Br. J. Psychiatry 148. 642-647. Kaiser. L. (1989) Adjusting for baseline: Change or percentage change? Statistics Med. 8. 1183-l 190. Keller, M.B.. Lavori. P.W., Klclman, G.L., Andreasen, N.C., Endicott. J.. Coryell, W.. Fawcett, J.. Rice. J.P. and Kirschfeld. R.M.A. (1986) Low levels and lack of predictors of somatotherapy and psychotherapy received by depressed patients. Arch. Gen. Psychiatr. 43, 458-466. Kerr, T.A.. Roth. M. and Schapira. K. (1974) Prediction of outcome in anxiety states and depressive illnesses. Br. J. Psychiatr. 124. 175-133. Kiloh, LG.. Andrews, G.. Neilson, M. and Bianchi. G.N. (1972) The relationship of the syndromes called endogenous and neurotic depression. Br. J. Psychiatr. Ill. 1X3-96. Matussek, P. and Wiegand. M. (1985) Partnership problems as causes of endogenous and neurotic depressions. Ac:a Psychiat. Stand. 71, 95-104. Parker. G., Tupling. K. and Brown. L.B. (1979) A parental bonding instrument. Br. J. of Med. Psychol. 52, l-10. Rounsaville, B.J.. Weissman. M.M.. Prusoff. B.A. and Kercog-Baron. R.K. (1979) Marital disputes and treatment outcome in depressed womcu. Compr. Psychiatr. 20, 4834sro.

Rounsaville. B.J., Prusoff, The course of marital 1X-month follow-up Sheldon. A.E.R.

study. Compr. Psychiatr, 71,

and West. M. (1989) The functional

nation of attachment demonstration. Span&.

B.A. and Weissman. MM. (1980) disputes in depressed women: a

and affiliation:

11I-118. discrimi-

theory and empirical

Br J. Psychiatr. 155. 18-23.

G.B. (1976) Measuring

dyadic adjustment:

new scales

Fam. 38. 15-78.

survey. Sot. Psychiatr. V’aughn. C.E. and Leff.

19. 63-67. J.P. (1976)

Weissman.

of family

and social factors on the course of psychiatric

illness. A

pa-

UM,

Kasl. S.V.

and Klrrman,

G.L.

(1976)

Fol-

treatment.

Am. J. Psychiatr. 133. 7S7-760. M.M.

(1987)

Advances

ogy: rates and risks for major Health

in psychiatric depression.

epidemiol-

Am.

J. Public

77. 445-45 1. K. and Parker,

G. (19X8)

The

development

of a

measure of intimate bonds. Psychol. Med. IX. 225-234. Zung.

The influence

and depressed neurotic

low-up of depressed women after maintenance

Wilhelm,

Surtees. P. (1964) Kith. kin and psychiatric health: a Scottish

of schizophrenic

tients. Br. J. Psychiatry 129. 125-137.

Weissman,

for assessing the quality of marriage and similar dyads. 1. Marriage

comparison

W.W.K.

(1965)

A self-rating

Gen. Psychiatr. 12. h&70.

depression

scale. Arch.