A number of studies of patients with major depression who live with spouses or other partners have indicated a link between the patients’ treatment outcome and the degree of criticism expressed toward the patient by his or her partner. A new study, part of the London Depression Intervention Trial, has found that patients who have major depression and are in a critical relationship do better when they participate in couples therapy rather than taking antidepressant medication.

The randomized controlled trial compared 37 patients who were taking antidepressants with 40 patients who participated in couples therapy in one partner’s treatment for major depression. Subjects in the antidepressant group primarily received desipramine for one year. After one year, the antidepressant dose was tapered off. If desipramine was contraindicated, intolerable side effects developed, or no response was noted after six weeks of medication, patients were switched to either trazodone or fluvoxamine.

Subjects participating in couples therapy attended between 12 and 20 sessions during the first year of the study. Therapy was aimed at helping the patient and his or her partner gain new perspectives on the presenting problems, attaching different meanings to behaviors symptomatic of depression, and experimenting with new ways to relate to one another. Both groups, those receiving antidepressants and and those in couples therapy, were followed up at two years as well.

Julian Leff, M.D., professor and head of the social psychiatry section at the Institute of Psychiatry in London, and his coauthors noted two significant trends in data from the two groups. Patients receiving only antidepressant therapy were nearly three times more likely to drop out of the study before its completion. The only statistically significant differences between dropouts and those who completed the study were that the dropouts were significantly younger than completers and had higher initial Beck Depression Inventory (BDI) scores.

The couples-therapy group showed a statistically significant advantage over the group taking the antidepressant in the degree of improvement of their depression, although both groups did improve. On average, BDI scores fell nearly 8 points for those receiving medication, while subjects participating in couples therapy saw an average reduction in BDI score of 11.8. This statistically significant reduction in BDI scores remained stable throughout the second year of follow-up for both groups.

The study, appearing in the August issue of the British Journal of Psychiatry, is provocative, according to Leff, because it implies that not only can a critical partner contribute to a worsening of the other partner’s depression, but a positive, supportive partner may help "lift a depressed patient out of their blues."

Leff advocates teaching couples-therapy skills to a wider range of mental health professionals and even to primary care physicians.

In an editorial accompanying the article, Jeremy Holmes, M.D., a consultant psychiatrist in psychotherapy at North Devon District Hospital in Barnstable, England, challenged the notion that more psychiatrists need to improve on their psychotherapeutic skills. "Psychotherapy can legitimately claim a place throughout the psychiatric spectrum, and it can be argued that no psychiatrist worth the name should lack psychotherapeutic skills and understanding."

The entire August issue of BJP is devoted to psychotherapy. According to the Royal College of Psychiatrists, the practice of psychotherapy in the United Kingdom. is the only psychiatric subspecialty in which there was no net growth in the number of practitioners between 1993 and 1998. Holmes noted that unless there is a conscious change of direction, psychiatrists’ skills in psychological understanding and treatment will atrophy.

"General psychiatry," suggested Holmes, "needs psychotherapy if it is to deliver effective psychosocial interventions to people with psychosis and find new ways to combine the prescription of medications with psychotherapeutic interventions." General psychiatry, he added, is going to have to learn, or relearn, the principles of the psychotherapeutic community.