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C 2002)
Journal of Contemporary Psychotherapy, Vol. 32, No. 4, Winter 2002 (

Marital History and Current Marital Satisfaction

in Chronic Depression
Lawrence P. Riso, Jaime A. Blandino, Erica Hendricks, Merida M. Grant,
and Jason S. Duin

Marital functioning is an important consideration in the treatment of depression.

Although there are several studies of the marriages of depressed individuals, there
is little data on the marital lives of those with chronic depression. In this article,
we compare the marital history and marital satisfaction in a sample of carefully
diagnosed outpatients with chronic depression compared to those with nonchronic
depression. The groups were similar in terms of a history of divorce and for the percentage who had ever been married. However, the chronic group had significantly
lower levels of marital satisfaction. Increased attention to marital functioning in
this group may be beneficial during treatment.
KEY WORDS: marital history; satisfaction; depression.

For several decades, it has been clear that marital functioning is an important
consideration in the treatment of depression. Paykel and colleagues (1969) found
that marital stressors were the most frequently reported precursors to hospitalization for depressed individuals. In cross-sectional research, depression was found
to be 25 times more common in individuals with distressed versus nondistressed
marriages (Weissman, 1987). Longitudinal research indicates that marital discord
is a significant predictor of changes in depressive symptomatology (Beach, Arias,
& OLeary, 1998; Dew, Bromet, Brent, & Greenhouse, 1987). Finally, treatment
outcome research with depressed, maritally discordant individuals indicates that
behavioral marital therapy results in increased marital satisfaction and decreased
levels of depression (OLeary & Beach, 1990). Thus, marital discord and depression are clearly linked and marital therapy can even been used to improve
depression.
Address correspondence to Lawrence P. Riso, Department of Psychology, Georgia State University,
1182 Urban Life Bldg., Atlanta, GA 30303; e-mail: riso@gsu.edu.
291
C 2002 Human Sciences Press, Inc.
0022-0116/02/1200-0291/0

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The reasons for the co-occurrence of these problems are complex and not entirely clear. For instance, it is not clear whether marital discord leads to depression
or vice versa. However, the most prominent model of the coexistence of discord
and depression posits that the direction of causality is bidirectional, although marital discord is typically a more powerful contributing factor to depression than the
reverse (Beach, Sandeen, & OLeary, 1990).
Given the association between discord and depression, it is important to determine if there are some types of depression that exhibit more problematic marital
relationships than others. We have speculated that the greater duration of chronic
forms of depression (i.e., with a duration of two years or longer) would lead to
even greater marital problems. Unfortunately, prior work has not addressed marital functioning in chronic samples. Virtually every study of marital discord and
depression has selected for acute nonchronic forms of depression.
In the present study, we compared patients with chronic and nonchronic
depression on both marital history (e.g., divorce rate) and marital satisfaction.
We predicted a higher divorce rate and lower levels of marital satisfaction in the
chronic group.
METHODS
Participants
Subjects were drawn from a larger study on cognitive factors in chronic depression (Riso, et al., in press). There were 61 subjects with chronic depression
and 35 subjects with nonchronic depression. The chronic group included outpatients with a DSM-IV diagnosis of chronic major depressive disorder or dysthymic
disorder. Both diagnoses require a duration of depression of two years or longer.
The nonchronic group was comprised of outpatients with DSM-IV defined major
depressive disorder with no history of chronicity (all episodes less than two years
duration and no history of dysthymic disorder). Never ill controls had no history of
any DSM-IV psychiatric disorder. All subjects were recruited from an outpatient
mood disorders clinic at Western Psychiatric Institute and Clinic of the University
of Pittsburgh.
Measures
All diagnoses were derived using the Structured Clinical Interview for DSMIV (SCID; First, Spitzer, Gibbon, & Williams, 1996). The SCID is a state-of-the-art
semi-structured interview and all raters for this study were trained in the use of
the SCID from other research (Keller et al., 2000). In addition to the diagnostic
information, the SCID derives demographic information as part of its overview
section. For this study, we used the marital history section of the overview.

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Marital satisfaction was measured with the Marital Adjustment Test (MAT;
Locke & Wallace, 1959). The MAT is a self-report inventory that has been used in
numerous studies of marital adjustment and has become the standard (p. 294)
instrument against which other measures are compared (OLeary & Arias, 1987).
It measures communication surrounding important life areas, positive feelings
toward a spouse, and the extent to which spouses enjoy spending time together.
In addition to the MAT, in our questionnaire packet we asked subjects to answer,
Looking back over all the years (months) you have been married, overall, what
percentage of the time have you been happy with your marriage?
Depressed mood was assessed with the Inventory of Depressive Symptomatology (IDS; Rush, et al. 1986). The IDS has exhibited excellent internal consistency (Cronbach alphas range from .92 to .94), and good concurrent and discriminant validity (Rush, Gullen, Basco, Jarrett, & Trivedi, 1996).
RESULTS
The two depressed groups were similar on basic demographic characteristics.
The chronic and nonchronic depressed were similar in mean age (37.6, SD = 10.9
versus. 40.6, SD = 10.7), percentage of male subjects (28.6%, n = 18 versus
35.9%, n = 14), and mean score on the Hollingshead (1975) socioeconomic index
(38.6, SD = 11.1 versus 42.2, SD = 13.5). There were differences for level of
depression with the chronic group having higher mean scores on the IDS (37.8,
SD = 10.0 versus 31.3, SD = 11.8; t(63) = 2.40, p < .05).
The demographic section of the SCID revealed that the groups were similar
in terms of marital history. There were no statistically significant differences for
the chronic and nonchronic groups for the percentage who were currently married (22.2%, n = 14 versus 30.8%, n = 12), ever married (58.7%, n = 35 versus
64.1%, n = 21), or ever divorced (28.6%, n = 18 versus 15.4%, n = 6).
Marital satisfaction in the chronic versus nonchronic groups were compared
for those who were currently married. The chronic group exhibited a significantly
lower mean marital satisfaction score on the MAT compared to the nonchronic
group (57.9, SD = 30.9 versus 85.4, SD = 33.1; t(27) = 2.3, p < .05). In addition,
the chronic group reported a substantially, and significantly, lower percentage
of time happy in their marriage (38.5% versus 69.0%; t(26) = 3.8, p < .01)
according to our questionnaire item discussed earlier. Importantly, for the married
subgroup of patients, there were no differences between chronic and nonchronic
groups on clinical and sociodemographic factors such as mean age (39.6, SD = 8.5
versus 42.5, SD = 10.3), socioeconomic status (according to Hollingshead, 1975)
(46.5, SD = 9.0 versus 44.9, SD = 14.6), or severity of depression (37.2, SD =
8.9 versus 33.0, SD = 11.9). There was a higher percentage of female patients in
the chronic versus the nonchronic group (87.5%, n = 14 versus 64.3%, n = 9),
although these differences were not statistically significant.

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DISCUSSION
We compared marital history and marital satisfaction in rigorously defined
chronic and nonchronically depressed groups. The groups were similar in terms
of divorce rate and the percentage of patients who had ever married. However, the
chronic group exhibited significantly lower levels of marital satisfaction.
Why was there poorer marital satisfaction in the chronically depressed group?
One possibility is that the sheer chronicity of the depression gradually alienated the
spouses of depressed individuals. One potential mechanism in this regard is excessive reassurance seeking on the part of depressed persons. Excessive reassurance
seeking has been shown to erode the support network of those with depression
over time (Joiner & Metalsky, 2001). Other possibilities include greater deficits in
interpersonal skill on the part of the chronically depressed individuals (Riso et al.,
in press) or perhaps a greater likelihood to choose incompatible partners.
It is interesting to note that the chronic group had lower levels of satisfaction while not differing from the nonchronic group on the rate of divorce. This
may indicate that there was somewhat greater cognitive distortion by the chronic
group in the appraisal of their relationship. However, the fact that the chronic and
nonchronic groups did not differ on level of depression severity makes this possibility less likely. Thus, it is possible that chronically depressed individuals are
more likely to remain in a poorly functioning marriage.
Larger samples of married depressed patients may help to sort out these possibilities. Longitudinal research or data that is better suited toward examining the
onset of marital problems and depression will help to address these questions.
Finally, future research will also benefit by studying long-standing intimate relationships whether or not the couples are actually married.
Regardless of the explanation for poorer marital satisfaction for those with
chronic depression, the marital problems are likely to contribute to the maintenance
of depressive symptoms. Thus, when treating chronically depressed patients, it is
important to assess for marital discord and remain cognizant of these difficulties
during treatment. Psychotherapeutic interventions may also benefit by examining
marital interactions more closely. Even if conjoint marital therapy is not done, individual treatments for chronic depression can examine maladaptive interpersonal
assumptions, biased thinking, and interpersonal problem solving deficits in the
context of the marital relationship.
REFERENCES
Beach, S.R.H., Arias, I. & OLeary, K.D. (1987). Life events, marital discord, and depressive symptomatology. : Longitudinal relationships. Presented at the 96th Annual Convention of the American
Psychological Association. Atlanta, Georgia.
Beach, S.R.H., Sandeen, E., & OLeary, K.D. (1990). Depression in marriage: A model for etiology
and treatment. New York: Guilford.

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Dew, M.A., Bromet, E.J., Brent, D., & Greenhouse, J.B. (1987). A quantitative literature review of the
effectiveness of suicide prevention centers. Journal of Consulting and Clinical Psychology, 55,
239244.
First, M.B., Spitzer, R.L., Gibbon, M., & Williams, J.B.W. (1996). Structured Clinical Interview for
DSM-IV Axis I Disorders-Patient Edition (SCID- I/P) (Version 2.0). New York State Psychiatric
Institute.
Hollingshead, A.B. (1975). Four factor index of social position. New Haven: Yale University.
Joiner, T.E., & Metalsky, G.I. (2001). Excessive reassurance seeking: Delineating a risk factor involved
in the development of depressive symptoms. Psychological Science, 12, 371378.
Keller, M.B., McCullough, J.P., Klein, D.N., Arnow, B., Dunner, D.L., Gelenberg, A.J., Markowitz, J.C.,
Nemeroff, C.B., Russell, J.M., Thase, M.E., Trivedi, M.H., & Zajecka, J. (2000). A comparison
of Nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination
for the treatment of chronic depression. The New England Journal of Medicine, 342, 14621470.
Locke, H.J. & Wallace, K.M. (1959). Short marital adjustment and prediction tests: Their reliability
and validity. Marriage and Family Living 21: 251255.
OLeary, K.D., & Arias, I. (1987). Marital assessment in clinical practice. In K.D. OLeary (Ed.),
Assessment of marital discord: An integration for research and clinical practice (pp. 287312).
New Jersey: Lawrence Erlbaum Associates.
OLeary, K.D., & Beach, S.R.H. (1990). Marital therapy: A viable treatment for depression. American
Journal of Psychiatry, 147, 183186.
Paykel, E.S., Myers, J.K., Dienelt, M.N., Klerman, G.L., Lindenthal, J.J., & Pepper, M.P. (1969). Life
events and depression: A controlled study. Archives of General Psychiatry, 21, 753760.
Pepper, C.M., Klein, D.N., Anderson, R.L., Riso, L.P., Ouimette, P.C., & Lizardi, H. (1995). DSM-III-R
Axis II comorbidity in dysthymia and major depression. American Journal of Psychiatry, 152,
239247.
Riso, L.P., du Toit, P.L., Blandino, J.A., Penna, S., Dacey, S., Duin, J.S., Grant, M.M., & Ulmer, C.S.
(in Press). Cognitive aspects of Chronic Depression. Journal of Abnormal Psychology.
Rush, A. J., Giles, D. E., Schlesser, M.A., Fulton, C. L., Weissenburger, J. E. & Burns, C.T. (1986). The
Inventory for Depressive Symptomatology (IDS): Preliminary findings. Psychiatry Research, 18,
6587.
Rush, A.J., Gullion, C.M., Basco, M.R., Jarrett, R.B., & Trivedi, M.H. (1996). The Inventory of
Depressive Symptomatology (IDS): Psychometric properties. Psychological Medicine, 26, 477
486.
Weissman, M.M. (1987). Advances in psychiatric epidemiology: Rates and risks for major depression.
American Journal of Public Health, 77, 445451.