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Determining What Works in Depression Treatment : Translating Research to Relational Practice Using Treatment Guidelines

Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. Translating Research Into Practice Using Treatment Guidelines Treatment Guidelines for Depression: What Do They Currently Say? Medication Treatment Individually Focused Psychosocial Interventions A Relational Perspective on Depression Treatment Lessons for Couple and Family Psychology A Relational Focused Approach to Treatment Guidelines Conclusions References ListenSelect: By: Steven D. Hollon Department of Psychology, Vanderbilt University Thomas L. Sexton Center for Adolescent and Family Studies, Indiana University Correspondence concerning this article should be addressed to: Steven D. Hollon, Department of Psychology, Vanderbilt University, 306 Wilson Hall, Nashville, TN 37203 Electronic Mail may be sent to:steven.d.hollon@vanderbilt.edu. Depression is a major public health problem that clearly runs in families. It is the fourth leading cause of disease burden worldwide and is expected to rank first in high-income countries by the year 2030 ( Mathers & Loncar, 2006). The lifetime prevalence of major depressive disorder (MDD) is >16% in the United States, with a particularly high rate among adults of parenting age ( Kessler et al., 2003). Unipolar depression is about 10 times more common than bipolar depression and is far less heritable ( Belmaker, 2004; Belmaker & Agam, 2008). Life stress plays a role in the etiology of each (Monroe & Harkness, 2005), often in the form of a diathesisstress interaction with underlying genetic vulnerabilities ( Caspi et al., 2003). Two-thirds of all depressed patients nowadays are treated pharmacologically, with only about a third receiving psychotherapy ( Marcus & Olfson, 2010). This is a complete reversal in the proportions receiving each as recently as 20 years ago ( Olfson et al., 2002). This shift largely occurred with the advent of the selective serotonin reuptake inhibitors (SSRIs) in the late 1980s. The SSRIs are relatively safe and easy to tolerate. This led general practitioners to be willing to prescribe them to their patients without feeling the need to make a psychiatric referral. Although antidepressant medications (ADMs) are often efficacious in reducing symptoms, it is not clear that they do anything to resolve underlying family or relational issues that may be driving the depression ( Hollon, Thase, & Markowitz, 2002). The empirically supported psychotherapies often are efficacious in the treatment of depression and appear to have broader or more enduring effects than medications ( Hollon, 2011). Our thesis in this article is that the treatment of depression can be enhanced by adopting a multisystemic focus.
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Although medication treatment and many of the primary psychological interventions are individually oriented, there is something inherently interpersonal about depression. This is evidenced by its similarity to grief (which lacks only a negative self-concept) in terms of its symptomatic expression ( Freud, 1917/1957) and the fact that separation loss is a major animal model for the etiology of depression ( Suomi, 2006). Women are twice as likely to become depressed as men, at least with respect to unipolar disorder (gender distribution is comparable in bipolar disorder), a disparity that first emerges in early puberty and stays constant across the life span ( Costello, Erkanli, & Angold, 2006). An estimated 15 million children in the United States live with a depressed parent, and the rate of exposure to parental depression in a child's lifetime is even higher ( National Research Council and Institute of Medicine, 2009). Offspring of depressed parents are three to four times more likely than children in the general population to develop a psychiatric disorder by young adulthood, with the risk for depression being especially high. Depression is both a cause and a consequence of marital dissatisfaction and divorce ( Bulloch, Williams, Lavorato, & Patten, 2009). Not attending to marital and family issues in the treatment of depression can interfere with remission and subsequent recovery, and increases the risk for relapse or recurrence ( Hooley & Gotlib, 2000). There is an emerging literature that suggests that a relational perspective may be critical to understanding how best to intervene clinically with clients experiencing depression ( Sexton, Alexander, & Mease, 2003). There are a number of couple and family therapies and intervention programs that have strong data to suggest they are effective in the treatment of depression. These are relationally focused approaches that target couple or family functioning as a mechanism to impact individual symptoms. Moreover, evidence regarding the limitations inherent in individual approaches suggests the utility of a systematic approach to treatment that addresses issues like the couple relationship, family conflict, and family support and involvement. There are reasons to think that the outcome of both ADM and individual psychosocial treatment might be enhanced through the adoption of a relational perspective. When faced with individual clients or members of a couple or family who are depressed, clinicians looking for the most effective treatments can look to the extensive body of research. However, translating research findings into clinical practice can be difficult. Although broad reviews of the research literature are common, they are not necessarily structured in a way that makes them immediately accessible to the practicing clinician. This may be best accomplished through the use of treatment guidelines. Well-constructed guidelines seek to integrate the strongest possible evidence within the complex interaction between therapist, client, and the context in which the intervention is delivered. When both the strength and level of the empirical evidence and the clinical context are considered, the resulting recommendations have both methodology rigor and clinical relevance. Yet, current treatment guidelines often underestimate relationally based psychological interventions. This often occurs because the systematic reviews that are the primary basis of reviews too often focus on individual treatments and outcome measures that miss the broader relational perspective. Our goal is to illustrate how the translation of research into practice through treatment guidelines can provide a trustworthy and reliable source of empirically based and clinically useful guidance with respect to the multisystemic and relational process that should be included. We begin with a discussion of current approaches to translating the empirical literature into clinical practice through the use of treatment guidelines and the role of systemic interventions and a broader range of outcomes (beyond just symptoms) in those models. We next review the current research literature on clinical interventions for depression that provides a basis for these guidelines. We

focus primarily on adults but have a few comments to make about the prevention and treatment of depression in children and adolescents. Finally, we end with a discussion of the implications of the clinical research on relationally based interventions for depression and provide suggestions for additions to the treatment guidelines that may include the relational focus to depression treatment. Translating Research Into Practice Using Treatment Guidelines Attempts to translate science into practice with respect to psychotherapy have been challenging and engendered considerable controversy. This is in part owing to the complexity of the relevant research, particularly regarding how and what can be translated into clinical practice. Not all research is equally reliable or produces as powerful or replicable a set of outcomes as other lines of study. It is difficult to gauge the clinical impact of research trends over time by merely reviewing current findings. Any review, this one included, suffers from unintended bias owing to selectivity in the evidence considered and the idiosyncratic way it is interpreted. Treatment guidelines use a systematic approach to find and summarize the existing research literature and a transparent methodology for weighing the findings and translating them into clear and specific clinical recommendations. When conducted according to current standards, treatment guidelines have the potential to help members of the public receive the best most upto-date care available by bringing to clinicians a systematic summary of the available interventions that have the best demonstrated benefits. Guidelines also help identify which interventions are not currently supported by the empirical evidence (remembering always that absence of evidence is not evidence of absence) and call attention to potentially harmful or ineffective interventions. Guidelines provide a valuable summary of the literature for busy clinicians who may not have the time to keep up-to-date with the relevant research literature ( Wolf, Hubbard, Faraday, & Forrest, 2011). They also alert the research community to gaps in the available evidence and can help enhance research quality and spark new innovations. Systemic reviews and the treatment guidelines that they generate also can spur new theoretical developments by highlighting commonalities among different interventions and relational techniques. In effect, everybody benefits when the literature is examined in an unbiased fashion. The Institute of Medicine (IOM) recently has described a set of procedures intended to build trust in the resultant produce by virtue of ensuring transparency in the guideline generation process, both with respect to the ways those guidelines themselves are generated (IOM, 2011a) and the ways the systematic reviews on which they are based are conducted (IOM, 2011b). Transparency and standardization are critical to consumer confidence. Previous guidelines have been quite diverse with respect to the methods that they followed and the recommendations that they generated, and it was not always clear how they got from one to the other. The IOM has set a high bar based on a comprehensive and deliberative process that includes a standardized and systematic approach to the search for evidence that limits bias, a prescribed method for evaluating the quality and relevance of the resultant findings, and a structured format for reporting that evidence that includes peer review and public scrutiny ( IOM, 2011b). The IOM further specifies standards for constructing guideline development panels that are charged with setting the scope for those systematic reviews and interpreting resulting evidence to generate specific recommendations regarding optimal practice for use in the field ( IOM, 2011a). Several strategies have been developed for making explicit the strength of recommendations. GRADE is perhaps the most widely used and has many desirable features, including applicability across a variety of clinical areas, consideration of individual preferences and values, and explicit

treatment of the quality of evidence and the strength of recommendation. Although it is virtually impossible to eliminate all bias from the process, it helps to be transparent about the evidential base selected and the process by which recommendations were developed. This allows others to determine for themselves just how much they trust the resultant guidelines. Treatment Guidelines for Depression: What Do They Currently Say? Existing treatment guidelines for depression typically address the efficacy of couple and family therapy but rarely do so from a relational perspective. A recent revision of the psychiatric guideline notes that marital and family problems are common in the course of MDD and should be addressed using marital or family therapy ( American Psychiatric Association [APA], 2010). It notes that these approaches have been shown to be effective in the treatment of depression and that family therapy has been shown to be a useful adjunct to medication treatment. Similarly, guidelines generated for the National Health Service in England recommend the use of Interpersonal Psychotherapy (IPT) in general and Behavioral Couple Therapy (BCT) for people with regular partners when problems in the relationship contribute to the development or maintenance of depression ( National Institute for Health and Clinical Excellence [NICE], 2010). Relational treatments fall into three broad types ( Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). Partner-assisted or family-assisted interventions are those in which the partner or family member(s) serves as a surrogate for the therapist assisting the patient in accomplishing some therapeutic task like exposure therapy. Disorder-specific couple or family interventions focus on the ways in which relational processes contribute to the patient's disorder. Identifying interaction patterns in the relationship that contribute to the maintenance of depression represents an example of this category. Finally, general couples or family therapy focuses on correcting relational problems for their own sake but often have a benign effect of individual distress. We review the research literature with reference to these broad categories of relational interventions. Medication Treatment ADM represents the current standard of treatment for depression ( APA, 2010; NICE, 2010). There are four major classes of antidepressants. All are generally efficacious in the treatment of depression, and choice of medication usually is made on the basis of symptom profile and ease of management ( Hollon et al., 2002). The monoamine oxidase inhibitors (MAOI) are the oldest and perhaps the most powerful of the ADMs, but they are difficult to manage and require that patients follow carful dietary restrictions so as not to trigger a potentially fatal hypertensive crisis. Their use nowadays tends to be reserved for patients who have not responded to multiple trials on other medications. The tricyclic antidepressants (TCAs) are the next oldest and perhaps the next most powerful of the ADMs, but also cause problematic side effects and can be lethal if taken in overdose. The SSRIs are relatively safe and free from major side effects (other than indigestion and impaired sexual interest/performance) and have largely fueled the surge in prescriptions in primary practice over the last two decades ( Olfson et al., 2002). Newer ADMs that target multiple neurotransmitter systems like venlafaxine or duloxetine (serotonin and norepinephrine) and wellbutrin (dopamine and norepinephrine) are more difficult to manage, but are starting to supplant the SSRIs in terms of frequency of prescription by psychiatrists. The SSRIs continue to be preferred by primary care physicians ( Marcus & Olfson, 2010). The antidepressants are among the best of the psychiatric medications. They tend to work for most patients and are relatively free of major complications other than those already noted. They are not addictive in the classic sense and as a consequence tend to be preferred for the treatment

of the anxiety disorders over the minor tranquilizers. That being said, the ADMs are not without their problems. First, their efficacy has been exaggerated owing to publication bias. A recent study found that of all the trials submitted to the Food and Drug Administration (FDA) for approval of the SSRIs and subsequent ADMs, nearly one-half failed to evidence any advantage for medications over pill-placebo. Moreover, whereas nearly all the positive studies were published, two-thirds of the negative trials went unpublished and the other third were spun to make it appear that their findings were positive ( Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008). This combination of study publication bias and outcome reporting bias inflated the apparent efficacy of medication treatment by about 25%. As a consequence, anyone reading the published literature would conclude that the ADMs are more efficacious than they really are. A second major problem is that true drug effects (differences relative to pill-placebo) are largely confined to patients with the most severe depressions ( Fournier et al., 2010; Khan, Leventhal, Khan, & Brown, 2002; Kirsch et al., 2008). That is not to say that patients with less severe depressions do not respond when put on medications, but when they do it is largely for psychological and not for pharmacological reasons. The fact that the majority of patients treated on an outpatient basis respond to ADM for largely nonspecific psychological reasons means that relational factors may play a larger role in medication response than most people realize. Such patients will get side effects but likely would have done as well with a psychosocial treatment. The third major problem with the ADMs is that they work only for as long as they are taken. Like aspirin, they will make a headache go away when they are taken, but will not prevent another headache from coming on at some subsequent time unless their use is continued in a prophylactic fashion. Depression tends to be recurrent (if not chronic), and the vast majority of patients will have multiple or ongoing episodes. This has led many psychiatrists to treat depression the way most physicians treat diabetes; once they get a patient stabilized on ADMs, they are unlikely to ever take them off. Individually Focused Psychosocial Interventions Several of the newer psychosocial interventions have been shown to be efficacious in the treatment of depression. IPT is predicated on the notion that most depressions are associated with problems in relationships. IPT focuses on four kinds of problem areas, with different strategies recommended for each; interpersonal loss (grief), interpersonal disputes, interpersonal deficits, and role transition (which usually has relational overtones). IPT generally has fared well in controlled trials and appears to be about as efficacious as ADM even among patients with more severe depressions ( Elkin et al., 1995). Moreover, IPT appears to have a broader effect than medications in terms of improving the quality of relationships and interpersonal skills ( Weissman, Klerman, Paykel, Prusoff, & Hanson, 1974; Weissman, Klerman, Prusoff, Sholomskas, & Padian, 1981). Although this is impressive, IPT typically is provided in an individual format (that is, patients talk with their therapists about their relationships with others) rather than having the other party present when working on relations. Moreover, IPT initially separated itself from more interpersonally oriented dynamic approaches by eschewing any focus on childhood issues or the therapeutic transference. Clearly there is more that could be done to integrate a relational perspective into the strategies used in IPT, not the least of which would be including the partner in the sessions in a disorder-specific fashion. Cognitive therapy is predicated on the notion that it is not just what happens to someone that determines how they feel and what they do about it, but rather the way they interpret that event ( Beck, 2005). Despite its name, it makes extensive use of behavioral strategies to test beliefs,

and considerable effort is made in early sessions to get patients active before moving on to focus more directly on the accuracy of their beliefs. For this reason (and to differentiate it from couple therapy), we will refer to cognitive therapy and related cognitivebehavioral interventions by the abbreviation CBT. As is the case for IPT, CBT can be as efficacious as medications in the treatment of patients with more severe (or atypical) depressions so long as it is adequately implemented; two studies with more experienced CBT therapists found it to be as efficacious as ADM and superior to pill-placebo ( DeRubeis et al., 2005; Jarrett et al., 1999), whereas two other studies with less experienced CBT therapists found it to be less efficacious than ADM and no better than pill-placebo with patients with more severe depressions ( Dimidjian et al., 2006; Elkin et al., 1995). Unlike IPT or ADM, there are robust indications that CBT has an enduring effect that lasts beyond the end of treatment; six of seven relevant trials have found that patients who responded to CBT were less likely to relapse after treatment termination than patients who responded to ADM, and all four of the relevant trials found previous CBT to be at least as efficacious in terms of the magnitude of its preventive effect as keeping patients on medications ( Hollon, Stewart, & Strunk, 2006). The implication is that patients treated with CBT learn to deal with their own depressions in a way that medications just cannot match. In a recurrent disorder like depression, any indication of an enduring effect is very welcome indeed. The other closely related approach that also appears to be both efficacious with respect to the reduction of acute symptoms and enduring after treatment termination is behavioral activation (BA). This more purely behavioral intervention also seeks to get the depressed patients more active, but, unlike CBT, makes no effort to address the content of their cognitions, treating them instead as avoidance behaviors that interfere with contact with potential rewards in the environment. BA was found to be as efficacious as ADM and superior to either CBT or pillplacebo among patients with more severe depression ( Dimidjian et al., 2006) and as enduring as previous CBT and more enduring than previous ADM after treatment termination (Dobson et al., 2008). Once again we have an example of a learning-based approach that appears to provide specific skills that can be used by the patient to reduce subsequent risk. Like ADM and IPT, both CBT and BA generally are recommended for the treatment of depression by the major clinical practice guidelines ( APA, 2010; NICE, 2010). Neither is specifically relational in nature (BA focuses on behaviors and CBT adds a focus on beliefs, and both typically are conducted in an individual format), but each tends to spend as much time dealing with interpersonal issues as with more achievement-related ones. That suggests that each might be improved by adopting a more explicitly relational focus. That might take the form of partner-assisted or family-assisted (in the case of children) interventions in which the significant other facilitates the homework process, or disorder-specific interventions in which relational process maintaining the distress is specifically targeted as a part of treatment. It might even involve general couples or family therapy from a cognitive or behavioral perspective in instances in which the marital or family bonds have been adversely impacted by the depression. In this regard, it is interesting to note that marital status appears to moderate response to treatment in that married patients do better in CBT than they do on ADM, whereas patients who are not married show no evidence of differential response to the two interventions ( Fournier et al., 2009), and it has long been known that married patients do better in CBT than unmarried ones ( Burns & Spangler, 2000; Jarrett, Eaves, Grannemann, & Rush, 1991; Sotksy et al., 1991; Thase, Simons, Cahalane, McGeary, & Harden, 1991). Moreover, both approaches often incorporate specific elements of assertion training for patients who show deficits in that regard, and CBT has evolved in recent years to address childhood antecedents and the ongoing nature of

the therapeutic relationship with patients with long-standing personality disorders ( Beck, Freeman, Davis, & Associates, 2004). CBT can be readily adapted for use with couples with marital distress ( Beck, 1988), and there is no reason to think that the same could not be done for BA, which grew in part out of behavioral marital therapy ( Jacobson, Martell, & Dimidjian, 2001). There is nothing incompatible in either cognitive or behavioral models, and there is reason to think that incorporation of a more explicitly relational approach and associated strategies might enhance the efficacy of both CBT and BA. As was the case for medications, there are indications that the psychosocial interventions have specific effects with respect to acute response only among patients with more severe depressions ( Driessen, Cuijpers, Hollon, & Dekker, 2010). Among patients with less severe depression, any reasonable approach appears to work better than its absence ( Cuijpers, van Straten, Andersson, & van Oppen, 2008), and none appears to work better than simply going into generic treatment ( Cuijpers et al., 2012). What this suggests is that response to acute treatment is driven by nonspecific factors, and these nonspecific factors are as likely to be relational in nature as they are a consequence of hopeful expectations. Care must be taken not to misconstrue the direction of causality with respect to these effects. For example, higher levels of support were associated with poorer response among patients treated with pill-placebo in one study ( Strunk et al., 2010). However, this may have been a consequence of refractory patients eliciting more support from their prescribing clinicians than any iatrogenic effect of the provision of that support (there also tends to be a negative correlation between medication dose and response because most physicians only continue to raise the dosage for nonresponsive patients). Conversely, the relation between quality of the therapeutic alliance and treatment outcome in CBT appears to be driven by early symptom change that in turn is brought about by the application of the behavioral and cognitive interventions that are specific to that approach ( DeRubeis & Feeley, 1990; Feeley, DeRubeis, & Gelfand, 1999). In effect, therapists who adhere more closely to the model produce higher levels of symptom change and that in turn leads to their being better liked by their patients. Finally, it is not so clear that nonspecific factors can account for the enduring effects produced by either CBT or BA (because neither IPT nor ADM appear to have such effects) or the delayed effect that IPT has on interpersonal skills and the quality of relationships (because neither CBT nor BA as currently practiced produce such effects). It remains to be seen whether greater attention to relational aspects in the treatment context would improve upon these outcomes, but that would seem to be important to pursue. The cognitive and behavioral interventions also are efficacious in the treatment of depression in children and adolescents, although the former are more likely to respond to more purely behavioral interventions, and family process looms large in both ( Kazdin & Weisz, 1998). CBT can even be used to prevent the onset of depression in adolescents who are not themselves currently depressed but at risk by virtue of having a parent with a history of depression ( Garber et al., 2009). However, if the parent was currently depressed, their adolescent offspring derived little benefit from the prevention program. This represents a clear instance of the importance of dealing with the larger relational context and extending the program to incorporate the parent. Finally, it should be noted that many patients are treated with a combination of ADMs and psychotherapy. The conventional wisdom is that the combination retains the specific benefits of each with little downside ( Hollon et al., 2005). However, the increment in efficacy actually is not all that large (response rates go up by about 10%15%, and there is a growing concern that adding ADMs may undercut the enduring effects of CBT like it does in panic and the anxiety disorders) ( Forand, DeRubeis, & Amsterdam, in press). None of the other Western democracies

relies so heavily on medications in the treatment of depression, as the United States and the United Kingdom has invested over 300 million to train psychotherapists to deliver empirically supported psychotherapies for depression, including behavioral marital therapy ( Clark, 2011). That whole enterprise represents a triumph of the guideline process because it was based upon recommendations made to the NHS based on a systematic review of the literature ( NICE, 2010). A Relational Perspective on Depression Treatment Neither of the major guidelines current in use today takes a particularly relational perspective ( APA, 2010; NICE, 2010). This is despite the considerable research on couple and family interventions to treat depression. For example, Couple Therapy (CT) has been used to treat a variety of relationship and individual adult and child problems including depression. CT targets the couple's relational system for the purpose of improving both personal and interactional functioning. Couple interventions vary from nonspecific (a broad theory or a nonspecific approach based on couples theory) to systematic intervention programs. The latter have comprehensive, specific, and systematic treatment approaches that target clinically meaningful syndromes or situations using a coherent conceptual framework that includes specific interventions and the therapist qualities necessary to carry them out. Treatment manuals, clinical supervision, and the measurement of treatment adherence (all suggestive of high treatment integrity) are often used to monitor model fidelity. Three decades of clinical trials, systematic reviews, and meta-analysis provide mixed support the role of couple and family psychology in the treatment of depression ( Sexton, Alexander, & Mease, 2003; Sexton, Datachi-Phillips, Evans, LaFollette, & Wright, in press). Early studies produced mixed results, but generally established CT as a potentially helpful treatment for depression. Two major meta-analyses were unable to link CT to differential improvements in individual depression ( Shadish et al., 1993; Shadish & Baldwin, 2005). Barbato and D'Avanzo (2008) considered the outcome of CT compared with individual therapy for clients with depression and relationship distress and found no differential effects on depression but significant advantage for CT on relationship distress. More recent well-specified marital therapy interventions have found CT superior to no treatment and indicate that it can be considered an evidence-based alternative approach for distressed couples in which one of the partners is depressed. In fact, Baucom and colleagues suggested that marital therapy might be preferable to individual psychotherapy among martially distressed couples when at least one partner is depressed because it leads to an improvement in both depression and marital adjustment ( Baucom et al., 1998). Well-specified manualized forms of marital therapy have demonstrated an ability to alleviate symptoms of depression for clients with MDD ( Beach, Fincham, & Katz, 1998). BCT is one of the most often studied of these approaches. It is based on learning theories that have been the focus of much effectiveness research. Traditional and brief versions of BCT have been tested in conjunction with individual therapy and 12-step group counseling in the treatment of substance abuse, a common comorbid feature of depression ( Fals-Stewart, Birchler, & Kelley, 2006; Kelley & Fals-Stewart, 2007; Lam, Fals-Stewart, & Kelley, 2008). Like the earlier studies, BCT has mixed evidence when compared with available individual treatments. For example,Emanuels-Zuurveen and Emmelkamp (1996) found that BCT made significantly greater improvements than CBT or controls on measures of marital satisfaction, spousal-expressed emotion, and communication quality between spouses, but not on levels of depression.

Relational processes that moderate intervention effects also may emerge as important change mechanisms in the treatment of depression. For example, process studies suggest that within families, relational conflict/negativity is associated with poor therapy outcome. Similarly, interventions targeted at increasing positive and nonblaming patterns of communication appear to reduce negative family interactions ( Sexton et al., 2003). Other relational processes also may be important mechanisms in depression treatment. Once these mechanisms are identified, the specific procedures that bring them about can be easily integrated into many types of couple and individual approaches, potentially improving the outcomes they produce. There also is evidence to suggest that relational factors may mediate the treatment of depression. For example, in a recent review, Sexton and colleagues (in press) found strong support across studies to suggest that the Incredible Years Program (an evidence-based program aimed at helping parents manage youth behavior) has a positive impact on parental depression. The Incredible Years Program focuses on child behavior problems (like hyperactivity and depression), as well as problems between parent and child. Similarly, one might expect that reducing adolescent behavior problems might impact adolescent depression. In that case, programs like Multisystemic Therapy (MST: Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998) or some of the other evidence-based family therapy programs for adolescent behavior problems like Functional Family Therapy or Multidimensional Family Therapy might have a beneficial effect. In fact, there is preliminary evidence to suggest that MST may indirectly impact individual depression by targeting multiple problem areas in the home and in the community. Specifically, MST encourages caregivers to increase protective factors (e.g., monitoring, supervision, discipline) in an effort to minimize destructive youth behaviors ( Henggeler et al., 2009). Relational issues may be important in the treatment of depression (and vice versa) in other ways as well. For example, depression is one of the major preexisting client characteristics that predict poorer treatment gains. Snyder, Mangrum, and Willis (1993) found that couples with depressive symptoms in at least one spouse before treatment were more likely to be depressed at both termination and a 4-year follow-up. Similarly, CT appears to reduce depression if the couple is experiencing marital problems. Recent studies suggest that there are a number of empirically based prescriptive indicators for marital therapy ( Beach et al., 1998). These studies suggest that CT might be the treatment of choice (as compared with other treatments) if: (1) the depressed partner is more concerned about marital problems than about depression, (2) marital problems are viewed by the depressed partner as preceding and perhaps causing the depression, or (3) cognitive symptoms are less salient to the depressed partner than the marital problems. Lessons for Couple and Family Psychology Thus, there are indications that relationally oriented interventions can improve the clinical symptoms associated with depression. Although not all existing treatments are relational in nature, there are several examples of relationally focused treatments that are among the most efficacious interventions for depression. This suggests that the incorporation of a relational focus may enhance the efficacy of those interventions that are not currently relational in nature. Neither CBT nor BA is explicitly relational in nature, but each might benefit from mobilizing the same mechanisms that underlie the efficacy of CT. Conversely, IPT works by focusing on problems in relationships in the life of the client. As an individual intervention, IPT does not typically bring both partners into the session, but it does address the relational aspects of depression and might be a useful adjunct to be used in conjunction with couple and family

interventions. If a couple or family therapist believes that an individual adjunct is necessary, IPT might be a particularly suitable option. Couple intervention programs show promise for reducing depression when at least one member of the couple is depressed. Programs like BCT and variations like Integrative Couple Therapy (ICT) have a systematic way of conceptualizing cases and targeting critical relational patterns in a precise way over time. Currently, the strongest evidence supports CT and family therapy as effective methods to reduce other clinical problem areas (e.g., youth behavior, alcohol use/abuse etc.). The degree to which these are important in depression treatment is unknown. This area is ripe for further research to understand how to help depressed clients. There also seem to be a number of common change mechanisms that are useful to include in treatment, regardless of modality or orientation. For example, behavioral activation appears to be a critical mechanism for change in both more purely behavioral interventions like BA and more cognitively oriented ones like CBT ( Jacobson et al., 1996). If behavioral activation is a mechanism of change it could usefully be integrated into couple and family treatments. Similarly, the reduction of negativity and other blaming behaviors within couples and families seems to be a critical mechanism of change incorporated by many of the couple and family approaches. Specific techniques developed by couple and family treatments that address these mechanisms could also be integrated into work with depressed individuals and couples. There also is reason to think that using a multisystemic approach to understand the treatment of depression may enhance current treatment methodologies. For example, focusing on the relationship quality between the depressed person and others in general, and more specifically those in the family and couple systems, might well prove to be an important component in the treatment of depression. This implies that evidence-based programs beyond those already described aimed at family conflict or youth behavior problems also might have an indirect, yet important, impact on depression treatment outcomes. We need to better understand the mediating role of relational satisfaction and functioning on individual depression. Few studies in the couple and family literature in the past 20 years have addressed these linkages ( Sexton et al., in press). One example of a multisystemic approach would be to think of needed intervention programs for clients with uniquely different consequences of depression. Combining individual and couple treatments in an evidence-based way to create a system of care may produce better outcomes than either component alone, either in terms of enhance effects on any given outcome or broadening the range of different outcomes affected. For example, IPT might help a depressed spouse improve to the point that couple therapy could be successful. Moreover, if both were given a relational focus, they would be even more likely to build on one another. Because both have the likelihood of producing positive outcomes, combining the two in a relational fashion should increase the likelihood of producing the outcomes desired. Doing so might provide a way to address the consistent finding that higher levels of pretreatment depression undermine the effects of treatment ( Dimidjian et al., 2006; Elkin et al., 1995). Similarly, it is not clear that CT produces the kind of enduring effects produced by CBT or BA. Combining those approaches in an integrative fashion might provide the benefits associated with each alone, much as appears to be the case for the combination of ADM and psychotherapy ( Hollon et al., 2005). Unfortunately, the research literature has given scant attention to the impact of required dosages and the integration of different types of psychosocial treatments like IPT and BCT. As in every area of clinical practice, the role of the therapist has gone largely unstudied. Therapist impact is often considered a part of the nonspecific factors that make all therapies effective. As translators of treatment models, therapists clearly exert an important influence on

outcomes that needs to be examined ( Sexton, 2007). Therapists bring theoretical models to life for clients through an interpersonal relationship in which they implement the treatment principles and interventions. The work on treatment adherence is an attempt to understand the role of the therapist. Currently there is a mixed picture in the empirical literature: some studies suggest that adherence is directly linked to positive outcomes ( Sexton & Turner, 2010), whereas others find little evidence for an effect ( Webb, DeRubeis, & Barber, 2010). Others find that it has a curious suppressor effect that needs to be considered in conjunction with the competence with which the intervention was implemented ( Shaw et al., 1999), and still others find that it affects outcomes in a curvilinear fashion ( Hoague et al., 2008). One might expect the therapist contribution to be quite important given the relational process within therapy because therapists are the ones who deliver the causally active ingredients of treatment (specific or otherwise). The role of the therapist in instantiating the treatment and forming the alliance has been understudied. As the causally active ingredients are identified and their links to the causal mechanisms that mediate treatment effects are made clear, we should be able to unravel what makes treatment effective. A Relational Focused Approach to Treatment Guidelines Recognizing the limitations of previous reviews, Division 43 of American Psychological Association (Family Psychology) formed an Evidence-Based Treatment Taskforce to develop a relationally focused approach to guidelines that would ensure that treatments and outcomes were relationally focused. Instead of simply generating a list of which treatments work, any approach that is likely to be adopted in clinical practice will have to encompass the complexities of larger systemic models that address the way interventions are conceptualized and outcomes are assessed beyond the level of simple symptom reduction ( Sexton et al., 2011). The authors of that report recommended adopting a three-tiered model that moves from evidence-informed to evidence-based to evidence-based and ready for dissemination and transportation within diverse community settings. At the highest level, treatments are further categorized with respect to their absolute (compared with no treatment) and relative (compared with nonspecific controls or other treatments) strengths, the extent to which their underlying model of change has been supported empirically, and their contextual efficacy (the extent to which they are robust across different populations, contexts, and delivery systems). This approach goes beyond what typically is done in guideline generation, but points the way toward a system for generating recommendations that speak directly to the needs of clients and therapists alike. Adoption of such a model will require broadening the scope of the typical systematic review by looking for evidence regarding a broader array of outcomes as assessed by a broader range of respondents than often is the case. With respect to depression, additional outcomes might include measures of relational and family function and the impact of treatment on others in the clients' lives. For example, in one of the rare examples of the kind of broader assessments that the relational guidelines might propose, there is evidence that successful treatment for depression in parents is reflected in improved functioning in their offspring ( Wickramaratne et al., 2011). Although efforts to incorporate a relational context into the scoping process in guideline construction are necessary, they likely will not be sufficient. It is not likely that much of the existing literature identified in a systematic review will have been generated from a relational perspective. What this means is that important and interesting aspects of the larger treatment process will have gone unassessed, and therefore will not be available for inclusion. Although regrettable, the guideline process can provide a valuable service to the field by highlighting gaps

in the available literature that fail to serve the needs of clients and clinicians alike. Most guidelines conclude by specifying the kinds of additional research that would need to be done to improve the relevance of the treatment literature to the populations that it is intended to serve. Our strong sense is that both the relevance of the empirical literature and the specific guideline construction process could be enhanced by incorporating a more relational perspective. Conclusions Depression is an inherently interpersonal process, yet it is most often treated with medications or individual psychotherapy. Although these interventions often work, we think their effects could be enhanced by incorporating a more relational perspective with respect to how treatments are delivered and resultant outcomes that are assessed. Treatment guidelines provide a systematic way to assess the absolute and relative efficacy of different interventions. Couple and family interventions routinely show well in those reviews, particularly when problems in relationships contribute to the genesis or maintenance of distress. However, the research reviewed and the wisdom provided by treatment guidelines are dependent on whether they consider the complex interpersonal process that make up the psychotherapy process. Whether in their ability to successfully deliver a treatment protocol or nonspecific relational factors they help create, the relational processes therapists engage in with their clients are an important and understudied element in depression treatment.

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