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(PSYCHIATRIC TIMES) - The current most commonly used model for the understanding and treatment of depression is a biomedical one that emphasizes symptom resolution. The mainstay of contemporary psychiatric treatment is pharmacotherapy, and of contemporary psychological treatment, cognitive-behavioral therapy. Both pharmacotherapy and psychotherapy can be effective treatments for depression, but, in spite of their efficacy, a significant minority of patients with depression do not respond well and continue to experience problematic residual symptoms (Hirschfeld et al., 2002; Thase et al., 2001). Double-blind, controlled trials for outpatients with mild-to-moderate depression have reported remission rates of 46% for medications, 46% for psychotherapy and 24% for control conditions (Casacalenda et al., 2002), leaving up to 50% of patients with some degree of persistent symptoms.

A biopsychosocial model that draws attention to the social environment in which the depressive episode evolves may be a more helpful way of approaching the management of major depression. There are many reasons to pay attention to the social context of depression in addition to the generally insufficient effectiveness of biological and/or psychological treatments by themselves.

The Interpersonal Context of Depression

More than half of patients with major depression experience distressing and problematic family functioning (Coyne et al., 2002; Keitner et al., 1995). Families of patients with chronic forms of depression experience similar levels of family dysfunction as patients with acute depression (Keitner et al., 2003). Changes in the social environment and the level of social support have a clear association with depression (Paykel and Cooper, 1992). Marital difficulties, especially arguments, are the most frequently reported events prior to the onset of depression (Paykel et al., 1969). Lack of support and inability to confide in a spouse can in itself increase the risk for depression (Parry and Shapiro, 1986). Even within a maritally distressed group of subjects, couples comprised of one partner with depression tended to have the lowest level of marital cohesion (Beach et al., 1988).

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