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Depression: A Family Matter

Families do better than patients at recognizing depression and mania. Depression disrupts family life, yet families can be major forces of care, comfort, even cure.

Depression is not just a medical matter. It's a family one, too.

The behaviors and mood of a depressed person affect the whole family. There's the irritability, which sets off conflicts and derails family dynamics. The negative thought patterns, which become a prism of pessimism for everyone. The withdrawal that literally disrupts relationships and breeds wholesale feelings of rejection. There are major responsibilities that get displaced. There is a general burden of stress.

And yet, families can be major forces of care, comfort, even cure. They are crucial to proper recognition and treatment of the disorder, not just at the beginning but throughout. They are the de facto caregivers, willingly or not. They contribute powerfully to the emotional atmosphere the depressed person inhabits, and so can be agents of recovery. Or not.

Yes, depression has a huge impact on families. And families have a huge impact on depression.

Nassir Ghaemi, assistant professor of psychiatry at Harvard, contends it's not even desirable to make the correct diagnosis of depression without the family. For one thing, many people—particularly those at either end of the age spectrum and those with medical conditions—don't realize they are depressed or may attribute symptoms to other things. The perspective of family members is useful.

But it's downright essential for prescribing. "To treat any depression accurately, you have to know whether it is unipolar or bipolar—in other words, whether the person has been manic in the past," says Ghaemi. "Our research shows that 50 percent of patients are not even aware they are manic when experiencing mania. Family members recognize manic symptoms twice as often."

Then there's the need for continuing diagnosis, because one episode of depression doesn't eliminate the possibility that mania will develop, especially in persons under 30. Bipolar disorder typically begins with a depressive episode, and the average age of onset is 19. But a first manic episode does not occur until age 25, on average.

The younger the patient, the greater the risk they will end up having bipolar disorder. Standard antidepressants could precipitate mania. In those cases, Ghaemi considers it essential to warn patients and family about manic symptoms. Even in established cases of bipolar disorder managed with mood stabilizers, the Harvard psychiatrist considers family members indispensable for the early recognition of manic symptoms.

When prospective patients first call for an evaluation, Ghaemi asks that they bring in a family member. "Then I ask the family to feel free to call me any time the patient is developing mood symptoms of any variety."

Confidentiality is not a problem. "There's no confidentiality constraints against my ear being open," says Ghaemi. "I can't say anything, but I can listen to what they say."

What's more, the attitude of family toward medications prescribed can spell the difference between compliance and continuing illness. If family members are not on the side of treatment, Ghaemi teaches patients to cope with that. Ideally, a family supports the treatment plan, reminding the patient to take medication.

Julie Totten knows how much of a family matter depression is. She learned the hard way, having grown up—perhaps too quickly—in a household ravaged by depression.

To spare others the pain she endured as a sister and daughter of undiagnosed depression, she has established an organization dedicated to helping families recognize the disorder and motivating them to seek and manage treatment.

Families for Depression Awareness ( urges family members to show they care, because depressed people feel isolated in their pain and hopelessness. "Depression often divides families," says Totten. Some people don't understand it and want to run far from it.

"Others do everything in their power to get a person well, including hunting out magic cures." Ultimately, she says, "they realize there's no such thing. And they feel cheated. Depression has to be managed."

No one disputes the need for treatment of the depression. Psychologist David Miklowitz, goes one step further. He has developed a treatment targeting the family, on the grounds that family dynamics affect the outcome of mood conditions.

Research shows that the course of the illness is worsened by "expressed emotion," a measure of attitudes expressed by a caregiver relative to a psychiatrically ill patient. It consists of criticism, hostility and emotional over-involvement. An atmosphere of high expressed emotion multiplies the chance of relapse two to three times, reports Miklowitz, professor of psychology at the University of Colorado.

Expressed emotion usually sets up a conflictual relationship between patient and relative. And that has biological effects. "Patients become hyperaroused," explains Miklowitz. "Imaging studies show that fear centers are activated in the brain when depression-susceptible people hear a family member criticizing them."

Expressed emotion "seems to impair the maximal benefit of medications," adds Harvard's Ghaemi. "Part of the problem is medications work best for symptoms. They don't necessarily work best for recovery of function. Complete functional recovery occurs in about 50% of unipolar patients and in about a third of bipolar patients. Patients seem to do better with interventions geared toward family issues."

Enter family-focused therapy, a treatment Miklowitz initially devised for families of bipolar patients but which is now also applied to those of unipolar patients. It aims to reduce expressed emotion by educating families about depression, training them in communication skills, and boosting their problem-solving skills. Since the early nineties, three studies have demonstrated that it dramatically reduces the relapse rate. A major national trial of the treatment program in bipolar disorder is underway.

"The idea of psychoeducation is just starting to hit the market," observes Miklowitz. "Family education should be part of the treatment, especially for recurrent disorders like depression."