Both research and experience have long informed mental health professionals of a strong link between depression and relationship dissatisfaction. So why is psychiatry losing that awareness? One major reason is the disappearance in psychiatry of psychotherapy (talk therapy), in which it becomes obvious just how important our significant relationships are to our mental health.
According to the August 2008 Archives of General Psychiatry article "National Trends in Psychotherapy by Office-Based Psychiatrists," the percentage of patient visits to a psychiatrist involving any psychotherapy fell to 28.9% in 2004-2005 (from 44.4% in 1996-1997), and the percentage of psychiatrists using psychotherapy with all their patients dropped to only 11 percent in 2004-2005.
Psychiatry has increasingly replaced psychotherapy with something called "medication management," which largely consists of symptom assessment and prescription updates. Medication management typically takes ten or fifteen minutes and is scheduled every two to three months.
When doctors only offer medical management sessions every couple of months, they can neglect to ask about a patient's marriage; and even if they do ask about it, they are likely to accept at face value a stoic patient's reply that "my marriage is fine." A competent psychotherapist knows that patients, initially, often avoid acknowledging an abusive or neglectful relationship, the pain of which may be too overwhelming; and that it can take a great deal of time and repeated gentle questioning to discover important truths.
In quality psychotherapy, a mental health professional takes the time necessary to create trust, which is required to effectively explore a patient's relationship life. Miserable significant relationships or the absence of any significant relationships are common sources of depression. And major antidotes to depression are genuine friendships, satisfying intimacy, and supportive community.
The Interactional Nature of Depression (1999), edited by psychologists Thomas Joiner and James Coyne, documents with hundreds of studies the interpersonal nature of depression -- and its interactional vicious cycle. In one study, the best single predictor of depression relapse was found to be the response to a single item: "How critical is your spouse of you?"
In another study of unhappily married women who were diagnosed with depression, 70 percent of them believed that their marital discord preceded their depression, and 60 percent believed that their unhappy marriage was the primary cause of their depression.
Depression is fueled by overwhelming emotional pain, and an unhappy significant relationship is one common source of such pain. Other common sources of pain that can fuel depression include workplace alienation, poor physical health, and financial difficulties. People use a wide variety of "compulsions" (actions one feels that are not freely chosen) to shut down overwhelming pain or to distract from it. Depression is one of those compulsions (others include substance abuse, overeating, and gambling).
In a vicious cycle, the pain of an unhappy marriage can fuel a wife's or husband's depression; then that depressed wife's or husband's negativity can result in their spouse's negative reactions; these negative reactions can make the marriage even unhappier; and the pain of that increasingly unhappy marriage can serve as additional fuel for depression.
Social isolation and loneliness can also fuel depression. Sociologist Robert Putnam in Bowling Alone (2000) reports, "Low levels of social support directly predict depression, even controlling for other risk factors." Putnam adds that "countless studies document the link between society and psyche: people who have close friends and confidants, friendly neighbors, and supportive coworkers are less likely to experience sadness, loneliness, low self-esteem, and problems with eating and sleeping."
Why has medication management replaced psychotherapy for psychiatrists? The simple answer is money.
Insurance companies favor medication management because the cost of a medication management session is approximately half the cost of a psychotherapy session, and medication management sessions are routinely scheduled once every two to three months rather than weekly, as is psychotherapy.
Drug companies -- exposed in recent Congressional investigations as being corrupting forces in psychiatry -- also favor medication management, the focus of which is primarily drugs.
Psychiatrists themselves can make far more money with medication management than psychotherapy. While psychiatrists bill about half as much for a medication management session as they do for a psychotherapy hour, they can conduct a minimum of four medication management sessions for every one psychotherapy session. Moreover, many psychiatrists do five- or ten-minute medication management sessions, so they can complete five or six of these sessions in the same hour that it would take to do a psychotherapy therapy session (including preparation and note writing). Psychotherapy also requires far more emotional involvement than medication management, making it psychologically difficult for a psychotherapist to work as many patient hours as a medication manager. The bottom line is that psychiatrists who offer only medication management routinely make nearly triple the income as do psychiatrists who provide mostly psychotherapy.
Psychotherapy is effective for some depressed people, as it can help them extricate from abusive relationships and gain knowledge of how to form caring relationships, but psychotherapy is no panacea. There are incompetent and mediocre psychotherapists; and even the best psychotherapist will tell you that they are not always successful, as sometimes they can only help patients gain awareness of the sources of their depression but are unable to help them effect necessary transformations.
While psychotherapy may not help all depressed people, the loss of psychiatrists practicing psychotherapy means the loss of basic common sense in psychiatry about depression. To the extent that the general public trusts psychiatry pundits, both depressed and nondepressed people will lose awareness that overwhelming emotional pain is the fuel of depression -- and that relationship dissatisfaction is a major source of such pain. If we lose that awareness, we lose a piece of our humanity.
Bruce E. Levine is a clinical psychologist and author of Surviving America's Depression Epidemic: How to Find Morale, Energy, and Community in a World Gone Crazy (Chelsea Green Publishing, 2007).www.brucelevine.net