With an estimated 17 million Americans suffering from a depressive illness, it is safe to say that mental illness is one of the most painful and persistent trials that a family will face. The American Medical Association considers it the most incapacitating of chronic conditions in relation to social functioning. More than one in ten people will suffer a serious depression at some point in their life; however nearly two-thirds do not get the help they need.
Such an illness impacts the home, specifically a marriage where one spouse is suffering from depression. Researchers who have taken a close look at relationships where depression is a major component have found that “the deck is stacked against [the couple] for as long as the illness goes untreated.” Both partners benefit from understanding depression.
Although this illness impacts so many lives it is apparent from the number of individuals who actually seek help that few victims and family members are equipped with the information they need to understand mental illness. Everyone feels sad from time to time. However, it is important to distinguish between major depression and life’s transient sadness or normal grief and mourning. The term mental illness does not refer to the temporary normal wear and tear of life that comes as a result of social and emotional concerns. Rather mental illness is described as abnormality in an individual’s mood or a brain disorder causing mild to severe disturbances in an individual’s understanding, thinking, and behaviors. Depression consists of negative behaviors such as lowered self-motivation, self-focus, and irritability that leads to strains in relationships. In Valley of Sorrow: A Layman’s Guide to Understanding Mental Illness, Alexander Morrison described the affects of mental illness:
It will have become apparent that emotional, spiritual, and physical toll from mental disease is horrendous. It exceeds the ability of words to describe. The tsunami of suffering extends outward from the victim to engulf family members, friends, Church associates, and fellow workers. All involved struggle to try to make sense out of what is going on. Dreams are discarded, hopes dashed. Panic, sorrow, and a sense of hopelessness can pervade every waking moment. (p. 115)
When disturbances are severe and last long enough they can affect the victim’s ability to function normally as an individual or productive member of society. Serious depression takes on a life of its own, all-encompassing and unlimited. Even though serious depression may disappear of its own accord, usually some sort of treatment will be necessary, and it may occur again.
Like other infirmities, mental illness appears in multiple forms requiring different treatments. Although certain characteristics will turn up consistently, it is impossible to predict how any given depression will manifest itself. For example, some people are consistently depressed for years while others will experience cycles of depression and remission.
Morrison points out there are several theories to explain depression. However, none of them can account for all aspects. For example, there is good evidence that depression runs in families. Just how much is genetic and how much is learned is unclear.
While depression still poses a mystery for scientists the study of the brain is opening doors to better treatment. Research has found that the brain, made of about one hundred billion cells, is connected by synapses. Communication is made possible through neurotransmitters which act as chemical messengers and jump between the synapses. Faulty functioning between the synapses has been found to be the beginning of the explanation for depression. However it is not certain that depression can be entirely explained by misfiring neurotransmitters and it is important to remember that this research is in its infancy.
Depression is an “internalizing” disorder, meaning it involves major disturbances in moods and emotions. It can be broken into five main types as cited by Morrison from The Essential Guide to Mental Health:
- Major Depression. Individuals are described as having a non-reactive mood. For example they cannot be cheered up by anything and experience disturbed sleep patterns. They usually are unable to think clearly or concentrate and are often fatigued. They spend hours blaming themselves for trivial things and have obsessive ruminations. They fantasize about death and dying and some commit suicide.
- Bipolar Depression. Individuals suffering from bipolar have altering periods of deep depression and manic euphoria. These extremes are often separated by periods of normal moods. This disorder starts earlier, often in the early twenties and is generally thought to be hereditary. The depressions experienced by individuals are often so deep that as many as 25 percent will kill themselves or attempt to do so if there is no treatment.
- Psychotic Depression. A variant of major depression, this differs in that the sufferer has hallucinations, delusions, or both. Often the individual may hear voices they perceive as someone telling them they are terrible people who deserve to be punished or even die.
- Atypical Depression. Unlike individuals with major depression, those suffering from atypical depression can usually be cheered up. Individuals suffering from this form can have their moods brightened by exposure to external events, such as those found previously enjoyable. However, mood improvement is temporary and sufferers will slide back into depression when the external event has ended. They are sensitive to rejection and criticism and tend to overeat and oversleep.
- Dysthymia. This is the term used for individuals who for at least two years are depressed most of the time. They are able to function despite often feeling down. They can be so accustomed to being depressed that they think is the way they are.
An understanding and an ability to interpret symptoms will give clues to a correct diagnosis. Anne Sheffield gives the following list of typical symptoms in How You Can Survive When They’re Depressed:
- A persistent and sad “empty” or anxious mood
- Loss of interest in pleasure in ordinary activities, including sex
- Decreased energy, fatigue, being “slowed down”
- Sleep disturbances (insomnia, early-morning waking, or oversleeping)
- Eating Disturbances (loss of appetite and weight or weight gain)
- Difficulty concentrating, remembering, making decisions
- Feelings of hopelessness, pessimism, thoughts of death or suicide, or suicide attempts
- Excessive crying
- Chronic aches and pains that don’t respond to treatment
As mentioned, type and severity of symptoms will vary. Those who suffer from a mild and untreated depression may be able to function well enough to fool those around them, but it is when depression goes beyond a mild form that it can wreak havoc in the individual’s life.
Anne Sheffield makes an unofficial list of symptoms of depression gathered from the experiences of caretaker spouses in Depression Fallout: The Impact of Depression on Couples and What You Can Do to Preserve the Bond:
- Self-absorbed, selfish, demanding, unaware or unconcerned about the needs of others
- Unresponsive, uncommunicative, aloof, withdrawn
- Uninterested in sex and dismissive or distrusting of a partner’s tenderness and affection
- Fractious, querulous, combative, contrary; finding fault with everything
- Demeaning and critical of partner
- Changeable and unpredictable, illogical and unreasonable
- Pleasant and charming in public and the opposite at home
- Prone to sudden, inexplicable references to separation or divorce
- Prone to workaholism or avoidance of all responsibility
- Increasingly dependent on alcohol and drugs
- Obsessively addicted to television, computer games and computer porn sites, and other compulsive distractions
Depression and the Family
Researchers have found depression tends to run in families. And while it is known that depression has a genetic connection, researchers have yet to discover exactly how.
Families with predispositions for mental illness face many challenges. For example, there are reports of victims who have records of past hospitalizations facing reduced career opportunities, receiving limited insurance coverage, and even being denied coverage from insurance companies. In addition many families will face social stigmas. Victims may encounter fears of being shunned, whispered, or laughed about. Also those suffering may believe spouses, friends, children, and even employers may abandon them.
The social costs of depression are not limited to the depressed individual but include family members. In sum, a large part of the burden for victims and their family members will be “the prejudice, ignorance, misunderstanding and social stigma which characterize the attitudes of many in society towards the mentally ill.”
The Facts About Depression and Marriage
Depression and marital problems have reached epidemic proportions. For example depression affects 10%-25% of the population and one half to two thirds of all marriages are likely to be affected by separation or divorce or both. This does not, however, mean that separation and divorce always lead to depression, or that depression always leads to separation and divorce. However, when individuals do seek help from a mental health facility, marital problems and depression are among the most prevalent problems. Furthermore research indicates that one of the most consistent predictors of difficulties in relationships is the negative effect of depression in one partner.
Research has found that the stress of taking care of someone who is mentally ill can trigger depression. This is crucial information when tied with other findings. For example more than 50% of depressed individuals report marital problems and depression has been found to precede marital problems, which in turn results in an increase of the one-year likelihood of divorce by a startling 70%. Thus, depression leads to marital problems and marital problems in turn lead to depression.
While it is certainly not depression alone that breaks up relationships, a growing number of experts believe depression is often the cause rather than the result of a divorce. For example, two ways in which the functioning of a marriage is affected by depression are first, the way the couples communicated when fighting and second, how they mentally represented their relationship and its functioning.
The Spouse as Caregiver
To be a spouse and also the caregiver of a depressed person can have a strong impact on the individual. Patients’ partners have been found to be at high risk of developing depression themselves, and report an increase in depressive symptoms. It is no surprise that spouses as caregivers are the most at risk because they have the most invested in the relationship.
In order to understand how depression wreaks such havoc, it is important to compare a loving and healthy relationship to the relationship troubled by depression. Individuals who form a couple bring with them individual beliefs about love, marriage, intimacy, gender roles, etc. Once a couple is formed there are attributes that act to help a relationship or marriage function in a healthy way. For example, there are conscious efforts to develop emotional closeness and show love. Individuals in strong relationships take time to really listen to each other’s hopes, dreams, feelings, and concerns. Strong marriages will include individuals who solve problems together, do family work together, and are based on equality in the marriage.
The Family: a Proclamation to the World declares a “Husband and wife have a solemn responsibility to love and care for each other . . .” Marriage contributes significantly to an individual’s self-esteem. It’s no wonder that when such an influential role is threatened or when an individual perceives they have failed, a sense of failure may permeate all aspects of life.
Spouses of depressed individuals come with expectations, dreams, and hopes. So when they examine their lives after becoming a caretaker they see multiple limitations and losses particularly concerning the partnership. Spouses of depressed individuals report restrictions in their social and leisure activities, a fall in the family income, and a strain in the marital relationship.
Not only do spouses deal with life’s daily hassles they also have to deal with the symptoms of their partner’s depression and inability to help or participate in the relationship. Often the caretaker is left with an increased work load and a decreased support system. The caretaker spouse often has more responsibility for maintaining family functioning and the well-being of any children. This lack of spousal support is one reason caretaker spouses may have an increased risk of depression. The won’t ask friends or neighbors for help with day-to-day tasks due to shame or fear, and this can lead to a general avoidance of social situations in an attempt to avoid uncomfortable questions.
Sheffield gives words to the emotions caretaker spouses experience in How You Can Survive When They’re Depressed, “[caretaker spouses] wonder why no one understands that another’s depression directs and colors our lives, our thoughts, our feelings, just as surely as it does those of the depressive.” For a caretaker, living with a depressive who views the world through despair is disheartening and leads to many of the same feelings the depressed person feels.
The problems for the caretaker begin out of the public view where the caretaker spouse is an eye-witness as their friend and lover transforms into someone they don’t recognize. The despair only increases when the caretaker spouse realizes that no matter how much love or sympathy they show they are not able to help their spouse and they begin to lose themselves as well.
The caretaker often finds life with a depressed partner is different from how they had imagined. Often they will have negative attitudes toward their depressed spouse and may even see their depressed partner as a burden. Many caretakers will talk about their depressed partner as though he or she were another child. Ironically these feelings can lead to the same feelings the depressed person experiences such as self-doubt, demoralization, anger, and a desire to escape.
As a result, both members view their partner as more “negative, hostile, mistrusting, and detached and less agreeable, [and] nurturing.” With such feelings, it’s no wonder that hurtful acts such as name calling, ridiculing, or negative social comparisons occur. This lack of mutual respect and courtesy can lead to psychological abuse. Such abuse is especially painful because it occurs between two individuals who have promised each other and the law to nurture and cherish each other.
Under such circumstances, what can be done for the depressed person, the caretaker, and the relationship?
Learning To Live with Depression
Much advice is written as though the process of diagnosis and treatment of depression is easy or occurs in a perfect world. However, those in the role of caretaker know it’s much harder then it seems. Sheffield describes the position of a caretaker spouse well, “Loving someone who is depressed brews confusion, frustration, resentment, and pain.” But it’s important to remember that family members are vital to helping those with mental illness.
The problems are often enhanced by the social stigma surrounding depression. Often, individuals who have loved ones suffering from depression have fears of being ridiculed or shunned if they are involved in seeking treatment. This sort of social discrimination can play a role in a person’s depression if the individual takes the discrimination personally and allows it to affect self-esteem. However there is hope discrimination will decrease as knowledge increases and people realize “no one is immune from mental disease.” Depression does not discriminate. Where individuals differ is in their response to feelings.
The blame game is often the source of much misunderstanding that leads to increased distress. When things go wrong in life it is common to look for someone to blame. It’s no surprise, then, that many individuals try to discover that thing which has caused the pain and despair and depression. The victims may even blame themselves for being sick and spouses might tear themselves apart trying to discovery where they went wrong.
However trying to attribute blame is pointless and results in unnecessary suffering for the depressed and the caretaker. It wastes energy better spent in learning more about the illness and possible treatments. Those who suffer from depression don’t choose to be sick and are not simply lacking willpower; “they cannot, through any exercise of will, get out of the predicament they are in.”
A better use of time and energy would be to search for understanding and increased capabilities for compassion and patience. Developing patience through increased understanding is one of the best tools a caretaker spouse can acquire. Patience will be especially beneficial when dealing with the continuous ups and downs of depression and even the constant care needed for patients who may be in danger of suicide.
Caretaker spouses can provide encouragement and realistically remind the depressed of God’s love and the love of family members. It’s important not to lose patience and to avoid saying things like “snap out of it” or “get a little backbone.” The importance of avoiding such phrases is exemplified through this quote from Helping and Healing Our Families:
Anyone who has ever witnessed the almost unbearable pain and uncontrollable weeping of a severe panic attack, or the indescribable sadness of a severely depressed person who cries all day and retreats in hopeless apathy, would never think for a moment that mental illness is just a matter of willpower.
Recognizing that depression and not the spouse is the villain is a huge step. However while patience, compassion, and love provide support and are crucial they are not a cure for the illness. Therefore, it is important to seek knowledge of the illness and of treatment options.
Understanding and Treatment
Understanding depression as an illness with a specific biological process can help caretakers to take an active role in treatment. Caretakers who have little understanding of depression may try to control the ill person as if the depressed spouse were a child. Having knowledge of the illness and where it comes from will help caretaker spouses to better cope and communicate with health care professionals. This includes understanding the length of time medication can take to become active and learning behavioral techniques that are crucial to the healing process. Sheffield put the importance of knowledge into perspective:
Knowledge is power; choices should be informed by an appreciation of the advantages and limitations of any treatment. Asking the right questions of the professionals reduces uncertainty and stress, and will help both partners assess progress, or lack of it, more accurately.
Encouraging the depressed to get treatment may require more than gentle assertiveness. Sheffield points out that the better informed a caretaker spouse is, the better able to help the depressed person overcome resistance and seek appropriate treatment.
However it’s important to seek help and treatment promptly. Quicker and better results can be expected from cases that received professional help early, before the illness becomes deep-seated and therefore less easily treated.
There are many forms of treatment and it can be daunting trying to understand what the doctors are talking about. The type of treatment prescribed will be determined by the form of depression the depressed person suffers from. For the caretaker, knowing what is medically wrong is essential to the depressed spouse’s well being and can provide a foundation for the future. It’s invaluable for the caretaker to learn about depression and how to deal with it. This is especially true since depressed individuals may not be good questioners or listeners, may distort information based on moods, and are often not the best judges of their progress.
Many victims of depression will find their suffering greatly reduced with proper treatment. An absence of necessary treatment increases the potential for depressed individuals to harm themselves and others.
Professional care providers often use a three-pronged treatment approach that includes social, biological, and psychological aspects of depression. Many sufferers seek help from primary care physicians rather than specialists such as psychiatrists and psychologists. In order to understand the treatment process, it’s helpful to understand the difference between psychiatrists and psychologists and the roles each fill.
- Psychiatrists. These physicians have special training in psychiatry and neurology. In addition they are trained to provide psychotherapy. Psychiatrists can prescribe medication and with their medical training can determine if a patient is suffering from some other medical problem which could cause symptoms of mental illness.
- Psychologists. Psychologists are often trained at a doctoral level and provide cognitive behavioral therapy to help those suffering from depression to understand why they act and think as they do. In addition, psychologists assist victims to develop behaviors to aid in the healing.
There is controversy within the medical community between medication and psychotherapy. How medication and psychotherapy are used and in what combination will depend on the mental health professional and the needs of the patient.
Herbal and other remedies are not subject to the FDA requirements for safety and efficacy trials. While these remedies may have been tested or researched the studies have been poorly designed and have been tested against placebos and not against antidepressants. Nonprescription remedies can be risky and have not been found to be the best remedy.
Current antidepressants, if used correctly, have been found to provide help to 60% to70% of those suffering from depression. One study found antidepressants to be helpful in alleviating most severe symptoms of depression and enabling sufferers to face life’s problems although they did not alleviate the problems. Medication can reverse bizarre behavior and assist in healing the brain and improving effectiveness of psychotherapy. The influence of an optimal dose of medication can occasionally be felt within ten days; however, for most sufferers a more gradual change, possibly taking up to twelve weeks, is more normal.
Caretakers should be aware that patients may start skipping pills and even discontinue them because they can’t discriminate between the pre and post-medicated self. In the minds of the depressed, behavior changes as a result of medication may not be noticed and this can lead to discouragement and the eventual stopping of medication.
Knowledge about medication a depressed partner is taking is only the beginning. A caretaker should maintain good communication with the care provider as they can provide good input as a close observer of the depressed.
Taking Time Out
With all the responsibilities and weight that caretakers face it is important they take time out for themselves. They spend much time caring for children and fulfilling outside roles, such as employee. Caretakers will also bear the brunt of the depressed moods of their spouses, which can lead to personal demoralization.
Sheffield describes five stages that caretaker spouses go through when they find themselves in a marriage with depression. She terms these stages “depression fallout,” or the response to someone else’s despair starting with the first confusing meeting with the illness. Those suffering from depression fallout often search for the source of the problem within themselves before realizing that an illness afflicts the spouse. The five stages are:
- Stage One: Confusion.Most individuals start out confused and asking questions, such as, why is the person I love becoming distant? Why is he or she dissatisfied, lethargic but demanding? They will often assume the fault to be their own.
- Stage Two: Self-Doubt. During this stage individuals ask themselves questions trying to discover how they went wrong and accepting blame.
- Stage Three: Demoralization. At this point they are confused and experience a loss of self-esteem. They feel deprived of spirit and courage and often have their morale destroyed.
- Stage Four: Anger. Individuals in this stage feel drained and are sick with guilt. Anger is directed not only at the spouse but at themselves.
- Stage Five: The Desire to Escape. By this stage individuals are wrestling with the decision of whether to stay or leave. Individuals feel guilt about such feelings because they understand that the spouse has an illness.
As a result, it is important that caretakers maintain lives of their own. Not only is this beneficial for the caretaker but it will allow him or her to be of most help to the depressed spouse. It is important that caretakers find time each day, even if it’s only a few minutes, to recharge themselves. Some suggestions for recharging include: reading a good book, talking to a trusted friend, or calling a family member. The method is not as important as realizing that nurturing the self is vital to the health of the relationship.
Depression is an illness that can greatly impact a marriage if it goes untreated. Not only does the depressed individual live with the symptoms of the illness but the caretaker spouse also is subject to similar symptoms and increased responsibility with less support.
More information on mental illness is available for the general public online at:
To accompany her books Anne Sheffield has created a website that includes a free discussion board that may be helpful for some individuals. Follow the link to the main page and then click on message board:
Written by Jaelynn R. Jenkins, Research Assistant, edited by Alan Springer, Ph.D., Marriage and Family Therapist, and Stephen F. Duncan, Professor, School of Family Life, Brigham Young University.
Dealing With Depression In Marriage is adapted from the website Forever Families. For references, see the original.