Couple‐based Intervention for Depression: An Effectiveness Study in the National Health Service in England

• Author: Donald H. Baucom,Sarah Corrie,Efthymia Molyva,Sara E. Boeding,Michael Worrell,Melanie S. Fischer,Jennifer M. Belus
• Date: 01 June 2018
• Published date: 01 June 2018
• DOI: http://doi.org/10.1111/famp.12332

Couple-based Intervention for Depression: An

Effectiveness Study in the National Health Service in

England

DONALD H. BAUCOM*

MELANIE S. FISCHER*

MICHAEL WORRELL

†

SARAH CORRIE

†

JENNIFER M. BELUS*

EFTHYMIA MOLYVA

†

SARA E. BOEDING

‡

This study represents an effectiveness study and service evaluation of a cognitive behav-

ioral, couple-based treatment for depression (BCT-D) provided in London services that are

part of the “Improving Access to Psychological Therapies” (IAPT) program in England.

Twenty-three therapists in community clinics were trained in BCT-D during a 5-day work-

shop, followed by monthly group supervision for 1 year. The BCT-D treatment outcome

findings are based on 63 couples in which at least one partner was depressed and elected to

receive BCT-D. Eighty-five percent of couples also demonstrated relationship distress, and

49% of the nonclient partners also met caseness for depression or anxiety. Findings demon-

strated a recovery rate of 57% with BCT-D, compared to 41% for all IAPT treatments for

depression in London. Nonclient partners who met caseness demonstrated a 48% recovery

rate with BCT-D, although they were not the focus of treatment. BCT-D was equally effec-

tive for clients regardless of the clinical status of the nonclient partner, suggesting its effec-

tiveness in assisting both members of the couple simultaneously. Likewise, treatment was

equally effective whether or not both partners reported relationship distress. The findings

are promising regarding the successful application of BCT-D in routine clinical settings.

Keywords: Treatment for Depression; Cognitive-behavioral Couple Therapy; Improving

Access to Psychological Therapies; Cognitive Behavioral Therapy

Fam Proc 57:275–292, 2018

Providing easily accessible, cost effective, empirically supported mental health servic es

to the general public is an immense challenge in all countries. Often there are barriers

to accessing much needed services, including high costs, an inadequate number of treat-

ment providers, and a lack of public awareness regarding available treatment options and

how to access them. Particularly challenging within this context is ensuring that treat-

ment providers are delivering interventions that have strong empirical support. In

*Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC.

†

Central & North West London Foundation and Trust, London, UK.

‡

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Clinic, Durham, NC; Veterans Affairs

Medical Center, Durham, NC.

Correspondence concerning this article should be addressed to Donald H. Baucom, Department of

Psychology and Neuroscience, University of North Carolina at Chapel Hill, CB# 3270, Chapel Hill,

NC 27599-3270. E-mail: donbaucom@unc.edu

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Family Process, Vol. 57, No. 2, 2018 ©2017 Family Process Institute

doi: 10.1111/famp.12332

response to this need for wide-spread access to empirically supported treatments, in 2008

England began one of the most ambitious efforts undertaken by any country to provide

mental health services within the National Health Service (NHS) and labeled this effort

“Improving Access to Psychological Therapies,” or IAPT. In developing IAPT, an impor-

tant guiding principle was that treatment was to follow the National Institute for Health

and Clinical Excellence (NICE) guidelines (National Institute for Health and Care Excel-

lence, 2015), with an initial emphasis on adults suffering from depression and anxiety dis-

orders. The NICE guidelines include the following interventions as appropriate for

treating adult depression: antidepressants, cognitive behavioral therapy (CBT), interp er-

sonal therapy (IPT), behavioral activation, and behavioral couple therapy (BCT), referred

to as cognitive-behavioral couple therapy (CBCT) in the USA.

1

To remain consistent with

NICE terminology, the couple-based intervention in this paper will be referred to as

behavioral couple therapy for depression (BCT-D). One of the guiding principles of IAPT is

that clients should have choice among NICE approved treatments for which they qualify.

While a large number of providers have been trained in IAPT services (clinics) throughout

London (Gyani, Shafran, Layard, & Clark, 2013), the dissemination of BCT-D within IAPT

is a more recent effort. The current paper presents the results of an initial service evalua-

tion of BCT-D within IAPT in London as a preliminary assessment of BCT-D as it is prac-

ticed in high volume, routine clinical care settings with implications for effe ctiveness

research. Because all BCT-D providers were trained in the same training model by one

group of trainers and were within the first year of their initial BCT-D program, this stud y

also more generally provides information regarding the dissemination of couple- based

interventions in real world settings.

The rationale for a couple-based intervention for depression derives from two sets of

findings. First, both cross sectionally and longitudinally, depression and relationship dis-

tress are associated in a reciprocal fashion. More specifically, the presence of relationship

distress predicts an increase in the subsequent development of depression in one partner,

and the presence of depression increases the likelihood that the couple will become rela-

tionally distressed (Whisman, 2001a; Whisman & Bruce, 1999; Whisman & Uebelacker,

2009). Second, there is strong empirical support for couple therapy and couple-ba sed inter-

ventions for treating depression (and improving relationship satisfaction) (Barbato &

D’Avanzo, 2008; Bodenmann et al., 2008; Cohen, O’Leary, & Foran, 2010). However, these

findings are based on randomized controlled trials within university settings (i.e., efficacy

studies) and often involve high levels of training for therapists, frequent supervision and

adherence to a detailed treatment protocol, and clients who must meet somewhat strict

selection and exclusion criteria. At present, there are no studies involving treating depres-

sion with a couple-based intervention in routine clinical settings (i.e., effectivenes s

research), and comparable effects to efficacy outcomes cannot be assumed. For example,

Halford, Pepping, and Petch (2016) showed that the rate of couple recovery from relation-

ship distress in clinical effectiveness trials was less than half of that reported in efficacy

trials. Similarly, when comparing efficacy and effectiveness trials for individual or group

CBT for depression (no partner involvement), Hans and Hiller (2013) concluded that CBT

1

For a history of the development of IAPT and how it has been implemented and evaluated, see Clark

(2011). The term “BCT for depression” (referring to behavioral couple therapy) is used in the NICE guideli-

nes in England, yet it is important to note that the intervention is consistent with the term “cognitive-

behavioral couple therapy” (CBCT) employed in the United States. This approach incorporates current

perspectives on behaviorally oriented approaches to assisting couples with a comprehensive inclusion of

behavioral, cognitive, and emotional factors addressing individual, relationship, and environmental fac-

tors. Thus the current approach is not to be confused with earlier limited behavioral approaches that at

times in the United States have been referred to as “behavioral couple therapy” or “traditional behavioral

couple therapy,” which emphasize behavioral factors almost exclusively.

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