With an estimated 17 million Americans suffering from a depressive illness13, it is safe to say that mental illness is one of the most painful and persistent trials that a family will face8. The American Medical Association considers it the most incapacitating of chronic conditions in relation to social functioning12. 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 need9, 13.
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"12 (p. 11). 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. This is unfortunate because mental illness is the number one psychiatric disability of our time and takes place within relationships, often having harmful effects on them5, 7, 10.
Everyone feels sad from time to time. However, it is important to distinguish between major depression and life's transient sadness9 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 concerns8. 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 behaviors8. Depression consists of negative behaviors such as lowered self-motivation, self-focus, and irritability that leads to strains in relationships10. In his book, Valley of Sorrow: A Layman's Guide to Understanding Mental Illness, Alexander Morrison described the affects of mental illness in the following manner:
"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 society8. Serious depression takes on a life of its own, all-encompassing and unlimited9. Even serious depression may disappear of its own accord but usually some sort of treatment will be necessary, and it may occur again9.
Like other infirmities such as cancer or heart disease, mental illness appears in multiple forms with different characteristics requiring different treatments9, 13. Although certain characteristics will turn up consistently, it is impossible to predict with complete accuracy how any given depression will manifest itself for example some people are consistently depressed for years at a time while others will experience cycles of depression and remission13.
Morrison9 points out that there are several theories to explain depression. However, despite the aptitude of these theories none of them can account for all aspects of the mental illness. For example there is good evidence that depression runs in families. Just how much is genetic and how much is learned from living with depressed individuals or other environmental factors is unclear9.
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 between the cells through neurotransmitters12. Neurotransmitters 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 depression12. However it is not certain that depression can be entirely explained by misfiring neurotransmitters and it is important to remember that this research is still in its infancy9.
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 Morrison9 fromThe Essential Guide to Mental Health:
- Major Depression. Individuals with this condition are described as having a non-reactive mood. For example they cannot be cheered up by anything and experience disturbed sleep patterns. These individuals usually are unable to think clearly or concentrate and are often fatigued with low energy. Individuals with major depression spend hours blaming themselves for trivial things and experience obsessive ruminations. Sufferers of major depression fantasize about death and dying and some commit suicide.
- Bipolar Depression. Individuals suffering from bipolar experience 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. Bipolar disorder is generally thought to be hereditary. The depressions experienced by individuals with bipolar disorder 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 form of depression differs in that the sufferer develops hallucinations, delusions, or both. Often the individual may hear voices when no one is talking. Those individuals perceive the voices as someone telling them that they are terrible people who deserve to be punished or even die.
- Atypical Depression. Unlike an individual with major depression, those suffering from atypical depression can usually be cheered up. Individuals suffering from this form of depression 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. Individuals suffering from atypical depression 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. Individuals suffering from dysthymia are able to function despite often feeling down. They can be so accustomed to being depressed that they think that is the way they are.
An understanding and an ability to interpret symptoms will give clues to a correct diagnosis of depression13. Anne Sheffield gives the following list of typical symptoms in her book 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 above, type and severity of symptoms will vary and will look different for each individual. Those who suffer from a mild and untreated depression may be able to function well enough to fools those around them, but it is when depression goes beyond a mild form that it can wreak havoc in the individual’s life12.
In addition, Anne Sheffield12 makes an unofficial list of symptoms of depression gathered from the experiences of caretaker spouses in her book 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 that depression tends to run in families13. And while it is known that depression has a genetic connection, researchers have yet to discover exactly how9.
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 companies8. In addition many families will face social stigmas about depression. Victims may encounter fears of being shunned, whispered, or laughed about8. Also those suffering from depression may believe that spouses, friends, children, and even employers may abandon them8.
The social costs of depression are not limited to the depressed individual but include family members1. 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"8 (p. 289).
The Facts About Depression and Marriage
Depression and marital problems have reached epidemic proportions in today's society3. 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 both3. This does not, however, mean that separation and divorce always lead to depression, or that depression always leads to separation and divorce. But it should be kept in mind that when individuals do seek help from a mental health facility, marital problems and depression are among the most prevalent problems for which treatment is sought4. Some researchers suggest that 50% of all distressed couples have at least one member who is clinically depressed3. Furthermore research done on depression and the marital relationship indicates that one of the most consistent predictors of difficulties in relationships is negative affect (depression, etc.) in one partner10. And indeed couples in which one spouse is depressed report more uncomfortable feelings and negative well-being when compared to non depressed couples5.
Research has found that the stress of taking care of someone who is mentally ill can trigger depression12. 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%1, 6. This is a lot of information and another way to understand this information is to realize that marital problems and depression form a detrimental cycle. Depression leads to marital problems and marital problems in turn lead to depression.
Marital problems and depression take on a cyclical relationship as shown by additional evidence suggesting that marital problems influence the onset, maintenance, and treatment of depressive episodes6, 7. For example difficulties in marriage, such as arguments, are most frequently reported as the events prior to the onset of depression7. On the other hand, research also indicates that depression may induce poor interpersonal relations, which cause additional stress resulting in increased levels of depression3. In sum, research has found the relationship between depression and marital conflict to be reciprocal10.
While it is certainly not depression alone that breaks up relationships, a growing number of experts believe that depression is often the cause rather than the result of a divorce12. 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 the individuals in the couple mentally represented their relationship and its functioning4.
The Spouse as Caregiver
To be a spouse and also the caregiver of a depressed person can have a strong impact on the individual14. In fact patients' partners have been found to be at high risk of developing depression themselves, and report an increase in depressive symptoms5, 14. Research also shows that living with a depressed spouse places a considerable psychological burden for the caregiving spouse1. It is no surprise that spouses as caregivers are the most at risk because they have the most invested in the relationship5.
In order to understand how depression wreaks such havoc on the spouse of depressed individual, it is important to compare a loving and healthy relationship to the relationship troubled by depression. Individuals who come together to form a couple bring with them individual beliefs about love, marriage, intimacy, gender roles, etc.10. 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 love2. Individuals in strong relationships take time to communicate and really listen to each other's hopes, dreams, feelings, and concerns2. Strong marriages will include individuals who solve problems together, do family work together, and are based on equality in the marriage relationship2.
The Family: a Proclamation to the World declares that a "Husband and wife have a solemn responsibility to love and care for each other . . ." (¶ 6). Marriage contributes significantly to an individual's self-esteem7. It is no wonder that when such an influential role is threatened or when an individual perceives they have failed in marriage, a sense of failure may permeate all aspects of life7.
Spouses of depressed individuals are like anyone else entering a relationship. They come with expectations, dreams, and hopes. As a result, when they examine their lives after becoming a caretaker they see multiple limitations and losses particularly concerning the partnership14. Living with a depressed spouse therefore acts as a source of strain and emotional distress for spouses1. Caretaker spouses not only experience limitations in their personal relationships but problems that may affect their careers and social acceptance and limit their leisure activities and lifestyles14. Spouses of depressed individuals who were interviewed reported restrictions in their social and leisure activities, a fall in the family income, and a strain in the marital relationship1.
Not only do spouses of depressed individuals 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 spouse is left with an increased work load and a decreased support system14. For example in a relationship where one spouse is depressed, the caretaker spouse often has more responsibility for maintaining family functioning and the well-being of any children1. This lack of spousal support is one reason caretaker spouses may have an increased risk of depression7. Spouses may be unable to 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 questions14.
Sheffield13 gives words to the emotions caretaker spouses experience in her book, How You Can Survive When They're Depressed, when she says, "[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" (p. 1). For a caretaker spouse, living with a depressive who views the world through despair is disheartening and leads to many of the same feelings, such as worthlessness, that the depressed person feels13.
The problems for the caretaker spouse begin out of the public view and within the private marital relationship where the caretaker spouse is an eye-witness as their friend and lover transforms into someone they don't recognize13. 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 as a result they begin to lose themselves as well13.
The caretaker spouse often finds that life with a depressed partner is different from how they had imagined it would be14. Often they will have negative attitudes toward their depressed spouse1. Sometimes caretakers may even see their depressed partner as a burden5. Many caretakers will talk about their depressed partner as though he or she were another child to be taken care of rather than a spouse14. Ironically these feelings can lead to the same feelings that the depressed person experiences such as self-doubt, demoralization, anger, and a desire to escape the source of distress13.
As a result, both members in the partnership where one member is depressed view their partner as more "negative, hostile, mistrusting, and detached and less agreeable, [and] nurturing"7. With such feelings, it is no wonder that hurtful acts such as name calling, ridiculing, or intentional negative social comparisons occur that are damaging to the relationship11. This lack of mutual respect and courtesy between spouses can lead to psychological abuse between the partners11. Such abuse between partners is especially painful because it occurs between two individuals who have promised to each other and the law to nurture and cherish each other11.
Under such circumstances, what can be done for the depressed person, the caretaker spouse, 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 world13. However, those in the role of caretaker spouse know that it is much harder then it seems. Sheffield12 describes the position of a caretaker spouse well when she says, "Loving someone who is depressed brews confusion, frustration, resentment, and pain" (p. xxii). But it is important to remember that family members are vital to helping those with mental illness8.
The problems are often enhanced by the social stigma surrounding depression and those seeking treatment for it9. Often, individuals who have loved ones suffering from depression have fears about being ridiculed or shunned if they are involved in seeking treatment9. 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 his or her self-esteem10. However there is hope that discrimination will decrease as knowledge increases and people realize that "no one is immune from mental disease"9. Depression does not discriminate. It makes an impact on all those who live in the vicinity of the illness. Where individuals will differ is in their response to feelings13.
The connection between depression and marital distress is influenced principally through the way individuals explain the negative behavior of their partner3. Individual's personal explanations of negative marital events greatly impacts marital satisfaction and their emotional state3.
For example the blame game is often the source of much misunderstanding that leads to increased distress. One myth that is often associated with mental illness and contributes to distress is that someone is to blame for mental illness8. When things go wrong in life it is common for individuals to look for someone to blame whether it is themselves or others. It is no surprise, then, that many individuals try to discover that thing which has caused the pain and despair and depression8. The victims of depression may even blame themselves for being sick and spouses might tear themselves apart emotionally trying to discovery where they went wrong8.
However trying to attribute blame to someone is pointless and results in unnecessary suffering for the depressed and the caretaker spouse. Searching for a source to blame wastes energy that would be better spent in learning more about the illness and possible treatments8. 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"8.
By understanding that depression is not intentional, caretaker spouses may be able to change the way they think of their spouses. For example a caretaker spouses may see the spouse as a victim rather than a saboteur of the marriage13.
A better use of time and energy would be to search for understanding and increased capabilities for compassion and patience8. 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 suicide8.
Caretaker spouses can provide encouragement and realistically remind the depressed of God’s love and the love of family members8. It will be important not to lose patience and to avoid saying things such as "just snap out of it" or "get a little backbone"8. 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 willpower8 (p. 292).
Recognizing that depression and not the spouse is the villain is a huge step in the battle. However while patience, compassion, and love provide support and are crucial for learning to live with depression within a marriage they are not a cure for the illness. Therefore, it is important to seek knowledge of the illness and of treatment options13.
Understanding and Treatment
Understanding depression as an illness with a specific biological process can help caretaker spouses to take an active role in treatment8. Caretaker spouses who have little understanding of depression may try to control the ill person and his or her behavior as if the depressed spouse were a child13. Having knowledge of the illness and where it comes from will help caretaker spouses to better cope and communicate with health care professionals13. This includes understanding the length of time medication can take to become active and learning behavioral techniques that are crucial to the healing process8. Sheffield12 put the importance of knowledge into perspective when she said:
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. (p. 108)
Encouraging the depressed to get treatment is not always easy and may require more than gentle assertiveness13. Caretaker spouses may even experience strong resistance to the idea of seeking help13. Sheffield12 points out that the better informed a caretaker spouse is, the better he or she will be able to help the depressed person overcome resistance and seek appropriate treatment.
However it is important to seek help and treatment promptly8. Quicker and better results can be expected from cases that received professional help early, before the illness becomes deep-seated and therefore less easily treated8.
There are many forms of treatment and it can be daunting to try and understand what the doctors are talking about13. The type of treatment that is prescribed will be determined by the form of depression from which the depressed person suffers9. For the caretaker spouse, knowing what is medically wrong with the spouse is essential to the depressed spouse's wellbeing and can provide a foundation for the future13. It is invaluable to the caretaker spouse to learn about depression and how to deal with it8. This is especially true since depressed individuals may not be good questioners or listeners, may distort information based on their moods, and are often not the best judges of their progress12.
Many victims of depression will find their suffering greatly reduced with proper treatment8. An absence of necessary treatment increases the potential for depressed individuals to harm themselves and others8.
Professional care providers often use a three-pronged treatment approach that includes the social, biological, and psychological aspects of depression9. Many sufferers, in fact just under half, seek help from primary care physicians rather than specialists such as psychiatrists and psychologists12. In order to understand the treatment process, it can be helpful to understand the difference between psychiatrists and psychologists and the roles each fulfill.
- 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 illness8.
- 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 healing8.
There is controversy within the medical community between medication and psychotherapy8. How medication and psychotherapy are used and in what combination will depend on the mental health professional and the needs of the individual patient8.
Herbal and other remedies are not subject to the Food and Drug Administration requirements for safety and efficacy trials12. While these remedies may have been tested or researched the studies have been poorly designed and have been tested against placebos and not against antidepressants12. Nonprescription remedies can be risky and have not been found to be the best remedy12.
Current antidepressants, if used correctly, have been found to provide help to 60% to70% of all those suffering from depression12. 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 problems10. Medication can reverse bizarre behavior and assist in healing the brain and improving effectiveness of psychotherapy8. 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 normal12.
Caretaker spouses should be aware that patients may start skipping pills and even discontinue them because they may not be able to discriminate between the pre and post-medicated self12. 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 medication12.
Knowledge about medication(s) a depressed partner is taking is only the beginning12. A caretaker spouse should maintain good communication with the care provider as they can provide for good input as a close observer of the depressed12.
Taking Time Out
With all the responsibilities and weight that caretaker spouses face it is important that they take time out for themselves. As caretaker spouses, individuals spend much time supporting not only the depressed, but also caring for children and fulfilling outside roles, such as employee, as well. Caretaker spouses will also bear the brunt of the depressed moods of their spouses, which can lead to personal demoralization12.
Sheffield13 describes five stages that caretaker spouses go through when they find themselves in a marriage with depression. She terms these stages as "depression fallout," or the response to someone else's despair starting with the first confusing meeting with the illness12. Those suffering from depression fallout often search for the source of the problem within themselves before realizing that an illness afflicts the spouse12. The five stages of depression fallout are as follows:
- 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? Individuals in this stage 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 individuals are confused and disordered 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 caretaker spouses maintain lives of their own. Not only is this beneficial for the caretaker spouse but it will allow him or her to be of most help to the depressed spouse. It is important that caretaker spouses find time each day, even if it's only a few minutes, to recharge themselves8. Some suggestions for recharging include: reading a good book, talking to a trusted friend, or calling a family member8. The method is not as important as realizing that nurturing the self is vital to the health of the relationship8.
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.
- Benazon, N. R., & Coyne, J. C. (2000). Living with a depressed spouse. Journal of Family Psychology, 14, 71-79.
- Duncan, S. F. (2000). Practices for building marriage and family strengths. In D. C. Dollahite (Ed.), strengthening our families: An in-depth look at the proclamation on the family (295-303). Salt Lake City, UT: Book craft.
- Gordon, K. C., Friedman, M. A., Miller, I. W., & Gaertner, L. (2005). Marital attributions as moderators of the marital discord-depression link. Journal of Social and Clinical Psychology, 24, 876-893.
- Heene, E. L.D., Buysse, A., & Van Oost, P. (2005). Indirect pathways between depressive symptoms and marital distress: The role of conflict communication, attributions, and attachment style. Family Process, 44, 413-440.
- Jeglic, E. L., Pepper, C. M., Ryabchenko, K. A., Griffith, J. W., Miller, A. B., &Johnson, M. D. (2005). A caregiving model of coping with a partner's depression. Family Relations, 54, 37-45.
- Johnson, S. L., & Jacob, T. (2000). Sequential interactions in the marital communication of depressed men and women. Journal of Consulting and Clinical Psychology, 68, 4-12.
- Kung, W. W. (2000).The intertwined relationship between depression and marital distress: Elements of marital therapy conducive to effective treatment outcome. Journal of Marital and Family Therapy, 26, 51-63.
- Morrison, A. B. (2005). Mental illness in the family. In C. H. Hart, L. D. Newell, E. Walton,& D. C. Dollahite (Eds.). Helping and healing our families (pp. 288-294). Salt Lake City, UT: Deseret Book Company.
- Morrison, A. B. (2003). Valley of sorrow: A layman's guide to understanding mental illness. Salt Lake City, UT: Deseret Book Company.
- Papp, P. (2003). Feminist family therapy: Empowerment in social context. Washington, DC: American Psychological Association.
- Roby,J. L., Buxton, M. S., Harrison, B. K., Roby, C. Y., Spangler, D. L., Stallings,N. C., & Walton, E. (2000). Awareness of abuse in the family. In D. C. Dollahite (Ed.), strengthening our families: An in-depth look at the proclamation on the family (pp. 253-265). Salt Lake City, UT: Book craft.
- Sheffield, A. (2003). Depression fallout: The impact of depression on couples and what you can do to preserve the bond. New York, NY: HarperCollins Publishers Inc.
- Sheffield, A. (1998). Howie can survive when they're depressed. New York, NY: Harmony Books.
- Wittmund, B., Wilms, H. U., Mory, C., & Angermeyer, M. C. (2002). Depressive disorders in spouses of mentally ill patients. Social Psychiatry and Psychiatric Epidemiology, 37, 177-182.