Journal of AbnormalPsychology Copyright2000 by the AmericanPsychologicalAssociation,Inc.
2000. Vol. 109,No. 3, 550-554 0021-843X/00/$5.00 DOI: 10.1037//0021-843X.109.3.550
Predicting Negative Spousal Attitudes Toward Depressed Persons:
A Test of Coyne's Interpersonal Model
Nili R. Benazon
Wayne State University
The utility of Coyne's (1976a) interactional model in predicting negative spousal attitudes toward
depressed patients was examined. Eighty-nine couples with at least 1member in treatment for depression
were selected on the basis of semistructured diagnostic interviews. Overall, spouses living with a
depressed patient reported significantly more distress than population norms. Consistent with prediction,
patients' reassurance seeking and spouses' mood contributed to negative spousal attitudes. Additional
analyses demonstrated that these effects persisted even after controlling for spouse marital adjustment,
suggesting that negative spousal attitudes were more than a simple reflection of marital maladjustment.
Interpersonal theories of depression emphasize that the complaints
of depressed persons are not simply a product of cognitive
distortion but arise in the context of conflictual and unsupportive
relationships. Coyne (1976b, 1999) delineated an interactional
theory of depression and posited that a negative response by others
plays a key role in the maintenance if not the cause of depression.
Their complaints and reassurance seeking are distressing (see also
Joiner, 1994; Joiner, Alfano, & Metalsky, 1992, 1993) and make
others feel responsible for their well-being. At the same time, they
succeed in eliciting guilt and inhibiting any direct negative response
(see also Biglan et al., 1985; Hops et al., 1987). In an effort
to reduce their aversive behavior, others may provide what seemingly
is being asked of them while also leaking their impatience,
hostility, and rejection (Coyne, 1976a). Depressed persons are thus
able to validate their sense of insecurity, leading to further expression
of distress. In this sense, others may respond in ways that
unwittingly perpetuate depressed persons' problems.
Coyne (1976a) first tested his interactional model with clinically
depressed persons who interacted briefly with strangers, yet the
findings were discussed in terms of their implications for enduring
relationships. In recent years we have seen a surge of studies
reexamining Coyne's theory in the context of ongoing relationships
(e.g., Joiner, 1994; Joiner et al., 1992; Katz, Beach, & Joiner,
1998). Taken together, these studies are supportive of the interNili
R. Benazon, Department of Psychiatry and Behavioral Neurosciences,
Wayne State University, School of Medicine, Detroit, Michigan.
This research is based in part on my doctoral dissertation conducted at
the University of Ottawa, Ontario, Canada. I thank Ms. Jane Downey of the
University of Michigan and David Magder of the Clarke Institute of
Psychiatry for facilitating the recruitment process. Appreciation is gratefully
expressed to Jim Coyne for his thoughtful comments on earlier
versions of this article and to the members of the thesis committee for their
contribution to this project: Philippe Cappeliez, John Hunsley, Monique
Lortie-Lussier, and Pierre Mercier.
Correspondence concerning this article should be addressed to Nili R.
Benazon, Department of Psychiatry, Wayne State University, School of
Medicine, UPC-Jefferson, 2751 East Jefferson Avenue, Suite 200, Detroit,
Michigan 48207-4100. Electronic mail may be sent to nbenazon@
med.wayne.edu.
550
personal model in the context of roommate and dating relationships
in which there are repeated contacts between the depressed
person and another individual.
Yet it is important to note that the interpersonal model has
received only limited testing in the context of more enduring
relationships, namely marriage. One possible paradox is that processes
postulated by Coyne may already have taken their toll on
the relationship and may no longer be observable. After years of
marriage and numerous episodes of depression, the depressed
person may abandon any hope of obtaining the reassurance originally
sought from the spouse, and the experience of repeated
rejections may be crystallized in a negative self-view that no
longer needs verification from the spouse. Coyne's (1976b) formulation
was silent on such longer term effects or even the
temporal parameters of the interpersonal processes that were being
described.
Quite separate from tests of Coyne' s theory, a large literature on
the marital and family relationships of depressed persons has
consistently demonstrated that these relationships are characterized
by negativity and conflict (see Beach, Whisman, & O'Leary,
1994, for review). In particular, the expressed emotion (EE) literature
has emerged showing that the spouses of depressed persons
are negative in their attitudes toward patients (Hooley, 1986;
Vaughn & Left, 1976b). Such display of negative attitudes has
been found to be highly prevalent and predictive of relapse among
recovering depressed patients (Hooley, Orley, & Teasdale, 1986;
Vaughn & Left, 1976a). However, as Hooley and Licht (1997)
pointed out, "The factors that underlie the development and maintenance
of high EE, and the EE--relapse link, are still little
understood" (p. 298). Thus, although it has been reported in the
literature that the spouses of depressed persons have negative
attitudes toward patients, it remains unclear what is associated with
this negativity and whether or not the interpersonal processes
originally identified by Coyne are relevant. Moreover, in turning to
the study of marriage, the additional question arises as to whether
spousal attitudes are best construed as a facet of marital maladjustment.
One possibility is that negative spousal attitudes can be
more parsimoniously understood as an aspect of a dysfunctional
marital relationship. There has been some suggestion in the literature
that marital distress rather than depression per se may be
SHORT REPORTS 551
responsible for the dysfunctional interaction patterns frequently
observed in depressed couples (Schmaling & Jacobson, 1990).
The present study was designed to test Coyne's interactional
model with depressed patients and their spouses. The model was
tested in a conventional manner against the null hypothesis of no
relations between the predictors specified by the theory and two
measures Of spousal attitudes: spouse EE and appraisal of the
patient. It was hypothesized that the two dependent variables
would be moderately correlated and that both dependent variables
would be predicted by patient reassurance seeking and spouse
depressed mood. Persistence of the relation between the theoretical
variables of interest and spousal attitudes, even after controlling
for spouse marital adjustment, would represent particularly strong
support for the interpersonal model.
Participants consisted of patients in treatment for depression.
Some were in a current episode of major depressive disorder
(MDD) and receiving acute-phase treatment, whereas others were
receiving maintenance treatment and no longer met criteria for
current MDD. There has been a shift in the treatment of depression,
with greater emphasis on unipolar major depressive disorder
as primarily a chronic, recurrent disorder rather than a singleepisode
disorder (Judd, 1997). Given the high risk of recently
recovered depressed patients for a new episode, many patients are
now remaining in maintenance treatment beyond the acute episode
(Depression Guideline Panel, 1993). Furthermore, previous research
indicated that the interpersonal difficulties of depressed
persons are not confined to the acute episode (Paykel et al., 1995;
Weissman & Paykel, 1974). It was, therefore, decided to test and
extend Coyne's interpersonal model in a mixed population of
patients in acute and maintenance treatment for depression, in
which depressed mood among these patients was treated as a
continuous variable.
Method
Participants and Procedure
Participants were drawn from two outpatient clinics---Clarke Institute of
Psychiatry and University of Michigan Medical Center--that specialize in
the treatment of mood disorders. Both patients and their spouses received
diagnostic interviews. In 7 of the 90 couples (7%), both partners were
depressed. It was arbitrarily decided that the person in treatment at the
recruitment setting would be designated the "patient." Patients either met
criteria for current MDD (n = 43) or dysthymic disorder (n = 16) or
remained in treatment while meeting criteria for past MDD (n = 30). On
average, patients reported having had seven major depressive episodes.
Approximately 15% of patients declined participation for reasons related to
the spouse. Persons who met criteria for bipolar I or bipolar II disorders
were excluded. On average, patients were 43 years old, Caucasian (99%),
married (94%), college educated (58%), and employed (70%). Spouses
were 44 years of age, Caucasian (98%), college educated (63%), and
employed (85%). Couples had been together for 16 years. The average
level of family income in this sample was $57,000. Of the 109 couples who
were mailed questionnaire packages, 89 returned questionnaire packages
that were complete (a total response rate of 82%).
Measures
Structured Clinical Interviewfor DSM-IV. The version of the Structured
Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, &
Williams, 1995) used in this study assesses current (defined as the preceding
month) and lifetime psychiatric status for major Axis I disorders in
accordance with DSM-IV criteria. Patients and spouses were administered
the Mood Disorders module only. The interviewer was a trained, experienced,
master's-level clinician. Concurrent validity of the SCID-based
diagnoses was established in comparison with diagnoses provided by the
three referring psychiatrists. The coefficient ks ranged from 0.79 to 0.90
between the SCID-based diagnoses from the investigatorand the diagnoses
provided by particular psychiatrists, with an overall k of 0.83 (n = 50).
MultipleAffectAdjectiveCheckList-Revised(MAACL-R; Zuckerman &
Lubin, 1985). The MAACL-R consists of 132 affective adjectives and
was developed to provide a brief, norm-referencedmeasure of self-reported
mood. Both patients and spouses completed the Depression subscale of the
trait version. Higher scores correspond to greater levels of depression.
MAACL-R scores are typically expressed as T scores; a score of 80 is
considered to be within the clinical range.
Depressive Interpersonal Relationships Inventory--Reassurance-Seeking
Subscale (DIRI; Metalsky et al., 1991). The DIRI is a self-report
measure of reassurance seeking, defined as a tendency to seek reassurance
excessively from others as to whether they "truly" care. The scale was
rendered specific to the seeking of reassurance from the respondent's
intimate rather than as an assessment of a more general trait. The
reassurance-seeking scale includes four items, each rated on a 7-point scale
ranging from 1 to 7, with higher scores corresponding to increasing
reassurance seeking. Joiner et al. (1992) reported a coefficient a of .88 for
the D1RI-RS, and the criterion and construct validity of the measure has
been supported by previous work (Joiner et al., 1992; Joiner & Metalsky,
1995). The DIRI-RS was completed by patients only.
Level of Expressed Emotion (LEE; Cole & Kazarian, 1988). The
60-item LEE was developed to reflect the four behavioral and attitudinal
correlates of the EE construct (Vaughn & Left, 1981): intrusiveness,
emotional response, attitude toward illness, and tolerance and expectations.
Scores can range from 0 to 60; higher scores indicate greater levels of EE.
A score of 9 on the LEE has been used for high-low splitting of LEE
scores. The LEE has been found to have high levels of internal consistency
(Cole & Kazarian, 1988). The concurrent validity (Kazarian, Malla, Cole,
& Baker, 1990; Kazarian, Mazmanian, McDermott, & Olinger, 1991) and
the predictive validity (Kazarian & Cole, 1993) have been supported in a
number of studies. The LEE was completed by spouses only.
Principal Indexof PartnerAppraisal (PPA; Pelham & Swann, 1989).
The PPA is a 10-item questionnaire that measures 10 self-views central to
self-worth (e.g., intellectual capability, physical attractiveness, leadership
ability, and emotional stability). Spouses rated patients on each of the 10
attributes relative to other people of the same age and gender as their
spouse on graduated-interval scales. The sum of their ratings of the patient
on these 10 attributes range from 10 to 100; higher scores indicate a more
positive appraisal of the patient by the spouse.
DyadicAdjustmentScale(DAS; Spanier, 1976). The DAS contains 32
items and is multidimensional in that it includes four subscales (Dyadic
Adjustment, Dyadic Cohesion, Dyadic Consensus, and Affectional Expression).
The psychometric properties of the DAS have proven adequate in
both clinical (e.g., Crane, Allgood, Larson, & Griffin, 1990) and nonclinical
samples (e.g., Sabatelli, 1988).
Results
Exploration of the Validity of the In-Episode~
Out-of-Episode Distinction
To establish the validity of the distinction between the in- and
out-of-episode patients, t tests were conducted with patient depressed
mood as the dependent variable. Results revealed that
in-episode patients report~t significantly more distress than outof-episode
patients, t(87) = 1.96, p < .05, but there was considerable
overlap between the two groups. Moreover, a t test indicated
552 SHORT REPORTS
that out-of-episode patients were more distressed than the population
norms, t(29) = 3.95, p < .05 (Zuckerman & Lubin, 1985).
Finally, no significant differences were found between in- and
out-of-episode patients on any of the other variables of interest in
this study. Depressed mood was, therefore, treated as a continuum
within a clinical group in treatment for depression rather than
utilizing the in-episode/out-of-episode distinction as a dichotomous
variable.
Bivariate Correlations, Means, and Standard Deviations
for All Variables
Zero-order correlations, means, and standard deviations for all
variables are presented in Table 1. Consistent with Coyne's theory,
patient and spouse self-reported depressed mood were correlated,
r(87) = .41, p < .05. A t test revealed that spouse distress was
significantly more elevated than the population norms,
t(88) = 3.15, p < .05 (Zuckerman & Lubin, 1985). Spouse EE was
correlated with patient reassurance seeking, r(87) = .31, p < .05,
and with spouse mood, r(87) = .36, p < .05. Spouse appraisal was
correlated with reassurance seeking, r(87) = -.42, p < .05, and
with spouse mood, r(87) = -.34, p < .05. Spouse marital adjustment
was related to both spouse EE, r(87) = -.44, p < .05, and
appraisal, r(87) = .55, p < .05. Finally, the two dependent variables,
spouse EE and appraisal, were moderately correlated,
r(87) = -.36, p < .05.
Formal Testing of Hypotheses
To examine whether the dichotomous episode status variable
(in- vs. out-of-episode) would reduce the effects of patient depressed
mood and reassurance seeking, it was entered first in all
regression equations. The dichotomous episode status variable was
not significant, nor did it reduce the significance of the theoretical
variables.
Table 2 presents a hierarchical regression analysis exploring the
ability of patient reassurance seeking and spouse depressed mood
Table 1
Intercorrelation Matrix, Means, and Standard Deviations
for All Variables
Variable 1 2 3 4 5 6
1. DEP-P .91 --
2. DIRI .11 .85 --
3. DEP-S .41"* .13 .93 --
4. DAS -.28** -.38** -.45** .94
5. PPA -.24** -.42** -.34** .55**
6. LEE .14 .31"* .36** -.44**
M 76.63 10.53 56.26 104.55
SD 27.00 6.07 17.64 18.22
.79
-.36** .85
53.78 9.88
11.41 6.79
Note. N = 89. Coefficient alpha for each of the measures is reported on
the diagonals. DEP-P = self-reported patient depressed mood; DIRI =
Depressive Interpersonal Relationships Inventory--Reassurance-Seeking
Subscale; DEP-S = self-reported spouse depressed mood; DAS = Dyadic
Adjustment Scale measuring spouse marital adjustment; PPA = Principal
Index of Partner Appraisal measuring spouse appraisal of patient; LEE =
Level of Expressed Emotion (spouse).
*p<.05. **p<.01.
to account for spousal attitudes. In a f'trst series of analyses, spouse
EE served as the dependent variable. The results indicated that
both patient reassurance seeking, t(85) = 2.7 l, p < .01, and spouse
depressed mood, t(85) = 2.88, p < .01, made a unique contribution
to the variance in EE, F(1, 88) = 9.04, p < .05, with an R 2
value of .18. Next, the model was retested to determine whether
the effects of patient reassurance seeking and spouse mood would
persist when spouse marital adjustment was first entered as a
control variable. The results indicated that, after controlling for
spouse marital adjustment, spouse mood, t(84) = 2.00, p < .05,
but not patient reassurance seeking, t(84) = 1.77, ns, continued to
make a unique contribution to EE, F(2, 87) = 3.54, p < .05, with
a change in g 2 of .05.
In a second series of analyses, spouse appraisal of the patient
served as the dependent variable. The lower portion of Table 2
indicates that patient reassurance seeking, t(85) = -4.07, p < .01,
and spouse mood, t(85) = -2.75, p < .01, entered at Step 1 each
made a unique contribution to the variance in spouse appraisal,
F(1, 88) = 13.81,p < .05, with an R2 value of .25. Next, the model
was retested with spouse marital adjustment treated as a control
variable. The results indicated that only patient reassurance seeking,
t(84) = -2.72, p < .01, but not spouse mood, t(84) = 1.44,
ns, continued to make a unique contribution to the variance in
spouse appraisal of patient, F(2, 87) = 4.77, p < .05, with a
change in R2 of .08.
Discussion
The results of the present study concur with previous reports
that those who live with depressed persons are themselves vulnerable
to psychological distress (Coyne et al., 1987). This finding is
noteworthy given that family functioning and child adjustment
when one adult in the family is depressed may depend on the
adjustment and availability of the other partner (Downey & Coyne,
1990). Repeated findings of distress among the spouses of depressed
persons adds to the accumulating evidence that the social
costs of depression are not limited to the patient.
Support for Coyne's (1976a) interpersonal model was obtained
in the context of marital relationships. In the case of each dependent
variable, spouse EE and appraisal, patient reassurance seeking,
and spouse distress made a significant contribution to the
variance explained. These results suggest the benefits of further
exploring the interface between Coyne's model and EE. One
fruitful direction may be to examine the temporal parameters of the
relation. In this study, cross-sectional data were analyzed and
interpreted with the assumption that interpersonal processes are
causally prior to EE. This assumption deserves an empirical test.
The two dependent variables, spouse EE and appraisal, were
moderately correlated, indicating some convergent validity, but
not so correlated as to suggest that they are identical. The size of
the relationship between them allows for different correlates.
The present study did not substantiate the suggestion that spousal
attitudes can be more simply understood as a facet of the
general marital distress characterized in these couples. In the case
of each dependent variable, partial support for the model was
obtained even after subjecting it to a conservative test, by controlling
for spouse marital adjustment. However, the patterning of
results was different for the two dependent variables: When expressed
emotion was the dependent variable, only spouse distress
SHORT REPORTS 553
Table 2
Regression Equations Predicting Spouse Expressed Emotion and Appraisal From Coyne's
Interactional Model
Dependent Step Increment
variable predictor /3 R 2 in R2
LEE 1. DIRI .27** .18"*
DEP-S .29**
LEE 1. DAS -.40** .16"*
2. DIRI .18 .23*
DEP-S .21"
PPA 1. D1RI -.39** .25**
DEP-S -.26**
PPA 1. DAS 54** .29**
2. DIRI -.26** .37**
DEP-S -.14
.07*
.07**
Note. N = 89. LEE = Level of Expressed Emotion (spouse); PPA = Principal Index of Partner Appraisal
measuring spouse appraisal of patient; DIRI = Depressive Interpersonal Relationships Inventory--ReassuranceSeeking
subscale; DEP-S = self-reported spouse depressed mood; DAS = Dyadic Adjustment Scale measuring
spouse marital adjustment.
*p<.05. **p<.01.
continued to make a significant contribution, whereas when partner
appraisal was the dependent variable, only patient reassurance
seeking remained significant. Within the limits of a cross-sectional
design and a moderate sample size, it is difficult to choose among
possible reasons for this. There is the risk of misinterpreting
spurious relations, in that these results could simply be due to
shared variance between the measure of marital adjustment and the
dependent variables. However, what does seem to be clear is that
the relation between the variables postulated by Coyne's model
and the dependent variables is not entirely reducible to marital
dissatisfaction.
In closing, some caution is needed in interpreting these findings.
First, a control group was not included in the study; consequently,
the design of this study does not address the specificity of the
reassurance seeking-spousal attitude connection to depression.
Second, the present study does not provide for a test of the
temporal ordering of what is undoubtedly a set of complex reciprocal
processes. An obvious solution would be to use a longitudinal
design. However, it should be recognized that the point at
which depressed married persons are available for study in a
treatment setting might be late in a long interpersonal process.
Depression is a recurrent, episodic disorder having a mean age of
onset in the mid-20s, somewhat earlier than the mean age of first
marriage (Coyne & Benazon, in press). The typical depressed
patient has had repeated episodes (Coyne, Pepper, & Flynn, 1999)
and has endured depression for years before entering treatment
(Kessler, Olfson, & Berglund, 1998). Indeed, patients in the
present study were in their mid-40s, had a mean of seven episodes
of depression, and had been married for more than 16 years. There
may even be selection biases in terms of which marriages with a
depressed person have endured to the point of this treatment
seeking (Bruce, 1998). The full maturation of an interpersonal
perspective on depression requires well-designed longitudinal
studies with attention to the temporal parameters of the interpersonal
processes that are being studied. However, what is needed
first is a careful delineation of the patterns accessible at a single
point in time.
References
Beach, S. R. H., Whisman, M. A., & O'Leary, K. D. (1994). Marital
therapy for depression: Theoretical foundation, current status, and future
directions. Behavior Therapy, 25, 345-371.
Biglan, A., Hops, H., Sherman, L., Friedman, L., Arthur, J., & Osteen, V.
(1985). Problem solving interactions of depressed women and their
spouses. Behavior Therapy, 16, 431-45 l.
Bruce, M. L. (1998). Divorce and psychopathology. In B. P. Dohrenwend
(Ed.), Adversity, stress, and psychopathology (pp. 219-234). New York:
Oxford Press.
Cole, J. D., & Kazarian, S. S. (1988). The Level of Expressed Emotion
Scale: A new measure of expressed emotion. Journal of Clinical Psychology,
46, 392-397.
Coyne, J. C. (1976a). Depression and the response of others. Journal of
Abnormal Psychology, 85, 186-193.
Coyne, J. C. (1976b). Toward an interactional description of depression.
Psychiatry, 39, 28-40.
Coyne, J. C. (1999). Thinking interactionally about depression: A radical
restatement. In T. E. Joiner & J. C. Coyne (Eds.), Interpersonal processes
in depression (pp. 369-392). Washington, DC: American Psychological
Association.
Coyne, J. C., & Benazon, N. R. (in press). Coming to terms with the nature
of depression in marital research and treatment. In S. R. H. Beach (Ed.),
Marital andfamily processes in depression. Washington, DC: American
Psychological Association.
Coyne, J. C., Kessler, R. C., Tal, M., Turnbull, J., Wortman, C. B., &
Greden, J. F. (1987). Living with a depressed person. Journal of Consuiting
and Clinical Psychology, 55, 347-352.
Coyne, J. C., Pepper, C. M., & Flynn, H. (1999). Significance of prior
episodes of depression in two patient populations. Journal of Consulting
and Clinical Psychology, 67, 76-81.
Crane, D. R., AUgood, S. M., Larson, J. H., & Griffin, W. (1990).
Assessing marital quality with distressed and nondistressed couples: A
comparison and equivalency table for three frequently used measures.
Journal of Marriage and the Family, 52, 87-93.
Depression Guideline Panel. (1993). Guideline report on the diagnosis and
treatment of depression in primary care. Rockville, MD: U.S. Department
of Health and Human Services, Agency for Health Care Policy
Research.
554 SHORT REPORTS
Downey, G., & Coyne, J. C. (1990). Children of depressed parents: An
integrative review. Psychological Bulletin, 108, 50-76.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995).
Structured Clinical Interviewfor DSM-IV (SCID-I/P Version 2.0). New
York: Biometrics Research Department, New York State Psychiatric
Institute.
Hooley, J. M. (1986). Expressed emotion and depression: Interactions
between patients and high- versus low-expressed-emotion spouses. Journal
of Abnornual Psychology, 95, 237-246.
Hooley, J. M., & Licht, D. M. (1997). Expressed emotion and causal
attributions in the spouses of depressed patients. Journal of Abnormal
Psychology, 106, 298-306.
Hooley, J. M., Orley, J., & Teasdale, J. D. (1986). Levels of expressed
emotion and relapse in depressed patients. British Journal of Psychiatry,
148, 642-647.
Hops, H., Biglan, A., Sherman, L., Arthur, J., Friedman, L., & Osteen, V.
(1987). Home observations of family interactions of depressed women.
Journal of Consulting and Clinical Psychology, 55, 341-346.
Joiner, T. E., Jr. (1994). Contagious depression: Existence, specificity to
depressed symptoms, and the role of reassurance-seeking. Journal of
Personality and Social Psychology, 67, 287-296.
Joiner, T. E., Jr., Alfano, M. S., & Metalsky, G. I. (1992). When depression
breeds contempt: Reassurance-seeking, self-esteem, and rejection of
depressed college students by their roommates. Journal of Abnormal
Psychology, 12, 113-134.
Joiner, T. E., Jr., Alfano, M. S., & Metalsky, G. I. (1993). Caught in the
crossfire: Depression, self-consistency, self-enhancement, and the response
of others. Journal of Social and Clinical Psychology, 12, 113-
134.
Joiner, T. E., Jr., & Metalsky, G. I. (1995). A prospective test of an
integrative interpersonal theory of depression: A naturalistic study of
college roommates. Journal of Personality and Social Psychology, 69,
778 -788.
Judd, L. L. (1997). The clinical course of unipolar major depressive
disorders. Archives of General Psychiatry, 54, 989-991.
Katz, J., Beach, S. R. H., & Joiner, T. E., Jr. (1998). When does partner
devaluation predict emotional distress? Prospective moderating effects
of reassurance-seeking and self-esteem. Personal Relationships, 5, 409-
421.
Kazarian, S. S., & Cole, J. D. (1993). Predictive validity of the Level of
Expressed Emotion Scale (LEE): Readmission follow-up data for 1, 2,
and 5-year periods. Journal of Clinical Psychology, 49, 216-218.
Kazarian, S. S., Malla, A. K., Cole, J. D., & Baker, B. (1990). Comparisons
of two expressed emotion scales with the Camberwell Family Interview.
Journal of Clinical Psychology, 46, 306-309.
Kazarian, S. S., Mazmanian, D. S., McDermott, K., & Olinger, L. J. (1991,
June). The interrelationship of measures of affective familial climates.
Paper presented at the annual convention of the Canadian Psychological
Association, Calgary, Alberta.
Kessler, R. C., Olfson, M., & Berglund, P. A. (1998). Patterns and
predictors of treatment contact after first onset of psychiatric disorders.
American Journal of Psychiatry, 155, 62-69.
Metalsky, G. I., Joiner, T. E., Jr., Potthoff, J., Pacha, L., Alfano, M. S., &
Hardin, T. (1991). The Depressive Interpersonal Relationships Inventory.
Unpublished manuscript.
Paykel, E. S., Ramana, R., Cooper, Z., Hayhurst, H., Kerr, J., & Barocka,
A. (1995). Residual symptoms after partial remission: An important
outcome in depression. Psychological Medicine, 25, 1171-1180.
Pelham, B. W., &Swann, W. B., Jr. (1989). From self-conceptions to
self-worth: On the sources and structure of global self-esteem. Journal
of Personality and Social Psychology, 57, 672-679.
Sabatelli, R. M. (1988). Measurement issues in marital research: A review
and critique of contemporary survey instruments. Journal of Marriage
and the Family, 50, 891-915.
Schmaling, K. B., & Jacobson, N. S. (1990). Marital interaction and
depression. Journal of Abnormal Psychology, 99, 229-236.
Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for
assessing the quality of marriage and similar dyads. Journal of Marriage
and the Family, 38, 15-28.
Vaughn, C. E., & Left, J. P. (1976a). The influence of family and social
factors on the course of psychiatric illness: A comparison of schizophrenic
and depressed neurotic patients. British Journal of Psychiatry,
129, 125-137.
Vaughn, C. E., & Left, J. P. (1976b). The measurement of expressed
emotion in the families of psychiatric patients. British Journal of Social
and Clinical Psychology, 15, 157-165.
Vaughn, C. E., & Left, J. P. (1981). Patterns of emotional response in
relatives of schizophrenic patients. Schizophrenia Bulletin, 7, 43-44.
Weissman, M. M., & Paykel, E. S. (1974). The depressed woman: A study
of social relationships. Chicago: University of Chicago Press.
Zuckerman, M., & Lubin, B. (1985). Manual for the MAACL-R: The
Multiple Affect Adjective Check List-Revised. San Diego, CA: Educational
and Industrial Testing Service.
Received July 30, 1997
Revision received January 21, 2000
Accepted January 22, 2000 ˇ