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. Author manuscript; available in PMC: 2016 Sep 1.
Published in final edited form as: Couple Family Psychol. 2015 May 25;4(3):136–149. doi: 10.1037/cfp0000040

Multi-family Group Treatment for Veterans with Mood Disorders: A Pilot Study

Michelle D Sherman 1, Ellen P Fischer 2, Richard R Owen Jr 3, Liya Lu 4, Xiaotong Han 5
PMCID: PMC4553244  NIHMSID: NIHMS679005  PMID: 26336613

Abstract

Mood disorders affect large numbers of individuals and their families; the ripple effects on relationship functioning can be great. Researchers have advocated for a relational perspective to mood disorder treatment, and several promising treatments have been developed. However, few rigorous evaluations have been conducted within the Veterans Affairs (VA) system. Multifamily group therapy, an evidence-based practice for people living with schizophrenia, has recently been adapted for other psychological disorders with promising results. This report describes the first published evaluation of this treatment modality in the VA system for veterans living with mood disorders. 101 male veterans (74 with major depression and 27 with bipolar disorder) and their family members participated in REACH (Reaching out to Educate and Assist Caring, Healthy Families), a 9-month, manualized, multi-family group treatment, intervention adapted from McFarlane's original multi-family group model. Participants completed self-report questionnaires at four time points across the course of the treatment, and service utilization data for veterans were obtained from VA databases. Both veterans and family members showed improvements in their knowledge about mood disorders, understanding of positive strategies for dealing with situations commonly confronted in mood disorders, and family coping strategies. Veterans also evidenced improvement in family communication and problem-solving behaviors, empowerment, perceived social support, psychiatric symptoms, and overall quality of life. The REACH intervention holds promise as a feasible, acceptable, and effective treatment for veterans living with mood disorders and their families. Further study is warranted.

Keywords: Mood disorders, veterans, multifamily groups, family psychoeducation, couples therapy

Mood disorders affect large numbers of individuals and their families. In the United States, the lifetime prevalence of major depression is 16.6% and bipolar disorder is 3.9% (Kessler, Chiu, Dempler, Merikangas, & Walters, 2005). Major depression is expected to rank first in disease burden in high-income countries worldwide by 2030 (Mathers & Loncar, 2006). Deployment to Iraq or Afghanistan has been shown to substantially increase the risk of depression among active duty military (Shen, Arkes & Williams, 2012), and levels of depression may continue to increase after service members return (Milliken et al., 2007).

Research has clearly documented the adverse effects of mood disorders on close relationships. Over time, people living with mood disorders often experience constriction in social support networks (e.g., Romans & McPherson, 1992; Lynch et al., 1999), increasing the importance of family relationships. Living with a mood disorder is associated with marital distress (Whisman, 2007; Zlotnick, Kohn, Keitner, & Grotta, 2000), decreasing marital satisfaction over time (Kronmüller et al., 2011), an increased risk of divorce, and shorter marriage duration (Kessler et al., 1998).

Relationship functioning is closely intertwined with the course of mood disorders. In major depression, research has documented a bidirectional longitudinal association between marital discord and depressive symptoms, with discord predicting the development of depression and depression predicting relationship discord (Whisman & Uebelacker, 2009). With bipolar illness, Johnson, Winnet, Meyer, Grenhouse and Miller (1999) found that individuals with low social support took longer to recover from depressive episodes and were more symptomatic over time than those with greater support. Similarly, perceptions of lesser availability and poorer quality of close relationships are associated with recurrence of a depressive episode (Cohen, Hammen, Henry, & Daley, 2004).

In light of the important interactions between close relationships and mental health, researchers have advocated for a relational perspective to mood disorder treatment (e.g., Hollon & Sexton, 2012). Disorder-specific interventions have been developed that promote changes in relationship functioning to enhance coping with psychiatric symptoms (Baucom, Whisman, & Paprocki, 2012). Numerous family-based treatments have been developed for both depression and bipolar disorder. Although some single-session family psychoeducational workshops on mood disorders have been developed (e.g., Anderson et al., 1986; Ruffolo, Nitzberg & Schoof, 2011), they are not reviewed herein due to the lack of published data on their efficacy.

Treatments for depression include a variety of couples therapy approaches as well as multi-family group (MFG) models. Randomized clinical trials of couples therapy with depressed patients have examined systemic therapy (Leff et al., 2000), coping-oriented couples therapy (Bodenmann et al., 2008), problem-focused couples therapy (Cohen et al., 2010), and emotion-focused couples therapy (Dessaullessa et al., 2003), with each model finding a range of promising preliminary outcomes across both symptom and relationship functioning domains. However, while couples therapy has been found to reduce depressive symptoms in some small studies, a meta-analysis (Barbato et al., 2008) concluded that the evidence for this mode of treatment for depression is inconclusive and further study is warranted. The only published study that examined multifamily group treatment for depression compared single-family therapy, MFG and treatment-as-usual (TAU) among hospitalized patients with major depression (Lemmens et al., 2009). Participants in MFG and single-family therapy had significantly higher rates of treatment response at 3 months (49%, 24%) and significantly higher rates of no longer needing antidepressants at 15 months (26%, 16%) than participants in TAU (9% and 0%, respectively).

Three modes of family-based treatments for bipolar disorder are described in the literature: couples therapy, MFG, and Family-Focused Therapy (FFT) (Miklowitz & Goldstein, 1990). In studies of these treatments, the family intervention has been added to medication as usual, so they have not been tested as stand-alone services. An early study that assessed the benefit of adding a 25-session “psychoeducational marital intervention” to TAU (Clarkin et al., 1998) found significant improvements in overall functioning and medication adherence among those receiving the marital intervention.

Early research with MFGs did not find any improvement in rate of the recovery among individuals with bipolar disorder who received MFG or family therapy (Miller et al., 2004; 2008). However, in Miller and colleagues' 2008 trial, participants in families with high levels of impairment who received adjunctive family treatment (MFG or problem-centered systems family therapy) had a significant decrease in the number and duration of depressive episodes. Further, in this same trial, only 5% of participants receiving adjunctive MFG required hospitalization over a 28-month period, compared to 31% of those getting adjunctive problem-centered systems family therapy, and 38% of those only taking medications (Solomon et al., 2008).

The family-based treatment for bipolar disorder that has been most rigorously evaluated is Family-Focused Therapy (FFT), a manualized single-family 21-session treatment. Randomized trials have shown that participants in FFT have fewer relapses, longer intervals between relapse, and better medication adherence than participants getting crisis management services (Miklowitz et al., 2003) or brief care (Miklowitz et al., 2007).

Some treatments have been developed specifically for the family members of individuals living with mood disorders, e.g., brief MFG exclusively for family members of depressed individuals (Katsuki et al., 2011), an adaptation of FFT for caregivers of individuals with bipolar disorder (Perlick et al., 2010), and a VA-based family education curriculum for adults who care about someone living with a mental illness (S.A.F.E. Program; Sherman, 2003). Each of these has demonstrated statistically significant reductions in emotional distress for family members.

One outgrowth of the increasing recognition of the role of the family in mood disorders as well as the benefits of family involvement in care is the inclusion of family involvement in practice and clinical guidelines. For example, the American Psychiatric Association's Practice Guideline for the Treatment of Patients with Major Depressive Disorder (2010) states that family members may benefit from psychoeducation about depression, including its impact on functioning and treatment options. It further says that “Marital and family problems are common in the course of major depressive disorder, and such problems should be identified and addressed, using marital or family therapy when indicated” (APA, 2010). Similarly, APA guidelines for bipolar disorder recommend providing education about illness management to both the patient and family (APA, 2002).

In the VA healthcare system, the development and use of evidence-based couples/family treatments has grown considerably in the past decade, in part due to the national trainings sponsored by VA Central Office (Makin-Byrd, Gifford, McCutcheon & Glynn, 2011). However, formal evaluation of these services in VA is limited. Exceptions include evaluation of the Structured Approach Therapy model for PTSD (Sautter, Glynn, Thompson, Franklin & Han, 2011), Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress Disorder (Monson et al., 2012), and Behavioral Couples Therapy for Alcoholism and Drug Abuse (O'Farrell & Fals-Stewart, 2006), all of which have been or are being tested in the VA system. Preliminary reports from these evaluations describe reduced mental health symptoms in veterans.

The REACH Intervention

The VA system has provided training for clinicians in the multi-family group therapy model (McFarlane, 2004), a family psychoeducational intervention originally developed for patients with schizophrenia. We adapted the MFG model for use in the VA system with support from the VA Office of Mental Health Services. The resulting program, Reaching out to Educate and Assist Caring, Healthy Families (REACH), has been described in detail elsewhere (author names removed for blind review, 2009). Briefly, REACH is a 9-month, 3-phase manualized psychoeducational intervention for veterans living with mental illness and a veteran-designated adult support person (complete manual available upon request from the first author). After an initial assessment session, the veteran and support person meet with a therapist for four single-family sessions; these meetings focus on rapport building, goal setting, and the assessment of functioning, coping skills, and social support. The second phase of REACH involves 6 weekly 90-minute multifamily group sessions. Each class has a specific topic (e.g., causes of mental illness, communication skills, problem-solving skills), and involves brief psychoeducation, role plays, and discussion. The final phase consists of six monthly 90-minute multifamily groups which support the maintenance and consolidation of gains, especially problem solving skills. There are three separate diagnostic cohorts in REACH, namely PTSD, mood disorders, and schizophrenia; the intervention is delivered separately for each cohort, with disorder-specific content tailored for each group. Across diagnostic cohorts, high levels of participant satisfaction, attendance, and program retention have been demonstrated (author names removed for blind review, 2009).

We have described outcomes for veterans in the PTSD cohort and their support persons previously (author names removed for blind review, 2013), and made the therapist manual and patient workbook for the PTSD cohort available online at: www.ouhsc.edu/REACHProgram. In the remainder of this report, we present outcomes for a preliminary study (without a comparison group) of the REACH mood disorders cohort. To the best of our knowledge, this is the first evaluation of an MFG intervention in the VA system for veterans living with depression or bipolar disorder.

Recruitment and Data Collection Procedures

The methodology for the current investigation is nearly identical to that used to evaluate outcomes for veterans living with PTSD in the REACH Program (Author Names Removed for Blind Review, 2013). To be eligible for the clinical REACH program, a veteran with a primary diagnosis of major depression or bipolar disorder must be currently enrolled at the Oklahoma City VA Medical Center (VAMC), live within 90 miles of the VAMC, and have an adult family member or friend willing to participate in REACH with him/her. Veterans who have an active and serious substance abuse problem or are imminently suicidal or homicidal are not eligible for the clinical program.

All participants in the clinical REACH program are invited to take part in the REACH evaluation; approximately 95% consent. After description of the evaluation during potential participants' first Phase 1 session, written informed consent is obtained from interested veterans and family members. Participants in the evaluation complete a battery of self-report measures at 4 times: at the time of consent (baseline) and again at the end of each of Phases 1, 2 and 3. Veterans and family members complete their evaluation batteries separately. Following each completed assessment, participants receive $20 compensation for their time. The evaluation has Institutional Review Board approval.

Measures

The measures and statistical approaches used with this sample are highly similar to those used in our previous evaluation of veterans with PTSD in the REACH Program (Author Names Removed for Blind Review, 2013). Data were collected to measure changes over time in the knowledge and skill domains directly and explicitly targeted by REACH (“primary outcomes”). Data were also collected to assess changes over time in more distal outcomes expected to be affected by changes in REACH-targeted knowledge and skills, i.e., relationship distress/satisfaction, social support, symptom status and, for veterans only, overall quality of life and use of VA mental health services (“distal outcomes”). The measures used for each of these domains are described below.

Targeted knowledge and skills

To assess changes in mood disorder-related knowledge and behaviors, a 29-item self-report instrument developed for this study was administered (available upon request from the first author). The instrument is comprised of 3 subscales. The 16-item Knowledge subscale, which addresses the causes, symptoms, diagnosis, treatment, and course of mood disorders, is scored as percent of items answered correctly. The 7-item Understanding subscale assesses the extent to which respondents feel that they understand how to handle various mood disorder-related behavioral situations, while the 6-item Coping subscale assesses how well they feel that their family communicates and manages stressors. Subscale scores for Understanding and Coping are the average of item responses on a scale ranging from strongly disagree (1) to strongly agree (7); higher scores are better.

Participants also completed the 10-item Family Problem Solving Communication (FPSC) Scale (McCubbin, McCubbin, & Thompson, 1996). Respondents rate FPSC items describing ways in which families may behave when struggling with upsetting situations on a scale from 0 (false) to 3 (true). Item-scores are averaged; higher scores are better. This measure has established internal reliability (alpha=.89) and test-retest (r=.86) reliability (McCubbin et al., 1996), and has been used in evaluations of other programs for families dealing with mental illness (Dixon et al., 2011).

Empowerment was also assessed for veterans and family members. Veterans completed the 28-item Rogers Empowerment Scale (item score range: 1-4; Rogers, Chamberlin, Ellison, & Crean, 1997; Rogers, Ralph, & Salzer, 2010), a measure with good internal consistency (alpha=.82-.86) and construct validity. Family members completed the 34-item Koren Family Empowerment Scale (item score range: 1-5; Koren, DeChillo, & Friesen, 1992), which has strong internal consistency (alpha=.87-.88) and construct validity, and has been used in evaluating other mental illness family education programs (Dixon et al., 2011). For both empowerment scales, scores were averaged across items; higher scores indicate greater empowerment.

Relationship distress/satisfaction

The 7-item Dyadic Adjustment Scale (DAS-7) was used to assess relationship distress/satisfaction (Hunsley, Best, Lefebvre, & Vito, 2001). Scores can range from 0-36, with higher scores indicating less distress. Relationships scored 20 or lower were considered in distress (Sabourin, Valois, & Lussier, 2005). DAS-7 data were only analyzed for dyads where the family member was the veteran's spouse or significant other because DAS-7 items are specific to those relationships.

Social support

Perceived adequacy of social support was assessed using the 12-item Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988; Zimet, Powell, Farley, Werkman, & Berkoff, 1990; Beck, Grant, Clapp, & Palyo, 2009). Participants rated each statement on a scale from 1 (disagree strongly) to 5 (agree strongly). The MSPSS score is the average of item scores; higher scores indicate greater perceived social support.

Symptom status

The 53-item Brief Symptom Inventory (BSI) was used to assess the psychological status of participating veterans and family members (Derogatis, 1993). The BSI, which has norms available for both patient and non-patient populations, generates 9 symptom-domain scores and 3 summary scores. Participants use a 5-point scale (0=not at all to 4=extremely) to rate the extent to which they have been bothered by each symptom in the previous week. Responses are averaged across relevant symptoms to generate summary and subscale scores. The General Severity Index (GSI), which combines information about number of symptoms and intensity of distress, is considered the most sensitive BSI measure of psychological distress (Derogatis, 1993). In addition to the GSI, scores on the Depression and Anxiety subscales were examined.

Quality of life, medication adherence and service utilization

Veterans rated their overall quality of life both at the beginning of the Quality of Life Questionnaire, Brief Version (Lehman, 2006), and again at the end. The Overall Quality of Life score was the average of the two ratings; scores can range from 1-7 with higher scores indicating better perceived quality of life. Both veterans and family members reported on the veteran's medication adherence over the previous 30 days using a 5-point self-report scale where 1=never missed and 5=stopped taking the medication altogether (Miklowitz, Goldstein, Neuchterlein, Snyder, & Mintz, 1986). Veterans who “never missed” or “missed only a couple of times, but basically took all the medicine” were classified as adherent. With veterans' written informed consent, data on their utilization of VA health services were extracted from the VA's administrative and clinical databases housed at the Austin Information Technology Center. Utilization data were extracted for the 33-month period beginning 12 months prior to the date of REACH consent and ending 12 months after the end of REACH Phase 3.

Statistical Analysis

Data were analyzed separately for veterans and family participants. Because outcome variables were approximately normally distributed, the magnitude and significance of changes over time were assessed using general linear modeling for repeated measures (SAS GENMOD with the identity link). When the overall model for a given dependent variable was statistically significant (two-sided p-value <.05), the location and stability of change over time were assessed via three pre-specified contrasts (Phase 2-Baseline, Phase 3-Baseline and Phase 3-Phase 2). Because significant change was not expected during the brief Phase I single-dyad “joining” sessions, a Phase 1-Baseline contrast was not included.

We hypothesized that, if within-participant changes in distal outcomes (relationship satisfaction, perceived social support, symptom measures, and veterans' perceived quality of life) were at least partially attributable to REACH participation, within-participant changes in REACH-targeted domains (Affective Disorders (AD) Knowledge, AD Understanding, AD Coping, FPSC and empowerment) should reduce or eliminate the association between time/REACH assessment and distal outcomes. Fixed effects regression modeling (SAS GLM) was used to explore the extent to which within-participant changes over time in distal outcomes could be explained by within-participant changes in targeted domains (Allison, 2005). Analyses were performed using SAS version 9.3.

Results

Participants

Sociodemographic characteristics

As shown in Table 1, a large majority of the 101 participating veterans were men (82%). They ranged in age from 23-75 years and averaged 51.4 years of age (standard error (SE)=1.21). Most were non-Hispanic White (89%), married or living as married (78%), and reported more than a high-school education (75%). Regarding veteran diagnosis, 73% had major depression and 27% had bipolar disorder. Most of the 93 participating family members were women (83%), and most were the spouse or significant other of their participating veteran (76%). They were also predominantly non-Hispanic White (82%), married or cohabiting (87%), and reported more than a high-school education (63%). Family members ranged in age from 19-84 years, with an average age of 49.0 years (SE=1.45).

Table 1. Baseline Demographics, Veterans and Family Members.
Veterans (n=101) Family (n=93)
Variable Number Percent Number Percent
Gender
 Male 83 82.18 16 17.20
 Female 18 17.82 77 82.80
Ethnicity
 White, Non-Hispanic 87 88.78 76 81.72
 African American, Non-Hispanic 9 9.18 6 6.45
 Hispanic 1 1.02 1 1.08
 Asian 0 0 2 2.15
 Native American - - 4 4.30
 Other 1 1.02 4 4.30
 Missing 3 0
Marital Status
 Never Married 8 7.92 4 4.30
 Married/Living as Married/Living with partner 79 78.20 81 87.10
 Separated 1 0.99 0 0
 Divorced 10 9.90 6 6.45
 Widowed 1 0.99 2 2.15
 Unknown 2 1.98 - -
Education
 Less than High School Graduate 4 3.96 5 5.38
 High School Graduate/GED 21 20.79 29 31.18
 Some College 49 48.51 38 40.86
 College Graduate 20 19.80 9 9.68
 Graduate/Professional Studies 7 6.93 12 12.90
Age
 18-29 7 6.93 9 9.68
 30-39 8 7.92 14 15.05
 40-49 27 26.73 28 30.11
 50-59 27 26.73 20 21.51
 60-69 28 27.72 16 17.20
 ≥70 4 3.96 6 6.45
 Mean (SE) 51.36 1.21 48.98 1.45
 Median (Interquartile Range) 52 43-60 48 40-58
 Range 23-75 19-84
Diagnosis
 Major Depression 74 73.3 NA NA
 Bipolar Disorder 27 26.7 NA NA
Family member's relationship to veteran
 Spouse/Significant Other NA NA 71 76.34
 Parent NA NA 9 9.68
 Sibling NA NA 2 2.15
 Child NA NA 5 5.38
 Other kin NA NA 3 3.23
 Non-kin/friend NA NA 3 3.23
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Baseline status

Table 2 provides participants' status on outcome variables at baseline. Fewer participants have baseline relationship satisfaction (DAS-7) scores because DAS-7 scores are only relevant for dyads comprised of spouses or significant others. In addition, the DAS-7 was added to the interview battery after the program had begun.

Table 2. Baseline Status on Primary Outcome Measures - Veterans.
Measures N Mean SE Median IQ Range Range
AD Knowledge (% correct) 100 68.94 1.42 68.75 62.5-81.25 31.25-93.75
AD Understanding1 98 4.47 0.12 4.50 3.67-5.33 1.00-7.00
AD Coping1 99 3.64 0.14 3.67 2.50-4.83 1.00-7.00
Empowerment (Rogers)1 98 2.68 0.03 2.64 2.46-2.86 1.93-3.46
Relationship Satisfaction (DAS-7)2 61 21.97 0.82 23.00 17.00-27.00 10.00-33.00
 Distressed at baseline (score ≤20) 25 15.6 0.66 16.00 13.00-18.00 10.00-20.00
 Not distressed at baseline 36 26.39 0.60 26.00 23.00-29.00 21.00-33.00
Family Problem Solving (McCubbin)3 98 1.52 0.07 1.50 1.00-2.00 0.00-3.00
Social Support (MSPSS)3 100 3.40 0.10 3.42 2.83-4.17 1.00-5.00
BSI – Global Severity Index (GSI)3 100 1.84 0.07 1.88 1.35-2.41 0.30-3.49
BSI – Depression3 100 2.10 0.09 2.08 1.50-2.67 0.17-3.83
BSI – Anxiety3 100 1.76 0.08 1.75 1.17-2.33 0.00-3.33
Overall Quality of Life 100 3.46 0.12 3.50 2.50-4.00 1.00-6.00
Baseline Status on Primary Outcome Measures - Family
AD Knowledge (% correct) 92 72.69 1.29 75.00 68.75-81.25 37.5-93.75
AD Understanding1 88 4.63 0.13 4.83 3.92-5.50 1.00-7.00
AD Coping1 90 4.15 0.14 4.33 3.17-5.17 1.00-7.00
Empowerment (Koren)1 89 2.99 0.07 2.97 2.68-3.35 1.41-5.00
Relationship Satisfaction (DAS-7)2 63 22.13 0.75 22.00 19.00-26.00 6.00-35.00
 Distressed at baseline (score ≤20) 21 15.76 0.92 16.00 13.00-19.00 6.00-20.00
 Not distressed at baseline 42 25.31 0.58 24.50 22.00-27.00 21.00-35.00
Family Problem Solving (McCubbin)1 92 1.82 0.07 2.00 1.30-2.30 0.20-3.00
Social Support (MSPSS) 1 90 3.78 0.09 3.83 3.25-4.42 1.17-5.00
BSI – Global Severity Index (GSI)3 90 1.07 0.07 0.92 0.55-1.56 0.02-2.45
BSI – Depression3 89 1.05 0.08 1.00 0.33-1.50 0.00-2.83
BSI – Anxiety3 90 1.04 0.08 1.00 0.50-1.50 0.00-2.83
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1

Average score

2

Includes only family members whose veteran participant is a spouse or significant other

3

Scored on 0-4 scale

BSI = Brief Symptom Inventory

The values shown for the Brief Symptom Inventory Global Severity Index (GSI), Depression subscale and Anxiety subscale are the raw scores. Veterans' mean GSI, Depression and Anxiety scores of 1.84, 2.10 and 1.76, respectively, at baseline places them in the 82nd, 63rd and 63rd percentiles, respectively, for adult male psychiatric outpatients. That is, their GSI, Depression and Anxiety scores indicate that 82% of adult male psychiatric outpatients will have lower (more desirable) scores on GSI, 63% will have lower scores on the Depression subscale, and 63% will have lower scores on the Anxiety subscale. Family members' mean GSI score of 1.07 at places them in the 95th percentile, their mean Depression subscale score of 1.05 places them in the 91st percentile, and their Anxiety subscale score of 1.04 places them at the 91st percentile for adult non-patient females (Derogatis, 1993).

Changes Over Time in REACH-targeted Knowledge and Skills

As shown in Table 3 (Change in Targeted Knowledge and Skill Outcome Variables over Time), veterans demonstrated statistically significant changes over time in the desired direction in all REACH-targeted knowledge and skills variables: AD Knowledge, AD Understanding, AD Coping, empowerment, and family problem-solving and communication (FPSC scores). Family members had statistically significant improvements over time in all of these domains except FPSC (p=.13). Improvement was consistent over time for all variables for veterans, but decreased somewhat during the maintenance Phase 3 for family members on AD Coping and empowerment.

Table 3. Change in Targeted Knowledge and Skill Outcome Variables over Time.

Time/Assessment Contrasts
Outcome N df X2 P Intercept Phase 2-Baseline Estimate Phase 3-Phase 2 Estimate Phase 3-Baseline Estimate
Veterans
AD Knowledge 99 3 25.14 <.0001 68.81*** 7.75*** 1.7330 9.48***
AD Understanding1 94 3 56.80 <.0001 4.47*** 1.07*** 0.31** 1.38***
AD Coping1 96 3 32.87 <.0001 3.61*** 0.80*** 0.28 1.08***
Rogers Empowerment1 98 3 21.32 <.0001 2.68*** 0.10*** 0.02 0.12***
FPSC1 98 3 25.83 <.0001 1.52*** 0.26*** 0.11 0.37***
Family
AD Knowledge 90 3 9.54 0.0229 73.06*** 3.91* 0.48 4.39*
AD Understanding1 83 3 37.34 <.0001 4.65*** 0.98*** 0.03 1.01***
AD Coping1 87 3 20.79 0.0001 4.11*** 0.63*** -0.09 0.55**
Koren Empowerment1 87 3 21.54 <.0001 2.99*** 0.30*** -0.01 0.29**
FPSC1 90 3 5.61 0.1321
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1

Average

*

p<0.05

**

p<0.01

***

p<0.001

FPSC: Family Problem Solving and Communication Scale

Changes Over Time for Distal Outcomes

As shown in Table 4, veterans had consistent and statistically significant improvements over time on all distal outcomes except relationship satisfaction. None of the changes in the family member distal outcome variables was statistically significant.

Table 4. Change in Distal Outcome Variables over Time.

Time/Assessment Contrasts
Outcome N df X2 P Intercept Phase 2-Baseline Estimate Phase 3-Phase 2 Estimate Phase 3-Baseline Estimate
Veterans
Social support(MSPSS)1 98 3 15.34 0.0015 3.41*** 0.28*** 0.03 0.31**
Relationship satisfaction (DAS-7)2
 Distressed 24 3 0.43 0.9346 15.79*** -0.67 0.25 -0.42
 Not Distressed 34 3 5.71 0.1265 26.44*** 0.38 0.96 1.34
BSI – GSI 100 3 15.55 0.0014 1.84*** -0.20*** -0.04 -0.23**
BSI – Depression 100 3 11.53 0.0092 2.10*** -0.23** -0.08 -0.31**
BSI – Anxiety 100 3 16.44 0.0009 1.76*** -0.23*** -0.10 -0.33***
Overall Quality of Life 100 3 33.27 <.0001 3.46*** 0.66*** 0.25 0.90***
Family
Social support (MSPSS)1 90 3 4.28 0.2331 3.78*** 0.12 -0.11 0.01
Relationship satisfaction (DAS-7)3
 Distressed 21 3 1.31 0.7260 15.76*** -0.43 -1.08 -1.51
 Not Distressed 37 3 7.71 0.0524 25.16*** 1.11 -0.01 1.10
BSI – GSI 90 3 2.33 0.5066 1.07*** -0.05 -0.04 -0.09
BSI – Depression 89 3 1.02 0.7957 1.05*** 0.02 -0.06 -0.05
BSI – Anxiety 90 3 2.10 0.5521 1.04*** -0.02 -0.12 -0.14
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1

Average

2

Includes only those veterans whose family participant is a spouse or significant other

3

Includes only those family participants whose veteran is a spouse or significant other

*

p<0.05

**

p<0.01

***

p<0.001

MSPSS: Multidimensional Scale of Perceived Social Support DAS-7: Dyadic Adjustment Scale-7

BSI-GSI: Brief Symptom Inventory-Global Severity Index; all BSI scores are raw scores

We also assessed the impact of REACH participation on veterans' medication adherence and use of VA healthcare services. On average, veterans used more VA outpatient mental health services in the 12 months following the end of REACH than they had in the 12 months preceding initiation of REACH (2.19 encounters per month versus 1.29 encounters per month; paired t=-1.97, df=100, p=.052). About one-fifth (19.8%, n=20) of the veterans had inpatient psychiatric stays in the year pre-REACH; approximately 11% (n=11) had an admission in the year following completion of REACH. This difference approached statistical significance (McNemar's statistic S=3.52, df=1, p=0.06).

Veterans' medication adherence was assessed via self-report and family-member report. Adherence among veterans taking psychotropic medications was relatively high at baseline (90% by veteran and 82% by family-member report. At the end of REACH, 94% of veterans and 93% of family members reported that veterans were adherent. While this suggests increasing adherence following participation in REACH, neither veteran-reported nor family-reported changes achieved statistical significance.

Relationship of Changes to REACH Participation

To examine the likelihood that within-participant changes in the more distal outcomes were at least partly attributable to REACH participation, changes in distal outcomes were regressed on time and changes in REACH-targeted knowledge and skills. As shown in Table 5, when changes in targeted domain scores for veterans were included in the models, “time” (REACH assessment) became non-significant for all distal outcomes except Quality of Life Global Life Satisfaction (p=.005) and Anxiety (p=.046). For veterans, within-participant changes in targeted-domain scores (primarily empowerment) were significantly associated with changes in all distal domains. Because changes in distal outcomes for family members were not statistically significant, we did not look at the relationship between REACH participation and changes in distal outcomes among family members.

Table 5. Within-Participant Change in Distal Outcome Variables as a Function of Time and Change in Targeted Knowledge and Skills.

Parameter Estimates: Change in Targeted Knowledge and Skills
Time AD Knowledge AD Understanding1 AD Coping1 Empower-ment1,3 FPSC1
Outcome p
Veterans
MSPSS1 0.1464 -0.0043 0.0498 -0.0076 0.9425*** 0.2204*
DAS-72 0.5682 -0.0563 -0.0031 1.4791** 1.8499 1.1929
Overall Quality of Life 0.0054 -0.0031 0.0601 0.1373* 1.0880*** 0.0519
BSI – GSI 0.3976 -0.0032 0.0569* -0.0415 -0.9427*** 0.0012
BSI – Depression 0.8407 -0.0041 0.0114 -0.0291 -1.2159*** 0.0163
BSI – Anxiety 0.0462 -0.0001 0.0788* -0.0448 -0.9152*** 0.0673
Open in a new tab
1

Average

2

Includes only those dyads in a distressed relationship with a spouse or significant other at baseline

3

Rogers Empowerment Scale

MSPSS: Multidimensional Scale of Perceived Social Support

DAS-7: Dyadic Adjustment Scale-7

BSI-GSI: Brief Symptom Inventory-Global Severity Index

*

p<0.05

**

p<0.01

***

p<0.001

Exploratory Subgroup Analyses

To explore whether the effects of participation in REACH differ by diagnosis, we repeated the analyses described above (changes over time in REACH targeted skills; changes over time in distal outcomes; relationships of changes to REACH participation) using only the data from the 74 veterans with a diagnosis of depression and their family members. (The bipolar disorder subsample (n=27) was too small for meaningful analysis.) Results from the depression group analyses mirrored those of the entire sample. In some cases, improvements were larger in the subset of veterans with major depression than in the combined sample of veterans with depression and veterans with bipolar disorder.

Discussion

To our knowledge, this is the first report of outcomes of participation in a multifamily group model program for veterans living with mood disorders. Our initial evaluation suggests that participation in REACH had a positive impact for veterans living with mood disorders and their family members. Veterans showed improvements in the knowledge domains and skills directly targeted in REACH sessions, specifically, knowledge about mood disorders, understanding of positive strategies for dealing with situations commonly confronted in mood disorders, family coping strategies, family communication and problem-solving behaviors, and empowerment. Improvements were also seen in perceived social support, psychiatric symptoms, and quality of life, outcomes less directly tied to the content of REACH sessions. Although average improvements in the BSI GSI scores moved veterans from the 82nd percentile for male outpatients at baseline to the 73rd percentile at the end of participation in REACH, on average, improvements were not sufficient to move veterans into the “normal” range for non-patients (Derogatis, 1993). The significant associations between within-participant changes in targeted knowledge and skills and changes in the more distal outcomes suggest that changes observed in the latter are attributable, at least in part, to program participation.

Regarding service utilization, veterans used more outpatient mental health services in the year following completion of REACH participation than in the year preceding entry into REACH. Many veterans who participated in REACH had been isolated and uninvolved in community as well as VA services; engagement in VA and other services was encouraged as part of the REACH intervention, suggesting that the increase in utilization is a positive change. The pre-/post-REACH decrease in the proportion of veterans admitted for inpatient mental healthcare is a desirable change and one that approached significance (p=.06). Although these findings are preliminary and warrant replication with a larger sample, they are promising, suggesting increased engagement in outpatient care and decreased need for psychiatric admissions.

Family members also showed improvements in knowledge and understanding of mood disorders, perceived ability to cope with mood-disorder challenges, and empowerment. However, there were no significant changes in their psychiatric symptoms or levels of perceived social support. Almost 80% of participants were in marriages or intimate partnerships, and some of the family members may have been dealing with veterans with episodic mood disorder symptoms for many years. Thus, it may take time for consistent improvements in the mental health of their veterans to positively impact family members. Notably, other couples-based treatment outcome research with veterans that documented improvement in veteran functioning has similarly failed to find positive changes in partner/spouse psychiatric functioning or partner relationship satisfaction (Cretu, Sautter, Glynn, Senturk & Vaught, in press; Monson, Fredman, Macdonald, Puka-Martin, Resick & Schnurr, 2012).

Surprisingly, there was no improvement in relationship satisfaction (DAS scores) for either veterans or family members, even for those in distressed relationships at baseline. This is in contrast to our experience with the REACH PTSD cohort (there is considerable overlap in curriculum content) in which both family members and veterans in distressed relationships at baseline showed statistically significant improvements on the DAS (Author Names Removed for Blind Review, 2013). The demographic characteristics of the samples and the baseline levels of relationship satisfaction were similar across groups (PTSD and mood disorders cohorts). In both cases, the subsamples in distressed relationships were quite small (n<30); nonetheless, the reasons for such different patterns in relationship-satisfaction outcomes are unclear and merit additional research.

This intervention was intentionally designed to meet the needs of veterans with either major depression or bipolar disorder and their families. Clinically, we speculated that the commonalities of families' shared experience with mood disorders and the power of multiple family groups would exceed the specific disorder-specific concerns. Recruitment of a sufficient number of families for a bipolar-disorder-only group would have been logistically challenging due to its lower prevalence. We discovered that this mixture of veteran diagnoses worked well in the groups, and did not pose any challenges clinically. Overall findings were driven by outcomes in the much larger subgroup of veterans with major depressive disorder; the bipolar disorder subsample was too small to allow for subgroup analyses. Further research with a larger sample of veterans with bipolar disorder is warranted.

The study has several limitations. Because we had no comparison group and veterans continued their usual care during REACH participation, we cannot rule out the possibility that observed improvements were attributable to something other than program participation. It is possible that the treatment gains were due to contact with the therapist or other families. Although additional research is needed, the multifamily group format is economical and has potential in light of the promising findings for families dealing with both depression and other mental illnesses (Author names removed for blind review, 2013; McFarlane, 2004; Solomon et al., 2008). In addition, the sample was restricted to one VA medical center in the Midwest, so generalizability of the findings must be considered with caution. The sample was somewhat homogenous, with primarily male, White, middle-aged veterans participating with their female, White, middle-aged spouses or significant others. Future research may examine this intervention with a broader range of families and relationships, including the predominantly younger sample of men and women recently returned from the wars in Iraq and Afghanistan. The ability of the families to maintain treatment gains over time is unknown; future research may include follow-up assessments with dyads after completion of treatment. Despite the limitations of the clinical evaluation, its promising findings warrant further research to verify results in controlled studies.

Acknowledgments

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of Veterans Affairs. This project was supported by Mental Health Enhancement funds from the Department of Veterans Affairs Office of Mental Health Services, the VA South Central (VISN 16) Mental Illness Research, Education and Clinical Center, the VA Health Services Research and Development Service Center for Mental Healthcare and Outcomes Research, and the National Institutes of Health (grant UL1 TR000039). The authors thank William McFarlane and Lisa Dixon for their invaluable support and advice, Alan Doerman for his clinical expertise, and Silas Williams for assistance with data extraction.

Contributor Information

Michelle D. Sherman, Email: MichelleDSherman2@gmail.com, University of Minnesota, Address: 290 McNeal Hall, 1985 Buford Avenue, St. Paul, MN 55108.

Ellen P. Fischer, Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas

Richard R. Owen, Jr., Center for Mental Healthcare & Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas and Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas

Liya Lu, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas

Xiaotong Han, Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas

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