A Dyadic Investigation of Relationship Dynamics and Depressive Symptoms in HIV-Affected Couples in Malawi


Depression is the leading cause of disability worldwide with health implications for people living with HIV. Primary partnerships like marriage could be protective against depression but may worsen depression depending on the relationship quality. We examined depression and its association with relationship dynamics in a cross-sectional sample of 211 HIV-affected married couples in Malawi. We fit multivariable multilevel linear regression models for depressive symptoms. Men and women reported similar levels of depressive symptoms; 28% had a score indicative of probable depression. Almost half of couples had at least one partner with probable depression. In the adjusted models, equality (B = − 0.22; p < 0.01) and unity (B = − 0.94; p < 0.05) were associated with fewer depressive symptoms while individuals with more experiences of physical (B = 0.81; p < 0.01), sexual (B = 0.87; p < 0.01), and emotional violence (B = 1.52; p < 0.001) had higher levels of depressive symptoms. Couples-based interventions aiming to improve relationships may address depression, especially in settings with inadequate mental health services.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.


  1. 1.

    Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001;158(5):725–30.

  2. 2.

    Krumme AA, Kaigamba F, Binagwaho A, Murray MB, Rich ML, Franke MF. Depression, adherence and attrition from care in HIV-infected adults receiving antiretroviral therapy. J Epidemiol Community Health. 2015;69(3):284–9.

  3. 3.

    Nel A, Kagee A. Common mental health problems and antiretroviral therapy adherence. AIDS Care. 2011;23(11):1360–5.

  4. 4.

    Shearer K, Evans D, Xhosa B, Hirasen K, Bracken C, Mahomed K, et al. Low prevalence of depressive symptoms among stable patients on antiretroviral therapy in Johannesburg, South Africa. PLoS ONE. 2018;13(9):e0203797.

  5. 5.

    Ortego C, Huedo-Medina TB, Llorca J, Sevilla L, Santos P, Rodríguez E, et al. Adherence to highly active antiretroviral therapy (HAART): a meta-analysis. AIDS Behav. 2011;15(7):1381–96.

  6. 6.

    Andersen LS, Magidson JF, O’Cleirigh C, Remmert JE, Kagee A, Leaver M, et al. A pilot study of a nurse-delivered cognitive behavioral therapy intervention (Ziphamandla) for adherence and depression in HIV in South Africa. J Health Psychol. 2016;23(6):776–87.

  7. 7.

    Lofgren SM, Nakasujja N, Boulware DR. Systematic review of interventions for depression for people living with HIV in Africa. AIDS Behav. 2017;22(1):1–8.

  8. 8.

    World Health Organization. Indicator Code Book Mental Health Resources. 2014 Aug 15;1–19. Retrieved Dec 18, 2018 from

  9. 9.

    Bhatia R, Hartman C, Kallen MA, Graham J, Giordano TP. Persons newly diagnosed with HIV infection are at high risk for depression and poor linkage to care: results from the steps study. AIDS Behav. 2010;15(6):1161–70.

  10. 10.

    Robles TF. Marital quality and health. Curr Dir Psychol Sci. 2014;23(6):427–32.

  11. 11.

    Aggarwal S, Kataria D, Prasad S. A comparative study of quality of life and marital satisfaction in patients with depression and their spouses. Asian J Psychiatry. 2017;30:65–70.

  12. 12.

    Kiecolt-Glaser JK, Newton TL. Marriage and health: his and hers. Psychol Bull. 2001;127(4):472–503.

  13. 13.

    Robles TF, Slatcher RB, Trombello JM, McGinn MM. Marital quality and health: a meta-analytic review. Psychol Bull. 2014;140(1):140–87.

  14. 14.

    Caetano R, Cunradi C. Intimate partner violence and depression among Whites, Blacks, and Hispanics. Ann Epidemiol. 2003;13(10):661–5.

  15. 15.

    Johnson SL, Jacob T. Marital interactions of depressed men and women. J Consult Clin Psychol. 1997;65(1):15–23.

  16. 16.

    Sher TG, Baucom DH, Larus JM. Communication patterns and response to treatment among depressed and nondepressed maritally distressed couples. J Fam Psychol. 1990;4(1):63–79.

  17. 17.

    Mitchell J, Wight M, Van Heerden A, Rochat TJ. Intimate partner violence, HIV, and mental health: a triple epidemic of global proportions. Int Rev Psychiatry. 2016;28(5):452–63.

  18. 18.

    Bodenmann G, Charvoz L, Widmer K, Bradbury TN. Differences in individual and dyadic coping among low and high depressed, partially remitted, and nondepressed persons. J Psychopathol Behav Assess. 2004;26(2):75–85.

  19. 19.

    Williams K. Has the future of marriage arrived? A contemporary examination of gender, marriage, and psychological well-being. J Health Soc Behav. 2003;44(4):470–87.

  20. 20.

    Conroy AA, McKenna SA, Ruark A. Couple interdependence impacts alcohol use and adherence to antiretroviral therapy in Malawi. AIDS Behav. 2018;63(2):1–10.

  21. 21.

    Conroy AA, McKenna SA, Comfort ML, Darbes LA, Tan JY, Mkandawire J. Marital infidelity, food insecurity, and couple instability_ A web of challenges for dyadic coordination around antiretroviral therapy. Soc Sci Med. 2018;214:110–7.

  22. 22.

    Malawi demographic and health survey 2015-16. Maryland: NSO and ORC Macro; 2016.

  23. 23.

    Sternberg RJ. Construct validation of a triangular love scale. Eur J Soc Psychol. 1997;27(3):313–35.

  24. 24.

    Ruark A. Couple functionality assessment tool (CFAT): user guide. Baltimore, MD: Catholic Relief Services; 2015.

  25. 25.

    Larzelere RE, Huston TL. The dyadic trust scale: toward understanding interpersonal trust in close relationships. J Marriage Fam. 1980;42(3):595.

  26. 26.

    Kurdek LA. The deterioration of relationship quality for gay and lesbian cohabiting couples: a five-year prospective longitudinal study. Pers Relat. 1996;3(4):417–42.

  27. 27.

    Funk JL, Rogge RD. Testing the ruler with item response theory: increasing precision of measurement for relationship satisfaction with the Couples Satisfaction Index. J Fam Psychol. 2007;21(4):572–83.

  28. 28.

    Aron A, Aron EN, Smollan D. Inclusion of other in the self scale and the structure of interpersonal closeness. J Pers Soc Psychol. 1992;63(4):596–612.

  29. 29.

    Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet. 2006;368(9543):1260–9.

  30. 30.

    Conroy AA. Gender, power, and intimate partner violence. J Interpers Violence. 2013;29(5):866–88.

  31. 31.

    Radloff LS. The CES-D Scale. Appl Psychol Meas. 1977;1(3):385–401.

  32. 32.

    Filmer D, Pritchett L. Estimating wealth effects without expenditure data–Or tears: an application to educational enrollments in states of India. Demography. 2001;38(1):115–32.

  33. 33.

    Bush K. The AUDIT alcohol consumption questions (AUDIT-C). An effective brief screening test for problem drinking. Arch Intern Med. 1998;158(16):1789.

  34. 34.

    Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001;158(5):725–30.

  35. 35.

    Townsend AL, Miller B, Guo S. Depressive symptomatology in middle-aged and older married couples: a dyadic analysis. J Gerontol B. 2001;56(6):S352–64.

  36. 36.

    Agresti A, Finlay B. Statistical methods for the social sciences. 4th ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2009.

  37. 37.

    Udedi M, Stockton MA, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, et al. Integrating depression management into HIV primary care in central Malawi: the implementation of a pilot capacity building program. BMC Health Serv Res. 2018;18(1):593.

  38. 38.

    Kidia K, Machando D, Bere T, Macpherson K, Nyamayaro P, Potter L, et al. “I was thinking too much”: experiences of HIV-positive adults with common mental disorders and poor adherence to antiretroviral therapy in Zimbabwe. Trop Med Int Health. 2015;20(7):903–13.

  39. 39.

    Pruchno R, Wilson-Genderson M, Cartwright FP. Depressive symptoms and marital satisfaction in the context of chronic disease: a longitudinal dyadic analysis. J Fam Psychol. 2009;23(4):573–84.

  40. 40.

    Proulx CM, Helms HM, Buehler C. Marital quality and personal well-being: a meta-analysis. J Marriage Fam. 2007;69(3):576–93.

  41. 41.

    Devries KM, Mak JY, Bacchus LJ, Child JC, Falder G, Petzold M, et al. Intimate partner violence and incident depressive symptoms and suicide attempts: a systematic review of longitudinal studies. PLoS Med. 2013;10(5):e1001439.

  42. 42.

    Tsai AC, Tomlinson M, Comulada WS, Rotheram-Borus MJ. Intimate partner violence and depression symptom severity among South African women during pregnancy and postpartum: population-based prospective cohort study. PLoS Med. 2016;13(1):e1001943.

  43. 43.

    Trevillion K, Oram S, Feder G, Howard LM. Experiences of domestic violence and mental disorders: a systematic review and meta-analysis. PLoS ONE. 2012;7(12):e51740.

  44. 44.

    Beydoun HA, Beydoun MA, Kaufman JS, Lo B, Zonderman AB. Intimate partner violence against adult women and its association with major depressive disorder, depressive symptoms and postpartum depression: a systematic review and meta-analysis. Soc Sci Med. 2012;75(6):959–75.

  45. 45.

    Tsai AC, Wolfe WR, Kumbakumba E, Kawuma A, Hunt PW, Martin JN, et al. Prospective study of the mental health consequences of sexual violence among women living with HIV in rural Uganda. J Interpers Violence. 2015;31(8):1531–53.

  46. 46.

    Kouyoumdjian FG, Calzavara LM, Bondy SJ, O’Campo P, Serwadda D, Nalugoda F, et al. Intimate partner violence is associated with incident HIV infection in women in Uganda. AIDS. 2013;27(8):1331–8.

  47. 47.

    Zakrison TL, Rattan R, Milian Valdés D, Ruiz X, Gelbard R, Cline J, et al. Universal screening for intimate partner and sexual violence in trauma patients—what about the men? An Eastern Association for the Surgery of Trauma Multicenter Trial. J Trauma Acute Care Surg. 2018;85(1):85–90.

  48. 48.

    Tsai AC. Intimate partner violence and population mental health: why poverty and gender inequities matter. PLoS Med. 2013;10(5):e1001440.

  49. 49.

    Thompson L, Walker AJ. The Dyad as the unit of analysis: conceptual and methodological issues. J Marriage Fam. 1982;44(4):889.

  50. 50.

    Bodenmann G, Randall A. Marital therapy for dealing with depression. In: Power M, editor. The Wiley Blackwell handbook of mood disorders. Chichester: John Wiley & Sons Ltd.; 2013. p. 13.

  51. 51.

    Carter M. Gender socialization and identity theory. Soc Sci. 2014;3(2):242–63.

  52. 52.

    Reczek C, Umberson D. Gender, health behavior, and intimate relationships: lesbian, gay, and straight contexts. Soc Sci Med. 2012;74(11):1783–90.

  53. 53.

    Riessman CK, Gerstel N. Marital dissolution and health: do males or females have greater risk? Soc Sci Med. 1985;20(6):627–35.

  54. 54.

    Williams K, Umberson D. Marital status, marital transitions, and health: a gendered life course perspective. J Health Soc Behav. 2004;45(1):81–98.

  55. 55.

    Umberson D. Gender, marital status and the social control of health behavior. Soc Sci Med. 1992;34(8):907–17.

  56. 56.

    Gove WR, Hughes M, Style CB. Does marriage have positive effects on the psychological well-being of the individual? J Health Soc Behav. 1983;24(2):122.

  57. 57.

    Simon RW. Gender, multiple roles, role meaning, and mental health. J Health Soc Behav. 1995;36(2):182.

  58. 58.

    Barbato A, D’Avanzo B. Efficacy of couple therapy as a treatment for depression: a meta-analysis. Psychiatr Q. 2008;79(2):121–32.

  59. 59.

    Whisman MA, Beach SRH. Couple therapy for depression. J Clin Psychol. 2012;68(5):526–35.

  60. 60.

    Jacobson NS, Dobson K, Fruzzetti AE, Schmaling KB, Salusky S. Marital therapy as a treatment for depression. J Consult Clin Psychol. 1991;59(4):547–57.

  61. 61.

    Jacobson NS, Fruzzetti AE, Dobson K, Whisman M, Hops H. Couple therapy as a treatment for depression: II. The effects of relationship quality and therapy on depressive relapse. J Consult Clin Psychol. 1993;61(3):516–9.

  62. 62.

    Olagunju AT, Ogundipe OA, Erinfolami AR, Akinbode AA, Adeyemi JD. Toward the integration of comprehensive mental health services in HIV care: an assessment of psychiatric morbidity among HIV-positive individuals in sub-Saharan Africa. AIDS Care. 2013;25(9):1193–8.

  63. 63.

    Bodenmann G, Plancherel B, Beach SRH, Widmer K, Gabriel B, Meuwly N, et al. Effects of coping-oriented couples therapy on depression: a randomized clinical trial. J Consult Clin Psychol. 2008;76(6):944–54.

Download references


The authors would like to thank the tireless efforts of the research staff at Invest in Knowledge in Malawi for data collection.


This research was funded by the National Institutes of Health under Grants K01MH107331 (AAC), K23MH116807 (ELT), K01MH106416 (JYT) and K24DA037034 (MOJ).

Author information

Correspondence to Emily L. Tuthill.

Ethics declarations

Conflicts of interest

The authors have no conflicts of interest to declare.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained for all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Tuthill, E.L., Neilands, T.B., Johnson, M.O. et al. A Dyadic Investigation of Relationship Dynamics and Depressive Symptoms in HIV-Affected Couples in Malawi. AIDS Behav 23, 3435–3443 (2019).

Download citation


  • Heterosexual couples
  • Relationship dynamics
  • HIV
  • Depression
  • Sub-Saharan Africa