Social cognition in adolescent depression: Evolution of research content and future perspectives

Abstract

Social cognition constitutes a fundamental component in establishing and maintaining healthy interpersonal relationships, achieving social goals, and effectively regulating emotions within social contexts. Inspired by a recent study examining the chain mediating roles of perceived social adversity and security in the relationship between impulsive personality and suicidal behaviors among depressed adolescents, this editorial synthesizes advances in social cognition research specific to adolescent depression. Research methodologies, theoretical frameworks, and neuroscientific insights in this domain have evolved substantially over the past fifteen years. Whereas earlier investigations primarily emphasized broad behavioral observations, contemporary research increasingly integrates neuroimaging techniques, computational modeling, and refined experimental paradigms. Current understanding of specific cognitive biases such as distinctions between interpretive and attentional biases has also grown more nuanced. This editorial reflects the evolving nature of the field by presenting shifts in research focus and demonstrating how these changes have deepened our understanding of social-cognitive functioning in adolescent depression. Building on this synthesis, we outline limitations of extant research and suggest promising directions for future inquiry.

Key Words: Adolescent depression; Cognitive bias; Emotion processing; Theory of mind; Social cognition

Core Tip: Empirical evidence accumulated over the past 15 years indicates that adolescent depression is associated with diverse social-cognitive impairments, which appear implicated in the etiology, progression, and maintenance of the disorder. Advancing longitudinal, cross-cultural comparative, and intervention research remains imperative. Elucidating neurobiological mechanisms, identifying protective factors, and strategically leveraging emerging technologies constitute critical pathways for developing more effective, individualized prevention and intervention approaches for depressed adolescents. Collectively, these advances promise to foster healthier socioemotional development and enhance overall well-being in this population.

INTRODUCTION

A recent study by Zhang et al[1] in the World Journal of Psychiatry reported the mediating role of perceived social adversity and security in the relationship between impulsive personality and suicidal behavior in depressed adolescents. This highlights the importance of social cognitive function in adolescent depression and possible associated deficits. This is supported by a recent study by our team investigating the role of perceived social support in the relationship between negative affect and impulsivity among adolescents who engage in non-suicidal self-injury[2].

Social cognition the mental processes underlying perception, interpretation, retention, and utilization of social information during interpersonal interactions undergoes critical neurodevelopment during adolescence. Key neural substrates supporting these functions (e.g., prefrontal cortex, amygdala) exhibit significant maturation during this period[3]. Disruptions in social cognitive processes may profoundly compromise adolescents’ capacity for emotion regulation in social contexts, establishment of healthy relationships, and achievement of prosocial goals[3].

The relationship between depression and social cognition reflects complex bidirectional dynamics rather than unidirectional causality. Substantial evidence indicates that depressed adolescents exhibit pervasive difficulties in social functioning and interpersonal relationships[4], while depressive symptomatology concurrently impairs social cognitive capacities[5,6]. Conversely, enhancements in social cognition[7] and social competence[8] represent promising preventive mechanisms against adolescent depression. Consequently, elucidating this bidirectional relationship is essential for developing targeted prevention strategies and clinical interventions.

Over the past 15 years, social cognitive research on adolescent depression has progressed substantially, marked by significant methodological refinements, theoretical model advancements, and deepened neuroscientific insights. Recent developments increasingly integrate neuroimaging techniques[9], computational modeling approaches, and sophisticated experimental designs[10], while yielding nuanced differentiation of specific social-cognitive domains[11]. This editorial aims to synthesize key developments in the field, delineate evolving research trajectories, and elucidate how these shifts have enhanced mechanistic understanding of social-cognitive functioning in adolescent depression.

THE SOCIAL-COGNITIVE PICTURE OF ADOLESCENT DEPRESSION

Theory of mind

Theory of mind (ToM) refers to an individual’s ability to understand others’ and his or her own mental states (e.g., beliefs, intentions, emotions, desires, etc.) and to predict and explain behavior accordingly. It can be broadly categorized into affective ToM (inferring others’ emotional states) and cognitive ToM (inferring others’ beliefs and intentions)[12]. ToM is the cornerstone of successful social interaction.

Overall manifestations of ToM: Research demonstrates ToM deficits among individuals with depression, including adolescents. These impairments typically manifest as difficulties in inferring others' beliefs, intentions, and complex mental states particularly during higher-order reasoning tasks[10]. A recent meta-analysis of adults with major depressive disorder revealed significant impairments across both cognitive and affective ToM domains[12]. However, findings in adolescent populations remain inconsistent[10,13]. This heterogeneity may stem from methodological variations in sampling, developmental stages, depression severity, and assessment paradigms. Alternatively, it suggests that ToM deficits in adolescent depression may represent non-universal impairments rather than generalized cognitive deficits. For instance, a study of adolescent girls assessed using the Movie for the Assessment of Social Cognition and Affect revealed no significant differences in overall ToM abilities between the depressed and control groups. However, within the depressed group, higher levels of borderline personality traits were linked to poorer mentalizing competence, while the severity of depressive symptoms was associated with lower levels of socio-moral reasoning[14]. More interestingly, Mellick and Sharp[15] found that depressed adolescent boys showed enhanced decoding of negative psychological states, suggesting a negative bias in ToM rather than a simple deficit in ability.

Emotional vs cognitive ToM: Several studies have suggested that deficits in depressed patients may be more pronounced in affective ToM, particularly in tasks that decode emotions through the eye region (e.g., the reading the mind in the eyes test)[12]. However, deficits in affective ToM overlap conceptually with deficits in facial emotion recognition (FER). An inability to accurately decode facial expressions directly impairs affective ToM, and a bias towards recognizing negative emotions or misinterpreting neutral or positive emotions as negative may also contribute to biases in affective ToM. Enhanced decoding accuracy for negative mental states among depressed adolescent boys[15] indicates a valence-specific affective ToM bias rather than a generalized impairment. On the other hand, depressive adolescents perform poorly on recognizing positive or neutral expressions[16,17]. Whether this is because they are unable to infer mental states from the eyes (a ToM inference problem), misperceive subtle emotional cues in the eye region (an emotion recognition problem) or are hypersensitive to negative cues, resulting in only negative emotion tasks being “performed well”[15] remains to be clarified.

Mentalization-factors correlate to impairment and its intervention: Empirical evidence demonstrated robust associations among impaired mentalizing, childhood trauma, attachment disturbances particularly insecure or trauma-related attachment patterns and deficits in epistemic trust (i.e., trust in the veracity and personal relevance of information conveyed by others)[18-20]. Early adverse experiences (e.g., attachment trauma) can interfere with the formation of secure attachments, thereby impairing the ability to metalize effectively[18]. This can lead to deficits in cognitive trust[19], making it difficult for adolescents to learn from social experiences, potentially causing them to become hypervigilant or misinterpret social cues. This can further impair mentalizing abilities and solidify depressive symptoms[6]. Thus, for a subset of “complex” cases of adolescent depression, deficits in ToM are not isolated cognitive issues, but are deeply intertwined with their attachment history and their ability to build trust and learn from social interactions[7]. Interventions also need to address this set of issues simultaneously, rather than just training mentalization skills in isolation. Mentalization-based treatment (MBT), particularly the MBT model for adolescents, whose central goal is to enhance an individual’s ability to understand his or her own mental states and those of others, has been shown in clinical trials to have the potential to improve mentalization skills and reduce depressive symptoms[7] and self-injurious behaviors[21], and has been identified as a key component in the treatment of “complex” depression in adolescents, especially for those with depression associated with attachment trauma and personality problems[7].

Emotion processing

Emotional processing involves recognizing, understanding, and experiencing the emotions of others, as well as regulating one’s own emotions. Previous research suggested that depressed adolescents showed abnormalities in all of these areas.

FER-biases and deficits: As faces are a major source of social information, biases or inaccuracies in FER can lead to the misinterpretation of social cues and inappropriate social responses. This can result in difficulties with interpersonal interactions and contribute to the maintenance of depression. Depressed adolescents often exhibit abnormalities in FER. A systematic review described three deficits in recognition associated with depression in adolescents: Increased sensitivity to sad emotions, overestimation of angry emotions and decreased sensitivity/accuracy in recognizing positive emotions[22]. Overperceiving anger may lead to defensive or avoidant behaviors, while underestimating happiness may result in missed opportunities for positive social connections and reinforcement. This can perpetuate negative perceptions of the social world and oneself, potentially leading to decreased social support and increased interpersonal conflict[22].

Auerbach et al[16] found that depressed adolescent girls exhibited impaired recognition accuracy for happy faces, especially those of low intensity. In contrast, they recognized sad faces more accurately. It has also been suggested that depressed adolescents struggle to recognize other negative emotions; for example, they may confuse fear with surprise. Notably, among depressed adolescents, boys had more difficulty recognizing fearful expressions than girls[23]. Impaired recognition of negative facial emotions has been associated with childhood trauma, difficulties in emotion regulation, dysphoria and deficits in empathy[16]. However, some studies have not found FER abnormalities in depressed adolescents[24]. Thus, the findings in this area were not entirely consistent.

Emotional reactivity-abnormal responses to social and emotional stimuli: Emotional reactivity refers to the nature and intensity of emotional responses. Abnormal emotional reactivity can affect mood, motivation, and social engagement. There is evidence that depressed adolescents have diminished reactivity to positive stimuli and increased reactivity to negative stimuli[25]. This pattern is highly consistent with the core symptoms of depression (i.e., persistent sadness and a lack of pleasure) and may be a key factor in maintaining the depressed state. Therefore, interventions need to simultaneously downregulate negative reactivity and upregulate positive reactivity.

Furthermore, recent studies have found that adolescents with major depressive disorder scored significantly higher than healthy controls on the empathy care, fantasy and personal pain subscales of the interpersonal reactivity index, and their fantasy scores were positively correlated with depression severity[26]. A high personal pain score may indicate that individuals experience intense emotional distress when perceiving negative emotions in others. This excessive emotional involvement could hinder their ability to seek effective social support and may even lead to social avoidance. High fantasy score associated with depression may indicate over-immersion in the inner worlds of others (especially virtual or imagined characters) rather than realistic, functional empathy. Thus, such “high empathy” is more likely to be a form of maladaptive emotional sensitivity or emotional contagion[27,28], rather than adaptive social understanding and prosocial competence.

Emotion regulation strategies-difficulties and maladaptations: Research has shown that, although adolescents had reduced levels of negative affect after using cognitive reappraisal strategies[29], this strategy was not used efficiently in depressed ones, and they were more inclined to frequently use maladaptive emotion regulation strategies, such as rumination and repression[30]. Depressed adolescents also scored significantly lower than healthy controls on the self-emotion management and emotion utilization dimensions of the emotional intelligence scale[26], suggesting that they have difficulties in managing their emotions and using them effectively to guide their thoughts and behavior. These may lead to persistent negative emotions, social withdrawal, and reinforcement of negative social schemas. Therefore, training to enhance emotion regulation strategies for adolescent depression is necessary[31].

Cognitive bias in social situations

Cognitive biases in social situations are systematic errors in processing social information, and they play an important role in the development and maintenance of adolescent depression.

Attentional bias-bias toward negative social information: Attentional bias manifests during initial stages of information processing and is typically assessed using paradigms such as the dot-probe task[32]. Depressed adolescents demonstrate attentional bias toward negative stimuli (e.g., sad or angry faces) and exhibit impaired disengagement from such stimuli[11]. Furthermore, studies indicate that negative attentional bias correlates with heightened depressive symptoms in community-based adolescent samples[33]. This pattern may stem from attentional bias serving as a foundational mechanism that amplifies subsequent negative cognitive biases in interpretation and memory domains.

Interpretation bias-negative interpretation of ambiguous social contexts: The depression-distortion model posits that depression fundamentally impairs social information processing[34]. Utilizing validated measures such as the ambiguous scenarios test for depression in adolescents, researchers have demonstrated that depressed adolescents exhibit a propensity for negative interpretations of ambiguous social situations[11]. Furthermore, negative interpretive bias correlates with depression severity, with clinically diagnosed adolescents showing more pronounced bias than high-risk counterparts[35]. Notably, Platt et al[36] established that such bias prospectively predicts depressive symptoms at 30-month follow-up, particularly among adolescents exposed to negative life events.

In addition, classic attribution research reveals that self-serving attributional bias is inversely associated with depression levels[37]. Depressed adolescents, however, consistently attribute negative events to stable, global internal factors while ascribing positive events to transient, specific external causes[26]. This maladaptive explanatory style perpetuates entrenched helplessness and reinforces depressive despair.

Memory bias-reinforced recall of negative social feedback or experiences: Johnston et al[38] found a normative positive bias in memory for social feedback, wherein individuals preferentially recall positive evaluations. However, research on depressed adolescents revealed enhanced recall of negative information particularly self-referential or socially relevant content relative to positive or neutral stimuli[11,39], though findings remain inconsistent across studies. Empirical evidence demonstrates this negative memory bias manifests behaviorally through heightened recollection of criticism vs praise[40]. Furthermore, during the adolescent-to-adult transition, socially anxious individuals with elevated depressive comorbidity[41] exhibit age-exacerbated negative memory biases[38].

Social decision-making and reward processing

Current evidence indicates that depressed adolescents exhibit reward system dysfunction, characterized by diminished reward sensitivity and heightened punishment sensitivity. An event-related potential (ERP) study demonstrated attenuated late positive potential amplitudes during reward anticipation relative to healthy controls, alongside augmented feedback negativity (FN) amplitudes to punitive outcomes and reduced FN responses to rewarding stimuli following outcome delivery[42]. Such neurocognitive alterations may significantly compromise motivation for social engagement and capacity for hedonic experience. Furthermore, adolescents with depression particularly those with non-suicidal self-injury show compromised risky decision-making capacities[43], potentially fostering maladaptive choices in social contexts involving risk-reward tradeoffs.

NEUROBIOLOGICAL BASIS OF SOCIAL COGNITIVE DYSFUNCTION IN ADOLESCENT DEPRESSION

A large number of neuroimaging studies have consistently shown that adolescent depression and its associated social cognitive deficits are associated with structural and functional abnormalities in multiple brain regions and neural networks. First, effective social interaction requires individuals to flexibly switch between focusing on the self, processing external salient cues, and exerting cognitive control. And resting-state studies have revealed hemispheric asymmetries and connectivity abnormalities within these key networks in adolescent depression. For example, the default mode network (associated with self-referential thinking and rumination) is overactive, the central executive network (involved in cognitive control) is underactive, the salience network is hypo-functional (therefore less responsive to important social cues), and the dorsal attention network is overactive (higher attentional bias toward negative stimuli)[44]. Collectively, these network dysregulations may contribute to excessive negative rumination and difficulties disengaging from negative thought patterns. Complementing these functional magnetic resonance imaging (fMRI) findings, electroencephalogram studies report increased θ- and α-wave intensity in the left dorsolateral prefrontal cortex (DLPFC) among depressed adolescents. This neurophysiological alteration has been specifically associated with reduced accuracy in recognizing happy facial expressions[16].

Additionally, certain key brain regions such as the prefrontal cortex particularly the DLPFC and medial prefrontal cortex (MPFC)[45], amygdala, anterior cingulate cortex (ACC) especially the subgenual ACC (sgACC), insula, hippocampus, precuneus, and temporal lobe region play a central role in critical functions related to social cognition, such as emotional processing, self-referential thinking, attention, and social cognitive control. However, when performing emotional processing and ToM tasks, depressed adolescents exhibit abnormal activation patterns in regions such as the DLPFC (reduced activity in this region is associated with impaired recognition of happy faces), MPFC (different in activation in this region between adolescents and adults during social emotional processing)[45], amygdala, and ACC[45]. Other studies have found that during negative emotion processing, depressed adolescents exhibited disrupted amygdala-prefrontal connectivity[44], with enhanced functional connectivity between the sgACC and amygdala, while connectivity with the fusiform gyrus, precuneus, and insula were weakened[46]. Notably, fMRI paradigms using dynamic emotional stimuli (such as watching movies) are emerging as promising tools for exploring adolescent depression and its neural responses to dynamic emotional information[9]. ERPs, such as the late positive component (LPP), have also been used to measure emotional arousal and emotional regulation processes. For example, an ERP study showed that the LPP was altered in depressed adolescents during cognitive reappraisal of negative stimuli[47].

LIMITATIONS OF CURRENT RESEARCH

Despite the significant progress made in the field of social cognition in adolescent depression over the past 15 years, there are still some limitations of the current research.

Firstly, existing studies have varied in sample characteristics such as sample source, age range, and depression severity, as well as diverse study designs, which have led to heterogeneity in findings. At the same time, adolescent depression is often co-morbid with other psychiatric disorders, especially anxiety disorders[48], and sometimes attention deficit hyperactivity disorder or post-traumatic stress disorder[49]. Whereas social cognitive impairments are not unique to depression, e.g., Zhang et al[50] and could also present in these co-morbidities[51], many studies have failed to control for the effects of co-morbidities on social cognitive measures.

Secondly, most current studies have used cross-sectional designs, which fundamentally constrains our understanding of how developmental trajectories in social cognition (including both abilities and biases) relate to depression onset and progression. The dynamic reorganization of cognitive biases and social competencies during adolescence suggests the existence of developmental windows of vulnerability. These critical periods may represent phases of heightened susceptibility to maladaptive social cognitive patterning and optimal intervention timing. Prospective longitudinal cohorts tracking social cognitive development alongside depressive symptomatology from early through late adolescence could elucidate these pivotal developmental epochs.

Thirdly, research on specificity is limited. As noted earlier, social cognitive deficits are trans-diagnostic. In adolescents, few studies have directly compared depression to other disorders such as anxiety disorders, bipolar disorder, and attention deficit and hyperactive disorder in terms of these deficits. Understanding its specificity is key to characterizing the unique pathophysiological mechanisms of depression in adolescents and developing targeted treatments.

Finally, most of the existing research originates from Western countries. Nevertheless, social norms, communication styles, and emotional expression vary across cultures[52,53]. To gain a deeper understanding of the influence of underlying cultural factors on social cognition and its relationship with depression, more research is urgently needed in different cultural contexts.

FUTURE DIRECTIONS

Based on the findings and limitations of current studies, future research in this area could focus on the following directions.

Firstly, strengthen longitudinal studies to elucidate causal relationships and developmental trajectories, and exploring the interactions between different social cognitive domains. For example, investigating how changes in the value assessment of social stimuli lead to biases in attention, interpretation, and memory of social information in depressed adolescents. Meanwhile, strictly controlling for comorbidity in the study sample and exploring differences between adolescent mental disorders.

Secondly, further clarify the protective factors of social cognition (such as the perception of social security and support) and develop and refine targeted interventions. For instance, examine high-risk but healthy adolescents to understand their protective mechanisms. Building on such insights, methodologically rigorous randomized controlled trials with longitudinal follow-ups warrant implementation across clinical, educational, and community contexts. Such investigations should evaluate efficacy, moderators, and mediators of cognitive bias modification interventions and mentalization-focused interventions for depressed adolescents, and examine optimal integration approaches for targeted social-cognitive training modules, including FER training and ToM enhancement protocols.

Thirdly, strengthen cross-cultural research. For example, develop and validate social cognition assessment tools suitable for people from different cultural backgrounds. Conduct further research into the social cognition of adolescent depression in non-Western cultural contexts, such as China and other East Asian countries, to determine how cultural values interact with social cognitive processes, distress, and expressions. In collectivist cultures, biases related to group acceptance/rejection or fulfilling social obligations may, for instance, be more central to depression than biases related to personal achievement or failure[54]. Research should remain sensitive to these culturally specific social dynamics.

Finally, utilize novel methodologies and techniques. Use computational modelling to construct more accurate theoretical models that explain how neural alterations lead to cognitive biases and behavioral outcomes. Additionally, novel intervention approaches, such as remote digital health platforms and artificial intelligence-enhanced gamification tools[55], warrant investigation to enhance accessibility and engagement. However, such innovations must undergo rigorous ethical evaluation, addressing issues such as privacy protections and developmentally sensitive algorithmic design.

CONCLUSION

Over the past 15 years, research has shown that adolescent depression is associated with a variety of social cognitive impairments that are likely to play an ongoing causal role in its onset, development and maintenance. Continued promotion of longitudinal, comparative, cross-cultural and interventional research is essential. Exploring neurobiological mechanisms, focusing on protective factors, and judiciously applying emerging technologies are all key to developing more effective and individualized prevention and intervention strategies for adolescents suffering from depression. Ultimately, this will contribute to their healthy socio-emotional development and overall well-being.