Addressing social function in the treatment of depression: A call for holistic approaches

Abstract

This article discusses the importance of addressing social functioning impairment in patients with residual depressive symptoms, as highlighted in the study by Liao et al. The authors showed that social dysfunction persists in many patients despite symptom remission. This observation calls for a shift in depression treatment strategies, with an emphasis on integrating social functioning as a key treatment goal. This article suggests targeted interventions that focus on both symptomatic relief and the restoration of social function.

Key Words: Social function; Depression; Residual symptoms; Treatment; Psychotherapy; Cognitive-behavioural therapy

Core Tip: Many patients continue to experience residual depressive symptoms even when they are in remission. Addressing social dysfunction as an important therapeutic goal along with symptom relief can improve recovery outcomes in depression treatment. Holistic approaches that integrate pharmacotherapy, psychotherapy, and lifestyle interventions have the potential to improve patients’ social functioning and overall quality of life.

TO THE EDITOR

The study by Liao et al[1], published in the World Journal of Psychiatry, is an important contribution to understanding the impairment of social functioning in patients with residual depressive symptoms. The study aimed to determined differences in social functioning by comparing 158 patients with residual depressive symptoms to a healthy control group. Social functioning was assessed using the Sheehan Disability Scale, a widely used self-report tool that measures functioning in three main domains: Work/school, social life, and family responsibilities. Participants rated the level of impairment in each domain on a 10-point Likert scale, with higher scores indicating more severe impairment[2]. The simplicity and comprehensiveness of the Sheehan Disability Scale provided a standardised measure of social dysfunction in the study. The results of the study showed that residual depressive symptoms as well as somatic symptoms and anxiety had a significant impact on social functioning. This suggests that not only treating residual depressive symptoms but also targeting these comorbidities is critical to improving social functioning. The present study emphasises the need for more targeted interventions to improve functioning in depression.

What we know about depression

Depression is a multifaceted mental health disorder that significantly affects an individual’s emotional, cognitive, and physical well-being. It is characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities once enjoyed, which can lead to profound impairments in daily functioning and quality of life[3,4]. Depression is a leading cause of disability worldwide, affecting more than 280 million people and contributing significantly to reduced quality of life. The burden of depression extends beyond the individual, affecting families and communities, and requires a nuanced approach to treatment that addresses both the psychological and physiological dimensions of the disorder.

The treatment of depression has evolved significantly over the years, with a growing body of evidence supporting different therapeutic approaches. There are dozens of medications, different psychotherapies and neurostimulation techniques currently used in treatment. Despite these advances, challenges remain, including high relapse rates and the persistence of residual symptoms. Research shows that about 50% of people who experience a first episode of depression will have another episode within two years. This statistic is supported by a number of studies which show that the likelihood of relapse increases with each subsequent episode. For example, it has been reported that the likelihood of experiencing a second episode rises to about 70% after two episodes and can reach 90% after three episodes[5]. Residual symptoms in depression are also a major concern, as they can persist even after patients have achieved remission from their depressive episodes. Studies suggest that the prevalence of residual symptoms can range from 30% to 54% in people who have responded to treatment, highlighting the challenge of achieving full recovery. These residual symptoms often include core mood disorders, anxiety, sleep problems and cognitive dysfunction, which can affect patients’ quality of life and increase the risk of relapse[6,7].

In their study, Liao et al[1] conducted a comprehensive analysis of the level of social functioning in patients with depression and the factors that influence it. They reported that patients on medication alone, poor adherence and residual symptoms had reduced social functioning. In a 12-week follow-up study by Harada et al[8], painful physical symptoms were one of the most common residual symptoms and were directly related to partial remission. They followed the same study group for a further 12 weeks and reported that patients with physical symptoms who achieved partial remission had significantly worse social functioning at the end of 24 weeks. Romera et al[9] investigated which residual symptoms were more common in people with depression in partial or complete remission, and their relationship to social functioning. They reported that the most common residual symptoms in those in partial remission were core mood symptoms, anxiety, insomnia, somatic symptoms and painful physical symptoms. In this group of patients, prolonged depressive episodes and residual core mood symptoms were also associated with impaired social functioning[9]. In the group that achieved complete remission, they found that anxiety was the residual symptom that most negatively affected social functioning[9].

Social functioning is often one of the last areas to recover after symptomatic relief in depression. Residual impairments in this area - such as difficulty maintaining relationships, participating in community activities, or succeeding at work - can perpetuate feelings of isolation and low self-worth, thereby increasing the risk of relapse[10]. When all these studies are considered together, the extent to which residual symptoms affect social functioning becomes clearer, and the importance of focusing more on treating residual symptoms becomes apparent.

Effective strategies for managing residual depressive symptoms: Exploring combined therapies

Residual depressive symptoms are challenging, but targeted approaches can effectively manage them. Sometimes, adjusting the dose or switching to a different antidepressant can help relieve residual symptoms[11]. Augmentation with other medications, such as atypical antipsychotics or mood stabilizers, may also be considered[12]. A meta-analysis that looked at the effectiveness of augmentation therapies highlighted aripiprazole among antipsychotics and lithium among mood stabilisers[13]. Integrated treatment approaches that combine antidepressants with psychotherapy have shown better results in treating residual depressive symptoms. A meta-analysis by Cuijpers et al[14] found that integrated treatments significantly reduced relapse rates and improved social and occupational functioning compared with either approach alone. Similarly, Guidi et al[15] found that cognitive-behavioural therapy, used alone or in combination with antidepressants, was effective in reducing relapse and recurrence rates. Cognitive-behavioural therapy and other psychotherapies are particularly useful in helping people to develop coping strategies and change negative thinking patterns[16]. In addition to pharmacotherapy and psychotherapy, lifestyle changes have shown promise in managing residual symptoms. Regular physical activity, a balanced diet and adequate sleep have a positive effect on mood and general wellbeing. For example, structured exercise routines combined with antidepressant therapy have been associated with greater reductions in depressive symptoms and improved physical health than medication alone[17]. A randomized controlled trial showed that patients who followed a programme of daily walking (at least 1 hour), exposure to sunlight (2 hours), sleep hygiene and a healthy diet had better treatment outcomes and remission rates than a control group[18]. Dietary interventions such as the Mediterranean diet or omega-3 supplementation have also been shown to reduce inflammation and modulate the gut-brain axis[19]. Finally, stress management techniques, including mindfulness practices and relaxation exercises, provide additional support in managing residual depressive symptoms and improving overall resilience[20,21].

CONCLUSION

Despite remission of core depressive symptoms, many patients continue to experience challenges in their social functioning, which can impede full recovery and increase the risk of relapse. This highlights the need for approaches to depression that go beyond symptomatic relief and emphasize the restoration of social function as a primary therapeutic goal. Integrating pharmacotherapy, psychotherapy, and lifestyle interventions can help manage residual symptoms and improve social functioning, ultimately improving patient outcomes in depression management. Holistic treatment strategies therefore hold promise for reducing the long-term effects of residual symptoms and promoting greater overall recovery in people with depression.