The Social Environment Shapes Whether Depression Treatments Work

Depression has certainly been in the popular press of late. You may or may not agree with the idea summarized in the NY Times Magazine that low mood states are adaptations that help with social problem solving. For reaction and commentary see here and here. My major concern about the debate about the "upside" of depression, both pro and con, is that it has become disconnected from any actual data.

Regardless of whether you think that depressed mood invariably helps solve social problems, there is clear and growing evidence that garden-variety depressed mood (and significant case-level depression) is often aroused by social adversity.

Case in point is the March 2010 issue of Journal of Affective Disorders, which contains a powerful and novel demonstration led by George Brown and Tirril Harris that the success of treatments is intimately connected to the social environment.

Brown and Harris have, in their previous work, found that significant depression is often preceded by very specific kinds of social contexts, particularly negative events that involve a theme of humiliation or entrapment.

The new study shows that these same social contexts also shape whether depression treatments will work. Shockingly, there had been virtually no research on whether the social environment influences the impact of antidepressant medications.

In their study, 220 patients with significant depression symptoms were randomly assigned to either supportive care or to SSRIs plus supportive care (SSRIs are the class of medications most commonly used to treat depression such as Prozac and Paxil).

The investigators undertook a detailed assessment of each person's social environment (both events that were negative and positive in nature) at the beginning of the study and 12 weeks later, after the treatments had begun.

What they found was that those patients who faced significant environmental adversity at any point were only half as likely to respond to the treatments and remit from depression than patients who were in more benign environments. It did not matter what kind of treatment the patients received. Remission rates among patients in aversive social contexts were much lower irrespective of treatment type. In fact, only 1/5th (!) of those in aversive social contexts remitted after 12 weeks of treatment.

One interesting question that is unresolved by the JAD study is exactly why ongoing adversity undermines treatment. Brown and Harris focus on the idea of entrapment -- the idea that an ongoing adversity will bring about cognitive changes, such as seeing the situation as hopeless, that might interfere with treatment, but this is just one idea.

Examples of aversive social environments that the authors mentioned (and were presumably reported by study participants) included (a) a father caring alone for three children one of whom is hyperactive and a constant concern, and (b) a woman with crippling arthritis living with a highly critical and at times violent partner.

These, certainly, are difficult life problems. And it seems our current mainline treatments for depression, whether antidepressants, or cogintive behavioral therapy are not all that well suited to addressing them. Whether or not depression itself is nature's solution to these life problems (and a single blog post is inadequate to address such a complex issue), clinical science and clinical practice needs to more fully engage the social environment if we are to understand and treat depression. Brown and Harris are pointing the way....

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