Research reportFeeling connected again: Interventions that increase social identification reduce depression symptoms in community and clinical settings
Introduction
Depression is currently ranked by the World Health Organisation, 2006, World Health Organisation, 2012 as the single greatest cause of disability worldwide. Although both psychotherapy and pharmacological treatments are effective in reducing acute symptoms (American Psychiatric Association, 2010), these treatments have shown limited effectiveness in preventing relapse over the longer term. As many as 80% of individuals with a history of depression can be expected to relapse, with an average of four episodes across a lifetime (Judd, 1997). Even among patients who have received evidence-based treatment, approximately one-third relapse within 18 months (Evans et al., 1992, Fava et al., 1998, Shea et al., 1992). For this reason, current guidelines state that “for many patients… some form of maintenance treatment will be required indefinitely” (American Psychiatric Association, 2010). Currently, best-practice maintenance phase treatment involves long-term continuation of anti-depressants at the level required to achieve remission (Kupfer et al., 1992) or ongoing “booster” sessions of psychotherapy following remission (Holländare et al., 2013, Piet and Hougaard, 2011).
Although these treatment models can be effective in reducing rates of relapse, they come with notable downsides. The cost of both pharmacological and psychological interventions can be prohibitive (Simon et al., 2004, Wang et al., 2003), particularly as depression is more common among disadvantaged groups (Eaton and Kessler, 1981, World Health Organisation, 2006). In addition, there is a shortage of mental health professionals with the high level of training needed to administer these evidence-based treatments. This shortage is most pronounced in areas of greatest need (Saxena et al., 2007, Thomas et al., 2009).
There are also other barriers to the effective treatment of depression. Previous research has suggested that only a minority of individuals with depression present to a health professional (Goldman et al., 1999), and only a minority of those who do present receive best-practice treatment (Simon et al., 2004). For instance, one of the most common pathways to treatment is a consultation with a General Practitioner and prescription for antidepressant medication. However, antidepressant medications have a compliance rate as low as 45% (Sawada et al., 2009), partly due to common side effects such as drowsiness, sexual dysfunction, and weight gain (Cascade et al., 2009, Kikuchi et al., 2011). The majority of patients prefer non-drug treatment (Dwight-Johnson et al., 2000, Gum et al., 2006, Rokke and Scogin, 1995), but in spite of this therapy is often avoided because it is perceived to be stigmatizing (Crabtree et al., 2010, Howard, 2008). There is therefore a need for the development of treatment alternatives (particularly in the maintenance-phase of treatment) that are cost-effective, non-stigmatizing, and widely accessible.
Basic research has demonstrated that social isolation both precipitates and maintains depression. For instance, several large-scale studies have found that perceived social isolation is a powerful longitudinal predictor of depression risk even after controlling for other candidate variables, such as depression history (Cacioppo et al., 2010). In addition, the specific trigger for a depressive episode is very often the loss of an important social tie, such as bereavement, divorce or retrenchment (Paykel, 1994, Tennant, 2002). Social isolation can also reduce responsiveness to treatment (Trivedi et al., 2005) and is a well-established risk factor for relapse (George et al., 1989, Paykel et al., 1980).
Results of a small number of studies suggest that interventions to facilitate social interaction can effectively alleviate depression. For instance, some studies have found that social skills training (Bellack et al., 1981) or mutual support groups (Bright et al., 1999) reduced depression symptoms, comparing favorably to pharmacological or professional-led psychotherapy interventions. Relatedly, socially isolated older men in residential care who joined gender-based social clubs reported a decrease in depression symptoms three months later (Gleibs et al., 2011). Even internet-based support groups, which involve no face-to-face interaction, appear to have potential benefits for patients with depression (Houston et al., 2002). Of particular relevance to the current investigation, a large longitudinal study recently found that each social group that a depressed individual joined reduced their risk of relapse four years later by approximately 24 percent, after controlling for gender, age, ethnicity, relationship status, socioeconomic status, subjective health, initial number of group memberships and severity of depression (Cruwys et al., 2013). This effect was such that a depressed person who joined no groups was at 41% risk of relapsing four years later, compared to a much lower 15% risk for a person who joined three groups.
Even though these results look promising, it is also clear that interventions that aim to reduce depression by increasing social interaction have produced mixed results. In particular, those that involve one-on-one contact or making friends are generally found not to be effective in reducing depression (Cattan et al., 2005, Perese and Wolf, 2005). We would argue this is not surprising because there is an important psychological difference between simply “showing up” at social activities and seeing oneself as a valued member of a given social group. In other words, social isolation is not simply a function of the amount of social contact a person has, but rather is related to the sense of belonging or affiliation a person subjectively experiences from these interactions.
We posit that it is only when a person identifies with a group – that is, when the group is internalized in a way that contributes to his or her sense of self – that the group is likely to have benefits for depression. This is consistent with social-psychological theorizing, which argues that it is identification with a social group, rather than group membership per se, that determines the nature of people׳s social behavior (Turner et al., 1987, Turner and Oakes, 1997). It is this psychological representation of the self as a group member that it is likely to have consequences for wellbeing.
Initial support for this claim is provided by a correlational study that found social identification was a better predictor of reduced depression symptoms than social contact alone (Sani et al., 2012). In addition, a recent meta-analysis (Cruwys et al., in press-a) found a moderate negative correlation between social identification and depression across 16 studies. Despite great variation in the type of groups (e.g., army reservists, students, family), in all cases higher social identification was associated with fewer depression symptoms. However, none of the studies involved an intervention or utilized clinically depressed samples.
The central argument of the current research is that social activities are effective in reducing depression to the extent that they facilitate social identification. We argue that this constitutes the “active ingredient” of groups that gives them the potential to be curative for depression. The benefits of social identification have previously been demonstrated for a wide-range of health conditions, such as recovering from stroke (Haslam et al., 2008) or trauma (Jones et al., 2012). Indeed, studies have found that merely reminding individuals of their group memberships serves to increase resilience to stress and tolerance of physical pain (Jones and Jetten, 2011). We expect that the benefits of social identification will be especially apparent in the case of depression, compared to other wellbeing outcomes, because depression symptomatology is partially defined by features that are antithetical to social identification: social withdrawal, lack of meaning and alienation from previously valued activities (or groups). In addition, existing evidence-based psychotherapies prescribe behavioral activation (cognitive-behavioral therapy; Beck, 2011) and conflict resolution (interpersonal psychotherapy; Weissman et al., 2000), both of which might potentially entail a boost to social identification by re-engaging a depressed patient with their social networks. Indeed, more generally, existing evidence suggests that social identification matters particularly for depression because lack of social identification is at the core of the condition (Cruwys et al., in press-a).
Our core hypothesis in the present research is therefore that social interventions (in both community and clinical settings) that facilitate the development of people׳s sense of social identification will be effective in reducing their depression symptoms. We expect this to be true regardless of the content of the intervention or whether the group is conducted in a clinical or community setting.
Section snippets
Study 1
Study 1 was a community-based intervention that centered on facilitating vulnerable and disadvantaged individuals (the majority of whom had a diagnosed mental illness) to join a recreational social group. Depression symptoms were measured at participants’ first attendance at the community group and approximately three months later. Our core hypothesis was that social identification with the community group would predict reduction in depression symptoms, even after controlling for initial
Study 2
Study 2 utilized an outpatient sample undergoing group-based cognitive behavioral psychotherapy for depression or anxiety at a psychiatric hospital cognitive behavior therapy (CBT) unit. This setting was particularly appropriate for addressing our research question, as it allowed us to explore whether social identification might be a so-called “non-specific factor” that can account for the effectiveness of group-based psychological treatments. That is, researchers know that group psychotherapy
General discussion
In two studies, social identification with a group predicted improvement in depression symptoms among disadvantaged members of the community who joined social groups (Study 1) and among outpatients at a psychiatric hospital who participated in group psychotherapy for depression or anxiety (Study 2). In both the studies, improvement in depression symptoms over time was significantly predicted by social identification with the group, over and above initial depression severity, group type or
Conclusion
The current research provides evidence that depression is responsive to social factors, by demonstrating that group-based interventions to increase social connectedness are most effective when patients identify with the social group in question. In other words, it would seem that it is not groups per se that cure depression, but rather groups with which we identify that cure depression. These findings point to the importance of social connectedness as a psychological phenomenon, and hence to
Role of funding source
This research was partially funded by an Australian Research Council Laureate Grant no. FL110100199, see http://www.arc.gov.au/. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflict of interest
None to declare.
Acknowledgments
We thank Anne Sheldon, Lynndall Dwyer, Ashleigh Kunde, Audrey Raffelt and Cheryl Walles for their assistance with data collection and entry.
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