International Journal of Psychiatry in Clinical Practice
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Focus on social functioning in depression Rma Hirschfeld, M Keller, M Bourgeois, Ds Baldwin, D Healy, M Humble, S Kasper & Sa Montgomery To cite this article: Rma Hirschfeld, M Keller, M Bourgeois, Ds Baldwin, D Healy, M Humble, S Kasper & Sa Montgomery (1998) Focus on social functioning in depression, International Journal of Psychiatry in Clinical Practice, 2:4, 241-243 To link to this article: http://dx.doi.org/10.3109/13651509809115367
Published online: 12 Jul 2009.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [Chinese University of Hong Kong]
Date: 05 November 2015, At: 17:26
0 1998 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 1998 Volume 2 Pages 241 -243
241
Focus on social functioning in depression
Downloaded by [Chinese University of Hong Kong] at 17:26 05 November 2015
RMA HIRSCHFELD~,M KELLER~, M BOURGEOIS3, DS BALDWIN4, D HEALY5, M HUMBLE6, S KASPER7 AND SA MONTGOMERY* 'Department of Psychiatry and Behavioral Sciences, University of Texas, USA; 2Department of Psychiatry and Human Behavior, Brown University, Rhode Island, USA; 31PS0, Universitt Victor Stgalen, Bordeaux, France; 4Faculty of Medicine, Health and Biological Sciences, University of Southampton, UK; '~niversity of Wales College of Medicine, Bangor, UK; 6Karolinska Institutet, Department of Clinical Neuroscience and Family Medicine, Huddinge University Hospital, Sweden; 7Department of General Psychiatry, University of Vienna, Austria; and 'Imperial College of Science, Technology and Medicine, London, UK
Correspondence Address Professor RMA Hirschfeld, Department of Psychiatry and Behavioral Sciences, The University of Texas, Graves Building, Room 1,200, 301 University Boulevard, Galveston, Texas, 77555-0429, USA Tek 001 409 772 4956 F a : 001 409 772 4288
Depressive disorders represent a significant global health burden. By the year 2020 the contribution of psychiatric and neurological conditions to the global burden of disease is predicted to reach 15%.Despite this, depression is frequently unrecognized and undertreated; most depressed people do not seek treatment for their depression, and of those who do, most do not receive adequate treatment. Depression is a debilitating condition and the effects of the illness extend beyond the classically defined symptoms to almost every facet of an individual's life, including their social interactions; and even beyond the individual, to close relatives. The treatment of impaired social functioning has not been widely adopted as a therapeutic principle in depression, although it is recognized as an important part of the treatment of schizophrenia. However, depressed individuals experience more functional impairment than patients with other chronic medical conditions such as diabetes and hypertension Early studies have suggested that antidepressants, in addition to improving the core symptoms of depression, are effective in the treatment of impaired social functioning; but few studies have directly compared different classes of antidepressants. This paper seeks to raise awareness of the key issues relating to the treatment of impaired social functioning in depression and to provide a basis for wider discussion of the topic prior to the establishment of treatment guidelines. (Int J Psych Clin Pract 1998; 2: 241 - 243)
Received 14 September 1998; accepted for publication 16 September 1998
INTRODUCTION epression is frequently unrecognized and undertreated.' The recent European DEPRES study showed that in a cohort of over 78 000 adults, more than 13 000 were identified as suffering from depression.2 Of these, 43%had not sought help from their doctor. Amongst those who did seek help, nearly 70% received no medical treatment whatsoever (Figure 1). In its 1998 World Health Report, the World Health Organization (WHO)3 reported that non-communicable diseases such as heart disease, cancer, diabetes and mental disorders are now more common in the developed world than infectious diseases. Indeed, conditions such as depression and heart disease are replacing the infectious diseases and malnutrition as the leading causes of disability and premature death in the developing world.
D
Another recent report from the WHO, The global burden of disease,' assessed (in 1990) the number of years lived by individuals with a disability. They found unipolar major depression to be the leading cause, contributing 10.7% of the total disability, the next highest being irondeficiency anaemia at 4.7%.In terms of the global burden of disease, forecasts suggest that by the year 2020 the proportion of disability due to psychiatric and neurological conditions may increase from 10.5% to almost 15%, a larger proportional increase than is expected for cardiovascular disease. These reports of the considerable disability associated with depression underscore the importance of addressing social and physical functioning in the treatment of depression. However, although this is well recognized, improvement in social functioning has often been overlooked as a target for the treatment of depression.
242
RMA Hirschfeld et ~l
Did not seek treatment Sought help but received no treatment
ISought help and
received drug therapy
I Received
antidepressant therapy
Downloaded by [Chinese University of Hong Kong] at 17:26 05 November 2015
Figure 1 Treatment received by depressed individuals who took part in the DEPRES study (1~1.3 359).2
SOCIAL FUNCTIONING AND DEPRESSION An individual’s ability to function within their usual environment defines their level of social functioning. Performance in various fields, such as work, social and leisure activities, and in various roles, for example as a spouse or parent, and in relationships with family and friends, all contribute to the overall level of functioning. Impairments in social functioning extend beyond the depressed person to include their family and friends, and there is evidence that the social performance of close relatives, in particular, may be adversely affe~ted.~ Depression is generally a chronic episodic condition, and social functioning is frequently impaired at the same time as (although it is largely distinct from) the conventional guideline definitions of depressive illness are found (extending beyond the classically defined symptoms). The cause and effect relationship between impaired social functioning and depression is not a simple one, and has long been discussed. As early as 1973 it was recognized that the symptoms of depression and impairments in social functioning do not improve at the same rate.6 Residual symptoms and functional impairment may persist between clinically defined episodes of depression, and can markedly decrease patients’ quality of The presence of residual symptoms between episodes of depression suggests that monitoring changes in social functioning may be useful in the prediction of relapse. This has implications for the long-term management of depression and may permit early therapeutic intervention. The degree of functional impairment associated with depressive disorders, and with depressive symptoms in the absence of disorders, has been ,reported to be comparable to, and in many cases to exceed, that experienced by patients with other chronic medical conditions such as diabetes and
SOCIAL FUNCTIONING AS A THERAPEUTIC PRINCIPLE Social functioning as a therapeutic principle and measure of outcome in the management of people with schizophrenia
has long been accepted. However, measuring, this facet of many other psychiatric disorders, including depression, has not yet been widely adopted. In the early 1970s it was shown that addressing impaired social functioning may represent an additional therapeutic principle in the treatment of depression. Interpersonal therapy (IPT), a psychotherapeutic approach, was originally developed for this purpose.” A number of early studies seemed to show that this is effective in improving both functional impairment and the core symptoms of depression, as compared with imipramine and with cognitive therapy.’.12 However, there remains doubt over the efficacy of this treatment approach and it has not been widely adopted. In 1990, Frank et al,13 in a randomized 3-year maintenance trial in patients with recurrent depression, showed that imipramine had a significant prophylactic effect, whereas the improvement in patients who received monthly IPT sessions was modest. The efficacy of antidepressants in the treatment of depressive disorders is clear. The early work on IPT, in the treatment of both the functional impairment and the symptoms of depression, poses the question of whether pharmacotherapy could also relieve both these facets of depression. A preliminary study by Finkelstein et all4 demonstrated an improvement in work performance of chronically depressed patients treated with either imipramine or sertraline, although potential differences between the two antidepressants were not examined. Improvements in overall social functioning have also been seen following short-term, open-label treatment with de~ipramine.’~ Most recently, a number of studies have demonstrated that antidepressants, including imipramine, sertraline, reboxetine and fluoxetine, were better than placebo in improving aspects of social fun~tioning.’~*’’
THE WAY AHEAD Given the importance of the impairment of social functioning in depression, a worlung group has been established to review the current literature, focusing on the definition, effects and implications for the management of
Social functioning in depression
depressed patients of the associated impairment of social functioning. The working group aims to consolidate current opinion on the subject and publish a substantial review. With the increasingly comprehensive approach to
243
patient management now being taken by health professionals, social functioning is once again a key factor in both policy and clinical decisions for the treatment of depressed patients.
REFERENCES 1. Hirschfeld RMA, Keller MB, Panico S et a1 (1997) The National
Downloaded by [Chinese University of Hong Kong] at 17:26 05 November 2015
2.
3.
4.
5.
6. 7. 8.
9.
Depressive and Manic-depressive Association Consensus statement on the undertreatment of depression.JAMA 277: 333-40. Lkpine JP, Gastpar M, Mendlewicz J, Tylee A and the DEPRES Steering Committee (1977) Depression in the community: the first pan-European study DEPRES (Depression Research in European Society). Int Clin Psychopharmacol 12: 19-29. World Health Organization (1998) The World Health Report 1998. Life in the twenty-first century: a vision for all. WHO, Geneva. Murray CJL, Lopez AD (eds) (1998) The global burden of disease. A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard University Press, Boston, MA. Coyne J, Kessler R, Tal M et a1 (1987) Living with a depressed person. J Consult Clin Psycho1 55: 347 - 52. Paykel ES, Weissman MM (1973) Social maladjustment and depression. Arch Gen Psychiatry 28: 659 - 63. Weissman MM, Prusoff B, DiMascio A et a1 (1979) The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. Am j Psychotherapy 136: 555-8. Hays RD, Wells KB, Donald Sherbourne C et a1 (1995) Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Arch Gen Psychiatry 52: 11- 19. Tarlov AR, Ware JE Jr, Greenfield S et a1 (1989) The medical outcomes study: an application of methods for monitoring the results of medical care. jAMA 262: 925-30.
10. Keller MB, Hanks DL (1994) The natural history and heterogeneity of depressive disorders: implications for rational antidepressant therapy. J Clin Psychiatry 55: 25 -33. 11. Klerman GL, DiMascio A, Weissman MM et a1 (1974) Treatment of depression by drugs and psychotherapy. Am j Psychiatry 131: 186-91. 12. Elkin I, Shea T, Watkins JT et a1 (1989) National Institute of Health treatment of depression collaborative program: general effectiveness of treatments. Arch Gen Psychiatry 46: 971 -86. 13. Frank E, Kupfer DJ, Perel j M et a1 (1990) Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 47: 1093-9. 14. Finkelstein SN, Berndt ER, Greenberg PE et a1 and the Chronic Depression Study Group (1996) Improvement in subjective work performance after treatment of chronic depression: some preliminary results. Psychopharmacol Bull 32: 33 - 40. 15. Friedman RA, Markowitz jC, Parides M, Kocsis j H (1995) Acute response of social functioning in dysthymic patients with desipramine. j Affect Dis 3 4 85-8. 16. Kocsis JH, Zisook S, Davidson J et a1 (1997) Double-blind comparison of sertraline, imipramine and placebo in the treatment of dysthymia: psychosocial outcomes. Am J Psychiatry 154: 390-5. 17. Dubini A, Box M, Polin V (1997) Do noradrenaline and serotonin differentially affect social motivation and behaviour? Eur Neuropsychopharmacol 7: 549-556.
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Focus on social functioning in depression Rma Hirschfeld, M Keller, M Bourgeois, Ds Baldwin, D Healy, M Humble, S Kasper & Sa Montgomery To cite this article: Rma Hirschfeld, M Keller, M Bourgeois, Ds Baldwin, D Healy, M Humble, S Kasper & Sa Montgomery (1998) Focus on social functioning in depression, International Journal of Psychiatry in Clinical Practice, 2:4, 241-243 To link to this article: http://dx.doi.org/10.3109/13651509809115367
Published online: 12 Jul 2009.
Submit your article to this journal
Article views: 25
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [Chinese University of Hong Kong]
Date: 05 November 2015, At: 17:26
0 1998 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 1998 Volume 2 Pages 241 -243
241
Focus on social functioning in depression
Downloaded by [Chinese University of Hong Kong] at 17:26 05 November 2015
RMA HIRSCHFELD~,M KELLER~, M BOURGEOIS3, DS BALDWIN4, D HEALY5, M HUMBLE6, S KASPER7 AND SA MONTGOMERY* 'Department of Psychiatry and Behavioral Sciences, University of Texas, USA; 2Department of Psychiatry and Human Behavior, Brown University, Rhode Island, USA; 31PS0, Universitt Victor Stgalen, Bordeaux, France; 4Faculty of Medicine, Health and Biological Sciences, University of Southampton, UK; '~niversity of Wales College of Medicine, Bangor, UK; 6Karolinska Institutet, Department of Clinical Neuroscience and Family Medicine, Huddinge University Hospital, Sweden; 7Department of General Psychiatry, University of Vienna, Austria; and 'Imperial College of Science, Technology and Medicine, London, UK
Correspondence Address Professor RMA Hirschfeld, Department of Psychiatry and Behavioral Sciences, The University of Texas, Graves Building, Room 1,200, 301 University Boulevard, Galveston, Texas, 77555-0429, USA Tek 001 409 772 4956 F a : 001 409 772 4288
Depressive disorders represent a significant global health burden. By the year 2020 the contribution of psychiatric and neurological conditions to the global burden of disease is predicted to reach 15%.Despite this, depression is frequently unrecognized and undertreated; most depressed people do not seek treatment for their depression, and of those who do, most do not receive adequate treatment. Depression is a debilitating condition and the effects of the illness extend beyond the classically defined symptoms to almost every facet of an individual's life, including their social interactions; and even beyond the individual, to close relatives. The treatment of impaired social functioning has not been widely adopted as a therapeutic principle in depression, although it is recognized as an important part of the treatment of schizophrenia. However, depressed individuals experience more functional impairment than patients with other chronic medical conditions such as diabetes and hypertension Early studies have suggested that antidepressants, in addition to improving the core symptoms of depression, are effective in the treatment of impaired social functioning; but few studies have directly compared different classes of antidepressants. This paper seeks to raise awareness of the key issues relating to the treatment of impaired social functioning in depression and to provide a basis for wider discussion of the topic prior to the establishment of treatment guidelines. (Int J Psych Clin Pract 1998; 2: 241 - 243)
Received 14 September 1998; accepted for publication 16 September 1998
INTRODUCTION epression is frequently unrecognized and undertreated.' The recent European DEPRES study showed that in a cohort of over 78 000 adults, more than 13 000 were identified as suffering from depression.2 Of these, 43%had not sought help from their doctor. Amongst those who did seek help, nearly 70% received no medical treatment whatsoever (Figure 1). In its 1998 World Health Report, the World Health Organization (WHO)3 reported that non-communicable diseases such as heart disease, cancer, diabetes and mental disorders are now more common in the developed world than infectious diseases. Indeed, conditions such as depression and heart disease are replacing the infectious diseases and malnutrition as the leading causes of disability and premature death in the developing world.
D
Another recent report from the WHO, The global burden of disease,' assessed (in 1990) the number of years lived by individuals with a disability. They found unipolar major depression to be the leading cause, contributing 10.7% of the total disability, the next highest being irondeficiency anaemia at 4.7%.In terms of the global burden of disease, forecasts suggest that by the year 2020 the proportion of disability due to psychiatric and neurological conditions may increase from 10.5% to almost 15%, a larger proportional increase than is expected for cardiovascular disease. These reports of the considerable disability associated with depression underscore the importance of addressing social and physical functioning in the treatment of depression. However, although this is well recognized, improvement in social functioning has often been overlooked as a target for the treatment of depression.
242
RMA Hirschfeld et ~l
Did not seek treatment Sought help but received no treatment
ISought help and
received drug therapy
I Received
antidepressant therapy
Downloaded by [Chinese University of Hong Kong] at 17:26 05 November 2015
Figure 1 Treatment received by depressed individuals who took part in the DEPRES study (1~1.3 359).2
SOCIAL FUNCTIONING AND DEPRESSION An individual’s ability to function within their usual environment defines their level of social functioning. Performance in various fields, such as work, social and leisure activities, and in various roles, for example as a spouse or parent, and in relationships with family and friends, all contribute to the overall level of functioning. Impairments in social functioning extend beyond the depressed person to include their family and friends, and there is evidence that the social performance of close relatives, in particular, may be adversely affe~ted.~ Depression is generally a chronic episodic condition, and social functioning is frequently impaired at the same time as (although it is largely distinct from) the conventional guideline definitions of depressive illness are found (extending beyond the classically defined symptoms). The cause and effect relationship between impaired social functioning and depression is not a simple one, and has long been discussed. As early as 1973 it was recognized that the symptoms of depression and impairments in social functioning do not improve at the same rate.6 Residual symptoms and functional impairment may persist between clinically defined episodes of depression, and can markedly decrease patients’ quality of The presence of residual symptoms between episodes of depression suggests that monitoring changes in social functioning may be useful in the prediction of relapse. This has implications for the long-term management of depression and may permit early therapeutic intervention. The degree of functional impairment associated with depressive disorders, and with depressive symptoms in the absence of disorders, has been ,reported to be comparable to, and in many cases to exceed, that experienced by patients with other chronic medical conditions such as diabetes and
SOCIAL FUNCTIONING AS A THERAPEUTIC PRINCIPLE Social functioning as a therapeutic principle and measure of outcome in the management of people with schizophrenia
has long been accepted. However, measuring, this facet of many other psychiatric disorders, including depression, has not yet been widely adopted. In the early 1970s it was shown that addressing impaired social functioning may represent an additional therapeutic principle in the treatment of depression. Interpersonal therapy (IPT), a psychotherapeutic approach, was originally developed for this purpose.” A number of early studies seemed to show that this is effective in improving both functional impairment and the core symptoms of depression, as compared with imipramine and with cognitive therapy.’.12 However, there remains doubt over the efficacy of this treatment approach and it has not been widely adopted. In 1990, Frank et al,13 in a randomized 3-year maintenance trial in patients with recurrent depression, showed that imipramine had a significant prophylactic effect, whereas the improvement in patients who received monthly IPT sessions was modest. The efficacy of antidepressants in the treatment of depressive disorders is clear. The early work on IPT, in the treatment of both the functional impairment and the symptoms of depression, poses the question of whether pharmacotherapy could also relieve both these facets of depression. A preliminary study by Finkelstein et all4 demonstrated an improvement in work performance of chronically depressed patients treated with either imipramine or sertraline, although potential differences between the two antidepressants were not examined. Improvements in overall social functioning have also been seen following short-term, open-label treatment with de~ipramine.’~ Most recently, a number of studies have demonstrated that antidepressants, including imipramine, sertraline, reboxetine and fluoxetine, were better than placebo in improving aspects of social fun~tioning.’~*’’
THE WAY AHEAD Given the importance of the impairment of social functioning in depression, a worlung group has been established to review the current literature, focusing on the definition, effects and implications for the management of
Social functioning in depression
depressed patients of the associated impairment of social functioning. The working group aims to consolidate current opinion on the subject and publish a substantial review. With the increasingly comprehensive approach to
243
patient management now being taken by health professionals, social functioning is once again a key factor in both policy and clinical decisions for the treatment of depressed patients.
REFERENCES 1. Hirschfeld RMA, Keller MB, Panico S et a1 (1997) The National
Downloaded by [Chinese University of Hong Kong] at 17:26 05 November 2015
2.
3.
4.
5.
6. 7. 8.
9.
Depressive and Manic-depressive Association Consensus statement on the undertreatment of depression.JAMA 277: 333-40. Lkpine JP, Gastpar M, Mendlewicz J, Tylee A and the DEPRES Steering Committee (1977) Depression in the community: the first pan-European study DEPRES (Depression Research in European Society). Int Clin Psychopharmacol 12: 19-29. World Health Organization (1998) The World Health Report 1998. Life in the twenty-first century: a vision for all. WHO, Geneva. Murray CJL, Lopez AD (eds) (1998) The global burden of disease. A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard University Press, Boston, MA. Coyne J, Kessler R, Tal M et a1 (1987) Living with a depressed person. J Consult Clin Psycho1 55: 347 - 52. Paykel ES, Weissman MM (1973) Social maladjustment and depression. Arch Gen Psychiatry 28: 659 - 63. Weissman MM, Prusoff B, DiMascio A et a1 (1979) The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. Am j Psychotherapy 136: 555-8. Hays RD, Wells KB, Donald Sherbourne C et a1 (1995) Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Arch Gen Psychiatry 52: 11- 19. Tarlov AR, Ware JE Jr, Greenfield S et a1 (1989) The medical outcomes study: an application of methods for monitoring the results of medical care. jAMA 262: 925-30.
10. Keller MB, Hanks DL (1994) The natural history and heterogeneity of depressive disorders: implications for rational antidepressant therapy. J Clin Psychiatry 55: 25 -33. 11. Klerman GL, DiMascio A, Weissman MM et a1 (1974) Treatment of depression by drugs and psychotherapy. Am j Psychiatry 131: 186-91. 12. Elkin I, Shea T, Watkins JT et a1 (1989) National Institute of Health treatment of depression collaborative program: general effectiveness of treatments. Arch Gen Psychiatry 46: 971 -86. 13. Frank E, Kupfer DJ, Perel j M et a1 (1990) Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 47: 1093-9. 14. Finkelstein SN, Berndt ER, Greenberg PE et a1 and the Chronic Depression Study Group (1996) Improvement in subjective work performance after treatment of chronic depression: some preliminary results. Psychopharmacol Bull 32: 33 - 40. 15. Friedman RA, Markowitz jC, Parides M, Kocsis j H (1995) Acute response of social functioning in dysthymic patients with desipramine. j Affect Dis 3 4 85-8. 16. Kocsis JH, Zisook S, Davidson J et a1 (1997) Double-blind comparison of sertraline, imipramine and placebo in the treatment of dysthymia: psychosocial outcomes. Am J Psychiatry 154: 390-5. 17. Dubini A, Box M, Polin V (1997) Do noradrenaline and serotonin differentially affect social motivation and behaviour? Eur Neuropsychopharmacol 7: 549-556.
