How groups beat depression

In the fourth piece in our special collection on The New Psychology of Health, Tegan Cruwys considers the evidence that identifying with others is a sustainable route to wellbeing.

Too many people know the suffering of depression firsthand. Approximately one in five experience it at some stage in their life – the figure is even higher in areas afflicted by disaster, trauma or poverty. It would be a lucky person indeed who avoids seeing depression in either themselves or the people they love. So why have we got no better at reducing its prevalence or impact? Is it time for a new approach?

Most people are well aware of the key signs of clinical depression: notably, the experience of profound sadness, a loss of enjoyment and interest, changes in energy levels and appetite, and a sense of guilt or hopelessness about the future. Depression has received more research attention than most other mental health issues, and thankfully we have two forms of treatment that work: psychological therapy and antidepressant medication. But here is the bad news: over the last 30 years, existing treatments have not reduced either the prevalence of depression or the disability caused by it (Baxter et al., 2014). As we will see, this is probably a reflection of issues related to access, compliance and relapse.

First, access to evidence-based treatments tends to be difficult, with only a small minority of people around the world able to get seen by a mental health professional who can offer antidepressants (most commonly a selective serotonin reuptake inhibitor, or SSRI) or psychological therapy (most commonly cognitive behavioural therapy, or CBT). These tend to be people who are financially better off, and who live in urban areas of wealthy nations (Simon et al., 2004). This is why UK initiatives like Improving Access to Psychological Therapies (IAPT) are so important: they make a big difference in getting evidence-based treatment to more people who need it.

Second, even people who have access to high-quality care don’t necessarily follow treatment recommendations. Some studies have found that less than half of those prescribed antidepressants take them as directed – often because of problematic side-effects such as weight gain, emotional numbing or sexual dysfunction. Moreover, even though many people prefer psychological therapy, the stigma of seeing a therapist can often stop people from following through on a referral.

Third, and perhaps of most concern, even among people who do manage to complete these ‘gold standard’ treatments, relapse is high. One of the highest-quality trials on depression treatment, comparing CBT and SSRIs, found that among people who received both, almost a third had relapsed only 18 months later (Shea et al., 1992). This high level of relapse is one of the reasons why depression remains a leading cause of disability worldwide. More than 80 per cent of people with depression relapse at some point in their lives, and the average person who has had one episode of depression can expect four or five more across their life, each of about six months in duration (Judd, 1997).

Taken together, this evidence suggests that we need new approaches to treating depression that are low-cost and non-stigmatising, and that protect people across the lifespan (and not only during periods of acute symptoms). A growing body of evidence suggests that social connectedness is a good place to start looking for these new solutions.

The first study that we conducted to explore the link between social connectedness and depression, published in 2013, included over 4000 adults living in England who were aged over 50 and who were tracked over six years. We compared people with severe depression with those who had fewer if any symptoms of depression. Consistent with a lot of existing research, the first finding here was that people who were depressed tended to report belonging to far fewer social groups than the rest of the population. We then looked at how these group memberships changed over the next two years. What we found was that people who joined more groups in this time – regardless of how many they belonged to at baseline – were less likely to be depressed four and six years later. Interestingly too, these effects were much stronger among those with a history of depression. Putting this in concrete terms, if a person with depression at baseline joined three groups across the next two years, they reduced their risk of relapse another four years later by as much as 63 per cent. Any way you look at it, this is a striking result. It suggested we were onto something meaningful and important that other researchers had overlooked.   

So is it that social isolation causes depression, as we might interpret from the above results, or the other way around? In fact, many health professionals who treat people with depression are trained to expect the latter, and see social isolation as a consequence of depression. To get a handle on this, we conducted a follow-up study, examining both the effect of social isolation on psychological distress over time and the effect of psychological distress on social isolation over time (Saeri et al., 2018). Following a sample of over 21,000 New Zealand adults across four years, we compared the size and significance of these longitudinal relationships.

As one might expect, we found that the effect worked both ways. However, the effect of social isolation on psychological distress over time was about three times stronger than the converse. What this suggests is that social isolation both leads to, and follows from, depression. But it also tells us that in most cases, people become socially isolated before, not after, they become depressed.

While this evidence is compelling, in psychological science nothing is more compelling than experimental evidence – and so this was the methodology we applied in our next study (Cruwys et al., 2015). For this we invited 88 young adults into the laboratory and assigned them to one of three conditions: to write about one group membership that was important to them, three group memberships, or to just skip this part of the study (the equivalent of writing about no groups). Participants then completed a problem-solving test, but what we did not tell them was that these were unsolvable problems. After 10 minutes all participants were individually given feedback that they had scored 0 on the test. What we were most interested in, though, was how participants interpreted this failure. Compared with the participants who had been thinking about one or three of their social groups, participants in the no groups condition were significantly more likely to interpret their failure in a way that was internal, global and stable: ‘I failed because I’m stupid’ (rather than, say, because the test was too hard or the time too short). This kind of interpretation is known as a depressive attribution style, and it is a recognised marker of depression. These participants were also more likely to report negative affect following their failure experience. All in all, then, this experiment suggests that merely thinking about the social groups we belong to can make us more resilient in the face of life stress, and less likely to respond with unhelpful interpretations and negative emotions that, if repeated over time, may well culminate in depression.

What is true in the lab, however, isn’t always true in practice. It is also true that not all groups are the same. Certainly, we can all think of times we have been involved in group activities that have felt like a chore, and where it is hard to imagine a benefit to our mental health. Indeed, the social identity approach says that just ‘showing up’ at a social group activity is not enough to make a difference. It is only when those groups are incorporated into our self-concept, thereby becoming social identities, that they enable health benefits. Our next study, then, aimed to test the role of social identification as the ‘active ingredient’ in groups that combats depression. Furthermore, this study looked to translate the above findings into practice by exploring how social identity principles could be applied in clinical and community settings (Cruwys et al., 2014).

For this purpose we followed two samples across a period of several months: first, a group of 91 outpatients with depression or anxiety disorders who joined a therapy group to receive CBT. Second, a group of 52 disadvantaged people, the majority of whom had complex mental health issues, who joined a recreational group facilitated by social workers. What we found, as expected, was that depression symptoms decreased over time in both groups. However, and consistent with a social identity approach to depression, we found that the more strongly people identified with the social group that they had joined, the greater the improvement in their depression symptoms over time – dropping below the diagnostic cut-off only in the ‘high social identifiers’. Put another way, even among people undergoing evidence-based CBT for depression, benefits were more likely to accrue to those people who identified with others in their therapy group.

Next steps
In sum, an increasing body of evidence suggests that social isolation (a lack or loss of social identities) is not only associated with depression, but is causally implicated in its development, maintenance and effective treatment. This is exciting, not just because it breaks new theoretical ground, but also because it helps us to address the need for new directions in depression treatment.

As an approach to treatment, social group connectedness suffers few of the issues related to access, compliance and relapse. Social groups are an affordable intervention because they can reach many people in need at one time, and are not the exclusive purview of highly trained mental health professionals. Moreover, compliance tends not to be a barrier to social group connectedness, as the ‘side-effects’ are not typically aversive, and with this approach it is also possible to avoid the stigma that can be associated with traditional diagnosis and therapy. Finally, being involved in social groups is open to people across their lives; thus this approach holds promise not only for people with acute depression symptoms, but also as a protection against its onset and relapse.

An important next step for this research is to translate these various lines of evidence into useful, concrete interventions that increase social group connectedness. This is an issue that Catherine Haslam addresses in the next article in this issue. The key point to reinforce here, though, is that groups have an important role to play in helping beat depression because they have an important role to play in its development. Understanding this provides a platform not just for better insight into the condition but also for a more sustainable approach to treatment. Indeed, because groups are probably the most natural and effective vehicle for self-development that humans have devised, this may feel less like treatment and more just like life at its best.

About the author

‘As a clinical psychologist, it has felt to me like a disconnect that most of our training focuses on dysfunction within people (e.g. social skills deficits or maladaptive schemas), when the vast majority of people seek help with things in their social worlds (e.g. workplace bullying, relationship breakdown or trauma). In my research I seek to address this disconnect, and give practitioners the concrete, evidence-based tools to work with their clients’ social worlds.’

- Tegan Cruwys is in the School of Psychology, University of Queensland
[email protected]

Key sources
Baxter, A.J., Scott, K.M., Ferrari, A.J. et al. (2014). Challenging the myth of an ‘epidemic’ of common mental disorders. Depression and Anxiety, 31, 506–516.
Cruwys, T., Dingle, G.A., Haslam, C. et al. (2013). Social group memberships protect against future depression, alleviate depression symptoms and prevent depression relapse. Social Science and Medicine, 98, 179–186.
Cruwys, T., Haslam, S.A., Dingle, G.A., et al. (2014). Feeling connected again. Journal of Affective Disorders, 159, 139–146.
Cruwys, T., South, E.I., Greenaway, K.H. & Haslam, S.A. (2015). Social identity reduces depression by fostering positive attributions. Social Psychological and Personality Science, 6, 65–74.
Judd, L.L. (1997). The clinical course of unipolar major depressive disorders. Archives of General Psychiatry, 54, 989–991.
Saeri, A.K., Cruwys, T., Barlow, F.K. et al. (2018). Social connectedness improves public mental health. Australian and New Zealand Journal of Psychiatry, 52(4), 365-374.
Shea, M.T., Elkin, I., Imber, S.D. et al. (1992). Course of depressive symptoms over follow-up. Archives of General Psychiatry, 49, 782–787.
Simon, G.E., Fleck, M., Lucas, R. & Bushnell, D.M. (2004). Prevalence and predictors of depression treatment in an international primary care study. American Journal of Psychiatry, 161, 1626–1634.

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