The effect of psychotherapy for depression onimprovements in social functioning: a meta-analysis

F. Renner1*, P. Cuijpers2 and M. J. H. Huibers1,2

1Department of Clinical Psychological Science, Maastricht University, The Netherlands2Department of Clinical Psychology, VU University Amsterdam, The Netherlands

Background. Patients with depression often report impairments in social functioning. From a patient perspective,improvements in social functioning might be an important outcome in psychotherapy for depression. Therefore, it is im-portant to examine the effects of psychotherapy on social functioning in patients with depression.

Method. We conducted a meta-analysis on studies of psychotherapy for depression that reported results for social func-tioning at post-treatment. Only studies that compared psychotherapy to a control condition were included (31 studieswith 2956 patients).

Results. The effect size of psychotherapy on social functioning was small to moderate, before [Hedges g=0.46, 95%confidence interval (CI) 0.320.60] and after adjusting for publication bias (g=0.40, 95% CI 0.250.55). Univariate mod-erator analyses revealed that studies using care as usual as a control group versus other control groups yielded lowereffect sizes, whereas studies conducted in the USA versus other countries and studies that used clinician-rated instru-ments versus self-report yielded higher effect sizes. Higher quality studies yielded lower effect sizes whereas the numberof treatment sessions and the effect size of depressive symptoms were positively related to the effect size of social func-tioning. When controlling for these and additional characteristics simultaneously in multivariate meta-regression, the ef-fect size of depressive symptoms, treatment format and number of sessions were significant predictors. The effect size ofsocial functioning remained marginally significant, indicating that improvements in social functioning are not fullyexplained by improvements in depressive symptoms.

Conclusions. Psychotherapy for depression results in small to moderate improvements in social functioning. Theseimprovements are strongly associated with, but not fully explained by, improvements in depressive symptoms.

Received 4 July 2013; Revised 1 November 2013; Accepted 3 December 2013; First published online 28 January 2014

Key words: Depression, meta-analysis, psychotherapy, social functioning.

Introduction

Social functioning can be defined as the degreeto which a person is able to fulfil various roles in differ-ent social environments such as at work, at home, inrelationships or during leisure activities (Bosc, 2000).Patients with depression usually report deficits insocial functioning in addition to depressive symptoms(Hirschfeld et al. 2000). These impairments are oftenlong-lasting and are equal to or exceed those of chronicmedical illnesses such as myocardial infarctionand diabetes (Hays et al. 1995). Impairments in socialfunctioning in depression contribute strongly to theincreased burden of depression (Greenberg et al.2003; Eaton et al. 2008) and predict depressive relapseand recurrences (e.g. Leon et al. 1999; Judd et al. 2000;

Solomon et al. 2004; Vittengl et al. 2009). Impairmentsin social functioning in depression are also relatedto high economic costs. The impact of depression onwork functioning, which is one important aspect ofthe broader concept of social functioning, often exceedsthat of other chronic illnesses. In 2011, about 13.3 mil-lion work days were lost due to depression and anxietydisorders in the UK (ONS, 2012). These findings stressthe importance of including social functioning as anoutcome measure in treatment studies of depression.

Treatment outcome studies in depression usuallyfocus on the effects of treatment in improving depress-ive symptom severity rather than social functioning.For example, several meta-analyses have shown thatdifferent types of psychotherapy for depression aremoderately effective in reducing depressive symptoms(e.g. Cuijpers et al. 2008a; Barth et al. 2013) but nometa-analysis to date has quantified the effects of psy-chotherapy on social functioning in depression. Defini-tions of response and remission in depression outcomestudies are exclusively based on relative and absolute

* Address for correspondence: Mr F. Renner, Department of ClinicalPsychological Science, Maastricht University, PO Box 616, 6200 MDMaastricht, The Netherlands.

(Email: Fritz.Renner@MaastrichtUniversity.nl)

Psychological Medicine (2014), 44, 29132926. Cambridge University Press 2014doi:10.1017/S0033291713003152

REVIEW ARTICLE

improvements in symptom severity. Although meas-ures of symptom severity tend to include aspects ofsocial functioning, improvements in social functioningare not usually explicitly included in the definitionof response, remission or recovery from depression.The World Health Organization (WHO, 1948) defineshealth as a state of complete physical, mental andsocial well-being and not merely the absence of diseaseor infirmity. Moreover, from a patient perspective, im-provements in social functioning might be a preferredtreatment outcome. For example, Zimmerman et al.(2006) found that, among 535 out-patients with majordepressive disorder (MDD), a return to a normallevel of functioning at work, home or school wasrated among the three most important factors in deter-mining whether a depression was in remission.Similarly, in a qualitative study on treatment goals ofdepressed out-patients, Battle et al. (2010) found thatpatients with MDD commonly articulated improvingtheir social and family relationships as desired treat-ment goals. Mintz et al. (1992) compiled data from 10published treatment studies (psychotherapy and anti-depressants) and found that one aspect of social func-tioning, work impairment, improved with symptomremission, although improvements in work function-ing were slower than symptomatic improvements.

Given that no meta-analysis to date has estimatedthe effects of psychotherapy for depression on socialfunctioning, it is not clear how large the effects of psy-chotherapy for depression on social functioning are,whether these effects are smaller, equal to, or exceedthe effects of psychotherapy on symptom severityand whether these effects differ between differenttypes of psychotherapy. The aim of this meta-analysiswas to summarize the effects of psychotherapy fordepression on improvements in social functioning.We hypothesized that psychotherapy for depressionhas positive effects on social functioning; that thereare no differences between different types of psycho-therapy for depression with regard to improvementsin social functioning; and that the effects of psycho-therapy for depression on social functioning are posi-tively correlated with the effects of psychotherapy fordepression on depressive symptom severity.

Method

Study selection

We used a database of 1476 papers on the psychologi-cal treatment for depression. A detailed description ofthe methods that were used to build the database isavailable elsewhere (Cuijpers et al. 2008c). This data-base is continuously updated, available to other re-searchers (www.evidencebasedpsychotherapies.com)

and has been used previously in a series of meta-analyses.

For the current meta-analyses we included studiescomparing the effects of psychological interventionsfor depression with a control condition [waiting list,care as usual (CAU) or placebo]. We further includedonly studies that classified depression according to adiagnostic interview or elevated depression levels onvalidated self-report questionnaires. Studies in chil-dren and adolescents (age

account for the heterogeneity among studies. The ran-dom effects model assumes that all included studiesare estimating different (underlying) effect sizes. Totest the homogeneity of effect sizes, we calculated I2

and the Q statistic (Higgins et al. 2003). Publicationbias was assessed by visual inspection of a funnelplot and by the trim-and-fill procedure, which pro-vides an adjusted estimate of the overall effect size,after adjusting for publication bias (Duval &Tweedie, 2000). A random effects model was used tolook for missing studies.

We used meta-regression analyses to test whetherthere was a relationship between the effect sizes ofsocial functioning and the effect sizes of depressionseverity. For categorical study characteristics, a seriesof subgroup or moderator analyses was conductedusing a mixed effect model. Tests for significance be-tween the different subgroups were conducted usinga fixed effects model. For continuous variables, meta-regression analyses were used. Multivariate analyseswere conducted using Stata/SE 12.0 for Windows(Stata Corporation, USA). In these analyses theweighted effect size in social functioning at post-treatment was the dependent variable and the effectsize of depressive symptom severity at post-treatmentalong with potential confounding variables wereentered as predictors.

Results

Selection and inclusion of studies

Three hundred and fifty-two randomized clinical trials(RCTs) were included in the database. Of these studies,204 included a control group. The method and resultssections of these 204 studies and the correspondingduplicate studies were checked to determine whethera measure of social functioning was included.Thirty-one studies met our inclusion criteria, reportedsocial functioning at post-test, and were included inthe meta-analyses comparing the effects of psycho-therapy (versus control group) on social functioning.

Description of included studies

The characteristics of the included studies are pre-sented in Table 1. The total number of participants inthe 31 included studies was 2956 (1655 in the treatmentcondition and 1301 in the control condition). In 11of the 31 studies, participants were recruited throughthe community, 13 used clinical referral and seven re-lied on other recruitment strategies. Seventeen studiesfocused on adults in general, eight studies only in-cluded women (two only women with postpartum de-pression, one only infertile women, one only womenseeking care following miscarriage, one only women

with a history of childhood trauma), five studiesfocused specifically on older adults, and one studyincluded adults with a general medical condition.Some studies compared more than one type of psycho-therapy to a control group, resulting in a total numberof 39 comparisons between psychotherapy and a con-trol group. In 18 of the 39 comparisons, cognitivebehavioural therapy (CBT) (including three studieson coping with depression course) was compared toa control group; six comparisons were between inter-personal psychotherapy (IPT) and a control group;four comparisons were between problem solving ther-apy and a control group and the remaining 11 compar-isons were between a control group and acceptanceand commitment therapy, behavioural activation, dia-lectic behavioural therapy, guided self-help, integrativeand instrumental reminiscence therapies, interpersonalcounselling, psychodynamic therapy or supportivetherapy. The control group consisted of CAU (19studies), wait-list control (eight studies) or other con-trol conditions (four studies; active socialization, medi-tation, pill placebo). Various instruments were used toassess social functioning: the Social Adjustment Scale(SAS; self-report or clinician rated or modified version;Weissman et al. 1978) was used by 14 studies; thesocial functioning subscale of the Medical OutcomesStudy (MOS) 36-item Short-Form Health Survey(SF-36; Ware & Sherbourne, 1992) was used by five stu-dies; the Inventory of Interpersonal Problems (IIP;Horowitz et al. 2000) was used by two studies; twostudies used the Sheehan Disability Scale (SDS;Sheehan, 1983) to assess social functioning; and the re-maining studies used other instruments to assess socialfunctioning.

Quality of included studies

Sixteen studies reported having used an adequatesequence generation (method to generate the randomallocation sequence); in 18 studies random allocationto conditions was conducted by an independentresearcher; in 24 studies assessors were blind to treat-ment condition; intention-to-treat analyses was con-ducted in 23 of the included studies. Eight studiesmet all four quality criteria.

Meta-analyses

Effects of psychotherapy on social functioning

Between-study heterogeneity was large (Q=129.22,p

Table 1. Selected characteristics of studies comparing psychotherapies with non-treatment control conditions in patients with depression

StudyRecruitmentsetting

Definition ofdepression

Targetgroup

Psychotherapy(format) n

No. ofsessions

Controlgroup N ITT

Outcome measures

CountrySocial adjustment Depression

Allart-van Dam et al.2003

Community Subthreshold Adults CWD (group) 61 12 CAU 41 + SIG BDI EU

Berger et al. 2011 Community MDD Adults GSH 25 10 WL 26 + IIP BDI-II EUChoi et al. 2012 Community MDD Adults GSH (CBT) 32 6 WL 31 + SDS BDI OtherDobkin et al. 2011 Community Mood disorder GMP Adults CBT (individual) 41 10 CAU 39 + SF-36 social functioning HAMD; BDI USADowrick et al. 2000 Other Mood disorder Adults PST (individual) 98 6 CAU 139 + SF-36 social functioning BDI UK

CWD (group) 80 12Ekers et al. 2011 Clinical Mood disorder Adults BA (individual) 16 12 CAU 22 + WSAS BDI-II; QIDS;

GDSUK

Faramarzi et al. 2008 Other MDD Women CBT (group) 29 10 CAU 30 GHQ social dysfunction BDI OtherFledderus et al. 2012 Community Other Adults GSH (ACT-E) 125 9 WL 126 + MHC-SF-SOC CES-D EU

GSH (ACT-M) 125 9Grote et al. 2009 Other Other Women with

PPDBrief IPT 25 8 CAU 28 + SAS BDI USA

Haringsma et al.2006

Community Subthreshold Older adults CWD (group) 52 10 WL 58 + MOS-SF-20 social androle functioning

CES-D; HADS EU

Harley et al. 2008 Clinical MDD Adults DBT (group) 10 16 WL 9 SAS-SR BDI; HAMD USAKlein et al. 1985 Community Mood disorder Adults CBT (group) 14 12 Other 8 SAS-SR; LIFE-RIFT SCL-90; CMID USALaidlaw et al. 2008 Clinical MDD Older adults CBT (individual) 20 8 CAU 20 WHOQOL social

relationships scaleBDI; GDS;HAMD

UK

Lynch et al. 1997 Clinical Subthreshold Adults PST (individual bytelephone)

7 6 CAU 9 DUKE social functioningscale

BDI USA

Lynch et al. 2004 Clinical Other Adults PST (individualby telephone)

9 6 CAU 13 DUKE social functioningscale

BDI USA

Miller & Weissman,2002

Other Other Women IPT (individual bytelephone)

15 12 CAU 15 + SAS-SR HAMD USA

Miranda et al. 2003 Other MDD Women CBT (individualor group)

90 8 CAU 89 + SAS-CR; SF-36 socialfunctioning scale

HAMD USA

Mynors-Wallis et al.1995

Clinical MDD Adults PST (individual) 29 6 Other 26 + SAS-M BDI; HAMD UK

Neugebauer et al.2006

Other Subthreshold Women IPC (individual) 10 6 CAU 9 + SF-36 role functioningscale

HAMD USA

OHara et al. 2000 Other MDD Women withPPD

IPT (individual) 48 12 WL 51 + SAS-SR BDI; HAMD USA

Perini et al. 2009 Community MDD Adults GSH (CBT) 27 6 WL 18 + SDS BDI-II OtherPropst et al. 1992 Community Other Adults RCTRT (individual) 10 18 WL 11 SAS-CR BDI; HAMD USA

RCTNRT (individual) 9 18

2916F.R

enneret

al.

NRCTRT (individual) 9 18NRCTNRT (individual) 10 18

Scott et al. 2000 Clinical Residualsymptoms

Adults CBT+CM (individual) 80 16 CAU 78 + SAS-CR BDI; HAMD;RDS; CDI

UK

Serfaty et al. 2009 Community Mood disorder Older adults CBT (individual) 51 12 CAU 46 + SFQ BDI-II UKSimpson et al. 2003 Clinical Other Adults DYN counselling

(individual)83 5 CAU 80 + IIP; SAS-M BDI UK

Talbot et al. 2011 Clinical MDD Women IPT (individual) 34 16 CAU 24 + SAS-SR BDI; HAMD USAvan Schaik et al.2006

Clinical MDD Older adults IPT (individual) 69 10 CAU 74 + SF-36 socialfunctioning scale

MADRS; GDS EU

Vitriol et al. 2009 Clinical Mood disorder Women DYN (individual) 44 12 CAU 43 + OQ-45 interpersonalrelationships andsocial role scales

HAMD Other

Ward et al. 2000 Clinical Other Adults CBT (individual) 63 6 CAU 67 + SAS-M BDI UKSupportive (individual) 67 6

Watkins et al. 1993 Clinical MDD Adults CBT (individual) 59 16 Other 62 + SAS-CR BDI; HAMD USAIPT (individual) 61 16

Watt & Cappeliez,2000

Community Other Older adults Integrative reminiscence(group)

9 6 Other 9 SAS-SR GDS; HAMD Other

Instrumentalreminiscence (group)

9 6

ACT-E, Acceptance and commitment therapy with extensive email support; ACT-M, acceptance and commitment therapy with minimal email support; BA, behavioural activation;BDI, Beck Depression Inventory; BDI-II, BDI Second Edition; CAU, care as usual; CBT, cognitive behavioural therapy; CDI, Childrens Depression Inventory; CES-D, Center forEpidemiologic Studies Depression Scale; CM, contingency management; CMID, Cornell Medical Index Depression Scale; CWD, Coping With Depression; DBT, dialectical behaviourtherapy skills training; DUKE, Duke health profile; DYN, psychodynamic counselling; EU, European Union; GDS, Geriatric Depression Scale; GHQ, General Health Questionnaire;GMP, general medical patients; GSH, guided self-help; HADS, Hospital Anxiety and Depression Scale; HAMD, Hamilton Rating Scale for Depression; IIP, Inventory of InterpersonalProblems; IPC, interpersonal counselling; IPT, interpersonal psychotherapy; ITT, intention-to-treat; LIFE-RIFT, Range of Impaired Functioning Tool; MADRS, MontgomerysbergDepression Rating Scale; MDD, major depressive disorder; MHC-SF-SOC, Mental Health Continuum Short Form social functioning subscale; MOS-SF-20, Medical Outcomes Study20-item Short-Form Health Survey; NRCTNRT, non-religious CBT, non-religious therapist; NRCTRT, non-religious CBT, religious therapist; OQ-45, Outcome Questionnaire; PPD,postpartum depression; PST, problem solving therapy; QIDS, Quick Inventory of Depressive Symptomatology; RCTNT, religious CBT, non-religious therapist; RCTRT, religious CBT,religious therapist; RDS, Raskin Depression Scale; SAS, Social Adjustment Scale; SAS-CR, Social Adjustment Scale clinician-rated; SAS-M, Social Adjustment Scale, Modified; SAS-SR,Social Adjustment Scale, Self-Report; SCL-90, Symptom Checklist-90; SDS, Sheehan Disability Scale; SF-36, 36-item Short-Form Health Survey; SFQ, Social Functioning Questionnaire;SIG, scale for interpersonal behaviour; WHOQOL, World Health Organization Quality of Life; WL, waiting list; WSAS, Work and Social Adjustment Scale.

Effectofpsychotherapy

fordepression

onsocialfunctioning

2917

from zero (z=6.42, p

significantly different from zero (z=5.16, p

CI 0.010.05, p

delivery format significantly predicted the effect sizeon social functioning (b=0.32, 95% CI 0.56 to0.09, p

psychotherapy for depression are strongly related toimprovements in depressive symptom severity where-as, on the other hand, social functioning improvementsare, at least in part, independent of depressivesymptoms.

Discussion

The aim of this meta-analysis was to summarize theeffect of psychotherapy for depression on improve-ments in social functioning. We found 31 studieswith a total of 2956 participants that compared psy-chotherapy for depression with a control group andassessed social functioning at post-treatment. Beforeand after adjusting for publication bias, the overalleffect size was small to moderate. These findings sug-gest that depressed patients receiving psychotherapyfor depression can benefit not only in terms of amelior-ation of depressive symptoms but also in terms ofimproved functioning in various social roles suchas work, recreational and interpersonal relationships.This is important because impairments in these areascontribute strongly to the burden of disease in de-pression (Greenberg et al. 2003; Eaton et al. 2008).After controlling for the effects of psychotherapy ondepressive symptom severity and selective studycharacteristic in multivariate meta-analyses, the effectsof psychotherapy on social functioning remainedmarginally significant, indicating that changes in socialfunctioning are not fully explained by changes in de-pressive symptom severity. In other words, our resultssuggest that social functioning improves as depressivesymptoms improve, although the direction or nature ofthe presumed causal relationship remains unknown.These findings are in line with previous studiesshowing that changes in psychosocial functioning areintercorrelated with changes in depressive symptomseverity (e.g. Vittengl et al. 2004; Dunn et al. 2012).

It should be noted that the current researchdesign does not allow us to determine the temporal re-lationship of this association. It is not clear whetherimprovements in depressive symptom severity driveimprovements in social functioning or vice versa. To de-termine the temporal relationship between these con-structs it would be necessary to establish a timelinewith repeated assessments of both constructs duringtreatment (Kazdin, 2007). One previous processout-come study on the effects of cognitive therapy onchange in psychosocial adjustment found that im-provements in psychosocial adjustment, assessed fourtimes during treatment, predicted subsequent reduc-tions in depressive symptoms rather than vice versa(Dunn et al. 2012). Future RCT-based studies withcontrol groups and repeated assessments of function-ing and depressive symptoms throughout treatment

should aim to determine the causal relationship be-tween these variables.

Overall, the effect size of social functioning wassmaller than the effect size of depressive symptomseverity. This finding is in line with previous studiesshowing that impairments in social functioning oftenpersist, even after symptomatic recovery (e.g. Coryellet al. 1993). Different explanations might accountfor this finding. For example, it is possible that socialfunctioning takes more time to improve compared todepressive symptom severity in psychotherapy for de-pression. This explanation is in line with the findings ofa previous meta-analysis showing that recovery fromwork impairments in depression takes longer thansymptom remission (Mintz et al. 1992). However,impairments in social functioning might be more per-sistent even in the long run and additional treatmentmight be necessary to improve social functioning to apre-morbid level. Our finding that social functioningimproved less than depressive symptom severitymight have important prognostic implications for thecourse of depression following treatment. For example,it has been shown that residual impairments in socialfunctioning following treatment are related to relapseand recurrences (e.g. Leon et al. 1999; Vittengl et al.2009). Such findings stress the importance of includingsocial functioning as the main outcome in treatmentstudies and in current definitions of response and re-mission. It should be noted that, after adjusting forpublication bias, the effect size of social functioning(g=0.40) was comparable to the adjusted effect sizeof depressive symptoms (g=0.43).

We conducted subgroup analyses to test whetherselective study characteristics were differentiallyrelated to the effects of psychotherapy on social func-tioning. In interpreting the results of these analyses,significant associations should not be interpreted interms of causal associations. Our univariate subgroupanalyses indicated that studies that compared psycho-therapy to CAU resulted in smaller effect sizes com-pared to studies comparing psychotherapy to othercontrol conditions. This finding is in line with previousmeta-analyses summarizing the effects of psycho-therapy on depressive symptom severity (e.g.Cuijpers et al. 2008d). In our subgroup analyses, studieswith a CAU control condition were mainly comparedto studies with a wait-list control condition and it istherefore not surprising that studies with CAU as thecontrol condition resulted in smaller effect sizes.Our subgroup analyses further showed that studiesthat were conducted in the USA and studies thatused clinician-rated scales to assess social functioningyielded higher effect sizes than studies that wereconducted in other countries or studies that reliedon self-reported instruments of social functioning.

2922 F. Renner et al.

Although speculative, it is possible that studies basedin the USA have a higher treatment delivery qualityand therefore achieve higher effect sizes. The findingthat clinician-rated instruments yielded higher effectsizes than self-reported instruments is in line withthe results of an earlier meta-analysis showing thatclinician-rated instruments were associated withhigher effect-sizes of depressive symptom severity(Cuijpers et al. 2010). In the current meta-analysis,only three studies (seven comparisons) used aclinician-rated instrument of social functioning andhence this finding should be interpreted with caution.Based on our findings, it is not clear whether one typeof assessment of social functioning is preferable overthe other and therefore it is probably best to includeboth in future studies and clinical practice when asses-sing social functioning.

There were no differences in improvements in socialfunctioning between different types of psychothera-peutic interventions (CBT v. others; IPT v. others).When interpreting these results it is important tokeep in mind that these findings are based on separatesets of comparisons and not on direct comparisons ofdifferent types of psychotherapies. Such indirect com-parisons might be confounded by differences in patientpopulations and other study characteristics and theresults should therefore be interpreted with caution.Our findings are in line with previous meta-analysesreporting that different types of psychotherapy areapproximately equally efficacious in reducing depress-ive symptoms (Cuijpers et al. 2008a). IPT focusesspecifically on social functioning (Weissman et al.2000) and we might therefore expect that studiesthat included IPT would result in larger effect sizesof improvements in social functioning compared tostudies on other forms of psychotherapy. It is unclearhow our finding that improvements in social function-ing were not different between IPT studies and otherstudies relates to the literature on the mechanisms ofchange in depression. It is possible, for example, thatIPT-based studies in this meta-analyses resulted ininitially stronger improvements in social functioningbut that these differences were no longer present atpost-treatment. However, it is impossible to testthis hypothesis in the current research design. FutureRCT-based studies with repeated assessments through-out treatment should aim to determine the temporalpattern of improvements in social functioning in differ-ent types of psychotherapy for depression.

We found that the number of therapy sessionswas positively associated with the effect size of socialfunctioning, even after controlling for the effects ondepressive symptom severity in multivariate analyses.This finding suggests that patients with depressionmight benefit from longer-term treatments or con-

tinuation treatments in terms of improvements insocial functioning. The relationship between the num-ber of therapy sessions and the effect size of socialfunctioning was fairly small. Our analyses suggestthat an increase of five therapy sessions is associatedwith an increase in the effect size of social functioningof 0.15. This is in line with the findings of a recentmeta-analysis showing that there is a small associationbetween the number of therapy sessions and the effectsize of depressive symptom severity (Cuijpers et al.2013). In the current meta-analysis, studies on con-tinuation and maintenance treatments were excludedand it therefore remains unclear whether continuedtreatment is related to further improvements in socialfunctioning. In the univariate and multivariate meta-analyses, we found that the treatment delivery formatwas significantly associated with improvements insocial functioning. Studies that used an individualtreatment format resulted in higher effect sizes com-pared to studies that used a group format. On theoreti-cal grounds it could be argued that group settingsshould result in stronger improvements in social func-tioning because group therapy, by definition, takesplace in a social interpersonal context allowing, forexample, social and interpersonal conflicts to be con-ducted in vivo in the group. Empirically, our findingthat individual treatments resulted in higher effectsizes of social functioning is in line with the resultsof a previous meta-analysis showing that an individualtreatment format for depression is associated withhigher effect sizes of depressive symptom severity(Cuijpers et al. 2008b).

Several important limitations should be mentioned.First, the number of studies was relatively smalland accordingly it was not possible to compare effectsizes between specific types of treatment other thanCBT and IPT. For example, it would be of interest totest whether psychotherapies for depression thatfocus on engagement in psychosocial activities (e.g.behavioural activation) are related to stronger im-provements in psychosocial adjustments compared toother forms of psychotherapies. A related limitationof this meta-analysis is that comparisons betweendifferent types of psychotherapies were based on sep-arate sets of comparisons and not on direct com-parisons of different types of psychotherapies. Thenumber of comparative outcome studies in the currentmeta-analysis was too small to allow for such a directcomparison. Second, the quality of included studieswas, on average, fairly low. As quality was negativelyassociated with the effect size, it might be that theeffect sizes in the current meta-analysis were over-estimated. Third, we compared the effects of psycho-therapy versus control groups at one assessmentmoment and hence we could not draw any conclusions

Effect of psychotherapy for depression on social functioning 2923

regarding the temporal relationships between changesin social functioning and changes in depressive symp-tom severity. The current meta-analysis was based onstudy-level data. Another approach that might alsoallow for analyses of temporal relationships and amore fine-grained analysis of predictors would havebeen to conduct an individual patient-level meta-analysis based on the original datasets of includedstudies. Finally, we assessed overall improvements insocial functioning rather than domain-specific improve-ments. It is possible, for example, that some aspects offunctioning show stronger improvements (e.g. recrea-tional functioning) than others (e.g. work functioning).

Despite these limitations, our findings have import-ant implications for clinical practice and future re-search. First, the results of this meta-analysis suggestthat psychotherapy for depression is associated withimprovements in social functioning. This is an import-ant finding because improvements in social function-ing are a highly desirable outcome from a patientperspective. Second, future research should aim todetermine the temporal relationship between socialfunctioning and depressive symptom severity byassessing both depressive symptom severity and socialfunctioning repeatedly throughout treatment. Finally,compared to the total number of RCTs on differenttypes of psychotherapies for depression, the numberof studies that included measures of social functioningas treatment outcome was relatively small, whichreflects the current focus of treatment outcome studieson depressive symptom severity rather than function-ing. Including social functioning as the main outcome,in addition to symptomatic improvements, in treat-ment studies for depression might add to a more com-plete definition of treatment effects.

In conclusion, psychotherapy for depression hassmall to moderate positive effects on the social func-tioning of depressed patients and no differences be-tween different types of psychotherapies emerged.

Declaration of Interest

None.

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