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Comorbid Major Depressive Disorder in Cognitive-Behavior Group Treatment for Social Anxiety Disorder: An Examination of Processes of Symptom Change

Authors:
Naama Rozen at Tel Aviv University
Naama Rozen
Eva Gilboa-Schechtman at Bar Ilan University
Eva Gilboa-Schechtman
Sofi Marom at Meir Medical Center
Sofi Marom
Haggai Hermesh
Haggai Hermesh
Haggai Hermesh
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Abstract

Individuals with social anxiety disorder (SAD) typically have elevated depressive symptoms and approximately 50% also meet criteria for major depressive disorder (MDD; Beesdo et al., 2007). In the present study, we examined the relationship between social anxiety and depressive symptoms during cognitive-behavior group treatment (CBGT) for SAD. Specifically, we compared individuals with SAD and comorbid MDD and individuals with SAD without MDD to examine the role of MDD as a moderator of social anxiety-depression relationship. Participants were 90 individuals seeking treatment for SAD (36% were diagnosed with MDD), who completed self-report measures of social anxiety and depression every 2 weeks during CBGT. Lower level mediational modeling indicated that for individuals without MDD, a reciprocal relationship was observed in which changes in both social anxiety and depressive symptoms mediated changes in each other. However, changes in social anxiety explained all subsequent changes in depression, whereas changes in depression explained 11.26% of subsequent changes in social anxiety. For individuals with both SAD and MDD, neither social anxiety nor depression significantly mediated changes in each other. Our findings suggest that different processes of change occur for individuals with and without MDD and clinical implications of these findings are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Comorbid Major Depressive Disorder in Cognitive-Behavior
Group Treatment for Social Anxiety Disorder: An Examination
of Processes of Symptom Change
Naama Rozen
1
, Eva Gilboa-Schechtman
2
,SofiMarom
3
, Haggai Hermesh
3
, and Idan M. Aderka
1
1
School of Psychological Sciences, University of Haifa
2
Department of Psychology and the Gonda Brain Science Center, Bar-Ilan University
3
Geha Mental Health Center, Petah-Tiqwa, Israel
Individuals with social anxiety disorder (SAD) typically have elevated depressive symptoms and approxi-
mately 50% also meet criteria for major depressive disorder (MDD; Beesdo et al., 2007). In the present
study, we examined the relationship between social anxiety and depressive symptoms during cognitive-
behavior group treatment (CBGT) for SAD. Specifically, we compared individuals with SAD and comorbid
MDD and individuals with SAD without MDD to examine the role of MDD as a moderator of social
anxiety–depression relationship. Participants were 90 individuals seeking treatment for SAD (36% were
diagnosed with MDD), who completed self-report measures of social anxiety and depression every 2 weeks
during CBGT. Lower level mediational modeling indicated that for individuals without MDD, a reciprocal
relationship was observed in which changes in both social anxiety and depressive symptoms mediated
changes in each other. However, changes in social anxiety explained all subsequent changes in depression,
whereas changes in depression explained 11.26% of subsequent changes in social anxiety. For individuals
with both SAD and MDD, neither social anxiety nor depression significantly mediated changes in each
other. Our findings suggest that different processes of change occur for individuals with and without MDD
and clinical implications of these findings are discussed.
Clinical Impact Statement
Question: The present study examined the effect of comorbid MDD on processes of change in
cognitive-behavior group treatment for SAD. Findings: For individuals without MDD, changes in
social anxiety predicted changes in depression, whereas for individuals with MDD, social anxiety and
depression changed independently. Meaning: Individuals with SAD that do not meet criteria for MDD
can be treated using treatments that primarily target social anxiety, and this can lead to reductions in both
social anxiety and depressive symptoms. Individuals with a dual SAD/MDD diagnosis may require
interventions that target shared factors to reduce both social anxiety and depressive symptoms. Next
Steps: Future studies can examine treatments that are tailored to address comorbid MDD in SAD, and
this can lead to enhanced efficacy.
Keywords: social anxiety disorder, depression, cognitive behavior group therapy, lower level mediational
modeling
Social anxiety disorder (SAD) is a common, distressing, and
persistent disorder which is associated with significant impairment
in almost all facets of daily life (Aderka et al., 2012). SAD is
frequently comorbid with major depressive disorder (MDD), with
approximately 50% of individuals with SAD meeting criteria for
MDD over a 10-year period (Beesdo et al., 2007). Comorbid
depressive symptoms among individuals with SAD have been found
to predict SAD persistence (Alpert et al., 1997;Stein et al., 2001),
recurrence (Bruce et al., 2005;Scholten et al., 2013), and treatment
outcome (e.g., Wersebe et al., 2018). In addition, depressive symp-
toms have been found to be associated with severity and generali-
zation of social fears among individuals with SAD (Perugi et al.,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This article was published Online First January 13, 2022.
Naama Rozen https://orcid.org/0000-0001-6914-9952
Eva Gilboa-Schechtman https://orcid.org/0000-0002-2831-5835
SofiMarom https://orcid.org/0000-0001-7989-9896
We have no known conflict of interest to disclose.
Naama Rozen played a lead role in conceptualization, formal analysis, and
writing of original draft. Eva Gilboa-Schechtman played a supporting role in
writing of original draft and equal role in conceptualization. SofiMarom
played a supporting role in writing of original draft. Haggai Hermesh played
a supporting role in writing of original draft. Idan M. Aderka played a lead
role in conceptualization, formal analysis, supervision, and writing of
original draft.
Correspondence concerning this article should be addressed to Idan M.
Aderka, School of Psychological Sciences, University of Haifa, 199 Aba
Khoushy Avenue, Mount Carmel, Haifa 3498838, Israel. Email: iaderka@
psy.haifa.ac.il
Psychotherapy
© 2022 American Psychological Association 2022, Vol. 59, No. 1, 48–56
ISSN: 0033-3204 https://doi.org/10.1037/pst0000413
48
... The severity of symptoms, social disability, and suicide rates indicate that the comorbidity is significantly more serious than "pure" SAD [20]. These studies revealed that SAD comorbidity was associated with early-onset MDD, more frequent depressive episodes, an increased risk of suicide, and higher alcohol consumption [21]. There are limited studies examining the effects of comorbidity on treatment success in SAD [22]. ...
... Additionally, a higher prevalence of the female gender was observed in the MDD-SAD group (59.5% vs 29.2%; P = 0.001). This interesting finding lends support to previous studies indicating a varying gender distribution in SAD and MDD, as well as their comorbidity [20][21][22][23]. Notably, we discovered that depressive complaints in this group were not only more severe but also displayed an atypical pattern (75.7% vs 58.5%; P = 0.010), aligning with the complex presentations often seen in patients with SAD. ...
Exploring the clinical characteristics and etiological factors of comorbid major depressive disorder and social anxiety disorder
Preprint
Full-text available
  • Sep 2023
The comorbidity between the major depressive disorder (MDD) and the social anxiety disorder (SAD) is significantly prevalent, necessitating a nuanced understanding of their overlapping clinical characteristics and shared etiological factors, including inflammatory biomarkers. To address this, we conducted a cross-sectional study from December 2021 to June 2022, encompassing 204 outpatients diagnosed with MDD-SAD comorbidity. We employed various psychometric assessments, such as the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Childhood Trauma Questionnaire (CTQ-28), Toronto Alexithymia Scale (TAS-20) and the Liebowitz Social Anxiety Scale (LSAS). Additionally, we analyzed inflammatory biomarkers including the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte platelet ratio (NLPR), systemic inflammation index (SII), and the systemic inflammation response index (SIRI). Our findings accentuated that patients primarily diagnosed with MDD exhibited elevated levels of certain inflammatory biomarkers. They reported more severe and atypical depressive symptoms (75.7% vs 58.5%; P = 0.010) and had significantly higher CTQ-28 subscale scores (P < 0.05). Our study unveils a complex relationship between MDD and SAD, with significant disparities in the symptom severity and inflammatory biomarker levels, thereby establishing a compelling case for dual-diagnosis treatment approaches. It elucidates the critical role of inflammation in the comorbidity of MDD and SAD, marking a pioneering step towards more comprehensive and holistic patient care strategies. These insights could potentially revolutionize therapeutic approaches in psychiatric care, promising significantly improved outcomes through early detection and integrated intervention strategies.
View
... Si consideramos algunas investigaciones por separado (que no forman parte del metaanálisis y la revisión anteriores), encontramos pruebas de una reducción significativa de los síntomas depresivos (d= 0,79) en un grupo de Terapia para la eficacia social (Social Effectiveness Therapy, SET) (Beidel et al., 2014). Rozen et al. (2022) también encontraron que un grupo de terapia cognitivo conductual (GTCC) era eficaz para reducir los síntomas depresivos en sujetos con TAS. Mörtberg et al. (2007) hallaron igualmente una reducción significativa de los síntomas depresivos, siendo mayor la mejoría en la terapia cognitiva individual que en grupo, mientras que Stangier et al. (2003) no encontraron diferencias entre la terapia individual y la grupal en su eficacia para reducir los síntomas depresivos. ...
... Específicamente, comparando los tamaños del efecto del programa IMAS con los informados por otros estudios que evalúan la eficacia de alguna forma de TCC sobre los síntomas depresivos en sujetos con TAS (p. ej., Beidel et al., 2014;Rozen et al., 2022;Stangier et al., 2003), vemos que el programa IMAS muestra un rendimiento superior. Sin embargo, es difícil discutir sobre la preocupación patológica, ya que no conocemos el efecto de las intervenciones psicológicas a este respecto en pacientes con TAS. ...
Aplicación internacional del programa “Intervención multidimensional para la ansiedad social” (IMAS): II. Eficacia del tratamiento para problemas relacionados con la ansiedad social
Article
Full-text available
  • Apr 2022
En un trabajo anterior (Caballo et al., 2021) comprobamos la eficacia del programa de Intervención multidimensional para la ansiedad social (IMAS) en la reducción de los síntomas de ansiedad social. En este estudio cuasiexperimental, con medidas pre/postratamiento y seguimiento, hallamos el impacto del programa IMAS en otros problemas relacionados con la ansiedad social. 57 personas diagnosticadas con un trastorno de ansiedad social (TAS), según el DSM-5, contestaron a cuestionarios que medían habilidades sociales, depresión, síntomas del trastorno de la personalidad por evitación, alcoholismo, autoestima, sensibilidad personal, preocupaciones y calidad de vida. Diferentes terapeutas llevaron a cabo el tratamiento en Ecuador, España y Paraguay. Los resultados mostraron importantes mejoras en el postratamiento en prácticamente todos los aspectos evaluados, mejoras que se mantenían a los seis meses. Los tamaños del efecto sobre la eficacia del tratamiento iban de medianos a grandes. Se comparó también el programa IMAS con terapia cognitivo conductual individual y tratamiento farmacológico, con resultados favorables para el programa IMAS. Este nuevo programa para el tratamiento de la ansiedad social tiene un impacto importante en otros problemas relacionados habitualmente con el TAS.
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... If we consider some research separately (not part of the above meta-analysis and review), we find evidence for significant reduction of depressive symptoms (d= 0.79) in a Social Effectiveness Therapy (SET) group (Beidel et al., 2014). Rozen et al. (2022) also found that a cognitive behavioral therapy group (CBGT) was effective in reducing depressive symptoms in subjects with SAD. Mörtberg et al. (2007) similarly found a significant reduction in depressive symptoms, with greater improvement in individual cognitive therapy than in group, while Stangier et al. (2003) found no difference between individual and group therapy in their effectiveness in reducing depressive symptoms. ...
... Thus, it can be expected that as positive reinforcement from exposure increases (and negative reinforcement from avoidance is reduced) they improve their exaggerated worries and depressive symptoms, as shown by the post-treatment results. Specifically, comparing the effect sizes of the MISA program with those reported in other studies evaluating the effectiveness of some form of CBT on depressive symptoms in subjects with SAD (e.g., Beidel et al., 2014;Rozen et al., 2022;Stangier et al., 2003), we see that the MISA program shows superior performance. However, it is difficult to discuss about pathological worry, as we do not know about the effect of psychological interventions in this regard in patients with SAD. ...
International application of the “Multidimensional Intervention for Social Anxiety” (MISA) program: II. Treatment effectiveness for social anxiety-related problems
Article
Full-text available
  • Apr 2022
In a previous work (Caballo et al., 2021) we tested the effectiveness of the Multidimensional Intervention for Social Anxiety (MISA) program in reducing social anxiety symptoms. In this quasi-experimental study, with pre/post-treatment and follow-up measures, we examined the impact of the MISA program on other problems related to social anxiety. 57 people diagnosed with social anxiety disorder (SAD), according to DSM-5, were assessed with a diagnostic interview and questionnaires measuring social skills, depression, avoidant personality disorder symptoms, alcoholism, self-esteem, personal sensitivity, worries, and quality of life. Different therapists carried out the treatment in Ecuador, Spain, and Paraguay. The results showed significant improvements at post-treatment in virtually all measures assessing the above variables, improvements that were maintained at six months. Effect sizes on treatment effectiveness ranged from medium to large. The MISA program was also compared with individual cognitive behavioral therapy and pharmacological treatment, with favorable results for the MISA program. In conclusion, this new program for the treatment of social anxiety has a significant impact on other problems usually related to SAD.
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... It can be assumed that, during necessary hospital treatment, which objectively involves increased health risks, individuals who are removed from their usual way of life and separated from their loved ones perceive the stress of the illness with a significant presence of anxiety and depressive symptoms. However, whether we can attribute this to the social conditioning of anxiety and the relationship between anxiety and depressive symptoms would require separate studies [27]. ...
Illness Perception and the Severity of Depression and Anxiety Symptoms in Patients with Multimorbidity: Observational Cohort Studies
Article
Full-text available
  • Dec 2023
Introduction. Many studies have shown a correlation between the patient’s engagement in treatment and their perception of the illness. Aim: The aim of this study has been to explore the link between the patient’s perception of their illness with anxiety and depression, and to leverage this link to promote health education. Materials and methods: The study was carried out using the following tools: the Hospital Anxiety and Depression Scale and the Illness Perception Questionnaire–Revised. The study participants included N = 143 patients. Results: The participants’ age was statistically significantly associated with the expected duration of the illness (p < 0.01), the conviction that the treatment was effective (p < 0.01), and the perception of the severity of the disease symptoms (p < 0.05). The employment status was statistically significantly associated with the illness perception (p < 0.01). Anxiety and depression levels were statistically significantly associated with the perceived impact of the illness on life (p < 0.001) and emotional status (p < 0.001), the perceived control over the illness (p < 0.01), the potential for recovery (p < 0.001), the concern about the illness (p < 0.001), and the impact of the illness on emotional well-being (p < 0.001). Conclusions: Individuals who perceived a high severity of illness symptoms also assessed that the illness significantly impacted their life and emotional state. The authors demonstrate a strong link of a “negative” perception of the illness with depression and anxiety. A better understanding of the illness predicted a less severe depression and lower anxiety. Implications for practice: The results suggest that the study of illness perception holds significant potential to contribute effectively to educational and psychotherapeutic practices.
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Many individuals with social anxiety disorder (SAD) have depressive symptoms that meet criteria for major depressive disorder (MDD). In our study, we examined the temporal relationship between symptoms of social anxiety and symptoms of depression during the course of an 11-week internet-delivered cognitive behavioral treatment (ICBT) for SAD (n = 170). Specifically, we investigated whether weekly changes in social anxiety mediated changes in depression, changes in depression mediated changes in anxiety, both or neither. In addition, we compared individuals with SAD and MDD (n = 50) and individuals with SAD and no MDD (n = 120) to examine the role of MDD as a moderator of the social anxiety-depression relationship. Lower-level mediational modeling revealed that changes in social anxiety symptoms mediated changes in depression symptoms to a greater extent than vice versa. In addition, mediation among individuals with SAD and MDD was significantly greater compared to individuals with SAD and no MDD. Our findings suggest that ICBT is effective in treating individuals with SAD regardless of comorbid depression, and that focusing ICBT interventions on social anxiety can lead to significant reductions in depression among individuals with SAD.
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