Framing depression as a functional signal rather than a disease promotes hope and reduces stigma, study finds

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New research reveals that individuals seeking depression treatment may benefit from an explanation of depression as serving an important human function, as opposed to a disease arising from genetic and environmental risk factors.

The study, published by Hans Schroder and colleagues in Social Science & Medicine, investigates the effects of different messages of depression aetiology on participants’ beliefs about depression, attitudes toward treatment, and self-stigma. Findings from the randomized controlled trial indicate that the message invoking the language of depression as serving an important function leads to more adaptive beliefs about depression and lower levels of self-stigma.

Messages that describe the chemical and genetic basis of depression, such as the disproven serotonin imbalance theory, have dominated clinical, public health, and popular discourses since the 1960s. Authors of the present research highlight multiple movements that have contributed to the pervasive popularity of biogenetic messages about depression, including direct-to-consumer advertising from pharmaceutical companies marketing SSRIs, public health campaigns showcasing depression as a medical disorder necessitating treatment, and technological advancements in research investigating the neuroscientific and genetic bases of mental health.

Researchers highlight a multitude of unintended iatrogenic consequences of biogenetic explanations of depression, including the implicit activation of biases and stigmatizing attitudes:

“For instance, biogenetic explanations exacerbate other forms of stigma, including reduced hope for recovery (prognostic pessimism), increased perceived dangerousness, and a greater desire to keep distance from those who suffer from mental health problems,” the authors write.
“Two studies of psychiatric patients in treatment show that biogenetic beliefs are uniquely related to poorer expectations… Experientially, invoking genetic and biochemical language undermines important aspects of recovery, including worsening some forms of stigma and reducing hope, curiosity, and introspection.”

When we learn that a certain behaviour or trait is linked to genetics or brain biology, we often fall into a thinking pattern known as genetic essentialism. This is the idea that the behaviour or trait comes from a hidden, fixed, and unchangeable core within a person. This way of thinking influences how we see things, like whether we believe a person’s behaviour can be changed. Such beliefs can also make us put people with depression in a separate group. This can lead to an “us versus them” mindset among patients, the general public, and healthcare professionals, making people more likely to stigmatize those with depression.

The biopsychosocial (BPS) model of depression is one alternative framing of depression that describes it as arising from the interaction of biological, environmental, and psychological risk factors. While this model is gaining popularity in clinical settings, it continues to emphasize the importance of genetics and, in doing so, may, at times, undermine the social and psychological components of depression.

Schroder and colleagues draw upon evolutionary-based perspectives and evidence from epidemiological data and social cognition research to support an alternative message that depression serves an important function.

The authors suggest that focusing on messages highlighting how traits, emotions, and skills can change and adapt helps people build resilience. This comes from research into how we think socially, which has identified some beliefs that help us adjust our attitudes and keep motivated when dealing with stress and challenges.

These ideas are especially noticeable when we look at ‘growth and stress mindsets.’ A ‘growth mindset’ is when someone believes personal qualities can be developed, not just stuck the way they are. A ‘stress mindset’ is when someone believes that stress can actually have some positive effects.

In their research, the authors found two main things. First, they discovered that people who believe that emotions can change and are helpful show differences in their symptoms, how they manage their feelings, and their choices for treatment. Second, when people are given messages encouraging them to see traits as changeable and valuable, it can lead to better mental health.

In this first attempt to examine the impact of the message of depression as a functional signal, 1698 individuals with a self-reported history of depression but no treatment history (i.e., no prescribed medication or psychotherapy attendance) were recruited via an online market-research firm and enrolled in a randomized, controlled simulation trial.

All participants were asked to imagine attending an initial telehealth appointment with a clinical psychologist for depression treatment. Participants were then shown a series of videos. All participants viewed the same initial video introducing the psychologist and describing the symptoms of depression.

Then, participants were randomly assigned to view three additional videos further explaining the aetiology of depression as either a functional signal alerting an individual that something in their life needs attention (Signal condition) or a disease similar to cancer or diabetes resulting from the interplay of behavioural, environmental, and biological risk factors (Biopsychosocial Risk Factor; BPS-RS condition).

Lastly, all participants watched the same final video describing their depression treatment options. After viewing the videos, participants completed measures to assess their beliefs about depression, treatment-seeking attitudes, and self-stigma.

Participants’ data were excluded from analysis if they did not pass necessary attention checks to ensure that they watched all videos or if they completed surveys in less than 5 minutes. Therefore, the final sample included in the analysis consisted of 877 participants: 432 in the Signal Condition and 445 in the Biopsychosocial Condition. The sample was predominantly (71.2%) White or European American, and the majority (63%) female.

Videos in both conditions were closely matched across multiple elements (i.e., introductory and closing video, actors, video duration, sentence structure, and reading level). Additionally, given previous literature showcasing that biogenetic explanations of depression may be correlated with decreased patient self-blame, videos in both conditions included explicit statements of “depression is not your fault.”

Results of the present study indicate that participants in the Signal condition endorsed greater depression offset efficacy (i.e., sense of autonomy and agency in overcoming their depression), less self-stigma, and more adaptive beliefs about depression (e.g., “Experiencing depression can lead to new insights”) compared to participants in the BPS-RS condition. There were no significant differences between the two conditions regarding participant growth mindset, feelings of personal responsibility for depression onset, or attitudes toward depression treatment.

Researchers conducted follow-up exploratory analyses to examine whether the intervention had any differential impacts on male and female participants. Results indicated that amongst male participants alone, conditions differed only on the adaptive beliefs about depression measure, such that those in the Signal condition endorsed more adaptive beliefs than those in the BPS-RS condition.

However, amongst female participants alone, four measures were significantly different across conditions, suggesting that depression offset efficacy, growth mindset, and adaptive beliefs were higher, and self-stigma was lower amongst women after undergoing the Signal condition. Consistent with full sample results, there were no differences amongst women in the two conditions on measures of treatment attitudes and depression onset responsibility.

Exploratory gender analyses suggest that the Signal intervention had a stronger impact on female participants than on males. Authors suggest that women may be more receptive to the signal framing of depression as a welcome counterpoint to pervasive biogenetic messages that essentialize depression as inherently tied to female bodily experiences (e.g., menopause, childbirth, hormonal changes).

Findings from the present study provide preliminary support for the notion that a functional framing of depression may be preferable over the traditional disease-based biopsychosocial approach. Results point to the positive impact of a functional framing on enhancing one’s sense of agency in autonomy in overcoming depression without simultaneously increasing a sense of personal responsibility or self-blame. Moreover, findings suggest that public health campaigns aimed at reducing stigma may be more effective if they present depression as a normal, functional aspect of the human experience rather than a medical disorder.

The authors note the need for future research to expand upon present findings by exploring how signal-based messages about depression vary by sociocultural characteristics not captured or analyzed in the present study, including gender identity, race, ethnicity, socioeconomic status, and sexual orientation.

The present study was the first to test the novel framing of depression as a functional signal rather than a disease in a randomized controlled trial. While preliminary findings show promise in the impact of the alternative frame on reducing self-stigma, promoting a greater sense of agency in overcoming depression, and increasing adaptive beliefs about depression, more longitudinal research is needed to determine whether these positive outcomes persist over time.

Researchers leverage the present study findings to advocate for more expansive and nuanced approaches to discussing the causes and treatment of depression and to developing public policies:

“From a public health perspective, viewing depression as a signal, rather than a biogenetic disease, may spur a call to action for more funding for preventive actions that deter the signal of depression from occurring in the first place. Of note, despite increases in psychotropic medication usage, the prevalence of depression has not reduced, and in some circumstances, has increased over the last several decades.”
“Implementing policies designed to address income inequality and racial disparities in achievement, housing, and employment would most certainly reduce depression rates in meaningful ways, particularly if depression is viewed as a disease of modernity. Viewing depression as a functional way for the body to face unsustainable environmental stressors may also encourage agencies such as the NIMH to direct some of their funding to these larger-scale issues.”

The present study extends previous literature that has demonstrated that patients who adopt biogenetic theories to explain their depression are more pessimistic and self-blaming and have worse depression outcomes. The current research findings suggest that framing depression as a functional part of the human experience may be a welcome antidote that promotes hope and reduces stigma.

 

 

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Schroder, H. S., Devendorf, A., & Zikmund-Fisher, B. J. (2023). Framing depression as a functional signal, not a disease: Rationale and initial randomized controlled trial. Social Science & Medicine, 115995. (Link)

Editor’s Note: Part of MITUK’s core mission is to present a scientific critique of the existing paradigm of care. Each week we will be republishing Mad in America’s latest blog on the evidence supporting the need for radical change.

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Julia Lejeune is a Clinical Psychology doctoral student at the University of Illinois at Chicago, studying the social and contextual factors that shape youth mental health and pathways to care. She is particularly interested in understanding how various youth-serving institutions, like schools or psychiatric services, approach neurodiversity and suicidality in young people. Julia hopes to use participatory action research and mixed methods to center youth narratives as guides in developing new systems of care.