Dyadic Relationship Provides Important Context in Antidepressant Treatment Evaluation

 

In part 3 of this video, Vladimir Maletic, MD, MS, clinical professor of neuropsychiatry and behavioral science, University of South Caroline, Greenville, and Bernadette DeMuri-Maletic, MD, medical director of Associated Mental Health Consultants and the TMS center of Wisconsin, Milwaukee, discuss the role relationships play in prevention psychiatry, the impact dyadic relationships have on the treatment of major depressive disorder (MDD), and the effect social adaptation has in antidepressant choice.

The pair recently co-presented a session titled "Love and loneliness in the time of COVID-19: clinical relevance of relationships" at Psych Congress 2021 in San Antonio, Texas.

In the previous part 1, Dr Maletic, who is also Psych Congress Network’s attention-deficit/hyperactivity disorder (ADHD) Section Editor, and Dr DeMuri-Maletic, explore the effects of social relationships, including loneliness and isolation, on the brain and the body.

In part 2, they reviewed the impact of loneliness on general health, including disease development such as depression or Alzhiemer, and the brain-body impact of marital connections.


Read the transcript:

Bernadette DeMuri‑Maletic, MD:  Vlad, what role do social relationships play in prevention in psychiatry?

Vladimir Maletic, MD, MS:  It's a really interesting question. Looking at some of the more contemporary treatment guidelines, they think about social relationships, not only in terms of etiology. It is one of the recognized etiological factors in rural New Zealand and Australia treatment guidelines for major depressive disorder.

Social relationships are one of the etiological factors. It is also a focus of intervention. Along with making sure that our patients sleep enough, and that they have good nutrition, that they exercise enough. There's also an element thereof recognizing that enhancing the quality of social relationships is an important factor in treatment.

You have asked something that is even better. That is social relationships and their role in preventing major depressive disorder. There was a large, large meta‑analysis. Tens of thousands of patients were included here. 100,000 patients from biobank data. They looked at 100 different factors.

Here's what they found. Frequency of confiding in others is one of the major factors in preventing onset of depression. There are implications to that. The assumption is that confiding in others is confiding in context with meaningful relationships. It's somebody we trust, somebody we feel comfortable sharing very personal information.

I've seen it in my life. When I'm close enough to somebody, and that's part of our relationship, to talk about something that is very deep and personal, it clearly has value. Confiding in somebody is not people sitting next to somebody in a bar on Friday night and displaying emotional incontinence. That's not it.

This is having close connection with somebody. Frequency of visits with family or friends, is on that list, along with exercise. What you have pointed out is actually good because intervention can encompass both of those.

If one exercise in a group, not only is there a greater chance that they will create friends but there's physical exercise as a positive factor in addressing some of the depressive symptomatology. Indeed, it is something that is very important, and unfortunately, often neglected.

Bernadette:  How about dyadic relationships? How do they impact our treatment of major depressive disorder?

Vladimir:  Another aspect of treatment of depression that has been sorely neglected. Many times, we're so pressured by limited time with our patients that we will focus on their symptom list, that we'll focus on doses of medications.

We'll be immediately thinking about, can we increase this medicine or that medicine, or create a new combination of medications? We don't ask about their dyadic function. It is very interesting because there was a stat study that took this into account.

This is a moderate‑sized study. It made a comparison between a cognitive‑behavioral type of psychotherapy using an antidepressant, which was nefazodone in combination. How will it influence the outcome of the study?

Of course, the finding was that cognitive‑behavioral analysis system of psychotherapy was beneficial, as were medications. A combination of the 2 seemed to be most effective in ameliorating symptoms of depression.

Then, there was another layer in the study. They looked at dyadic functioning. The ones who had mostly discord and the ones who had good dyadic relationships. This was above and below the median that was assessed using the standardized instrument.

Here was the finding. Individuals who had good relationships compared to ones who had poor relationships had double remission rates.

Bernadette:  Wow.

Vladimir:  When we look at comparisons between antidepressants, and even antidepressant versus placebo, there is nothing there that will double the remission rate. Yet the difference between poor dyadic functioning and good dyadic functioning is double the remission rate.

That is something that is very rarely addressed in the context of a brief appointment in evaluation. It gives us a very clear suggestion. That while antidepressants may work for depression, antidepressants are rarely a solution for bad relationships.

Therefore, having in mind what dyadic relationship is provides very important context in which to evaluate success of antidepressant treatment.

Bernadette:  Very interesting. Very applicable to our everyday practice, where we can refer out for marital therapy or family therapy to try to improve the quality of the relationships of the people we treat.

Bernadette:  Does social adaptation play any role in the choice of an antidepressant?

Vladimir:  It may sound like a really odd question. There are studies suggesting that social elements are important even in choice of antidepressants.

There are several studies that have compared efficacy of agents that boost norepinephrine. Norepinephrine reuptake inhibiting medications, and SNRIs, serotonin‑norepinephrine reuptake inhibiting agents comparing them to SSRIs, medicines that only boost serotonin.

Here is the finding. When it comes to overall improvement in social functioning in context of depression, and improvement in depression scores in individuals who have challenges when it comes to their social functioning, it seems that the medicines that are capable of enhancing norepinephrine have a substantial advantage in improving social adaptation.

This is social adaptation self‑rated scale. Norepinephrine boosting agents were superior to SSRIs in that respect. Another study that I mentioned compared an SNRI to an SSRI. It looked at two components that were important.

One of these components had to do with psychomotor retardation. Individuals who had prominent psychomotor retardation ‑‑ so on HAM‑D item eight, they had scores of three or four. Use of agent that also increased norepinephrine in addition to serotonin was associated with significantly greater improvement in psychomotor retardation‑related symptomatology.

The other part that was also interesting is not only the presence of norepinephrine modulating agent help with social adaptation, it also reduced psychomotor retardation.

These were counter correlated, which does make sense because, from neuroimaging studies, we are recognizing that we have been neglecting something that is called somatomotor or sensory‑motor network in the brain.

Those are interconnected brain areas that do include basal ganglia, thalamus, motor cortices, premotor, supplemental motor area, as well as sensory cortices.

Interestingly enough, norepinephrine has a lot to do with functioning of this network. More recent studies have found that this function of sensory‑motor network is the most reliable and replicated finding in neuroimaging studies of depression.

It appears that there is a relationship between sensory‑motor network functioning, as in being active and being in tune with environmental cues, including social cues, and improvement in social adaptation. Both are highly correlated with better outcomes and treatment of depression.

Bernadette:  Vlad, it's been great talking with you and working with you on this presentation about the importance of social relationships and their impact on our physical health and our mental health.

Vladimir:  Thank you very much. You have had some important things to the part about the importance of social relationships, especially in the concept of COVID‑19 pandemic. Thank you very much for joining us today.