Neuroethics DOI 10.1007/s12152-016-9292-5

ORIGINAL PAPER

Addressing Depression through Psychotherapy, Medication, or Social Change: An Empirical Investigation Jeffrey M. Rudski & Jessica Sperber & Deanna Ibrahim

Received: 10 August 2016 / Accepted: 18 November 2016 # Springer Science+Business Media Dordrecht 2016

Abstract Women are diagnosed with clinical depression at twice the rates as men. Treating depression through psychotherapy or medication both focus on changing an individual, rather than addressing socioecological influences or social roles. In the current study, participants read of systemic inequality contributing to differential rates of depression in either American men or women, or in two fictitious Australian First Nation groups. Participants then considered the acceptability and efficacy of treating depression through psychotherapy, medication, or social change. When socioecological inequities and unequal social roles were presented through an unfamiliar foreign lens, participants were more likely to recognize the systemic unfairness, and endorsed social change more than psychotherapy or medication as a treatment strategy. However, when identical social inequities and social roles were presented through descriptions of American men and women, social intervention was less likely to be endorsed, and psychotherapy or medication gained in acceptability. Participants of color were also more likely to recognize and endorse social change J. M. Rudski (*) : J. Sperber : D. Ibrahim Department of Psychology, Muhlenberg College, 2400 Chew Street, Allentown, PA 18104, USA e-mail: [email protected] J. Sperber e-mail: [email protected] D. Ibrahim e-mail: [email protected]

as a strategy for treating depression, while those reporting a history of psychotropic medication for affective disorders rated medication as more effective and acceptable. Keywords Depression . Psychotherapy . Social change . Antidepressants . Gender . Sex roles . Biopsychosocial approach . Sociocultural factors

The diagnostic criteria for major depression in the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V) includes depressed mood or loss of interest or pleasure, and a constellation of symptoms such as fatigue, change in weight, insomnia or hypersomnia, difficulty concentrating or making decisions, and feelings of worthlessness or guilt [1]. Women receive approximately twice as many diagnoses of depression as men, and once diagnosed they are more likely to be prescribed medication [2–5]. According to the Centers for Disease Control and Prevention, one in four American women are currently taking medication classified as an antidepressant [6]. Psychologists tend to explain depression through the biopsychosocial model. Biologically, specific genotypes, and neurotransmitter or hormonal influences have been proposed as contributors [7]. Poor coping mechanisms, rumination, distorted self-image, an external locus of control, perceptions of powerlessness, pessimism and hopelessness, temperament and affect, and other various cognitive vulnerabilities may contribute to a psychological component [8–11]. Social influences

Rudski J.M. et al.

contribute to the model in several ways. Psychosocial factors include interpersonal interactions, stigma, social relationships, residual effects from past parent–child relationships, or other family dynamics. The physiological or neurological responses associated with depression can be elicited by social stressors, reflecting biosocial influences [12]. Occasionally, social influences are broadened to include systemic contributors such as socioeconomic status (SES), although the focus often remains on how interactions between SES and social relationships, family environment, or health-impairing behavior are mediated by psychological or physiological reactions [13, 14]. Each aspect of the biopsychosocial model is used to explain gender disparities in diagnoses. For example, gender discrepancies in serotonin binding capacity in the type-2 serotonin receptor are proposed as contributors [10, 15]. Psychologically, depression has been linked to women’s disproportionate use of coping mechanisms such as rumination, objectified body consciousness, tendency to have an external locus of control, or tendency to place a greater emphasis on interpersonal relationships [10, 11, 16]. Socially, women have greater care-taking responsibilities, dual demands of work and home obligations, greater fear for their safety from sexual abuse, assault, or domestic violence— all factors that increase depression risk [17–19]. Additionally, male social roles may lower diagnostic recognition, as men are more likely to suppress emotions, or cope with depression outside the health care system or by self-medicating with alcohol [2]. Different constituencies emphasize different aspects of the biopsychosocial model. The mainstream medical establishment prioritizes biological contributions. This perspective has gained public currency, as evidenced by growing acceptability of pharmacological treatment increasing over the last two decades [20, 21]. Biological factors are also more likely to be endorsed by men or women with depression, who often claim that medicalization legitimizes their diagnosis [3, 22–24]. Psychological or psychosocial influences contributing to stress-induced etiology are also often highlighted, particularly outside the United States. Germans attributed depression to family or work-related stress much more readily than to a brain disease or heredity [25, 26]. Australians listed day-to day problems and childhood trauma as having the strongest contributions [27]. Similar emphasis of psychosocial stressors and negative

life experiences were found in samples of Canadian and Swedish respondents [28]. The perceived etiology of depression influences treatment choices. Medication is chosen to alter the putative neurochemical imbalances inherent to a biological model. Psychotherapy alters the distorted cognitions and inefficient coping strategies accompanying a psychological model. Past literature in neuroethics has often contrasted psychotherapy with medication. For example, DeGrazia [29] discusses the tension between concerns of medication circumventing the opportunity for growth and insightful developmental narratives produced by psychotherapy with the assertion that the active choice to transform oneself through medication may be construed as authentic self-creation, particularly if a person autonomously consents to such therapy. Although different, both psychotherapy and medication place depression within an individual, be it through their neurological systems, behaviors, or cognitions, possibly obscuring remedies focusing on sociocultural contributors [30]. Moreover, this internalization can persist even when broader social influences are considered. For instance, despite identifying systemic inequities faced by women, depression is still characterized as being mediated by gendered cognitive habits such as self-doubt or a sense of lacking control resulting in self-blame [31]. A d d i t i o n a l l y, t h e Bs o c i a l ^ c o m p o n e n t o f Bbiopsychosocial^ most often refers to social roles, social relationships, social interactions, or social support– not social structures [32]. On a general level, social critics claim that the anonymity and alienation found in modern life, coupled with shifts in employment, new diseases, and political uncertainty can create psychologically toxic environments that all contribute to depression. Under such conditions, emotional malaise may signal societal malaise, and psychological or pharmacological treatment may remove the impetus to address the global causes [33, 34]. As long as the victims of these toxic influences become better adjusted through medication or therapy, the urgency to address them is lost. Societal factors can perniciously target specific groups, particularly those experiencing systemic discrimination and deprivation. In investigating depression in African Americans, Hammack [9] contrasted the cognitive, biological, family stress, and biopsychosocial models with a socioecological model that emphasizes racism, discrimination, economic oppression and powerlessness. According to this model, systemic factors

Medication Therapy or Social Change for Depression

that limit the potential of African Americans to be selfactualized produce feelings of hopelessness and despair. These responses may be considered appropriate psychological reactions to a pathological society. Additionally, the racism accompanying oppression can become internalized into a person’s self-concept, leading to many of the psychological covariates of depression such as powerlessness and lack of control. Consequently, an individual’s depression reflects societal pathology, and eliminating oppression, social injustices, and inequities become appropriate strategies for treatment. Hammack’s model can be applied to women’s experiences, with sexism replacing the role of racism. Women encounter economic and social oppression. They are more likely to live in poverty, are over-represented in jobs at the lower end of the wage scale, and get paid less for equivalent work [35, 36]. Women also experience higher levels of family violence and abuse, and more family and work-related stress [2, 37]. Worell & Remer [31] propose a social status hypothesis to explain gender disparities in depression. Social factors influence individual identity development through four main platforms: the media, the workplace, the family, and the education system. Patriarchal social institutions disadvantage women in many ways, subjecting them to stress and a reduced sense of autonomy. For example, women are often subjected to workplace discrimination, or are expected to take on multiple roles such as wife, worker, and homemaker. The stressors of such circumstances can accumulate over time, contributing to a sense of learned-helplessness. Additional variables relating to sociocultural influences on depression include perceptions of sexism, incidence of discrimination, entrenched gender divisions in reproductive labor, and lack of conformity to traditional gender roles [5, 38]. Parallel to Hammack’s conjecture, women’s depression may be considered an appropriate response to pathological social structures. Neither medication nor psychotherapy addresses the socioecological or sociocultural contributors to depression [19, 38–40]. Indeed, by targeting individuals, these therapies can be construed as adjusting a person’s mood to fit cultural requirements, returning them to functioning within established social contexts and gender roles. Feminist critics have charged that such use of medication or most forms of psychotherapy (i.e., those that are individually focused) supports the status quo, preserving the social and political factors contributing to the oppression and sexism forming depression’s foundation

[5, 30, 41–43]. From this perspective, medication or psychotherapy acts as a balm, but not as a cure. The present study examined people’s recognition and acceptance of elements in the biopsychosocial model of depression, both in terms of etiology and proposed treatment. When confronted with evidence of structural sexism within one’s own culture, people can often become defensive, denying its influence to justify the social system [44, 45]. In the current study, we circumvented this defensiveness by presenting the power and experiential disparities that contribute to depression in an unfamiliar context. To accomplish this, half of the participants had the disparities found between men and women in American society presented as existing between two fictionalized Australian First Nations. We expected that participants would be able to recognize the structural inequities, and recommend socioecological remedies in the unfamiliar context.

Methods Participants Three hundred and eighty five participants (127 men, 255 women, two Bother not specified, one Bprefer not to answer^), ranging in age from 18 to 72 (M = 34.8, SD = 12.1) were recruited thorough Amazon’s Mechanical Turk. IP addresses were restricted to the United States, and the Informed Consent requested that only Americans participate. Seventy six percent of participants identified as White, 6.8% as African American, 6.8% as Asian, 4.2% as Latino, and other racial identities comprised the rest of the sample. Forty seven percent of the sample had a college degree, and an additional 41% had completed some post-secondary education. One hundred and ninety four participants reported using or having used medication for depression, and 177 reported having experience with psychotherapy, with 143 participants reporting history with both forms of treatment. Materials and Procedure After providing informed consent, participants were assigned to one of eight conditions based upon their self-reported date of birth. The study employed a mixed 2 (Cultural Context, i.e., American versus Australian as a Between Subject variable) X 4 (Causal Model of

Rudski J.M. et al.

Depression, i.e., Biological, Psychological, Sociocultural, or Biopsychosocial as a Between Subject variable) X 3 (Type of Treatment, i.e., Psychotherapy, Medication, Sociocultural modifications as a Repeated Measures variable) design. Approximately half of the participants were in the American cultural context condition. They read a brief description of women’s experience in the United States, highlighting past and continuing social and economic inequities experienced by American women (e.g., lower pay, fewer career options and opportunities for economic advantages, greater responsibilities regarding care-taking and traditional family roles, increased crime victimization). They also read of gender disparities in measures of physical and mental health, culminating with women having twice the rates of depression as men. Participants in the Australian cultural context read a parallel historical description of two fictitious groups, the Badaar and Jajaurung of Australia. The Badaar were described as better assimilating into colonial culture, resulting in social inequalities in which the Jajaurung were matched to identical socioeconomic, social roles, and crime statistics that were presented for American women. They were also informed that the Jajaurung and Badaar differ on indices of physical and mental health, with the Jajaurung having twice the rates of depression. Participants then read one of four causal models accounting for this disparity. The Biological model accounted for the difference as due to women or Jajaurung being more likely to carry a particular gene (5-HTTLPR) and greater variation of serotonin levels. The Psychological model accounted for the difference as due to women or Jajaurung experiencing more personal traumatic experiences and feelings of helplessness than men or a Badaar. The Psychosocial model explained the discrepancy as due to women’s or Jajaurung’s lower social status producing increased rates of poverty, and familial obligations producing chronic stress. Finally, the Biopsychosocial model, accounted for the difference through the contributions of all the variables described in the other conditions. After answering 3 short questions assessing comprehension of the passage, participants responded to several series of questions. First was five items adapted from the General System Justification Scale [46] that examined perceptions of inequality and opportunity for the groups

described in the passage. Sample questions include BIn general, relations between men and women are fair^ and BEveryone (Badaar or Jajaurung) has a fair shot at wealth and happiness^ Items were scored on a 1(strongly disagree) to 6 (strongly agree) Likert scale. The 5 items produced a Chronbach’s alpha of .78, and a composite BFairness^ score was calculated by averaging responses. Participants then compared pharmacological, psychotherapeutic, or widespread social changes as possible treatment strategies. Questions were adapted from the Treatment Acceptability and Effectiveness Questionnaire [47]. Items included goodness (BThis treatment is a good way to handle depression in adult Jajaurung/women^), effectiveness (BThis is an effective treatment for depression in adult Jajaurung/women^), easy way out (BBy accepting this treatment, a Jajaurung/ woman is taking the easy way out^), opportunity to flourish (BThis treatment will allow Jajaurung/women to flourish^), and discouragement of sociopolitical solutions (BThis treatment discourages us from finding social and political solutions to treating depression for Jajaurung/women^). Participants answered all give questions for each of the three treatments. Items were scored on a 1(strongly disagree) to 6 (strongly agree) Likert scale. Participants then answered two questions regarding the effectiveness of social change or medication in treating depression if utilized independently of the other strategies (1 = not at all effective to 6 = very effective). Two questions then measured whether the vignettes were believable (BIn your opinion, the text you read provided an accurate account of the topic^) or biased (BThis passage struck you as biased or inaccurate^) (1 = strongly disagree, 2 = somewhat disagree, 3 = somewhat agree, 4 = strongly agree). Before finishing, participants also provided background knowledge and experience with treatments for depression and demographic information. The study received IRB approval from Muhlenberg College, and conformed to APA standards on ethical treatment of participants.

Results Our main hypothesis was that when social inequities are presented in an unfamiliar context, participants would be more likely to value social interventions than when inequities reflect gender disparities in the United States. A series of Mixed Analyses of Variances (ANOVAs)

Medication Therapy or Social Change for Depression

with Cultural Context, Causal Model, and Treatment as the independent variables and each of the five Treatment Acceptability and Effectiveness repeatedly supported the hypothesis.

There was also a 3-way interaction between Treatment, Cultural Context, and the Causal Model for depression (F 2752 = 2.31, p = .03, ηρ2 = .02). In the Australian context, Social Change received higher ratings than psychotherapy or medication when depression was presented through the Social, Psychological, or Biopsychosocial models. However, in the American context, Social Change received the lowest ratings for those three models (Table 1, left).

Is this Treatment a Good Idea? There was general agreement that all three treatment strategies were a good way to address depression. Psychotherapy (M = 4.46, SD = 1.00) was rated highest, followed Social Change (M = 4.34, SD = 1.06) and Medication (M = 3.98, SD = 1.22), F 2, 752 = 22.76, p < .001, ηρ2 = .06. There were no main effects for the Cultural Context variable, but there was a significant Treatment by context interaction (F 2, 752 = 20.22, p < .001, ηρ2 = .05). In the Australian context, Social Change (M = 4.59, SD = .97) received the highest ratings, followed by Psychotherapy (M = 4.26, SD = 1.04) and Medication (M = 3.86, SD = 1.19). However, for the American context, Psychotherapy was rated highest (M = 4.66, SD = 0.92), followed by Medication (M = 4.09, SD = 1.25) and Social Change (M = 4.09, SD = 1.09) (Fig. 1, top left). This finding closely matches our overarching hypothesis. Good Idea

6

How Effective Is this Treatment? All three treatments scored above the midpoint in ratings of effectiveness. There was a main effect for treatment type (F 2, 754 = 6.58, p < .001, ηρ2 = .02), with Psychotherapy (M = 4.32, SD = 1.01) rated as more effective than Medication (M = 4.08, SD = 1.23) or Social Change (M = 4.08, SD = 1.20). Once again there was a Treatment by Cultural Context interaction (F 2754 = 25.91, p < .001, ηρ2 = .06). In the Australian context, Social Change was rated as most effective (M = 4.35, SD = 1.17), followed by Psychotherapy (M = 4.08, SD = 1.02) and Medication (M = 3.88, SD = 1.22). However, for the American

5

5

4

4 Australian American

3

Australian American

3

2

2

1

1 0

0 Psychotherapy

6

Effectiveness

6

Medication

Psychotherapy

Social Change

Permit Flourishing

6

Medication

Social Change

Efficacy of Individual Treatments

5

5

4

4 Australian American

3 2

2

1

1 Psychotherapy

Medication

Social Change

Australian n American

3

Medication alone

Social Change alone

Fig. 1 Summary of interactions between cultural framing (Australian versus American/Gender) and types of treatment for mean levels of agreement on whether each treatment was a good idea, would be effective, and would permit flourishing

Rudski J.M. et al. Table 1 Descriptive statistics supporting the three-way interactions between types of treatment, cultural context, and model of depression for the questions of whether a particular form of treatment is a good idea, or will allow the user to flourish Good idea Psychotherapy M (SD)

Flourish Medication M (SD)

Social Change M (SD)

Psychotherapy M (SD)

Medication M (SD)

Social Change M (SD)

Australian Biological

4.45 (.85)

4.11 (1.10)

4.30 (1.07)

3.77 (0.83)

3.50 (1.11)

4.25 (1.22)

Psychological

3.96 (1.10)

3.54 (1.32)

4.54 (.96)

3.38 (1.09)

3.00 (1.21)

4.38 (.095)

Social

4.42 (.99)

3.77(1.12)

4.75 (.84)

3.81 (1.01)

3.07 (1.20)

4.67 (1.12)

Biopsychosocial

4.26 (1.04)

3.86 (1.19)

4.77 (.97)

3.54 (1.27)

3.58 (1.24)

4.31 (1.27)

Biological

4.49 (1.00)

4.06 (1.13)

4.29 (1.14)

4.20 (0.95)

3.90 (1.17)

4.34 (1.33)

Psychological

4.49 (1.04)

4.10 (1.36)

3.82 (1.07)

4.04 (1.04)

3.59 (1.40)

4.27 (1.27)

Social

4.79 (.81)

3.96 (1.23)

3.94 (1.09)

4.09 (0.95)

3.53 (1.23)

4.19 (1.19)

Biopsychosocial

4.87 (.74)

4.26 (1.26)

4.43 (.99)

4.33 (0.93)

3.65 (1.25)

4.83 (1.10)

American/Gender

context, Psychotherapy (M = 4.56, SD = 0.93) was rated highest, followed by Medication (M = 4.28, SD = 1.21) and Social Change (M = 3.80, SD = 1.17) (Fig. 1, top right). Is this Treatment Taking the Easy Way out? Participants tended to disagree that any of the treatment strategies were a way of Btaking the easy way out^, but ratings were highest for Medication (M = 2.37, SD = 1.45), than Psychotherapy (M = 1.92, SD = 1.16) or Social change (M = 1.87, SD = 1.19), F 2, 754 = 36.76, p < .001, ηρ2 = .090. There were no significant interactions between Treatment Strategy and other independent variables. Will this Treatment Provide the Opportunity to Flourish? A strong effect was found between the different treatment strategies regarding whether it would permit a person with depression to flourish (F 2, 746 = 78.58, p < .001, ηρ2 = .17). Social Change received the highest ratings (M = 4.40, SD = 1.20), followed by Psychotherapy (M = 3.90, SD = 1.06) and Medication (M = 3.48, SD = 1.25). A small Treatment by Cultural Context interaction was observed (F 2746 = 6.85, p < .001, ηρ2 = .02). Social Change (M = 4.40, SD = 1.15)

received fairly high ratings relative to Psychotherapy (M = 3.61, SD = 1.07) or Medication (M = 3.28, SD = 1.21) in the Australian context, but in the American context, levels of agreement were more similar (Means = 4.41 (SD = 1.24), 4.16 (0.97), and 3.67 (1.26) for Social Change, Psychotherapy, and Medication, respectively) (Fig. 1, bottom left). As was the case for the first question, a 3-way interaction was found regarding Treatment Strategy by Cultural Context by Causal Model (F 6, 2 746 = 2.30, p = .03, ηρ = .02). Under Australian framing, Social Change was rated as being most likely to permit flourishing for all models, with ratings for psychotherapy and medication always scoring considerably lower. In the American framing, Social Change was still consistently rated the highest, but Psychotherapy was often rated only slightly lower (Table 1, right).

Will this Treatment Discourage Finding Social or Political Solutions for Depression? Although there was general disagreement, a large difference across treatment strategies was found (F 2, 2 752 = 55.81, p < .001, ηρ = .13). Medication was rated as the most discouraging (M = 2.90, SD = 1.59), followed by Psychotherapy (M = 2.45, SD = 1.31) and Social Change (M = 2.06, SD = 1.21).

Medication Therapy or Social Change for Depression

Effectiveness of Medication or Social Change, Independent of Other Strategies. A Mixed 2 (Medication alone versus Social Change alone) by 4 (Causal Model) by 2 (Cultural Context) ANOVA examined ratings of the efficacy of medication or social change independent of other strategies. Social Change alone (M = 4.06, SD = 1.16) was rated higher than Medication alone (M = 3.57, SD = 1.24), F 1, 2 376 = 28.07, p < .001, ηρ = .07. No main effects were obtained for Cultural Context or Causal Model, but a Context by treatment interaction was obtained, F 2 1376 = 22.81, p < .001, ηρ = .06. In the American context, Medication alone (M = 3.78, SD = 1.27) and Social Change alone (M = 3.82, SD = 1.13) received similar ratings, but in the Australian context, Social Change alone (M = 4.30, SD = 1.13) was rated much higher than Medication (M = 3.36, SD = 1.17) (Fig. 1, bottom right). Perceptions of Fairness Ratings of fairness compared with Independent Samples t-tests. Perceived fairness was significantly higher in the American (M = 3.24, SD = 1.07) than the Australian (M = 2.70, SD = 0.80) contexts, t 382 = 5.64, p < .001, d = .57. As perceived ratings of fairness of the socioecological contexts describing the histories experiences of women or the Jajaurung increased, endorsement of societal change decreased. Fairness was negatively correlated with Social Change being a good strategy (r374 = −.32, p < .001), an effective strategy (r = −.21, p < .001), provide the opportunity to flourish (r = −.32, p < .001), and positively correlated with it being a way of taking the easy way out (r = .30, p < .001). Additionally, fairness ratings were also positively correlated with Psychotherapy (r = .24. p < .001) and Medication (r = .22, p < .001) being considered a way of taking the easy way out. Correlation sizes tended to be similar in the Australian and American contexts. Participant Variables Attitudes towards the acceptability and efficacy of various treatment strategies may also be related to participant variables. Fifty one percent of participants reported using or having used medication for affective disorders, and 45% reported using or having used psychotherapy.

In addition, demographic variables such as gender (66.8% female) and racial identity (76.2% White) may covary with attitudes. A series of multiple regressions were run with Gender (Male =0, Female =1), Race (White =0, Not White =1), Medication history (Did not use Medication =0, Used Medication =1), Therapy history (No therapy =0, Therapy =1) as the predictor variables, and the questions regarding acceptability and efficacy as the criterion variables. Chi Square analyses found that women were disproportionately overrepresented in the American condition relative to men (Chi Square1 = 6.98, p = .008) so Cultural Context (Australian =0, American =1) was also entered as a predictor variable. Chi square analyses were not significant for the other participant variables. Similar to the ANOVAs reported earlier, Therapy and Medication were seen as more acceptable and effective by participants in the American/Gendered context, and Social Change more Bgood^ and Beffective^ by those in the Australian context (Table 2). Participants’ gender only predicted perceptions of treatment being Bthe easy way out^, with men having significantly higher ratings of agreement for all 3 treatments (Table 2). Non-White participants had higher ratings of therapy and medication as distracting us from addressing the real causes of depression, as well as higher ratings for social change being effective. Participants with a history of medication use viewed medication as more acceptable and effective, and less of it being an easy way out (Table 2). They also tended to have less positive attitudes towards psychotherapy, agreeing less that it will allow a person to flourish, and agreeing more that it is taking the easy way out. History of psychotherapy predicted very few attitudes. Accuracy and Bias of Vignettes Participants tended to disagree that the vignettes were biased (Australian vignette M = 2.15, SD = 0.82; American vignette M = 1.95, SD = .86) and tended to agree that vignettes were accurate (Australian M = 2.84, SD = .62; American M = 2.93, SD = .70). Accuracy and bias were negatively correlated (r = −.53, p < .001).

Discussion Women receive approximately twice as many depression diagnoses than men. When the cause of depression

Rudski J.M. et al. Table 2 Summary of multiple regressions in which the efficacy and acceptability of possible treatments for depression are predicted by participant variables such as gender, race, medication and psychotherapy history, and cultural context F5,364

R2

Cultural context

Gender

Race history

Medication history

Psychotherapy

4.52**

.06

.20**

ns

ns

-.12#

ns

Effective

5.12**

.07

.24**

ns

ns

ns

ns

Easy out

16.21**

.18

-.11*

-.09*

.24**

-.14*

-.16**

Treatment Psychotherapy Good

Flourish

7.24**

.09

.26**

ns

ns

-.16*

ns

Distraction

7.16**

.09

-.17**

ns

.16**

ns

ns

Good

7.61**

.10

.11*

ns

ns

.30**

ns

Effective

8.12**

.10

.16**

ns

ns

.28**

ns

Easy out

10.16**

.12

ns

-.14**

.09#

-.27**

ns

Flourish

3.47**

.05

.17**

ns

ns

.12#

ns

Distraction

4.27**

.06

ns

ns

.15**

-.16**

ns

Good

5.16**

.07

-.23**

ns

.10#

ns

ns

Effective

5.00**

.06

-.21**

ns

.13*

ns

ns

Easy out

11.78**

.14

ns

-.18**

.21**

ns

-.12#

Flourish

3.36**

.04

ns

ns

.11*

-.14*

.19**

Medication

Social change

Distraction

4.39**

.06

ns

-.15**

ns

ns

ns

Medication alone

4.05**

.05

.16**

ns

ns

.18**

ns

Social Change alone

4.33**

.06

-.20**

ns

.11*

ns

ns

ns not statistically significant **p < .01, *p < .05, #p < .07

is perceived to be psychological or biological, treatments such as psychotherapy or medication aim to remedy it at an individual level. However, depression can also be conceived as a reaction to external socioecological or sociocultural factors including systemic inequities in resources or power, or social oppression like sexism. These latter influences require structural social fixes—change society, and depression may not be triggered. However, cultural defensiveness can lead to denying or minimizing systemic inequities [44, 45]. To decrease potential reactance, we examined systemic inequities potentially contributing to depression not only in American culture, but also in a foreign context; some participants read of inequities between American women and men, while others read of identical inequities in the experiences of two hypothetical Australian First Nations. While there was an overall acknowledgement of the utility of social change in addressing depression, participants were significantly more likely to endorse societal modification when the systemic inequities were framed in the unfamiliar

context than when framed in an American, gendered context. Social change was rated superior to psychotherapy or medication for addressing the high rates of depression found in Australian context. Conversely, social change was perceived as the least effective strategy in reducing the relatively high rates of depression in American women. Additionally, the perceived efficacy of social change to decrease depression was negatively associated with general perceptions of societal fairness. While cultural context affected attitudes towards medication, psychotherapy, and social change, the model of depression (i.e., biological, psychological, psychosocial, or biopsychosocial) did not. We had expected that ratings for social changes might increase following psychosocial or biopsychosocial descriptions, and that endorsement of medication would increase following exposure to the biological model. Perhaps the model did not influence ratings because they were presented after participants had read about structural inequalities between the two groups, likely establishing the primacy of a socioecological or sociocultural perspective. This

Medication Therapy or Social Change for Depression

priming effect may have persisted in the Australian context, but may have been more easily overridden with the familiar American one. Such an interpretation is consistent with the 3-way interaction showing that when prior knowledge was not possible (owing to the fictitious nature of the Australian narrative), participants exposed to the social, psychological, or biopsychosocial models gave higher ratings to sociocultural remedies. However, in the American cultural framing, social change received the lowest ratings following those models. It is also possible that our participants overlooked the information presented in the different models due to high background knowledge levels. Slightly more than half of the participants had used medication, 60% had experience with either medication or psychotherapy, and an additional 11% reported such histories for a family member. This background knowledge may have diminished the power of the different narratives, with participants responding to questions according to already established beliefs. Consistent with past research, psychotherapy was rated as more acceptable and effective than medication [e.g., 48, 49]. Psychotherapy might be preferred because unlike medication, it can provide a sense of personal contribution and permits development of a personal narrative [34]. Medication may also stigmatize its user as weak or defective, clinical changes may be seen as lacking authenticity, and the whole treatment modality may be interpreted as discouraging self-work [24, 50–52]. Similar to past research, medication was rated as more effective and acceptable by participants with a medication history [53–55] and by White participants [e.g., 56–58]. Conversely, Non-White participants gave higher ratings for the effectiveness of social change. Psychotherapy and medication focus primarily on individuals, whereas social change is a more community centered [9]. Since Non-White Americans tend to be more collectivistic than White Americans [59], a collectivistic approach might resonate more with the former, although caution is required to avoid oversimplifying a White-individualistic/ NonWhite-collectivistic dichotomy. Aside from socioecological differences, the vulnerable group in our study was also described as having greater responsibilities regarding care-taking and traditional family roles. These factors also contribute to depression [31]. Social roles can also produce psychological pressure that becomes disabling. In one study,

women’s depression was exacerbated by their feeling like less of a Bgood^ woman due to difficulty living up to expectations of selflessness, self-sacrifice, other focus, cheerfulness, and productivity [60]. Social experiences can also contribute to the psychological factors involved in depression. For example, the negative uncontrollable events and greater lifetime experience of sexual violence experienced by women cause them to look for ways in which they can control their environments. This contributes to women’s tendency to ruminate, increasing incidence of depression [61]. Gender roles might even moderate systemic factors. Consider power. Job authority decreases depression in men. This should not be surprising, given that depression is often linked to powerlessness. Paradoxically, job authority increases depression in women [62]. This paradox is resolved through consideration of traditional sex roles. Women in positions of power diverge from traditional gendered scripts and expectations, resulting in critical evaluations, subtle gender discrimination, social exclusion, and more harassment than men in similar positions [43]. Thus, a proximal influence of authority gets contextualized within a pervasive system of gender roles, decreasing the risk of depression in men, but increasing its risk in women. Gender roles may also lead to underestimating depression in men. Nontraditional presentations of depression include excessive physical activities, diversion or denial of stressors, or heavy drinking match male gender roles and norms, but may be overlooked or classified as other disorders [e.g., 2, 63–65]. Interestingly, men in our study were more likely than women to rate all of the treatment options as a way of Btaking the easy way out^, a perspective consistent with the male norm of independence. This study has several methodological limitations. First, the Australian versus American conditions do not only differ with respect to familiarity, but they differ in that in one condition groups differ by gender, and in the other by culture/race. Thus, our results might indicate that structural influences and remedies are more recognized 1) in unfamiliar than familiar contexts, or 2) in cultural/racial disparities than in gender disparities. Intersectionalities between culture, gender, and race may further complicate identification of specific influences. However, regardless of interpretation, the present results clearly establish that context matters with respect to recognition of sociocultural influences on the cause of or treatment for depression. Moreover, these cultural

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contexts conspire to minimize the role of socioecological factors in causing or reversing the relatively high rates of depression in American women. Other limitations follow from our sample. Use of Mechanical Turk results in self-selection into studies. The percentage of participants reporting use of medication or psychotherapy exceeds rates found in the general population. It is quite possible that the use of keywords of Bdepression^, and Bpsychopharmacology^ in recruiting likely influenced participation. It is also well established that people with histories of depression differ regarding perceptions of the causes and appropriate treatments for depression (see above). Additionally, participants recruited through Mechanical Turk are often underemployed and less religious, but more politically liberal and educated than the general population [66]. Participants’ IP addresses were also restricted to the United States. When Castaldelli et al. [67] reviewed stigma and acceptability of medication across countries and cultures, they found substantial differences associated with biological attribution or pharmacological treatment, with American and British samples being most supportive. As described in the Introduction, participants from other countries attribute different relative weight to biological, psychological or psychosocial causes of depression. Socioecological approaches may be more favored in other countries. Finally, two thirds of our participants identified as women. While this percentage matches the gender disparity in diagnoses, men and women may vary on attitudes towards the causal models or treatment options, although these latter concerns are minimized by our finding very few statistically significant interactions found between gender and the other independent variables. The present study utilized third person vignettes to assess treatment acceptance, which may or may not match personal choices. For example, support for medications is reported to be lower when people consider taking a pill themselves than when they weigh medication for an acquaintance, family member, or hypothetical other [24]. Participants may have also held different conceptions of the ease with which social change may be possible across the difference conditions. Mitigating discrimination in an unfamiliar, alien society may seem considerably simpler than overcoming known and identifiable institutional obstacles and entrenched forces that disempower familiar groups within the United States. Such differences in perceived ease of social transformation may then influence treatment acceptance.

Despite this paper’s focus on socioecological factors, the commonly utilized approaches of psychotherapy or medication are still valuable for particular individuals, lest we risk dismissing their distress [5]. While there are some who doubt medication’s efficacy [68], most practitioners and researchers believe that medication and psychotherapy generally provide legitimate benefits [12, 69]. Medication has been described as acting like a safety net, allowing a person to cope with daily experiences [52]. Additionally, medication does not always have to be construed as anti-feminist; it can be interpreted as benefitting women if it increases energy, resilience, or the confidence to assist in political or personal change [51]. Additionally, the active choice to transform oneself through medication may also be construed as an authentic form of self-creation, particularly if a person autonomously consents to such therapy. Just because a root cause of depression may be socio-ecological, it does not preclude person-centered approaches such as medication or psychotherapy as potential remedies. However, if medication results in acquiescence to deleterious situations such as abusive relationships or environments, discourages the process of self-discovery, reduces autonomy, or leads to self-objectification, it harms women. Moreover, benefits of medication may be short-lived if underlying structural issues are left unaddressed. The hope and optimism accompanying early improvements following antidepressant regimens can change into disillusionment with the drug’s impotence in addressing structural contributors [e.g., 70, 71]. The role for psychotherapy in treatment should not be overlooked. Most cases of depression follow personally stressful life events relating to loss, social rejection, or disempowerment [72]. Learning new coping mechanisms, or altering one’s physiological responses to setbacks or stressors can be therapeutic in such instances, even when these treatments are individual focused. Moreover, the present study did not provide a distinction between different types of psychotherapy. Not every form of therapy is purely individually focused. Feminist therapies can also be incorporated to address social influences on depression. For example, Empowerment Feminist Therapy (EFT) treats clients in consideration of their sociocultural standing. EFT aims to make patients conscious members of society by encouraging them to work toward institutional changes, training them to reframe

Medication Therapy or Social Change for Depression

social situations by analyzing the influences of power and gender roles in daily experiences [31]. In sum, we found that when socioecological and sociocultural inequities contributing to depression were presented through an unfamiliar foreign lens, participants were more likely to recognize the systemic unfairness, and also endorsed social change more than psychotherapy or medication as a treatment strategy. However, when identical social inequities were present in American men and women, the preferences reversed— social strategies were less likely to be endorsed, and psychotherapy or medication gained in acceptability. Socioecological strategies for depression should not be overlooked in addressing depression. Diagnostic rates are lower in women living in States that provide more economic autonomy and reproductive rights, and societies where gender roles are equally valued have fewer gender differences in diagnoses [73, 74]. Given the well-established links between poverty, inequality, and discrimination with psychological well being, efforts focusing on public policy that diminish economic hardship and discrimination should be central to our efforts in treating depression [75]. Medication or psychotherapy can alter an individual person’s synapses or coping strategies, but in many cases, effective social changes may render these interventions unnecessary [11]. Compliance with Ethical Standards Conflict of Interest conflict of interest.

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The authors declare that they have no

Human Studies All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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14. Informed Consent Informed consent was obtained from all individual participants included in the study. 15.

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