Psychotherapy, Antidepressants, and Combined Treatment for Depression: A Network Meta-Analysis on Social Functioning Outcomes.

INTRODUCTION

Social functioning is a key component of recovery in depression, yet most research on first-line treatments focuses on symptom reduction, and comparative evidence on social functioning is limited. We aimed to evaluate the comparative effects of psychotherapy, antidepressant medication, and their combination on social functioning in adults with major depression.

METHODS

We conducted a systematic review and network meta-analysis of randomized controlled trials up to May 1, 2025. Eligible trials compared psychotherapy, antidepressant medication, combined treatment, and control conditions (placebo, care as usual, waitlist, or no/minimal treatment) in adults with major depression. Effects were calculated as standardized mean differences (SMDs) in social functioning instruments (e.g., Sheehan Disability Scale) at posttreatment (mean 12 weeks) and follow-up (mean 32 weeks). Random effects models were used. We assessed risk of bias and conducted sensitivity analyses. Certainty of evidence was evaluated using CINeMA.

RESULTS

Of 490 identified trials, 94 (19%; 23,874 participants) reported social functioning and were included. All active treatments outperformed control conditions. Effects varied substantially by control condition type, with waitlist comparisons yielding the largest estimates and comparisons against placebo or care as usual yielding more conservative effects. Combined psychotherapy and pharmacotherapy showed the largest effects versus placebo at posttreatment (SMD 0.75, 95% CI: 0.57-0.94) and follow-up (1.08, 0.62-1.54). Psychotherapy and pharmacotherapy did not differ at posttreatment (SMD 0.10, 95% CI: -0.05 to 0.25) or follow-up (0.27, 95% CI: 0.00-0.54). Certainty of the evidence ranged from moderate to low.

CONCLUSION

First-line depression treatments support not only symptom reduction but also meaningful participation in daily life. However, only one-fifth of trials assessed this outcome, highlighting the need to better integrate patient-valued outcomes into future trials.