Conclusion
The symptoms that constitute the noradrenergic symptom cluster are those that play an important role in social dysfunction. There is a suggestion that antidepressants activating NE neurotransmission may improve social functioning more rapidly and/or to a greater extent than those acting exclusively on 5-HT function.43 The efficacy of reboxetine in the recovery of social function compared with SSRIs is compatible with the importance of noradrenergic deficit in social dysfunction. If this is indeed true, SNRIs would also be expected to be particularly effective in improving social functioning.
Milnacipran is the most noradrenergic SNRI in terms of its selectivity for the NE transporter and 5-HT transporter. It has been shown to have positive effects on concentration and retardation. This latter effect has been shown to be significantly greater than with paroxetine. Among the SNRIs, milnacipran might therefore be expected to be particularly effective in reducing social dysfunction associated with depression. Evidence, which is still incomplete, suggests that milnacipran may improve social function in depressed patients. Although the effects on depressive symptoms and social dysfunction are correlated, improvement in social function appears to have a slower time course than improvement of other depressive symptoms.
The studies that are currently available are all small, and many of them are not comparative. This is a clear limitation of support for the hypothesis. Although there is a first indication that milnacipran may possibly produce a greater improvement of social function than paroxetine, the question is still open. Clearly, the studies need to be replicated in a controlled and comparative environment. In addition, the interesting question of the potential positive interaction between psychotherapy and pharmacotherapy in the improvement of social function needs to be addressed.
Social dysfunction is one of the most important factors affecting quality of life of depressed patients, and it is possibly of even greater importance in the treatment of elderly patients suffering from major depression. For the patient to recover fully from the effects of depression, it is important to have not only full and sustained relief from the classical symptoms of depression but also a complete recovery of the ability to interact with friends and other individuals in the family and work environment. The enhancement of social functioning should thus be considered a major therapeutic goal in the management of depression.