Effects of family cognitive therapy on aggressive behavior, family functioning, and marital quality in patients with major depression

Abstract

BACKGROUND

Depression is a prevalent mental health disorder with significant impacts on individuals and families. We hypothesize that combining family cognitive therapy (FCT) with pharmacotherapy will be more effective in managing depression and improving family dynamics than pharmacotherapy alone.

AIM

To investigate the effects of FCT combined with sertraline on depression, aggressive behavior, and family functioning in patients with major depressive disorder (MDD).

METHODS

This study involved 178 patients diagnosed with MDD at the Shaoxing 7th People's Hospital from January 2022 to April 2024. Patients were divided into two groups according to whether they received FCT. FCT included both patient-focused cognitive therapy and family-focused psychological guidance over a 12-week period.

RESULTS

The observation group receiving combined treatment showed significantly greater reductions in depressive symptoms (Beck Depression Inventory scores: 27.4 ± 4.7 to 18.6 ± 5.2) compared to the control group (28.1 ± 5.5 to 20.9 ± 4.9), with P = 0.031 for the difference between groups. Improvements in family functioning and marital quality were also observed, with P < 0.001 for key dimensions on the Family Assessment Device and Enrich Marital Scale.

CONCLUSION

The combination of FCT with sertraline effectively reduces depressive symptoms and improves family dynamics in patients with MDD.

Key Words: Major depressive disorder; Family cognitive therapy; Depressive symptoms; Aggressive behavior; Marital quality

Core Tip: The study innovatively combines family cognitive therapy with sertraline for major depressive disorder (MDD), emphasizing the importance of family involvement in treatment. This approach not only targets depressive symptoms but also aims to improve family dynamics and marital quality, providing a holistic strategy for managing MDD and its broader impacts.

INTRODUCTION

Depression, a prevalent mental health disorder, has been recognized as a significant public health issue due to its debilitating impact on individuals and their families[1]. It is a complex condition that not only affects emotions but also extends to cognitive and physiological aspects, significantly impairing quality of life[2]. The emergence of psychotherapy as a treatment modality, with efficacy comparable to pharmacological treatments, underscores its importance in the management of depression[3]. Among various psychological treatments, cognitive behavioral therapy has emerged as a frontline approach, focusing on altering negative thought patterns and behaviors that contribute to depressive symptoms[4].

Major depressive disorder (MDD), a severe form of depression, poses a considerable challenge to global public health. It is characterized by a combination of mental, emotional, and physiological abnormalities, which can lead to aggressive behaviors in severe cases, impacting the individual, their family, and society at large[5]. The etiology of MDD is multifaceted, involving genetic predisposition, psychological stress, work pressure, physiological status, and the social environment[6]. It is crucial in clinical practice to address not only the alleviation of primary symptoms but also the prevention and management of aggressive behaviors[7]. Current treatment approaches for MDD often center on medication and general psychotherapy, with family therapy being an underutilized yet essential component. Family dynamics play a significant role in the development and progression of depression, with deficits in family functioning contributing to the onset and perpetuation of the illness[8]. Integrating family therapy into the treatment plan can enhance the family's understanding of depression, improve their cooperation with the treatment process, and strengthen the patient's sense of responsibility and role within the family, thereby optimizing the restoration of the patient's family and social functions[9].

Family cognitive therapy (FCT), in particular, offers a promising alternative or adjunct to standard treatments, focusing on problem-solving and emotional regulation to alleviate negative psychological states and reduce aggressive behaviors[10]. The relationship between aggressive behavior and depression is well established, with aggression playing a significant role in the progression of the disease[11]. Given the severe consequences of aggressive behavior on the family and society, it is imperative to predict, identify, and effectively manage aggressive and violent behaviors in individuals with mental illnesses[12]. Previous studies have shown that antidepressant treatment can significantly reduce anger outbursts, with 53% to 71% of such outbursts disappearing in outpatients with depression treated with medications such as fluoxetine, sertraline, and imipramine[13]. The serotonergic neurotransmitter system, involved in regulating aggressive behaviors in humans and animals, suggests that selective serotonin reuptake inhibitors such as sertraline may effectively alleviate the anger and aggressive behaviors associated with depression[14].

However, research on aggressive behaviors in Chinese patients with depression remains limited due to cultural and demographic differences across countries. International studies have demonstrated the applicability of systematic family psychotherapies for patients with depression, improving their social skills and psychological well-being[15]. FCT, in particular, employs various psychological techniques such as problem-solving training and emotional control, which could potentially reduce anger and aggressive behaviors in patients with depression.

In light of these findings, the present study investigated the effects of FCT on aggressive behavior, family functioning, and marital quality in patients with major depression. By doing so, we aim to contribute to a more holistic approach to treatment that addresses not only the individual's mental health but also the dynamics of their family environment, offering insights into the potential of FCT as a valuable component in the comprehensive management of depression and its impact on family dynamics.

MATERIALS AND METHODS

Participant selection and grouping

The study was conducted at the Shaoxing 7^th People's Hospital from January 2022 to April 2024. A total of 178 patients diagnosed with MDD were selected as subjects. This study was approved by the Shaoxing 7^th People's Hospital Medical Ethics Committee (Approval No. 2024-022-01). Patients were divided into two groups according to whether they received FCT, specifically as the control group with 88 cases and the observation group with 90 cases. The demographic details of the participants are as follows.

Control group: 39 males and 49 females, aged between 21 years and 56 years, with an average age of 38.95 ± 2.33 years, and illness duration ranging from 2 months to 12 months, averaging 7.84 ± 0.33 months. The control group included 209 family members, consisting of 123 parents and 86 spouses, with 88 males and 121 females, aged between 40.23 ± 2.67 years, and varying educational backgrounds from primary school to university.

Observation group: 39 males and 51 females, aged between 22 years and 56 years, with an average age of 39.01 ± 2.35 years, and illness duration ranging from 3 months to 13 months, averaging 7.88 ± 0.31 months. The observation group included 213 family members, consisting of 125 parents and 88 spouses, with 88 males and 65 females, aged between 41.23 ± 2.13 years, and educational backgrounds from primary school to university.

Inclusion and exclusion criteria

The inclusion criteria for the study were as follows: (1) Confirmed diagnosis of MDD, meeting the standards of the International Consensus Statement on MDD[15]; (2) Presence of aggressive behavior at the onset of the disease; and (3) Not receiving medication.

The exclusion criteria were: (1) Age greater than 60 years; (2) Use of antidepressant medication within the past month; (3) Severe suicidal tendencies or behaviors; (4) Concurrent other psychiatric or psychological disorders; or (5) Withdrawal from the study midway or loss of follow-up information.

Control group

The control group received a medication-only treatment protocol. The medication used was sertraline, produced by Sichuan Baicao Bio-Pharmaceutical Co., Ltd. (Sichuan, China), with batch numbers 100702-201602 and national drug approval number H20070179, in a dosage form of 50 mg per tablet, with a pack containing 28 tablets. The medication was dispensed by the pharmacy only upon presentation of a prescription from a psychiatrist. Prior to medication administration, face-to-face communication was conducted to explain the therapeutic effects, potential adverse reactions, and other relevant information to the patient and their family. The initial dosage of sertraline was 50 mg per day, with the dosage adjusted based on the patient's condition, typically increasing to 100 mg per day, with a maximum dosage of 150 mg per day. After seven consecutive days of treatment, the attending psychiatrist reviewed the patient's medication adherence, condition, and any adverse reactions before prescribing the next phase of treatment. This medication was carried out for a total of 12 weeks.

Observation group

In addition to the medication protocol, which was identical to that for the control group, the observation group also received FCT. FCT treatment was tailored to the patient's specific condition and included two main components: Patient-focused and family-focused treatments.

Patient cognitive therapy: This component aimed to provide cognitive correction to help patients recognize normal cognitive behavioral states and included training in problem-solving and emotional control. The specific techniques are described below.

(1) Cognitive restructuring: Assisting patients in identifying negative self-evaluations and distorted thinking patterns, helping them reassess their views of themselves and the world to reduce triggers for aggressive behavior.

(2) Emotional regulation: Teaching patients to better recognize and manage their emotions to reduce the occurrence of aggressive outbursts.

(3) Problem-solving skills: Helping patients learn effective problem-solving skills to cope with life's challenges in a more positive and constructive manner.

(4) Situational exposure: Gradually exposing patients to situations that can trigger aggressive behavior, helping them adapt and learn more appropriate responses.

And (5) Behavioral activity adjustment: Encouraging patients to engage in positive behavioral activities to improve their mood and reduce opportunities for aggressive behavior.

FCT: This component provided psychological guidance to family members to help them correctly understand the basic conditions of MDD and correct past misconceptions about the condition, enabling them to provide more psychological and family support. The techniques included:

(1) Education and information sharing: Providing education about the patient's psychological disorder, including symptoms, triggers, and treatment methods.

(2) Emotional support: Offering support through listening, understanding, and expressing emotions to alleviate the patient's feelings of loneliness and anxiety.

(3) Positive communication: Learning positive communication skills such as listening, expressing concern, and avoiding criticism.

(4) Emotional management: Learning to effectively manage their own emotions to avoid excessive emotional reactions when interacting with the patient.

(5) Problem-solving skills: Learning to work together to solve problems related to the patient, including developing coping strategies and setting goals.

(6) Setting boundaries: Learning to set their own boundaries while supporting the patient to avoid over-sacrificing their own needs and health.

(7) Positive reinforcement: Using encouragement and praise to reinforce the patient's positive behaviors and efforts, helping to boost their self-esteem and confidence.

(8) Shared goal setting: Setting shared recovery goals with the patient, working together, and providing support to achieve these goals.

(9) Coping strategies: Learning strategies to cope with the patient's emotional fluctuations and behavioral issues to reduce tension and conflict.

And (10) Remodeling family interactions: Helping family members reshape the patterns of interaction within the family to create an environment more conducive to the patient's recovery.

The FCT was structured to begin with 10 sessions during the acute phase of the patient's condition, with each session lasting 45-50 minutes and occurring once a week. After the initial 10 sessions, the frequency was reduced to once a month for three continuation sessions. The treatment was designed to be flexible and responsive to the needs of both the patient and the family, with the goal of improving the patient's cognitive and emotional functioning and enhancing the family's ability to support the patient's recovery process.

Assessment of outcomes

The efficacy and psychological impact of the treatment were evaluated using a battery of standardized and validated instruments.

Depressive symptom assessment: The Beck Depression Inventory (BDI) was utilized to quantify the severity of depressive symptoms. This 13-item inventory ranges from 0 to 39, with higher scores indicating more severe depressive symptoms. The categorization of scores is as follows: 0-4: Minimal or no depressive symptoms; 5-13: Mild depression; 14-20: Moderate depression; 21-39: Severe depression.

Psychological state evaluation: The Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) were employed to assess the psychological state of the participants. Both scales are scored out of 100, with critical values set at 50 for SAS and 53 for SDS. Scores exceeding these thresholds indicate the presence of anxiety or depressive symptoms, respectively.

Assessment of aggressive behavior: The State-Trait Anger Expression Inventory-2 (STAXI-2) was used to evaluate changes in aggressive behaviors. This inventory assesses multiple facets of anger and aggression, with scores ranging from 0 to 20 for each dimension, where higher scores reflect increased aggressive behaviors.

Family functioning and marital quality assessment: The Family Assessment Device (FAD) and the Enrich Marital Scale were applied to assess family functioning and marital quality. The FAD comprises seven subscales: Problem-solving, communication, roles, affective responsiveness, affective involvement, behavior control, and a total score. The Enrich Marital Scale evaluates 12 dimensions of marital quality such as satisfaction, leisure activities, role equality, and personality compatibility.

Statistical analysis

Data analyses were conducted using SPSS version 27.0 (IBM Corp., Armonk, NY, United States). Descriptive statistics were used to summarize demographic and baseline characteristics. The normality of data distribution was assessed, and appropriate statistical tests were selected based on the data type and distribution. Categorical data are presented as frequencies (n) and percentages (%), and group comparisons were performed using the χ² test. Continuous data are presented as the mean ± SD. The independent samples t-test was used for normally distributed continuous data to compare the means between groups, while the non-parametric Mann-Whitney U test was used for data not meeting normality assumptions. The significance level was set at P < 0.05, indicating that the observed differences were statistically significant and not attributable to chance. All statistical tests were two-tailed, and confidence intervals were set at 95%.

RESULTS

Comparison of depressive symptoms pre- and post-treatment

The comparative analysis of depressive symptoms between the observation and control groups revealed no statistically significant difference in the mean BDI scores at baseline (t = 0.670, P = 0.505). Following the 12-week treatment period, the observation group and control group exhibited a significant reduction in BDI scores compared to pre-treatment levels (P = 0.014 and P = 0.009, respectively), indicating an improvement in depressive symptoms. Notably, the observation group demonstrated a significantly greater reduction in BDI scores compared to the control group, with a mean difference that reached statistical significance (t = 2.188, P = 0.031), suggesting the efficacy of the combined treatment approach.

The distribution of BDI score severity in both groups, as depicted in Table 1, showed no significant difference post-treatment in the proportion of patients in each severity category (χ² = 3.810, P = 0.149). This finding suggests that while the treatment was effective in reducing depressive symptoms, the distribution of symptom severity remained relatively consistent between the two groups after the treatment.

Table 1 Beck Depression Inventory scores of patients before and after 12 weeks of treatment.

Group	Cases, n	BDI score		BDI distribution among cases, n
		Before treatment	After treatment	Before treatment			After treatment
				Mild depression	Moderate depression	Severe depression	Mild depression	Moderate depression	Severe depression
Observation	90	27.4 ± 4.7	18.6 ± 5.2a	0	0	90	27	44	19
Control	88	28.1 ± 5.5	20.9 ± 4.9a	0	0	88	16	53	19
χ2/t		0.670	2.188	-	-	-	-	3.810	-
P value		0.505	0.031	-	-	-	-	0.149	-

^aP < 0.05, vs before treatment.

Data are mean ± SD. BDI: Beck Depression Inventory.

Psychological state assessment

Upon admission, the psychological state assessment of patients in both the observation and control groups showed no statistically significant differences (P > 0.05), indicating comparable baseline levels of anxiety and depression. Post-treatment, the observation group exhibited significantly lower scores on both the SAS and SDS compared to the control group (P < 0.001), as presented in Table 2. Specifically, the mean SAS score in the observation group dropped from 72.3 ± 5.4 to 45.8 ± 3.1, and the SDS score decreased from 75.9 ± 3.1 to 50.5 ± 4.2, demonstrating a significant improvement in the psychological state of the patients who received the combined treatment.

Table 2 Psychological status assessment.

Group	Cases, n	SAS		SDS
		Before treatment	After treatment	Before treatment	After treatment
Observation	90	72.3 ± 5.4	45.8 ± 3.1	75.9 ± 3.1	50.5 ± 4.2
Control	88	72.2 ± 5.4	51.9 ± 3.0	75.8 ± 3.1	57.3 ± 4.2
χ2/t		0.073	8.570	0.071	7.179
P value		0.942	< 0.001	0.943	< 0.001

Data are mean ± SD. SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

By contrast, the control group, which received standard treatment, showed a less pronounced reduction in scores, with SAS scores decreasing from 72.2 ± 5.4 to 51.9 ± 3.0 and SDS scores from 75.8 ± 3.1 to 57.3 ± 4.2. Statistical analyses revealed significant differences between groups post-treatment, with t-values of 8.570 for SAS and 7.179 for SDS, both indicating a highly significant improvement in the observation group.

Comparison of aggressive behaviors pre- and post-treatment

The initial comparison of STAXI-2 scores between the observation and control groups showed no significant differences (P > 0.05), indicating a similar baseline level of aggressive behaviors. Post-treatment, both groups exhibited a significant reduction in several STAXI-2 dimensions, including state anger, angry feelings, and angry actions (P < 0.05). Notably, the observation group demonstrated a more pronounced decrease in these dimensions compared to the control group, as evidenced by the significant t-values (e.g., state anger: t = 2.970, P = 0.004; angry language: t = 4.532, P < 0.001).

Furthermore, the observation group showed a significant increase in the control of external and internal expressions of anger after treatment (P = 0.001 and 0.011, respectively), suggesting improved ability to manage anger expression, which was also reflected in the control group but to a lesser extent. The control group's scores for control of external expressions increased significantly post-treatment (t = 2.817, P = 0.006), while the observation group showed an even greater increase (t = 2.980, P = 0.004).

Table 3 illustrates the comparative STAXI-2 scores between the two groups. The observation group's scores for state anger, angry feelings, and angry language were significantly lower than those of the control group after treatment. Conversely, the observation group's scores for control of external and internal expressions were significantly higher than those of the control group, indicating a more effective management of aggressive behaviors in the observation group.

Table 3 Comparison of the State-Trait Anger Expression Inventory-2 scores between the two groups before and after treatment.

Item	Observation group, n = 90		Control group, n = 88		Before treatment		After treatment
	Before treatment	After treatment	Before treatment	After treatment	t	P value	t	P value
State anger	34.7 ± 7.6	26.5 ± 6.8a	33.8 ± 6.9	30.2 ± 4.7a	0.594	0.554	2.970	0.004
Angry feelings	14.2 ± 3.5	10.7 ± 3.4a	13.9 ± 4.1	12.1 ± 2.8a	0.385	0.701	2.137	0.035
Angry language	12.4 ± 4.7	8.8 ± 4.2a	13.2 ± 5.4	12.9 ± 4.6	0.716	0.476	4.532	< 0.001
Angry actions	8.1 ± 2.6	7.0 ± 1.9	8.8 ± 3.2	7.5 ± 1.7a	1.181	0.241	1.327	0.188
Trait anger	28.2 ± 5.9	26.6 ± 5.7	27.6 ± 6.3	27.1 ± 4.5	0.478	0.634	0.429	0.669
Aggressive behavior	11.4 ± 2.3	10.1 ± 1.8a	10.9 ± 3.1	10.5 ± 2.2	0.908	0.366	0.978	0.331
Aggressive reaction	16.8 ± 3.6	16.5 ± 4.1	16.0 ± 3.9	15.7 ± 4.6	1.037	0.303	0.896	0.373
Anger external expression	19.7 ± 5.1	18.0 ± 4.8	20.1 ± 4.9	19.3 ± 5.9	0.385	0.701	1.188	0.238
Anger internal expression	20.6 ± 3.3	19.5 ± 3.5	20.3 ± 4.6	18.2 ± 4.8	0.372	0.711	1.535	0.128
Control external expression	17.3 ± 4.2	21.7 ± 4.6a	16.3 ± 3.7	19.2 ± 3.8a	1.208	0.230	2.817	0.006
Control internal expression	16.5 ± 4.5	21.6 ± 4.8a	16.1 ± 4.2	18.9 ± 3.7a	0.441	0.660	2.980	0.004

^aP < 0.05, vs before treatment.

Data are mean ± SD.

Comparison of FAD scores pre- and post-intervention

The FAD was utilized to evaluate the family functioning of patients in both the control and observation groups. Initially, there were no significant differences in FAD scores between the two groups (P > 0.05), indicating a comparable level of family functioning at baseline.

Following treatment, the observation group demonstrated significant improvements in several FAD dimensions. Notably, the scores for behavior control, emotional response, and communication were significantly lower in the observation group compared to the control group (P < 0.001 for all), indicating enhanced family functioning in these areas.

Table 4 presents the detailed FAD scores for both groups before and after treatment. For the observation group, the scores in behavior control decreased from 2.7 ± 0.8 to 1.8 ± 0.2, emotional response from 1.6 ± 0.4 to 0.9 ± 0.3, and communication from 2.6 ± 0.7 to 1.8 ± 0.3 after the treatment. These reductions are indicative of positive changes in family dynamics and suggest that the FCT treatment contributed to better family communication and emotional regulation. By contrast, the control group showed minimal changes in these dimensions, with scores remaining relatively stable or showing less pronounced improvements. For instance, the behavior control score in the control group only slightly decreased from 2.6 ± 0.9 to 2.5 ± 1.1, and the communication score from 2.7 ± 0.5 to 2.5 ± 0.6.

Table 4 Comparison of Family Assessment Device scores between the two groups before and after treatment.

Group	Treatment	Total score	Emotional involvement	Role	Problem solving	Behavior control	Emotional response	Communication
Observation, n = 90	Before treatment	2.3 ± 0.5	2.5 ± 0.6	1.7 ± 0.7	1.6 ± 0.5	2.7 ± 0.8	1.6 ± 0.4	2.6 ± 0.7
	After treatment	2.2 ± 0.6	2.4 ± 0.7	1.6 ± 0.9	1.4 ± 0.9	1.8 ± 0.2	0.9 ± 0.3	1.8 ± 0.3
Control, n = 88	Before treatment	2.3 ± 0.4	2.5 ± 0.5	1.7 ± 0.9	1.5 ± 0.4	2.6 ± 0.9	1.6 ± 0.4	2.7 ± 0.5
	After treatment	2.2 ± 0.7	2.4 ± 0.6	1.7 ± 0.1	1.4 ± 0.6	2.5 ± 1.1a	1.7 ± 0.3a	2.5 ± 0.6a

^aP < 0.05, vs observation group.

Data are mean ± SD.

Comparison of enrich scores pre- and post-intervention

The Enrich Marital Scale was employed to assess the marital quality of patients in both the observation and control groups. Initially, there were no significant differences in Enrich scores between the two groups (P > 0.05), indicating a comparable level of marital quality at baseline.

Following treatment, the observation group demonstrated significant improvements in several aspects of marital quality. Notably, the scores for marital satisfaction, relationships with friends and relatives, and spousal communication were significantly higher in the observation group compared to the control group (P < 0.001 for all), indicating an enhancement in these critical areas of marital life (Table 5).

Table 5 Comparison of Enrich scores between the two groups before and after treatment.

Item	Observation group, n = 90			Control group, n = 88
	Before treatment	After treatment	P value	Before treatment	After treatment	P value
Idealization	25.4 ± 6.2	26.2 ± 6.1	0.042	25.3 ± 6.1	26.1 ± 7.0	0.003
Marital satisfaction	24.5 ± 6.2	31.4 ± 4.9a	< 0.001	24.6 ± 6.2	25.0 ± 6.9	0.046
Leisure activities	24.3 ± 8.8	25.6 ± 7.6	0.026	24.9 ± 8.1	25.1 ± 7.9	0.342
Personality compatibility	27.8 ± 6.9	28.1 ± 6.1	0.034	27.3 ± 6.9	28.1 ± 6.4	0.021
Conflict resolution	25.8 ± 7.0	26.7 ± 3.3	0.011	25.1 ± 7.2	26.0 ± 6.9	0.016
Financial arrangements	26.3 ± 8.1	27.0 ± 8.2	0.023	26.4 ± 7.9	26.9 ± 6.7	0.069
Belief consistency	28.4 ± 5.4	28.5 ± 4.9	0.263	28.4 ± 5.4	29.1 ± 3.3	0.006
Children and marriage	26.7 ± 7.5	27.1 ± 5.6	0.074	26.9 ± 7.1	28.4 ± 3.2	< 0.001
Role equality	27.3 ± 6.4	28.1 ± 6.9	0.014	27.6 ± 6.1	28.1 ± 3.6	0.103
Sex life	27.7 ± 7.6	28.0 ± 6.6	0.039	27.9 ± 7.6	28.0 ± 6.7	0.668
Relationships with family	28.2 ± 6.9	33.9 ± 6.1a	< 0.001	28.1 ± 7.0	29.0 ± 4.9	0.079
Communication between couples	28.9 ± 8.2	34.2 ± 5.9a	< 0.001	29.0 ± 8.1	28.3 ± 7.2	0.063

^aP < 0.05, vs control group.

Data are mean ± SD.

Adverse reactions

One patient in the control group showed restlessness, anger, excitement, and aggressive behaviors such as smashing objects after stopping the drug for 2 days. The patient's mood gradually stabilized after taking sertraline 100 mg in the morning the next day. No adverse reactions were observed in the observation group after stopping the drug.

DISCUSSION

Aggressive behavior is recognized as a core symptom and typical manifestation accompanying anger, with the relationship between depressive symptoms and aggressive behavior gaining increasing clinical attention and importance. A previous study[15] indicated that the lifetime prevalence of depression among men and women can reach up to 20%, and in addition to psychological issues such as low mood, despondency, and even suicidal attempts caused by depression, as depressive symptoms increase, so too does the manifestation of anger and aggressive behavior in patients. Emotions and aggressive behaviors exist on a spectrum[16], and the common factors in their co-occurrence are the patient's tendencies toward aggression when reacting overly sensitively to any threat.

Under stable emotional conditions in patients, the spectrum often begins with hypersensitivity reactions, with increasing severity of threats, accompanied by verbal intimidation, physical violence, bullying, and even murder, sometimes leading to a propensity for violence and abuse[16]. Agitation and violent behavior are commonly seen as symptoms of many mental disorders, and the presence of violence and aggressive behavior has been observed in patients with substance abuse, personality disorders, and emotional and anxiety disorders[17]. The frustration-aggression theory posits that individuals are prone to exhibit various forms of aggressive behavior after encountering frustration, which is a significant factor leading to depression; thus, the driving force behind aggressive behavior may stem from the frustration and depressive emotions. Surveys[18] show that over 20% of patients with major depression may exhibit symptoms of aggressive behavior. The angry phase of patients is often associated with activation of the autonomic nervous system, such as tachycardia, sweating, hot flashes, and chest oppression. Patients with depression are more likely than those without depression to exhibit anxiety, emotional outbursts of anger, and a tendency to exhibit dependent, narcissistic, or antisocial and borderline personality disorders. Violence and aggressive behavior can easily cause harm and serious impact on society and families.

Previous research[19,20] has shown that sertraline can effectively alleviate patients' depressive emotions and also has a certain effect on improving their anger states. The results of this study confirm that in the control group of patients treated with sertraline alone, after 12 weeks of intervention, there was a significant reduction in depressive symptoms, as well as a significant reduction in anger and aggressive behavior. This study is consistent with the preliminary conclusions of previous research by Fava et al[21], who concluded that sertraline is effective in reducing aggressive attacks and controlling anger. Since sertraline's main action is to inhibit the reuptake of serotonin, clinical studies[19] have shown that brain regions closely related to aggressive behavior include the frontal cortex, hippocampus, hypothalamus, amygdala, midbrain tegmentum, pons, and the dorsal and anterior lobes of the cerebellum. A previous study[19] in rat models of anger and irritability showed that the hypothalamic serotonin level in the anger model rats was significantly increased, which may be the main reason why sertraline reduces anger and aggressive behavior after inhibiting the rise in serotonin levels. Guidi and Fava[22] also showed that there is a significant link between depressive symptoms and aggressive behavior, which is influenced by medication. At the same time, patients with brain damage who took sertraline for antidepressant treatment showed a simultaneous reduction in depression and aggressive behavior after taking the medication; thus, sertraline treatment can significantly alleviate patients' anger and aggressive behavior.

In FCT, the focus for patients is on cognition, problem-solving, and emotional control, while the training content for family members includes psychological counseling, impulse behavior control, emergency handling, problem-solving training, and dealing with their own anxiety and depressive emotions, to avoid and reduce the contradictions and conflicts caused by long-term family cohabitation with patients[23]. Because the contradictions and emotions in the family have an important impact on the emotional control of patients with depression in their interactions, the family members' impulse control and strategies for handling emergencies have a promoting effect on regulating the family atmosphere to reduce the patient's response when anger occurs[24]. At the same time, in response to the emergency response methods and adjustment of psychological plans, this study, with the help of psychotherapists, improves patients' abilities to find appropriate ways to solve problems, which can better control the expression of the patient's anger. This study further used sertraline combined with FCT compared to the effect of sertraline alone, and the results showed that the combined treatment's state anger, angry feelings, and angry language, control of external expression, and control of internal expression scores were all significantly improved compared to the control group. This indicates that this model of joint regulation and control by the patient and the family can further promote the patient's ability to control emotions and help reduce the expression of aggressive behavior. Therefore, the above results further confirm the effectiveness of sertraline combined with FCT in treating depression and aggressive behavior.

In this study, one case of adverse reactions after stopping medication occurred in the control group, indicating a potential risk of promoting anger and aggressive behavior after stopping sertraline, possibly due to the sudden rise in 5-HT in the brain, which may activate the brain areas related to aggressive behavior[25]. However, no related cases were seen in the observation group. Whether combined FCT can further reduce the recurrence of symptoms and activation of related brain areas after stopping medication still requires further in-depth study. For the majority of families, marital satisfaction is often a process that slowly decreases and then slowly increases. A good marital condition can improve people's physical and mental health and prevent the occurrence of diseases. The recovery from depression is a long process, and in this process, the impact of the disease and treatment can weaken the relationship between husband and wife, reduce the quality of marriage, and this situation will further affect the patient's condition, deepening the degree of depression and forming a vicious cycle. FCT starts with family intervention to improve the overall relationship between the patient and family, breaking this vicious cycle, thereby improving the patient's psychological condition. From the data of this study, it can be seen that through the intervention of FCT, the scores of behavior control, emotional response, and communication of the observed group after the intervention were significantly lower than those of the control group, and the difference was statistically. This indicates that through family therapy intervention, the patient's symptoms were alleviated, they could better control their own behavior, and could communicate positively with their family, promoting the cultivation of mutual feelings. After the intervention, the scores of marital satisfaction, relationships with friends and relatives, and spousal communication of the observed group were significantly higher than those of the control group, and the difference was statistically significant. This indicates that under the intervention of family therapy, the communication ability of the observed group patients was effectively improved, the impact of depressive emotions on patients was reduced, the communication between husband and wife was more harmonious, and it was of great significance in improving the quality of marriage.

Our study underscores the critical need for early detection and management of aggressive behaviors in individuals with MDD, advocating for the incorporation of assessments for such tendencies during initial patient evaluations. This strategy allows clinicians to craft tailored treatment plans that concurrently address depressive symptoms and the potential for aggression, thereby potentially preventing escalation and the subsequent negative impacts on both patients and their families. The demonstrated efficacy of sertraline in mitigating aggressive behaviors positions selective serotonin reuptake inhibitors as a pivotal component in the pharmacological management of MDD, particularly for patients with aggressive inclinations, reinforcing their consideration as a first-line therapeutic option. Furthermore, our findings advocate for the integration of FCT into MDD treatment protocols. By focusing on cognitive and emotional regulation and actively involving the family in therapy, FCT not only enhances the family's comprehension of MDD but also bolsters the patient's sense of responsibility within the family, leading to improved family dynamics, and consequently, better patient outcomes. The observed improvements in marital satisfaction and communication following FCT underscore its potential to fortify patients' social support networks, a key factor in recovery and relapse prevention. This insight suggests that clinicians may benefit from referring patients to FCT to augment family support and elevate the quality of patients' social interactions. The potential risks associated with discontinuing sertraline, as indicated by our study, stress the importance of diligent medication withdrawal management. Clinicians are advised to closely monitor for signs of aggression or other withdrawal symptoms and to adjust treatment plans accordingly to provide optimal patient support.

This study had limitations, namely, a small sample size, short treatment period, and lack of further comparison with other drugs. In summary, the results of this study demonstrate that the combination of sertraline and FCT can further improve the state of depression, alleviate the state of anger, strengthen the internal and external control of anger emotions, improve patients’ quality of life, and improve patients’ family function and marital quality.

CONCLUSION

In conclusion, our study provides compelling evidence that the integration of FCT with pharmacological treatment significantly enhances the management of MDD. By addressing not only the individual's depressive symptoms but also the familial and marital dynamics, this comprehensive approach leads to a notable reduction in aggressive behaviors, improved family functioning, and enhanced marital quality. These findings underscore the importance of a holistic treatment strategy that incorporates both psychological and pharmacological interventions, offering a more effective pathway to recovery for patients with MDD and their families. Despite the limitations of our study, including a small sample size and brief treatment duration, the results suggest that further research and clinical application of FCT in conjunction with medication may yield substantial benefits in the realm of depression care.

ACKNOWLEDGEMENTS

We would like to express our appreciation to the medical staff at the Shaoxing 7th People's Hospital for their invaluable support in conducting this study, making our research feasible. We also thank the peer reviewers for their constructive feedback, which has significantly enhanced the quality of this manuscript.