Exploring the mediating role of self-compassion in the relationship between emotional distress and quality of life in celiac disease

Abstract

BACKGROUND:

Celiac disease is a chronic autoimmune condition with gastrointestinal and extraintestinal symptoms, often impairing physical and psychological well-being. Although a strict gluten-free diet remains the only effective treatment, many patients continue to experience persistent, distressing symptoms. Psychological difficulties—particularly anxiety and depression—are highly prevalent among individuals with celiac disease. Self-compassion has been suggested as a positive psychological resource that may influence the impact of anxiety and depression on psychological and social quality of life in this population. This study aimed to investigate whether self-compassion mediates the relationships between anxiety, depression, and the psychological and social dimensions of quality of life in individuals with celiac disease.

MATERIALS AND METHODS:

A cross-sectional study was conducted with 198 adult celiac patients recruited from Taleghani Hospital in Tehran, Iran. Participants completed validated measures of anxiety, depression, self-compassion, and quality of life. Mediation analyses were performed using the R lavaan package.

RESULTS:

Self-compassion fully mediated the relationship between anxiety and psychological quality of life (P < 0.001), and partially mediated the relationship between depression and psychological quality of life (P < 0.001). Depression significantly predicted social quality of life, but self-compassion showed no significant mediation for social QoL (P > 0.05).

CONCLUSION:

Self-compassion mitigates the impact of anxiety and depression on psychological QoL but not social QoL, while depression strongly impairs social functioning. To enhance QoL in celiac disease, self-compassion therapy could be integrated into clinical care to improve psychological well-being, while cognitive-behavioral or group-based interventions should be explored to address depression’s social impact more effectively.

Introduction

Celiac disease (CD) is a common immune-mediated enteropathy affecting people worldwide, with a global prevalence estimated between 0.7% and 1.4%.[1,2] In Iran, however, a systematic review and meta-analysis of 63 studies reported a higher prevalence ranging from 2% to 3%, indicating a notable national burden.[3] Epidemiological studies have shown that CD is more commonly diagnosed in women than in men.[4] This chronic disease affects the small intestine and is triggered by the ingestion of gluten in genetically susceptible individuals.[5] Gluten induces an inflammatory response, leading to villous atrophy, resulting in gastrointestinal symptoms (e.g., diarrhea, bloating, abdominal pain) and nutrient malabsorption, often accompanied by additional extraintestinal (e.g., fatigue, headache, weight loss) symptoms.[6] Currently, the primary treatment for CD is a gluten-free diet (GFD), which typically leads to symptom relief within days or weeks.[7,8] However, many individuals keep experiencing symptoms despite strict adherence.[5,9,10] Furthermore, adhering to a GFD presents challenges across multiple areas: lifestyle adjustments, financial strain due to limited access to gluten-free food, emotional impacts such as reduced pleasure in eating, and social limitations imposed by the diet.[11,12,13] These challenges can collectively reduce quality of life (QoL).[14]

Beyond physical and dietary challenges, emotional, social, and psychological factors also play a crucial role in the overall well-being and QoL of individuals with CD.[15,16,17] While adherence to a GFD can improve certain aspects of QoL,[18] many report persistent impairment compared to the general population.[17] Given the multidimensional nature of QoL, a range of psychological contributors—including negative illness perceptions, maladaptive coping, pain catastrophizing, and psychological distress—have been identified as mediators between symptoms and QoL, with anxiety and depression being the most prominent predictors.[19]

Depression and anxiety are common in chronic illnesses,[20] and CD patients are especially vulnerable due to persistent physical and psychosocial stressors.[21] These symptoms are the most frequently reported psychological issues in CD.[22,23] Several mechanisms have been proposed to explain the development of depression and anxiety in individuals with CD. These include psychosocial factors such as the burden experienced after diagnosis and the restrictive nature of the GFD,[24] as well as physiological contributors like vitamin malabsorption,[25,26] reduced tryptophan levels,[27] altered gut microbiota,[28] and autoimmune activity.[29] Depression and anxiety resulting from these mechanisms may, in turn, impair quality of life; both directly through cognitive and emotional symptoms, and indirectly through poor dietary adherence.[19,22] Notably, Sainsbury, Mullan, and Sharpe (2013) found that distress may persist despite full dietary compliance, highlighting the need to address emotional well-being beyond symptom control.[30]

Emotional distress can reduce motivation for health-promoting behaviors and lead to self-blame over poor symptom management.[31,32,33] Overcoming these challenges requires psychological resources that promote resilience and reduce self-blame. Baxter and Sirois, in their meta-analysis, identified self-compassion as a protective factor, offering a balanced and accepting approach to coping with chronic illness.[34] Neff defines self-compassion as the ability to respond to one’s suffering, failures, and inadequacies with kindness and understanding rather than avoidance or self-judgment, comprising three components: self-kindness versus self-judgment, common humanity versus isolation, and mindfulness versus over-identification.[35] In chronic illness, self-compassion facilitates adaptive coping,[33,36,37] reduces maladaptive cognitive patterns such as catastrophizing and rumination, and fosters constructive symptom appraisal.[38,39] Among CD patients, it’s associated with lower anxiety and depression,[34,40] improved adherence to health behaviors,[41,42] and better GFD compliance.[43] By reducing distress and enhancing resilience, self-compassion can improve psychological and social well-being in CD,[43,44] underscoring its value in interventions targeting mental health and disease management.

A growing body of research has demonstrated that anxiety and depression are strongly associated with reduced quality of life in individuals with CD and other chronic illnesses.[16,17,19,22] These emotional difficulties have been linked to both diminished psychological well-being and disruptions in social functioning. In parallel, studies have increasingly identified self-compassion as a protective factor that may alleviate psychological distress and enhance adjustment in chronic illness populations.[33,34,42,43] However, while previous research has examined self-compassion in relation to either emotional distress or quality of life independently, the potential mediating role of self-compassion in the relationship between anxiety, depression, and specific dimensions of quality of life in patients with CD has not yet been investigated. Addressing this gap is essential to better understand the complex interplay of these factors in this population.

Identifying mediators like self-compassion is crucial for improving care in CD. As a core concept in third-wave therapies, self-compassion is a promising intervention target. If confirmed as a mediator, it could guide psychological treatments and support integrating mental health into comprehensive CD care. While previous literature has largely focused on global QoL, the current study specifically addresses its psychological and social components. Moreover, prior work has predominantly emphasized medical and dietary aspects, often overlooking psychological mechanisms. To address this gap, the present study aimed to examine whether self-compassion mediates the relationship between anxiety, depression, and the psychological and social dimensions of quality of life in adults with CD.

Material and Methods

Study design and setting

This cross-sectional study was conducted at Taleghani Hospital in Tehran, Iran, involving adult patients diagnosed with CD by a gastroenterologist and referred to the hospital’s psychology department. The study aimed to investigate the relationships among anxiety, depression, self-compassion, and quality of life in this population.

Study participants and sampling

Participants were recruited using convenience sampling from adult patients diagnosed with CD by a gastroenterologist at Taleghani Hospital in Tehran, Iran. Eligible patients were referred to the hospital’s psychology department for participation. A trained clinical psychologist, familiar with standardized psychological assessments, provided a detailed explanation of the study’s aims and procedures. The majority of our sample consisted of female participants (72%), consistent with the higher prevalence of CD and depression among women.[4,45] Inclusion criteria were: a confirmed diagnosis of CD by a gastroenterologist, age 18 years or older, the ability to read and comprehend study materials, and willingness to provide informed consent and complete the questionnaires. Exclusion criteria included the presence of severe psychiatric disorders (e.g., psychosis, bipolar disorder) that could compromise the validity of self-report data, major medical comorbidities (e.g., active cancer, autoimmune diseases) that could interfere with psychological assessment or participation, and incomplete or patterned questionnaire responses such as selecting the same option across all items.

Data collection tool and technique

Participants completed validated measures of anxiety, depression, self-compassion, and quality of life. A clinical psychologist provided a standardized explanation of the study objectives, after which the questionnaires were administered in paper-and-pencil format. The WHOQOL-BREF[46] is a 26-item self-report questionnaire developed by the World Health Organization. The first two items assess overall health quality (OHQ) and overall health status (OHS), while the remaining 24 items evaluate four domains: physical health, psychological health, social relationships, and environment. In the current study, only the psychological health and social relationships subscales were used, as they were most relevant to the study’s aims. Responses are rated on a 5-point Likert scale,[1,2,3,5,6] with higher scores indicating a better quality of life. The total score is converted to a scale of 0–100, and each domain score is calculated by summing its respective items. The original questionnaire has demonstrated good internal consistency with Cronbach’s alpha ranging from 0.66 to 0.84. The Persian version of WHOQOL-BREF was first translated and validated for the Iranian population by Nedjat (2008) using a forward-backward translation method. Their study found good internal consistency, though the social relationships domain exhibited lower reliability.[47] However, a subsequent validation by Usefy et al. (2010)[48] in a more heterogeneous and larger sample reported improved reliability, with Cronbach’s alpha values ranging from 0.76 to 0.82 across the four domains.

The Hospital Anxiety and Depression Scale (HADS)[49] is a 14-item self-report measure of psychological distress, developed by Zigmond and Snaith to assess levels of anxiety and depression. It consists of two subscales—anxiety and depression—each containing seven items. Respondents rate each item on a four-point Likert scale (0 = “not at all” to 3 = “always”). The total score for each subscale ranges from 0 to 21, yielding a combined score from 0 to 42. In the original scale, scores of 0–7, 8–15, and 16–21 indicate normal/mild, moderate, and severe levels of anxiety or depression, respectively. The HADS has demonstrated good internal consistency in its original development sample, with Cronbach’s alpha values of 0.83 for anxiety and 0.82 for depression. Additionally, the Persian version validated in a breast cancer sample reported α = 0.78 for anxiety and α = 0.86 for depression.[50]

The Self-Compassion Scale-Short Form (SCS-SF),[51] developed by Raes, Pommier, Neff, and Van Gucht (2011), is a shortened version of the original Self-Compassion Scale. It consists of 12 items, and Responses are rated on a 5-point Likert scale ranging from 1 to 5 (1 = never, 2 = almost never, 3 = I don’t know, 4 = almost always, 5 = always). The minimum and maximum possible scores are 12 and 60, respectively, with higher scores indicating greater self-compassion. The SCS-SF includes six factors representing different dimensions of self-compassion: Self-Kindness, Self-Judgment, Common Humanity, Isolation, Mindfulness, and Over-Identification. The scale demonstrates excellent internal consistency, with a Cronbach’s alpha greater than 0.86, and shows a very strong correlation with the full SCS (r > 0.97). It is particularly useful when the overall self-compassion score is needed. The Persian version of the SCS-SF, validated by Khanjani et al. (2016)[52], has shown acceptable psychometric properties. Specifically, Cronbach’s alpha coefficients for the total scale and its subscales—“Self-Kindness, Self-Judgment,” “Common Humanity, Isolation,” “Mindfulness, and Over-Identification”—were reported as 0.79, 0.68, 0.71, and 0.86, respectively.

Ethical consideration

The study protocol was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Approval Code: IR.SBMU.MSP.REC.1402.632). Written informed consent was obtained from all participants after a detailed explanation of the study’s aims and procedures. Confidentiality of responses was assured, and data were used solely for research purposes. Participants were informed of their right to withdraw from the study at any time without consequences.

Statistical analysis method

Path analysis was conducted using the lavaan package in R software, version 4.4.3 (R Core Team, Vienna, Austria) to assess the direct, indirect, and total effects among anxiety, depression, self-compassion, and quality of life indicators (SQoL and PQoL). In this model, self-compassion was examined as a mediator between emotional symptoms (anxiety and depression) and quality of life. The robust maximum likelihood estimator (MLR) was used to account for potential violations of multivariate normality. Model fit was assessed using multiple indices, including Chi-square (χ²), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). A significance level of P < 0.05 was considered for all statistical tests.

Results

Descriptive data

The dataset comprised 198 participants with a mean age of 35.35 years (SD = 8.77). Among them, 143 individuals (72.22%) were female, while the remaining 55 participants (27.78%) were male. In terms of marital status, 89 participants (44.95%) were single, whereas 109 (55.05%) were married. Regarding educational attainment, 96 individuals (48.48%) had no academic education, while the remaining 102 (51.52%) held a university degree [Table 1].

Table 1.

Demographic characteristics of participants

Variables		Frequency		Precent
Gender
Female		143		72.22
Male		55		27.78
Marital Status
Single		89		44.95
Married		109		55.05
Educational Level
Below Diploma		96		48.48
Diploma		102		51.52

The mean and standard deviation of the model variables are summarized in Table 2.

Table 2.

Descriptive data and correlations among study variables (n=198)

Variables		Mean		S.D*		Skewness		Kurtosis		Anxiety		Depression		Self-Compassion		PQOL		SQOL
Anxiety		9.77		4.47		0.30		-0.55		1		0.72**		-0.63**		-0.58**		-0.35**
Depression		7.87		4.33		0.23		-0.23		0.72**		1		-0.63**		-0.67**		-0.61**
Self-Compassion		71.50		13.68		-0.03		-0.09		-0.63**		-0.63**		1		0.77**		0.40**
PQoL**		53.84		15.62		0.47		0.41		-0.58**		-0.67**		0.77**		1		0.60**
SqoL***		50.55		18.23		0.15		0.56		-0.35**		-0.61**		0.40**		0.60**		1

*S.D: standard deviation, **PQoL: Psychological quality of life, ***SQoL: Social quality of life

Model fit results

The model demonstrated an acceptable fit to the data. The Chi-square test yielded a non-significant result (χ² = 1.559, df = 1, P = 0.212), suggesting no substantial discrepancy between the hypothesized model and the observed data. The Comparative Fit Index (CFI = 0.999) and the Tucker-Lewis Index (TLI = 0.990) both indicate excellent fit. Additionally, the Root Mean Square Error of Approximation (RMSEA = 0.053, 90% CI [0.000, 0.203], P = 0.321) and the Standardized Root Mean Square Residual (SRMR = 0.016) fell within acceptable ranges.

Direct effects

The analysis revealed several significant direct effects [Table 3]. Anxiety had a negative and significant direct effect on self-compassion (β = -1.065, P < 0.001), and so did depression (β = -1.131, P < 0.001), indicating that higher levels of anxiety and depression were associated with lower levels of self-compassion. Self-compassion, in turn, positively predicted psychological QoL (PQoL) (β = 0.642, P < 0.001), while depression had a significant negative effect on PQoL (β = -1.185, P < 0.001). However, anxiety had no significant direct effect on PQoL (β = 0.041, P = 0.830). Regarding social QoL (SqoL), depression had a significant negative direct effect (β = -3.181, P < 0.001), while the effect of anxiety was marginally significant (β = 0.737, P = 0.057).

Table 3.

Direct effects

Predictor		Outcome		Path Coefficient (β)		Standard Error (SE)		Z		P
Anxiety		Self-compassion		-1.065		0.227		-4.695		<0.001
Depression		Self-compassion		-1.131		0.269		-4.206		<0.001
Self-compassion		PQoL*		0.642		0.062		10.427		<0.001
Anxiety		PQoL		0.041		0.192		0.214		0.830
Depression		PQoL		-1.185		0.251		-4.728		<0.001
Anxiety		SQoL**		0.737		0.387		1.905		0.057
Depression		SQoL		-3.181		0.391		-8.138		<0.001

*PQoL: Psychological quality of life, **SQoL: Social quality of life

Indirect effects

The analysis indicated several significant indirect effects [Table 4]. Anxiety had a significant indirect effect on PQoL through self-compassion (β = -0.684, P < 0.001), and so did depression (β = -0.726, P < 0.001). These results suggest that part of the impact of anxiety and depression on PQoL is mediated by self-compassion. However, the indirect effects of anxiety and depression on the SQoL via self-compassion and PQoL were not statistically significant (Anxiety: β = -0.011, P = 0.832; Depression: β = -0.039, P = 0.846).

Table 4.

Indirect effects

Predictor		Outcome		Indirect Path		Indirect β		SE		Z		P
Anxiety		PQoL*		Anxiety → self-compassion → PQoL		-0.684		0.154		-4.443		<0.001
Depression		PQoL		Depression → self-compassion → PQoL		-0.726		0.163		-4.448		<0.001
Anxiety		SQoL**		Anxiety → self-compassion → PQoL → SQoL		-0.011		0.055		-0.212		0.832
Depression		SQoL		Depression → self-compassion → PQoL → SQoL		-0.039		0.206		-0.194		0.846

*PQoL: Psychological quality of life, **SQoL: Social quality of life

Total effects

The total effects of anxiety and depression on the outcome variables are presented in Table 5. The total effect of anxiety on PQoL was statistically significant (β = -0.643), combining both its nonsignificant direct effect (β = 0.041) and its significant negative indirect effect through self-compassion (β = -0.684, P < 0.001). Similarly, depression had a significant total negative effect on PQoL (β = -1.911), including a strong direct effect (β = -1.185, P < 0.001) and an indirect effect via self-compassion (β = -0.726, P < 0.001). Regarding SQoL, depression showed a statistically significant total effect (β = -3.220, P < 0.001), whereas the total effect of anxiety on SQoL was marginally significant (β = 0.726, P = 0.057), driven primarily by its direct path. The proposed structural model with self-compassion as a mediator is presented in Figure 1.

Table 5.

Total effects

Predictor		Outcome		Direct β		Indirect β		Total β		P
Anxiety		PQoL*		0.041		-0.684		-0.643		<0.001
Depression		PQoL		-1.185		-0.726		-1.911		<0.001
Anxiety		SQoL**		0.737		-0.011		0.726		0.057
Depression		SQoL		-3.181		-0.039		-3.220		<0.001

*PQoL: Psychological quality of life, **SQoL: Social quality of life

Figure 1.

Path diagram illustrating the relationships between variables

Predictive power

The predictive power of the model was assessed by examining the explained variance (R²) for the primary outcome variables. The model explained a substantial proportion of the variance in SQoL (R² = 0.398), indicating that the predictors (anxiety, depression, PQoL) together accounted for 39.8% of the variability in SQoL. For the mediating variable PQoL, the explained variance was moderate (R² = 0.654), suggesting that anxiety, depression, and self-compassion had a considerable predictive influence on the PQoL. In contrast, the variance explained for self-compassion was relatively modest (R² = 0.461), indicating that anxiety and depression had a moderate predictive power for compassion.

Discussion

This study investigated whether self-compassion mediates the association between anxiety, depression, and psychological and social domains of quality of life in adults with CD. Consistent with our hypothesis, self-compassion significantly mediated the relationships between both anxiety and depression and psychological quality of life (PQoL). Specifically, anxiety exerted no significant direct effect on PQoL and its influence was fully mediated by self-compassion. In contrast, the relationship between depression and PQoL was only partially mediated by self-compassion, indicating both direct and indirect effects. Neither anxiety nor depression’s effect on social quality of life (SQoL) was mediated by self-compassion; however, depression significantly predicted SQoL, while anxiety’s effect was marginal. This is, to our knowledge, the first study to identify self-compassion as a protective factor influencing QoL in adults with CD.

Our findings align with previous research linking anxiety and depression to diminished QoL in chronic illnesses like CD.[17,21,22] As noted by Moller (2021), depression and anxiety are among the most influential psychosocial predictors of QoL in CD.[22] In our study, depression significantly influenced both psychological and social QoL, particularly impacting social functioning. Interestingly, although depression is often conceptualized as an internalizing disorder.[53] Its stronger impact on social QoL may reflect how such symptoms visibly disrupt interpersonal engagement. Given the higher prevalence of depression and CD in females, the significant effect of depression on social quality of life may be particularly pronounced in female patients, potentially due to increased emotional distress and social challenges associated with dietary restrictions.[45] Our data also support Sainsbury’s (2013) findings, indicating that depression is a stronger predictor of QoL than even gastrointestinal symptoms in CD.[16]

In contrast, Anxiety did not show a significant direct association with the PQoL and only a marginal association with SQoL. One possible explanation is the predominantly internalized nature of anxiety symptoms, which may primarily impact individuals’ subjective psychological functioning rather than observable behavior or social interaction.[53,54] Furthermore, the high comorbidity between anxiety and depression might suppress anxiety’s independent contribution to QoL.[55] These findings underscore the distinct roles of depression and anxiety in shaping QoL among CD patients, emphasizing the need to investigate psychological mechanisms that may buffer these effects.

Our analysis identified self-compassion as a significant mediator, fully accounting for the influence of anxiety on PQoL and partially mediating the effects of depression on PQoL. These findings support a growing body of literature on the protective role of self-compassion in chronic illness populations.[33,34,43] A meta-analysis by MacBeth and Gumley (2012) demonstrated that low self-compassion is consistently associated with higher psychological distress, including depression and anxiety.[44] More recent work by Pinto-Gouveia et al. (2014)[56] further supports this, showing that individuals with chronic illnesses who report lower self-compassion also report poorer QoL and greater psychological symptoms. Similarly, Sirois (2015), in a study of individuals with IBS and arthritis, found that self-compassionate individuals were more likely to use adaptive coping strategies (e.g., acceptance, positive reframing) and less likely to rely on maladaptive strategies (e.g., self-blame, behavioral disengagement).[33]

These findings provide theoretical and empirical support for self-compassion’s role in buffering the psychological toll of living with CD. Self-compassion promotes effective self-regulation by fostering adaptive emotions and reducing self-blame and defensiveness, leading to improved adherence to medical recommendations and health-promoting behaviors.[33,42,43,57] This may explain the full mediation of anxiety’s effect on PQoL: the hypervigilance and self-critical rumination often associated with a GFD may be particularly responsive to self-compassionate attitudes, mitigating their impact on daily functioning. The partial mediation observed for depression may reflect the broader and more entrenched impairments associated with depressive states. As Sainsbury et al.[16] demonstrated, depression can reduce QoL through both emotional symptoms and reduced GFD adherence, as well as by exacerbating physical symptoms. Thus, self-compassion may not be sufficient on its own to fully buffer depression’s impact.

We also examined a series of indirect pathways, hypothesizing that anxiety and depression might affect SQoL through self-compassion and PQoL. However, these indirect effects were not significant (P > 0.8 for both anxiety and depression), suggesting that self-compassion’s protective effect is more specific to psychological functioning than to social aspects of QoL. Still, our model demonstrated strong predictive power, explaining a moderate proportion of variance in PQoL (R² = 0.654), substantial variance in SQoL (R² = 0.398), and modest variance in self-compassion (R² = 0.461), supporting the robustness of our findings.

Our findings underscore the importance of psychological factors, particularly self-compassion and its unique association with well-being. While most interventions prioritize medical and dietary needs, the psychological dimensions of CD frequently remain neglected.[17,58] Integrating self-compassion into comprehensive CD care can enhance well-being and improve long-term adherence to dietary restrictions. Self-compassion is a core component in several evidence-based interventions such as compassion-focused therapy, acceptance and commitment therapy, and mindfulness-based cognitive therapy, which have shown efficacy in treating chronic illnesses. Tailoring these interventions to the unique psychosocial challenges of CD could complement traditional dietary management, promoting both adherence and emotional resilience.

Limitations and recommendations

While these findings provide valuable insights, several limitations must be acknowledged. First, the cross-sectional nature of the study prevents us from drawing causal inferences about the directionality of associations. Additionally, recruiting participants from a single hospital using convenience sampling resulted in a female-majority sample (72%) that was not controlled for gender differences, limiting the generalizability of the findings. The reliance on self-report measures may also introduce response biases. Another limitation is the absence of a measure for adherence to a GFD. Given that numerous studies have linked GFD adherence to both physical and psychological well-being, its omission limits our ability to fully assess the unique contribution of psychological variables to QoL. Future research should adopt longitudinal designs with more diverse samples to enhance external validity. It would also be beneficial to include measures of GFD adherence and investigate other transdiagnostic psychological constructs. For instance, psychological inflexibility may be a promising avenue, as one study in a chronic illness population found it to be more strongly associated with anxiety, depression, and QoL than self-compassion.[59]

Conclusion

This study examined the role of self-compassion in mediating the impact of anxiety and depression on quality of life in adults with CD. Self-compassion significantly mediated the relationship between anxiety, depression, and psychological quality of life, but not social QoL. A key finding of our study is that depression significantly predicted social quality of life, likely due to symptoms like anhedonia, social withdrawal, and emotional fatigue, which severely impair social engagement. These findings highlight self-compassion as a buffer against emotional distress and a mechanism to enhance well-being in CD patients. Given the limited integration of psychological services into Iran’s healthcare system—particularly for chronic conditions like CD, which are primarily managed through dietary interventions—integrating brief self-compassion therapy into primary care could help improve psychological well-being and dietary adherence. Additionally, community-based support groups led by trained health workers could address depression’s impact on social QoL by reducing isolation and fostering social engagement.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.