Most research on depression focuses on the afflicted, a new paper argues, overlooking a potentially informative group: people who have recovered.
A generation ago, depression was viewed as an unwanted guest: a gloomy presence that might appear in the wake of a loss or a grave disappointment and was slow to find the door. The people it haunted could acknowledge the poor company — I’ve been a little depressed since my father died — without worrying that they had become chronically ill.
Today, the condition has been recast in the medical literature as a darker, more permanent figure, a monster in the basement poised to overtake the psyche. For decades, researchers have debated the various types of depression, from mild to severe to “endogenous,” a rare, near-paralyzing despair. Hundreds of studies have been conducted, looking for markers that might predict the course of depression and identify the best paths to recovery. But treatment largely remains a process of trial and error. A drug that helps one person can make another worse. The same goes for talk therapies: some patients do very well, others do not respond at all.
“If you got a depression diagnosis, one of the most basic things you want to know is, what are the chances of my life returning to normal or becoming optimal afterward?” said Jonathan Rottenberg, a professor of psychology at the University of South Florida. “You’d assume we’d have an answer to that question. I think it’s embarrassing that we don’t.”
In a paper in a recent issue of Perspectives on Psychological Science, Rottenberg and his colleagues argue that, in effect, the field has been looking for answers in the wrong place. In trying to understand how people with depression might escape their condition, scientists have focused almost entirely on the afflicted, overlooking a potentially informative group: people who once suffered from some form of depression but have more or less recovered.
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Indeed, while this cohort almost certainly exists — every psychiatrist and psychologist knows someone in it — it is so neglected that virtually nothing is known about its demographics, how well its members are faring and, fundamentally, how many individuals it contains.
“We know that many people with bipolar disorder, for instance — a serious, lifetime condition — do very well after treatment, and end up in creative jobs,” said Sheri Johnson, director of the mania program at the University of California, Berkeley. “But we can’t predict who. So it would be very important to have this kind of information, to know more about that group. Imagine if doctors could give you some sense of what’s possible.”
In the new paper, Rottenberg and his co-authors, Todd Kashdan and David Disabato of George Mason University, and Andrew Devendorf of the University of South Florida, argue that the effort to understand how people recover from depression is stunted by the kind of evidence available. Treatment trials typically last six to eight weeks, and they focus on reducing negative symptoms, such as feelings of worthlessness, fatigue and thoughts of suicide. What happens in the subsequent months and years — and which positive developments occur, and for whom — is largely unknown.
“I think it’s fine — it’s a good idea — to look at people who do well after a period of depression, over the longer term,” said Dr. Nada Stotland, a psychiatrist at Rush University Medical Center in Chicago. “But we might simply find that they’re the people who were doing better in the first place.”
In a forthcoming analysis, to be published in Clinical Psychological Science, the same team of psychologists make a rough estimate of the number of post-depression “flourishers,” using data from a periodic national survey called the Midlife Development in the United States. The survey includes more than 6,000 people between the ages of 25 and 75 and more than 500 who met criteria for depression. About half of the people who had received a diagnosis recovered afterward, meaning they had been symptom free for at least a year, the researchers found. One in 5 of those — 10 percent of the total — were thriving a decade later. The research team based that judgment on an assessment that includes measures of how people feel, how well their relationships are going, and their work.
That 10 percent number might look disappointingly low, or encouragingly high, depending on one’s perspective. The best comparison is the portion of people who were rated as thriving who never had depression: 20 percent.
“That is, having depression cuts in half your chances of ending up in this group” at the high end of the well-being scale, Rottenberg said. He added: “But we really don’t know for sure, until we have better evidence.”
To gain that evidence, the ideal approach would be to follow a large cohort of people who had recovered from depression, over many years, to tease apart the differences between the 10 percent or so who thrived and those who did not. Such studies would be costly, the authors acknowledge, and likely would require collaboration among many large clinical centers.
Still, individuals who have routed what Winston Churchill called his “black dog” and built a full life have a collective knowledge that others do not. And researchers can only speculate about what that vanquishing entailed until they ask, systematically and empirically.
The answers will not necessarily fall into a straightforward pattern. Whereas some people who thrive after depression might swear by daily pills, others may depend on weekly talk therapy. Good friends, good opportunities and good genes are likely to play a role. And there very well may be many people who have developed idiosyncratic methods of their own, a kind of daily self-therapy or routine not found in any manual, textbook or study.
“If so, it would be exciting to find out what those are,” Rottenberg said. “You’d not only be giving people with depression some hope, by studying this group. You might also be able to give them something they could use.”
For now, said Stotland, the Chicago psychiatrist, the fact that depression can be chronic, and recurrent, hardly means that people are doomed by the diagnosis. “I’ve never told patients that,” she said. “I tell them they’re likely to get better, and I suspect that most of my colleagues do the same.”