Thriving after depression—why are scientists ignoring good outcomes?
In the wake of suicides by Kate Spade and Anthony Bourdain, we as a nation are newly sobered by depression's threat to the public health. Depression is a common mood condition considered by the World Health Organization to be the leading cause of disability worldwide, ahead of widely publicized contenders such as cancer, heart disease and diabetes. Reading the news today, you will learn that depression leads to self-harm and suicidal thoughts, drug overdoses, school shootings and altercations with the police. Can this darkest of human frailties ever point the way to something better?
What do clinical scientists know about redemption and personal growth in the aftermath of depression? How often does it happen? What initiates it?
In a forthcoming article to appear in Perspectives on Psychological Science with our students, we reached a shocking conclusion: Experts have virtually nothing to say about this topic.
A gloomy prognosis
The consensus opinion in psychology, psychiatry and public health goes something like this: "Depression is a chronic and recurrent condition, with each experienced depressive episode increasing the risk of future episodes," as Dr. David Solomon and colleagues from the National Institute of Mental Health put it in 2000. Or as Saba Moussavi and colleagues from the World Health Organization wrote in the Lancet, "Without treatment, depression has the tendency to assume a chronic course, be recurrent, and over time to be associated with increasing disability." So one can sum up the thoughts of world leading thinkers in a single sentence: Depression is a recurrent and chronic condition that is difficult to contain, even when treated.
In other words, the scientific literature clearly states that if you've had depression once, it will probably strike you down again, and lay waste to your good years (ironically, making pessimistic predictions might exacerbate people's depression). You'll be impaired at work, your relationships will suffer, and your happiness and sense of meaning in life will be obstructed.
Yes, depression can be a lifelong problem. Yet as we dug deeper into the epidemiological findings, we also saw signs of better outcomes – an aspect that we found is rarely investigated. For example, in rare longitudinal studies that modeled the whole population, 40 to 60 percent of people who had depression once never experienced a recurrence, even after being questioned years and even decades later.
Also encouraging, of 2,528 Canadians who had been diagnosed with major depression at least once in the past, 39 percent now report positive mental health, defined as having no mental disorders in the last year and a sense of satisfaction with life on a nearly daily basis for the last month.
These glimmers suggest that a substantial percentage of those who have depression can shake it off and go on to thrive. This means living better than the average human being without depression, experiencing frequent positive emotions, good relationships, autonomy in thought and action, and meaningful goals. From Demi Lovato to Duane "The Rock" Johnson to Robert Downey Jr., we already have spectacular testimonials about thriving after mental health struggles. The task now for researchers is to follow these encouraging signs with systematic data collection on how people thrive after depression.
A key step for scientists will be to use clear definitions of thriving, or well-being, guided by norms for well-being collected in national population samples. For example, our newly proposed standard for thriving after depression incorporates nine different aspects of well-being, and requires a person not only to be free of the major symptoms of depression, but also to report a well-being profile that is superior to 75 percent of nondepressed adults.
Filling in the blind spot
Clearly, for some, depression is a bridge to something better, rather than an inevitable death sentence. For some, full healing may simply take the passage of time. Others may achieve it through formal treatment. Still others may discover a new purpose in life or a daily routine that works for them. Some people may thrive after the first time they were depressed; others may get there only after several bouts of depression.
The most exciting thing about illuminating different pathways to thriving is that some may aid the 300 million people who struggle with depression worldwide. The need to improve depression intervention is crucial because current medications and psychotherapies, though helping the majority of patients, often provide only partial relief of symptoms; and sadly, most people who struggle with mood problems still do not engage in any treatment.
Clinical scientists' neglect of thriving after depression is jarring since survey data show that patients with depression seek more than the simple absence of distress and disorder. They want to love and be loved, be engaged in the present moment, extract joy and meaning, and do something that matters – something that makes the pain and setbacks of daily life worthwhile. Isn't the point of intervention to help people unlock their potential despite a mental disorder?
We discovered that psychology and psychiatry have a blind spot for good outcomes. This blind spot is larger than depression. It covers suicidal gestures, substance use problems, anxiety and eating disorders. It covers most major mental health problems. In all these cases, we found a lack of even the most basic estimates of how many people go on to fully recover and flourish in their lives.
We believe that until this blind spot is filled in, therapists and physicians should tread more lightly. People experiencing problems in treatment settings are routinely told their condition has a grim prognosis. Until we know how common flourishing is, such pronouncements are misinformed, even hurtful. They do not serve patients well.
People need to see other human beings as they are, which often differs from our intuition, expert opinions and the inner monologue that plagues us when we experience the depths of depression or any emotional disturbance. Our new view about the possibilities after depression is not only a closer fit to existing scientific evidence, it also happens to be more hopeful.