The public “deserve to know” that there is an overlooked subset of people who thrive after major depression

GettyImages-523561713.jpgBy Emma Young

Depression is a chronic, recurrent, lifelong condition. Well, that’s the current orthodox view – but it is overstated, argues a team of psychologists led by Jonathan Rottenberg at the University of South Florida. “A significant subset of people recover and thrive after depression, yet research on such individuals has been rare,” they write in their recent paper in Perspectives on Psychological Science. They propose a definition for “high functioning after depression” (HFAD); argue that the advice given to people with depression need not be so gloomy; and lay out key areas for future research.

The “gloomy” view of depression is relatively recent, the researchers argue. Just a generation or two ago, conventional wisdom held that depression was the opposite – transient and self-limiting. “But what if neither the older orthodoxy nor the new view of depression fully captures the truth?”, Rottenberg and his colleagues ask. “What if, instead, two variants of depression operate simultaneously – a grim chronically-recurring, lifelong variant, and a relatively benign, time-limited variant?” 

Long-term studies certainly suggest that a substantial population of people are affected by a burdensome, recurrent form of the disorder. But Rottenberg’s team cite three studies finding that an average of 40 to 50 per cent of people who suffer an episode of depression don’t go on to experience another (for example, this study in Sweden) – but overall these individuals have been little studied. “This omission, and the field’s lack of focus on good outcomes after depression more broadly, virtually guarantees an unduly pessimistic impression of depression’s course”, Rottenberg and co write – and this is an impression they would like to see changed. 

HFAD has been overlooked in part, they argue, because researchers, influenced by the current view, have focused on finding factors associated with chronicity and recurrence. Also, people with recurrent depression are highly likely to be over-represented in depression studies simply because, when researchers put a call out for subjects with depression, these people are statistically more likely to be suffering at the time, and so to be recruited.

To be categorised as experiencing HFAD requires more than simply remitting or recovering from the symptoms of major depression for at least a year, Rottenberg and his colleagues add. An individual must also have achieved “high end-state functioning” – doing well at work and home and socially, and reporting “robust” wellbeing – feeling satisfied with life and enjoying high levels of self-acceptance, for instance.

With such powers of recovery, what leads people who exhibit HFAD to become depressed in the first place? “One hypothesis might be that HFAD represents a more psychosocial form of depression that is more likely to be precipitated by environmental adversity, such as death, a break up of a romantic relationship or a job loss,” the team suggest.

Whether or not this is the case clearly needs exploring. And they point to other big questions. For instance: Are people who are HFAD more likely to have sought help while they were depressed? Does depression itself play a role in triggering  the long-term improvement seen in HFAD? (Something similar has been proposed for trauma). Can we apply what is learnt about HFAD to enhance clinical interventions? 

What does HFAD tell us about thriving after other mental disorders? 

There are clearly a lot of questions. But here, at least, is a framework for finding potentially useful answers. 

“One reason HFAD needs to be discussed,” the researchers write, “is that it is part of the truth, which patients and the broader public are owed. It would be odd if an oncologist did not tell a cancer patient his or her chances of achieving lifetime remission. We submit that a depressed patient also deserves to know. The public deserves to know as well.” 

The Curious Neglect of High Functioning After Psychopathology: The Case of Depression

Emma Young (@EmmaELYoung) is Staff Writer at BPS Research Digest

9 thoughts on “The public “deserve to know” that there is an overlooked subset of people who thrive after major depression”

  1. Surly an important element here is to think about why this has changed ‘The “gloomy” view of depression is relatively recent, the researchers argue. Just a generation or two ago, conventional wisdom held that depression was the opposite – transient and self-limiting’
    could it be that a transient issue is not as profitable for the mental health industry? we do not have personal disorders but understandable reactions to suffering in life – the mental health industry after a century of clinical psychology hundreds of made up talk therapies, disorders and drugs – so called cutting edge treatments and do we see greater well-being no its the opposite because it is the culture that is disordered not us We are all in dynamic interactions with self and world to label a person as disordered while hiding the world from view of reducing it to a ‘trigger’ is clearly doing us more harm than good

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  2. I agree there should be more research on the reality of how people experience depression over their lifetime. It seems to me “depression” is an umbrella term that covers many different experiences. I have read that the majority of people who experience depression will have a relatively mild episode and recover without treatment. However some people will have moderate to severe depression, where treatment is needed.

    I became depressed in my early 20s although this was not diagnosed until my early 40s. I had long term treatment, including medication, ECT and psychotherapy. There was a pattern of ups and downs, which my psychiatrist referred to as “double depression” – severe episodes interspersed with periods of apparent remission to a state of chronic low-level depression, which I perceived as being normal. I did have 6 months of what I called “an extraordinary good mood” and my psychiatrist called “an ordinary good mood – it’s just that you have never experienced it before”. That was followed by a catastrophic crash, with years of severe depression following. Then I made what I regard as a recovery, when I was 60. My psychiatrist was cautious. He said if it is a genuine recovery, this means I am unlikely to have a recurrence. But if it is a remission, further depressive episodes are to be expected.

    My recovery has now continued for 7 years. I believe that I have reached the state of being high functioning, as described in the article. I continue to see my psychiatrist, firstly because it is his job to monitor me and be vigilant about signs of becoming depressed again. But secondly, because I still need psychotherapy to deal with the change in my life. For example, I have long described myself as “a born introvert” and my brother as “a born extrovert”. I now think that I too was “a born extrovert”, but became introverted and inhibited very early in childhood. My current experience, since my recovery, is that I am very sociable and outgoing, connected to other people and very creative and productive in my activities. Life has never been better.

    However, what I have to come to terms with is the re-definition of who I am, and the realisation of the enormity of my loss, due to the impact of chronic depression. Since my 30s I have not had an intimate relationship, and have never had children, even though I now think I am the sort of person who would have been suited to a long-term committed relationship. This is a huge loss. I now wonder whether it is still a possibility, at the age of 67. Having children is not, but I do now have some nurturing relationships with young adult students. I am now being very productive in my working life, making a success of creative projects, whereas when .i was depressed I was not able to bring opportunities to a successful outcome. This is also a huge loss to come to terms with.

    I have an understanding of what brought my recovery about, following 5 years of being mentally and physically shut down, to a point where my life ground to a halt. If the proposed research is going to be helpful, it will have to be qualitative, in-depth and nuanced, to take account of the range of experiences of depression, and the difference between remission and recovery. It will also have to take the pattern of changes which take place over a lifetime.

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  3. If I remember correctly, Robert Whitaker in Anatomy of an Epidemic argued that most people suffering an episode of depression used to fully recover. (He suggested that anti-depressants are responsible for changing this, which is obviously controversial; even if that is true, I’d suspect other factors are also at play – eg worse/depressogenic diet, decreased social connectedness).

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  4. Almost perfect description of my personal experience: one massive five year bout of such severe depression I could barely function, followed by a growing resilience, professional success, and a great deal of contentment, enjoyment, satisfaction, and continuing sense of purpose. The trigger I’ve always seen as social dislocation (home to college – smoggy north of England to Brighton psychedelia) followed by loss of the career I’d expected through changes in undergraduate funding policy. There are echoes from time to time, little reverberations, but nothing so utterly numbing and debilitating as that dreadful late 60s/early 70s descent into nihilistic nothingness. It resolved untreated. Maybe I’m an HFAD, maybe depression kickstarted everything else, or maybe life would have been even better if it hadn’t happened. It’s intriguing to think there may be commonalities among such a group; understanding them may ultimately benefit people whose depression is recurring.

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  5. I mirror the earlier posts
    Relapsing depression since first episode at 14 years old.
    Now 50 years old, 20 years service as a CBT therapist in the NHS, establishing Lancashire Mindfulness CIC (www.lancashiremindfulness.co.uk) when provision was removed from IAPT NHS provision in 2015.
    I still struggle with relapses, this year was a quite bad relapse April to October but still manage to make a difference to peoples lives when I can.
    So important to conduct more hopeful research.
    Thank YOU

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