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The Curious Neglect of High Functioning After Psychopathology: The Case of Depression
Abstract
We address a key issue at the intersection of emotion, psychopathology, and public health—the startling lack of attention to people who experience benign outcomes, and even flourish, after recovering from depression. A rereading of the epidemiological literature suggests that the orthodox view of depression as chronic, recurrent, and lifelong is overstated. A significant subset of people recover and thrive after depression, yet research on such individuals has been rare. To facilitate work on this topic, we present a generative research framework. This framework includes (a) a proposed definition of healthy end-state functioning that goes beyond a reduction in clinical symptoms, (b) recommendations for specific measures to assess high functioning, and (c) a road map for a research agenda aimed at discovering how and why people flourish after emotional disturbance. Given that depression remains the most burdensome health condition worldwide, focus on what makes these excellent outcomes possible has enormous significance for the public health.
... Overall, the stereotyped and prejudiced notion that persons with mental illness lack the ability to understand their illness or successfully recover tends to accompany public stigma, leading to discriminatory behaviors (Corrigan, 2000;Day et al., 2007;Hinshaw & Cicchetti, 2000;Gesicki & Nelson-Becker, 2018;Liberman & Kopelowicz, 2005;Noordsy et al., 2002;Rottenberg et al., 2018;Walsh & Foster, 2020). Overt discrimination is most easily displayed by those who possess more social, economic, and/or political power than persons with mental illness (Link & Phelan, 2001). ...
... Regardless of terminology, positive psychosocial functioning is not typically viewed as an attainable, worthy goal compared with prolonging relapses or recurrence of mental illness symptomatology (Gesicki & Nelson-Becker, 2018;Harvey & Bellack, 2009;Liberman & Kopelowicz, 2005;Rottenberg et al., 2018). When positive psychosocial functioning is indeed pursued, strict and objective criteria are typically used to gauge success (Harvey & Bellack, 2009). ...
... A person with schizophrenia is deemed a "schizophrenic," a person with bipolar disorder "is" bipolar, a person experiencing psychosis "is" psychotic, and so on. Inconsistent language regarding stages of recovery (e.g., being in "partial" or "full" remission, relapse vs. recurrence) also play a role in stigmatizing this population by insinuating mental illness is tied to identity or that a normal, stable life cannot be attained (Frank et al., 1991;Gesicki Nelson & Becker, 2018;Liberman & Kopelowicz, 2005;Rottenberg et al., 2018). ...
Persons with mental illness are highly susceptible to experiencing public, anticipated, and internalized mental illness stigma, which can manifest in a myriad of ways to negatively affect quality of life, treatment outcomes, and attainment of personally meaningful goals. Research also shows that the impostor phenomenon and rumination are prominent cognitive processes experienced by persons with mental illness in unique ways. This is the first study to examine the relationship among all three psychological constructs. Survey data were collected from an online sample of 90 participants with one or more professionally diagnosed mental illnesses. Mental illness stigma was assessed with the Inventory of Stigmatizing Experiences and the Internalized Stigma of Mental Illness scale. The impostor phenomenon was assessed with the Leary Impostorism Scale, and rumination was assessed with the Scott-McIntosh Rumination Inventory. Correlational analyses revealed that public, anticipated, and internalized mental illness stigma scores were significantly correlated with both impostor phenomenon and rumination scores. Impostor phenomenon scores were significantly correlated with rumination scores as well. Moderated multiple regression models revealed that the impostor phenomenon moderated the relationship between public mental illness stigma and the distraction dimension of rumination. These results add to the growing body of evidence documenting the nuanced ways in which stigma interacts with other psychological factors to impact persons with mental illness.
... Adding more follow-up points in longitudinal studies will allow researchers to establish the stability and duration of periods of well-being (and ultimately enable work that identifies what can prolong periods of good functioning). Finally, although we have made the case for specific conservative cutoffs for defining thriving (Rottenberg et al., 2018;e.g., the 75th percentile in a nondisordered population), further work is needed to refine how good outcomes are defined. • • Improve prediction in mental-health research: A relatively small evidence base consistently suggests that people who report emotional, psychological, and social well-being will be protected from mental illness, whereas those who report low levels of well-being are at increased risk for mental illness (e.g., Wood & Joseph, 2010). ...
... An important and influential article outlining a broader conceptualization of mental health that goes beyond the reduction of symptoms. Rottenberg, J., Devendorf, A. R., Kashdan, T. B., & Disabato, D. J. (2018). (See References). ...
... Note: InRottenberg et al. (2018) andRottenberg et al. (2019), we reported analyses of data from the second wave of the National Survey of Midlife Development in the United States. The table shows the scales used, with examples of the items (seeRyff et al., 2021). ...
If one struggles with depression, anxiety, or suicidal impulses, what is the best outcome that one can hope for? Can psychopathology be a bridge to a better place where people operate with autonomy and self-mastery, enjoy healthy relationships, experience frequent positive emotions, and view life as meaningful and purposeful? Studies of national samples have revealed that a substantial number of people with depression, panic disorder, and suicidal impulses go on to achieve high levels of psychological well-being. We consider the practical and theoretical implications of these findings and call for a transformational mental-health agenda that focuses on good outcomes.
... There are several reasons to incorporate measures of well-being and functioning into studies of clinical outcome rather than solely relying on symptom measures (McKnight & Kashdan, 2009;Rottenberg et al., 2018). First, contrary to assumptions that symptoms are sufficient proxies for functioning, levels of psychiatric symptoms correlate only modestly with well-being and functional impairment (McKnight et al., 2016;McKnight & Kashdan, 2009;Ryff & Keyes, 1995), and although traditional psychotherapy interventions (e.g., cognitivebehavioral therapy) reduce symptoms, they are less effective at repairing well-being (Widnall et al., 2020). ...
... The relative neglect of well-being and functioning assessments in psychopathology research motivated our team to consider long-term well-being after psychopathology. Because few studies have considered the prevalence of high functioning after psychopathology, including OWB, we developed rigorous criteria to operationalize OWB (Rottenberg et al., 2018;Tong et al., 2021), informed by prior work on self-determination theory, well-being, and quality of life (Keyes, 2002;Ryff, 1989). Research from these interrelated literatures suggest that a set of psychological needs must be satisfied for effective functioning and psychological health. ...
... We defined good outcomes after psychopathology with an approach involving population-based norms (for details, see Rottenberg et al., 2018). OWB after a mental-health diagnosis required four elements: (a) a lifetime history of a mental-health diagnosis; (b) absence of a 12-month mental-health diagnosis; (c) high wellbeing, indicated by exceeding population-based norms on psychological well-being (top quartile on the Mental Health Continuum-Short Form [MHC-SF]; Lamers et al., 2011); and (d) low functional impairment, indicated by population-based norms on disability measures (bottom quartile on World Health Organization Disability Assessment Schedule [WHODAS] 2.0; Üstün et al., 2010). ...
Optimal functioning after psychopathology is understudied. We report the prevalence of optimal well-being (OWB) following recovery after depression, suicidal ideation, generalized anxiety disorder, bipolar disorder, and substance use disorders. Using a national Canadian sample (N = 23,491), we operationalized OWB as absence of 12-month psychopathology and scoring above the 25th national percentile on psychological well-being and functioning measures. Compared with 24.1% of participants without a history of psychopathology, 9.8% of participants with a lifetime history of psychopathology met OWB. Adults with a history of substance use disorders (10.2%) and depression (7.1%) were the most likely to report OWB. Persons with anxiety (5.7%), suicidal ideation (5.0%), bipolar 1 (3.3%), and bipolar 2 (3.2%) were less likely to report OWB. Having just one lifetime disorder increased the odds of OWB by 4.2 times relative to multiple lifetime disorders. While psychopathology substantially reduces the probability of OWB, many individuals with psychopathology attain OWB.
... Little is known regarding the prevalence of high levels of psychological well-being after a mental health diagnosis (Wood and Tarrier, 2010;Rottenberg et al., 2018). Well-being can broadly be conceptualized as "[the] perceived enjoyment and fulfillment with one's life as a whole" (Disabato et al., review), and subsumes elements such as positive emotions (e.g., happiness), life satisfaction, purpose in life, and close social relationships (for different models of well-being, see Diener, 1984;Ryff, 1989;Keyes et al., 2002). ...
... Given the importance of well-being as an outcome, our research team has drawn from models of well-being and human functioning (Diener, 1984;Ryan and Deci, 2001;Ryff, 1989) to outline criteria to define OWB after psychology (Rottenberg et al., 2018). These criteria implement a population-based norms approach containing three elements: 1) a lifetime history of a mental health diagnosis, 2) the absence of a 12-month mental health diagnosis, and 3) high well-being, indicated by exceeding the top quartile of population-based norms on a battery of psychological-well-being measures (see Rottenberg et al., 2018 for extended discussion of the population-based approach). ...
... Given the importance of well-being as an outcome, our research team has drawn from models of well-being and human functioning (Diener, 1984;Ryan and Deci, 2001;Ryff, 1989) to outline criteria to define OWB after psychology (Rottenberg et al., 2018). These criteria implement a population-based norms approach containing three elements: 1) a lifetime history of a mental health diagnosis, 2) the absence of a 12-month mental health diagnosis, and 3) high well-being, indicated by exceeding the top quartile of population-based norms on a battery of psychological-well-being measures (see Rottenberg et al., 2018 for extended discussion of the population-based approach). ...
Background: Although preliminary research has explored the possibility of optimal well-being after depression, it is unclear how rates compare to anxiety. Using Generalized Anxiety Disorder (GAD) and Panic Disorder (PD) as exemplars of anxiety, we tested the rates of optimal well-being one decade after being diagnosed with an anxiety disorder. Based on reward deficits in depression, we pre-registered our primary hypothesis that optimal well-being would be more prevalent after anxiety than depression as well as tested two exploratory hypotheses.Method: We used data from the Midlife in the United States (MIDUS) study, which contains a nationally representative sample across two waves, 10 years apart. To reach optimal well-being, participants needed to have no symptoms of GAD, PD, or major depressive disorder (MDD) at the 10 year follow-up and exceed cut-offs across nine dimensions of well-being.Results: The results failed to support our primary hypothesis. Follow-up optimal well-being rates were highest for adults previously diagnosed with MDD (8.7%), then PD (6.1%), and finally GAD (0%). Exploratory analyses revealed optimal well-being was approximately twice as prevalent in people without anxiety or depression at baseline and provided partial support for baseline well-being predicting optimal well-being after anxiety. Results were largely replicated across different classifications of optimal well-being.Limitations: Findings are limited by the somewhat unique measurement of anxiety in the MIDUS sample as well as the relatively high rate of missing data.Conclusions: We discuss possible explanations for less prevalent optimal well-being after anxiety vs. depression and the long-term positivity deficits from GAD.
... Little is known regarding the prevalence of high levels of psychological well-being after a mental health diagnosis (Wood and Tarrier, 2010;Rottenberg et al., 2018). Well-being can broadly be conceptualized as "[the] perceived enjoyment and fulfillment with one's life as a whole" (Disabato et al., review), and subsumes elements such as positive emotions (e.g., happiness), life satisfaction, purpose in life, and close social relationships (for different models of well-being, see Diener, 1984;Ryff, 1989;Keyes et al., 2002). ...
... Given the importance of well-being as an outcome, our research team has drawn from models of well-being and human functioning (Diener, 1984;Ryan and Deci, 2001;Ryff, 1989) to outline criteria to define OWB after psychology (Rottenberg et al., 2018). These criteria implement a population-based norms approach containing three elements: 1) a lifetime history of a mental health diagnosis, 2) the absence of a 12-month mental health diagnosis, and 3) high well-being, indicated by exceeding the top quartile of population-based norms on a battery of psychological-well-being measures (see Rottenberg et al., 2018 for extended discussion of the population-based approach). ...
... Given the importance of well-being as an outcome, our research team has drawn from models of well-being and human functioning (Diener, 1984;Ryan and Deci, 2001;Ryff, 1989) to outline criteria to define OWB after psychology (Rottenberg et al., 2018). These criteria implement a population-based norms approach containing three elements: 1) a lifetime history of a mental health diagnosis, 2) the absence of a 12-month mental health diagnosis, and 3) high well-being, indicated by exceeding the top quartile of population-based norms on a battery of psychological-well-being measures (see Rottenberg et al., 2018 for extended discussion of the population-based approach). ...
Background
: Although preliminary research has explored the possibility of optimal well-being after depression, it is unclear how rates compare to anxiety. Using Generalized Anxiety Disorder (GAD) and Panic Disorder (PD) as exemplars of anxiety, we tested the rates of optimal well-being one decade after being diagnosed with an anxiety disorder. Based on reward deficits in depression, we pre-registered our primary hypothesis that optimal well-being would be more prevalent after anxiety than depression as well as tested two exploratory hypotheses.
Method
: We used data from the Midlife in the United States (MIDUS) study, which contains a nationally representative sample across two waves, 10 years apart. To reach optimal well-being, participants needed to have no symptoms of GAD, PD, or major depressive disorder (MDD) at the 10 year follow-up and exceed cut-offs across nine dimensions of well-being.
Results
: The results failed to support our primary hypothesis. Follow-up optimal well-being rates were highest for adults previously diagnosed with MDD (8.7%), then PD (6.1%), and finally GAD (0%). Exploratory analyses revealed optimal well-being was approximately twice as prevalent in people without anxiety or depression at baseline and provided partial support for baseline well-being predicting optimal well-being after anxiety. Results were largely replicated across different classifications of optimal well-being.
Limitations
: Findings are limited by the somewhat unique measurement of anxiety in the MIDUS sample as well as the relatively high rate of missing data.
Conclusions
: We discuss possible explanations for less prevalent optimal well-being after anxiety vs. depression and the long-term positivity deficits from GAD.
... Why do some depressed adults achieve excellent long-term outcomes (Rottenberg, Devendorf, Kashdan, & Disabato, 2018) and avoid a recurrent or chronic course of disorder (Monroe & Harkness, 2011)? An initial investigation found that a substantial minority (nearly 10%) of adults with depression history went on to recover and achieve high levels of psychological well-being at a 10-year follow-up (Rottenberg, Devendorf, Panaite, Disabato, & Kashdan, 2019). ...
... Why do some persons with depression achieve excellent long-term outcomes (Rottenberg, Devendorf, Kashdan, & Disabato, 2018)? In the current study, we shed light on this question with an eight-day daily process design, examining the relationship between daily wellbeing (PA and NA), involvement in daily positive events, and long-term positive outcomes for depression, including symptom reduction and elevated psychological well-being. ...
... A few limitations restrict the scope of our findings. For example, although sample size was relatively high for a daily process study, we did not have a sufficient sample of depressed persons to predict thriving as a categorical outcome at follow up (see Rottenberg et al, 2018 for a review on high functioning after depression). In fact, the smaller remaining sample with followup data likely increased the possibility for Type II error in this study. ...
We know relatively little concerning the links between the events and emotions experienced in daily life and long-term outcomes among people diagnosed with depression. Using daily diary data from the Midlife Development in the United States (MIDUS), we examined how positive daily life events and emotions influence long-term (10 years later) depression severity and well-being. Participants met criteria for major depressive disorder (MDD; n=121) or reported no depression (n=839) over the past 12-months. Participants reported positive events, socializing activities, and negative and positive affect (NA, PA) for 8 consecutive days. Relative to non-depressed adults, depressed adults reported fewer positive events (fewer positive interactions, spending less time with others), lower PA, and higher NA. Among initially depressed adults, higher baseline well-being was related to higher daily PA, lower NA, and fewer days of low reported social time; higher daily PA and positive interactions predicted higher well-being 10 years later (N=77). Variations in day-to-day events and emotions among people with depression may presage psychological functioning years later.
... This dearth of knowledge has particularly been signalled with regard to good outcome in the case of major depression. Rottenberg, Devendorf, Kashdan, and Disabato (2018) argue that a dominant perception of depression as a chronic mental illness with poor prognosis has limited the attention for high functioning patients. Consequently, the mechanisms of overcoming one the most prevalent mental conditions worldwide largely remain uncomprehended (GBD 2017 Disease andInjury Incidence andPrevalence Collaborators, 2018;Rottenberg et al., 2018). ...
... Rottenberg, Devendorf, Kashdan, and Disabato (2018) argue that a dominant perception of depression as a chronic mental illness with poor prognosis has limited the attention for high functioning patients. Consequently, the mechanisms of overcoming one the most prevalent mental conditions worldwide largely remain uncomprehended (GBD 2017 Disease andInjury Incidence andPrevalence Collaborators, 2018;Rottenberg et al., 2018). ...
... A comparative study on the perspectives of patients showing "good" and "poor" outcome found relevant similarities in patients' experiences of psychotherapy (McElvaney & Timulak, 2013), generally calling for more specified research into the relationship between these outcome classifications on the one hand and patients' underlying experiences on the other. Therefore, in the present study, we explore the change processes as experienced by patients who show good psychotherapy outcome in an RCT on the treatment of major depression, which is utilized as a representative case (cf., Rottenberg et al., 2018). Relying on the widely used classification by Jacobson and Truax to identify good outcome, we examine the perspectives of those patients who fall within the categories of "recovery" (i.e., reliable change and evolution to the non-clinical range) and "improvement" (i.e., reliable change but remaining in the clinical range) based on self-reported depression symptoms. ...
Aim: Exploring change processes underlying “good outcome” in psychotherapy for major depression. We examined the perspectives of patients who “recovered” and “improved” (Jacobson & Truax) following time-limited CBT and PDT. Method: In the context of an RCT on the treatment of major depression, patients were selected based on their pre–post outcome scores on the BDI-II: we selected 28 patients who recovered and 19 who improved in terms of depressive symptoms. A grounded theory analysis was conducted on post-therapy client change interviews, resulting in an integrative conceptual model. Results: According to recovered and improved patients, change follows from an interaction between therapy, therapist, patient, and extra-therapeutic context. Both helping and hindering influences were mentioned within all four influencing factors. Differences between recovered and improved patients point at the role of patients’ agency and patients’ internal and external obstacles. However, patients marked as “improved” described heterogeneous experiences. CBT- and PDT-specific experiences were also observed, although our findings suggest the possible role of therapist-related influences. Conclusion: From patients’ perspectives, various change processes underlie “good outcome” that do not necessarily imply an “all good process”. This supports a holistic, multidimensional conceptualization of change processes in psychotherapy and calls for more fine-grained mixed-methods process-outcome research.
... A recent article by Rottenberg, Devendorf, Kashdan, and Disabato (2018) suggested that a lack of adequate understanding of good outcome might be a particular hurdle in the attempts to understand positive change processes in the case of major depression, generally considered one of the most prevalent mental conditions worldwide (World Health Organization, 2017). The authors more specifically stated that the dominant perception of depression as a chronic mental illness with poor prognosis has resulted in a "curious neglect of high functioning after psychopathology" (p. ...
... 549) and a lack of focus on good outcomes after depression in general. To address this neglect, they argue that successful outcome requires a definition that expands the absence of clinical symptoms (Rottenberg et al., 2018; see also Zimmerman et al., 2012). ...
... Nonetheless, our findings suggest that a symptom-based distinction may not always be meaningful in light of patients' experiences, and consequently, a continuum based on outcome would still not do justice to the variety of experiences that do yield varying clinical implications. In that sense, good outcome in psychotherapy for depression seems to require a multidimensional understanding, in line with the complex and diverse experiences of depression itself (Ratcliffe, 2014;Rottenberg et al., 2018). ...
This study explored the meaning of "good outcome" within and beyond the much-used statistical indices of clinical significance in standard outcome research as developed by Jacobson and Truax (1991). Specifically, we examined the experiences of patients marked as "recovered" and "improved" following cognitive-behavioral therapy and psychodynamic therapy for major depression. A mixed-methods study was conducted using data gathered in an RCT, including patients' pre-post outcome scores on the Beck Depression Inventory-II and posttreatment client change interviews. We selected 28 patients who showed recovery and 19 patients who showed improvement in self-reported depression symptoms. A grounded theory analysis was performed on patients' interviews, ultimately resulting in a conceptual model of "good outcome." From patients' perspectives, good outcome can be understood as feeling empowered, finding personal balance and encountering ongoing struggle, indicating an ongoing process and variation in experience. The Jacobson-Truax classification of "good outcome" could not account for the (more pessimistic) nuances in outcome experiences, especially for "improved" patients, and did not grasp the multidimensional nature of outcome as experienced by patients. It is recommended that statistical indications of clinical meaningfulness are interpreted warily and ideally contextualized within personal narratives. Further research on the phenomenon of change and good outcome is required, aiming at integrating multiple perspectives and methods accordingly the multidimensional phenomenon under study. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
... The possibility of thriving after depression has been overlooked for several reasons (Rottenberg, Devendorf, Kashdan, & Disabato, 2018), including the strength of the prevailing view in epidemiology, outcome studies failing to incorporate measures of functioning or wellbeing into their designs (McKnight & Kashdan, 2009), and overrepresentation of chronic forms of depression in clinical studies (Monroe & Harkness, 2011). Therefore, the present study provided a first, direct estimate of thriving after depression using a 10-year follow up of a representative sample of the United States population. ...
... We focused on psychological well-being because it is a rich, complex, and accepted aspect of optimal human functioning that has spawned extensive research (Ryan & Deci, 2001). The MIDUS battery of well-being measures has established reliability and predictive validity (Keyes & Simoes, 2012) and possesses adequate normative data from a nationally representative sample of adults on which to base decisions (Rottenberg et al., 2018). ...
... At Wave 2, participants were classified as thriving after depression if they (a) had a depression diagnosis at Wave 1, (b) screened negative for all major symptoms of depression at Wave 2, and (c) at Wave 2, both scored > 50th percentile on at least eight of the nine well-being facets, relative to age and gender-matched sample means from the full national probability MIDUS sample at Wave 2 (N = 1805), and scored higher than the 84th percentile (i.e., at least 1 SD above the age-and sexmatched population means) on at least three of the nine well-being facets (Rottenberg et al., 2018). The eight-out-of-nine and three-out-of-nine thresholds reflect levels of well-being met by the top 25% of nondepressed persons in the MIDUS sample (see Supplemental Material). ...
Can people achieve optimal well-being and thrive after major depression? Contemporary epidemiology dismisses this possibility, viewing depression as a recurrent, burdensome condition with a bleak prognosis. To estimate the prevalence of thriving after depression in United States adults, we used data from the Midlife Development in the United States study. To count as thriving after depression, a person had to exhibit no evidence of major depression and had to exceed cutoffs across nine facets of psychological well-being that characterize the top 25% of U.S. nondepressed adults. Overall, nearly 10% of adults with study-documented depression were thriving 10 years later. The phenomenon of thriving after depression has implications for how the prognosis of depression is conceptualized and for how mental health professionals communicate with patients. Knowing what makes thriving outcomes possible offers new leverage points to help reduce the global burden of depression.
... What Is Needed Next need 1: think more broadly about outcomes after nonfatal suicide attempts Broadly in psychology and psychiatry research, traditional clinical end points refer to the presence or absence of symptoms when evaluating mental health (Suldo & Shaffer, 2008), typically with sypmtom reduction rather than a state of wellbeing considered as the primary outcome (Keller, 2003). 2 In one sense, that is as it should be, due to the potential asymmetry involving how ominous risk presentations can be, and how ineffectual even clear buffering factors can be in the face of such presentations. Meanwhile, many scholars have argued that the presence of wellbeing should be assessed in addition to the absence of disorders when evaluating mental health or assessing the success of an intervention (Keyes, 2005), since (a) the presence of well-being uniquely contributes to the assessment of mental health and is not merely the opposite of psychopathology (Huppert, 2009;Trompetter et al., 2017); and (b) the presence of positive mental health has been shown to contribute to adaptive functioning and protect against psychopathology, such as depression (Rottenberg et al., 2018;Wood & Joseph, 2010). ...
... Establishing the third criterion is more complex because the concept of "well-being" is multifaceted and sometimes contested (Kashdan et al., 2008). Frameworks using Diener's (1984) subjective well-being and Ryff's (1995) psychological well-being models offer some of the bestaccepted approaches (Rottenberg et al., 2018). In a recent study, nine facets are used to operationalize psychological well-being after depression: life satisfaction, autonomy, environmental mastery (self-direction and productivity), personal growth and improvement, positive social relationships, purpose in life, self-acceptance, positive emotions, and low levels of negative emotions (Rottenberg et al., 2019). ...
Over 48,000 people died by suicide in 2018 in the United States, and more than 25 times that number attempted suicide. Research on suicide has focused much more on risk factors and adverse outcomes than on protective factors and more healthy functioning. Consequently, little is known regarding relatively positive long-term psychological adaptation among people who attempt suicide and survive. We recommend inquiry into the phenomenon of long-term well-being after non-fatal suicide attempts, and we explain how this inquiry complements traditional risk research by (a) providing a more comprehensive understanding of the sequelae of suicide attempts, (b) identifying protective factors for potential use in interventions and prevention, and (c) contributing to knowledge and public education that reduces the stigma associated with suicide-related behaviors.
... Chronic presentations were significantly more common than presentations that portrayed depression as temporary or acute and lasting less than one year (see Table 8); 32.5% of all videos presented depression as recurring. These findings support hypotheses of depression presented as a chronic and recurrent condition (Rottenberg, Devendorf, Kashdan, & Disabato, 2018). ...
... Additionally, our findings that informal treatments (diet/exercise, alternative, and mindfulness practices) in YouTube content were relatively common and more endorsed than traditional treatments (medication, therapy) aligns with community surveys from Australia and Canada (Jorm et al., 2005;Wang, Fick, Adair, & Lai, 2007). Finally, similar to what we observed with YouTube content, there is also evidence that laypeople and patients view depression as categorical (Wood et al., 2014), chronic (Baines & Wittkowski, 2013;Rottenberg et al., 2018) but treatable (Baines & Wittkowski, 2013), and recurrent (Kirk, Haaga, Solomon, & Brody, 2000). ...
We review knowledge concerning public presentations for depression. These presentations impact illness beliefs and may influence public stigma, self-stigma, and depression literacy. We provide a critical review of messages, images, and information concerning depression’s causes, continuum conceptualization, timeline, curability, coping/treatment regimen, and strengths. To provide data regarding the prevalence of particular presentations, we conducted a content analysis of 327 videos about depression representative of material on the YouTube social media platform. YouTube presentations of depression indicate that depression: 1) is caused by either biological (49.5%) or environmental (41.3%) factors; 2) is a categorical construct (71%); 3) is treatable, with 61% of relevant videos (n=249) presenting recovery as “likely”; 4) is chronic, found in 76% of videos mentioning timeline; 5) is recurrent (32.5%); 6) is mostly treated via medication (48.6%) or therapy (42.8%), although diet/exercise (29.4%) and alternative treatments (22.6%) are commonly endorsed; and 7) is rarely associated with strength (15.3%). We discuss how these presentations may influence stigmatizing attitudes and depression literacy among people with and without depression and suggest future research directions to better understand how to optimize public presentations. Ultimately this work may help to decrease stigma, increase depression literacy, and improve social support and treatment seeking behaviors.
... Even with better treatments being more widely available, its impact on the prevalence is dependent on how optimal they are targeted. Crucial here is the distinction between recurrent-chronic cases and those with one or two lifetime episodes (nonrecurrent cases) since effective treatment of recurrent-chronic cases has much more impact at the population level than effective treatment of nonrecurrent cases, even if the nonrecurrent cases by far outnumber the recurrent-chronic cases [70][71][72][73][74]. The reason for the larger population-level impact is that recurrent-chronic cases make up the majority in prevalence rates as the total time during their life that they meet diagnostic criteria is much longer than for the nonrecurrent cases because of which they have a much higher Psychother Psychosom DOI: 10.1159/000528544 probability to be picked up in epidemiological prevalence studies. ...
... Non-recurrent cases, too, may have benefitted from their depressive experiences. Evolutionary theory proposes that the capability for becoming depressed enhances survival of the immediate threat, potentially 'steeling' the person for surviving future threats (Andrews & Thomson, 2009;Hollon, Andrews, Singla, Maslej, & Mulsant, 2021;Gut, 1989;Keller, 2018;Monroe & Harkness, 2011;Nesse, 2000;Rottenberg et al., 2018). Conceivably, recurrences could become even less likely to happen if severely stressed again. ...
Major depression is one of the most prevalent and debilitating personal and public health conditions worldwide. Less appreciated is that depression's tremendous burdens are not shared equally among all who become depressed. Some will suffer recurrences over the rest of their lives, whereas half or more will never have a recurrence. Based on these two distinctive life course prototypes, we propose a subtype distinction for research on the origins and lifetime course of major depression. A pressing goal is to determine at the time of depression's first onset who will follow which clinical trajectory. The lack of recognition of this distinction has resulted in many obstacles, including conceptual biases, methodological oversights, and definitional dead ends. Current theories are reviewed and compared. The implications for contemporary diagnostic controversies, reevaluating research on treatment and prevention, and enhancing the predictive strength of traditionally weak indicators of recurrences and recurrent depression are discussed.
Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
... Furthermore, the sustainability of outcomes may benefit from a broader look on outcome measures in depression (Johnson & Wood, 2017;Rottenberg, Devendorf, Kashdan, & Disabato, 2018). For example, a lower risk of symptomatic relapse was found in individuals with higher psychosocial functioning (Solomon et al., 2004) and quality of life (IsHak, Greenberg, & Cohen, 2013). ...
Introduction
An important aspect of depression relapse prevention programs is identifying personalized warning signals (PWS). These PWS are typically defined as depressive symptoms. Yet, no study has investigated to what extend PWS fit within the diagnostic classification framework, and how this compares to a more transdiagnostic, integrative approach towards depression.
Objectives
To examine how well PWS reflect depressive symptoms, describe the remaining PWS, and examine how well PWS can be assigned to domains of an existing transdiagnostic and integrative framework, the positive health concept.
Methods
162 PWS of 66 individuals with a history of depression were labeled as one or more symptoms of depression or to a residual category. The same process was repeated for labeling the domains of the positive health model. Labeling was done by three independent reviewers (inter-rater percent agreement: symptoms: 0.83 & positive health domains: 0.73). Disagreements were resolved by discussion.
Results
The three most commonly reported depressive symptoms were insomnia/hypersomnia, anhedonia and fatigue/loss of energy. However, sixty-five percent of the PWS were not depressive symptoms, but other symptoms (e.g. irritability, rumination) or aspects of functioning (e.g. withdrawing, managing time). The positive health domains captured all the PWS. However, 44% of PWS were labeled as multiple positive health domains, whereas labeling as symptoms of depression resulted in almost no such overlap.
Conclusions
A more transdiagnostic and integrative approach seems necessary to capture PWS. Depending on one’s purpose, one may consider expanding the definition with other symptoms and aspects of functioning, or using the positive health concept.
... For instance, it has been shown that about half of all people with depression have one single episode and fully recover thereafter; others, however, have recurrent episodes and a small minority (about 10-15%) even has a chronic course (Steinert et al., 2014;ten Have et al., 2018). The most important research question therefore is why some people fully recover, even flourish after going through emotional disturbances (Rottenberg et al., 2018), while others do not. Our results also have clinical and public health implications highlighting the need for early identification and treatment of DD, AD and SUD. ...
Background and objective.
Studies exploring longitudinal reciprocal associations between depressive, anxiety, and substance use disorders (DD, AD and SUD, respectively) over long periods of time are mainly lacking. Therefore, the aim of the present study is to test longitudinal associations (i.e. temporal dynamics) between DD, AD and SUD from young adulthood to middle adulthood.
Methods.
A stratified community sample of 591 participants from the canton of Zurich, Switzerland, was interviewed with the Structured Psychopathological Interview and Rating of the Social Consequences of Psychological Disturbances for Epidemiology over seven interview waves from ages 20/21 to 49/50. Diagnostic and Statistical Manual of Mental Disorders criteria were used to evaluate the presence of DD, AD and SUD. We fitted an auto-regressive cross-lagged path analysis within a Bayesian structural equation model to test longitudinal associations.
Results.
Regarding autoregressive effects, AD (except during young adulthood) and SUD predicted themselves over the entire time period, while DD recurrently predicted itself not consistently over time. Regarding cross-lagged effects, DD predicted SUD at different time points, and vice versa. DD predicted subsequent AD in adulthood, whereas the reverse did not happen. Female gender was associated with DD and AD at all ages while male gender was associated with SUD only in young adulthood.
Conclusions.
Reciprocal longitudinal associations were found between DD and SUD and DD usually preceded AD. Our results further confirm an increased risk of DD and AD in women and a higher risk of SUD in young men. Early treatment and broad psychosocial interventions should be provided in order to prevent chronicity and further maladjustment as well as interrupting the cycle of mutual reinforcement between DD and SUD.
... However, life will shed darkness over all of us, but should not leave us without hope. Therefore, it is essential to underscore that there are some bright sides to struggling with darkness, such as the likelihood for post-traumatic growth (353), possibility for high functioning (354), and resilience (355). ...
... Positive mental health assets such as character strengths may provide clinicians new resources to help individuals manage their illness (Macaskill and Denovan, 2014). The systemic neglect of functioning after depression is emerging in the literature (Rottenberg et al., 2018), and positive mental health and the dual-continua of mental health could facilitate the shift in recovery narrative (Slade, 2010). ...
The dual-continua model of mental health suggests that mental illness and positive mental health reflect distinct continua, rather than the extreme ends of a single spectrum. The aim of this review was to scope the literature surrounding the dual-continua model of mental health, to summarise the evidence, highlight the areas of focus for individual studies and discuss the wider implications of the model. A search was conducted in PsycINFO (n = 233), PsycARTICLES (n = 25), Scopus (n = 137) and PubMed (n = 47), after which a snowballing approach was used to scope the remaining literature. The current scoping review identified 83 peer-reviewed empirical articles, including cross-sectional, longitudinal and intervention studies, which found overall support for superior explanatory power of dual-continua models of mental health over the traditional bipolar model. These studies were performed in clinical and non-clinical populations, over the entire life-course and in Western and non-Western populations. This review summarised the evidence suggesting that positive mental health and mental illness are two distinct but interrelated domains of mental health; each having shared and unique predictors, influencing each other via complex interrelationships. The results presented here have implications for policy, practice and research for mental health assessment, intervention design, and mental health care design and reform.
... Furthermore, the sustainability of outcomes may benefit from a broader look on outcome measures in depression (Johnson & Wood, 2017;Rottenberg, Devendorf, Kashdan, & Disabato, 2018). For example, a lower risk of symptomatic relapse was found in individuals with higher psychosocial functioning (Solomon et al., 2004) and quality of life (IsHak, Greenberg, & Cohen, 2013). ...
Responses to evidence-based interventions for depression are divergent: Some patients benefit more than others during treatment and some do not benefit at all or even deteriorate. Tailoring interventions to the individual may improve outcomes. However, such personalization of evidence-based treatment in depression requires investigation of individual outcomes and the individual trajectories towards these outcomes.
This theoretical paper provides a critical reflection on individual outcomes of depression treatment. First, it is argued that outcomes should be broadened, from a focus on mainly depressive symptomatology to recovery ion different domains. It is acknowledged that recovery from depression reflects a personal journey that differs from person to person. Second, outcome measures should be lengthened beyond the acute treatment phase, taking a lifetime perspective on depression. The challenge then becomes isis to discovering which trajectories of what measures during what interventions result in personalized sustainable recovery and for whom.
Routine outcome monitoring systems may be used to inform this quest towards assessment of personalized sustainable therapeutic outcomes. Adaptations to broaden and lengthen measurements in routine outcome monitoring systems are proposed to identify predictors of personalized sustainable recovery. Routine outcome monitoring systems may eventually be used to implement personalized treatments for depression that result in personalized sustainable recovery.
... Furthermore, the sustainability of outcomes may benefit from a broader look on outcome measures in depression (Johnson & Wood, 2017;Rottenberg, Devendorf, Kashdan, & Disabato, 2018). For example, a lower risk of symptomatic relapse was found in individuals with higher psychosocial functioning (Solomon et al., 2004) and quality of life (IsHak, Greenberg, & Cohen, 2013). ...
Responses to evidence-based interventions for depression are divergent: Some patients benefit more than others during treatment and some do not benefit at all or even deteriorate. Tailoring interventions to the individual may improve outcomes. However, such personalization of evidence-based treatment in depression requires investigation of individual outcomes and the individual trajectories towards these outcomes.
This theoretical paper provides a critical reflection on individual outcomes of depression treatment. First, it is argued that outcomes should be broadened, from a focus on mainly depressive symptomatology to recovery ion different domains. It is acknowledged that recovery from depression reflects a personal journey that differs from person to person. Second, outcome measures should be lengthened beyond the acute treatment phase, taking a lifetime perspective on depression. The challenge then becomes isis to discovering which trajectories of what measures during what interventions result in personalized sustainable recovery and for whom.
Routine outcome monitoring systems may be used to inform this quest towards assessment of personalized sustainable therapeutic outcomes. Adaptations to broaden and lengthen measurements in routine outcome monitoring systems are proposed to identify predictors of personalized sustainable recovery. Routine outcome monitoring systems may eventually be used to implement personalized treatments for depression that result in personalized sustainable recovery.
... Nonetheless, the number of components is an unexplored measure of psychopathological networks, and the meaning of these changes does not currently have a theoretical foundation to enable us to derive a decisive conclusion regarding its importance for psychopathological networks. In fact, in most cases, after a successful therapeutic process, the remission of symptoms is not total (see Rottenberg et al., 2018 for an example in depression), so it is fair to assume that these symptoms might still be forming separate components. Connectivity within these components might still be high, so the change in connectivity is not particularly noticeable, and an increase in the number of components might be a better measure for therapeutic success. ...
The network model of psychopathology suggests that central and bridge symptoms represent promising treatment targets because they may accelerate the deactivation of the network of interactions between the symptoms of mental disorders. However, the evidence confirming this hypothesis is scarce. This study re-analyzed a convenience sample of 51 cross-sectional psychopathological networks published in previous studies addressing diverse mental disorders or clinically relevant problems. In order to address the hypothesis that central and bridge symptoms are valuable treatment targets, this study simulated five distinct attack conditions on the psychopathological networks by deactivating symptoms based on two characteristics of central symptoms (degree and strength), two characteristics of bridge symptoms (overlap and bridgeness), and at random. The differential impact of the characteristics of these symptoms was assessed in terms of the magnitude and the extent of the attack required to achieve a maximum impact on the number of components, average path length, and connectivity. Only moderate evidence was obtained to sustain the hypothesis that central and bridge symptoms constitute preferential treatment targets. The results suggest that the degree, strength, and bridgeness attack conditions are more effective than the random attack condition only in increasing the number of components of the psychopathological networks. The degree attack condition seemed to perform better than the strength, bridgeness, and overlap attack conditions. Overlapping symptoms evidenced limited impact on the psychopathological networks. The need to address the basic mechanisms underlying the structure and dynamics of psychopathological networks through the expansion of the current methodological framework and its consolidation in more robust theories is stressed.
... Although the study of resilience has expanded to include social, cultural, and psychological and developmental factors that help individuals overcome hardships, scant research exists that identifies concrete, everyday behaviors or routines that individuals enact to develop resilience. About this point, research has argued not only that behavioral science tends to overlook the study of successful recoveries but that many of those who overcome or even prevent disorder may use methods of their own that are still unknown and cannot be found in any books or publications (Rottenberg, Devendorf, Kashdan, & Disabato, 2018). And yet, even when motivation is lacking, small everyday actions in the context of routines contribute to sustaining behavioral change (Gardner, Lally, & Wardle, 2012 This article describes two case studies situated in communities on the U.S.-Mexico border that used a positive deviance (PD) inquiry framework to elicit the habits or routine practices that contributed to sustained resilience in two vulnerable populations: migrant women and individuals recently released from prison. ...
In this article, we describe habits that lead to resilience. We summarize empirical findings of two projects implemented with people living in the U.S.–Mexico border region that illustrate how when facing adversity, some individuals devise simple, uncommon strategies that through practice become habits and help them adapt positively. The studies discussed used a positive deviance inquiry framework. Positive deviance focuses on finding statistical outliers—those who are successful in the face of intractable problems without the use of special resources. As an inquiry framework, positive deviance enables identification of replicable behaviors that become habits and offer an avenue for behavioral change and the cocreation of sustainable interventions. The positive deviance approach has many potential applications in public health and is a useful framework for health promotion practitioners and researchers working in diverse settings.
... Furthermore, there was a significant reduction in residual depression symptoms, d = 0.33, despite there being a restricted potential for positive change. Many studies have demonstrated the clinical importance of reducing residual depression symptoms, as they have a large impact on long-term depression outcomes (Rottenberg et al. 2018). In the absence of long- Where post-treatment PHQ-9 data were missing, the pre-treatment PHQ-9 value was carried forward a Pairwise comparisons were used to compare the pre-to post-treatment change in PHQ-9 scores between services (using Tukey HSD adjustment). ...
Abstract
Depression is common with a high risk of relapse/recurrence. There is evidence from multiple randomised controlled trials (RCTs) demonstrating the efficacy of mindfulness-based cognitive therapy (MBCT) for the prevention of depressive relapse/recurrence, and it is included in several national clinical guidelines for this purpose. However, little is known about whether MBCT is being delivered safely and effectively in real-world healthcare settings. In the present study, five mental health services from a range of regions in the UKcontributed data (n = 1554) to examine the impact ofMBCTon depression outcomes. Less than half the sample (n = 726, 47%) entered with Patient Health Questionnaire (PHQ-9) scores in the non-depressed range, the group
for whom MBCT was originally intended. Of this group, 96% sustained their recovery (remained in the non-depressed range) across the treatment period. There was also a significant reduction in residual symptoms, consistent with a reduced risk of
depressive relapse. The rest of the sample (n = 828, 53%) entered treatment with PHQ-9 scores in the depressed range. For this group, 45% recovered (PHQ-9 score entered the non-depressed range), and overall, there was a significant reduction in depression
severity from pre-treatment to post-treatment. For both subgroups, the rate of reliable deterioration (3%) was comparable to other psychotherapeutic interventions delivered in similar settings. We conclude that MBCT is being delivered effectively and
safely in routine clinical settings, although its use has broadened from its original target population to include people experiencing current depression. Implications for implementation are discussed.
... Furthermore, there was a significant reduction in residual depression symptoms, d = 0.33, despite there being a restricted potential for positive change. Many studies have demonstrated the clinical importance of reducing residual depression symptoms, as they have a large impact on long-term depression outcomes (Rottenberg et al. 2018). In the absence of long- Where post-treatment PHQ-9 data were missing, the pre-treatment PHQ-9 value was carried forward a Pairwise comparisons were used to compare the pre-to post-treatment change in PHQ-9 scores between services (using Tukey HSD adjustment). ...
Depression is common with a high risk of relapse/recurrence. There is evidence from multiple randomised controlled trials (RCTs) demonstrating the efficacy of mindfulness-based cognitive therapy (MBCT) for the prevention of depressive relapse/recurrence, and it is included in several national clinical guidelines for this purpose. However, little is known about whether MBCT is being delivered safely and effectively in real-world healthcare settings. In the present study, five mental health services from a range of regions in the UK contributed data (n = 1554) to examine the impact of MBCT on depression outcomes. Less than half the sample (n = 726, 47%) entered with Patient Health Questionnaire (PHQ-9) scores in the non-depressed range, the group for whom MBCT was originally intended. Of this group, 96% sustained their recovery (remained in the non-depressed range) across the treatment period. There was also a significant reduction in residual symptoms, consistent with a reduced risk of depressive relapse. The rest of the sample (n = 828, 53%) entered treatment with PHQ-9 scores in the depressed range. For this group, 45% recovered (PHQ-9 score entered the non-depressed range), and overall, there was a significant reduction in depression severity from pre-treatment to post-treatment. For both subgroups, the rate of reliable deterioration (3%) was comparable to other psychotherapeutic interventions delivered in similar settings. We conclude that MBCT is being delivered effectively and safely in routine clinical settings, although its use has broadened from its original target population to include people experiencing current depression. Implications for implementation are discussed.
... Childhood disorder episodes are often indicative of lifespan developments, as 75% recur during adolescence, up to an average of 9 separate episodes over their lifespan ( Burcusa et al., 2007;Rutter et al., 2011). Some studies suggests that the majority of the youth who have ever been clinically depressed will be in an episode in any given year over the remainder of their lives (Kessler & Wang, 2009), although others paint a less gloomy future ( Rottenberg et al., 2018). ...
Anxiety and depression disorders are the biggest mental health hazards of our time and in many ways closely related. The first anxiety disorder episodes emerge during childhood, while the first depression episodes more typically emerge in adolescence. Such early episodes are highly predictive for lifespan developments. This chapter reviews literature on dynamic system perspectives on anxiety and depression across scales of temporal resolution, from affect and highly contextualized emotion episodes to more persistent moods that evaluate the world as a whole, and the personality traits anxiety and depression that capture thematic recurrences of feelings, thoughts and behavior along the lifespan and how people talk about themselves. These various processes are intimately connected via their self-organizing and dynamic nature and circular causality, which demonstrates how dynamic system perspectives can help us to understand anxiety and depression across the lifespan.
From risk to resilience and from mental illness only to including mental well-being, a paradigm shift occurs within the field of clinical psychology. Resilience, consisting of recovery as well as sustainability and growth processes, pertains to the successful (and common) adaptation to adversity. This includes a return to baseline functioning or a new emotional equilibrium, as well as maintaining approach motivations toward personal values and goals. There is growing evidence that self-compassion is an inner resource that promotes resilience. Self-compassion aspects of mindfulness, self-kindness, and common humanity facilitate both short-term and long-term adaptation processes. Using examples of going through war (veterans) and going through cancer, this chapter illustrates how self-compassion can contribute to decreased mental distress (including anxiety and loneliness) and increased mental well-being (including emotional stability and self-care behaviors). Compassion-based interventions, both face-to-face and in online format, can contribute to facilitating resilience in the face of adversity. Future research should further investigate the different ways in which self-compassion can promote resilience, taking into account both mental distress and mental well-being aspects of mental health.KeywordsResilienceSelf-compassionMental well-beingMental distressCancerVeteransCompassion-based interventionsAdaptation
Emotional disturbances are well-recognized features of depression and contemporary psychotherapeutic programs offer a variety of treatment strategies directly targeting these disturbances (e.g., cognitive restructuring, decentering, acceptance). In addition to emotional disturbances, evidence increasingly points to depression also being characterized by profound bodily dysfunction. The goal of the present article is to evaluate the potential of bodily dysfunction as a treatment target in interventions aimed at alleviating emotional problems in depression. We begin by delineating two of the major yet diverging theoretical predictions about the role of the body in and for emotions. We then review evidence of bodily dysfunction in depression with a focus on inflammation, endocrine functioning, the motoric system (i.e., posture and movement), physiological reactivity, and interoception. In our review, we (a) present cross-sectional research investigating differences between healthy and clinical groups, (b) describe experimental evidence, looking at acute and long-term effects of manipulation of bodily parameters on symptoms of depression, and (c) explore longitudinal evidence on how bodily dysfunction may or may not normalize upon successful pharmacological or psychological treatment of depression. We conclude by discussing how bodily dysfunction may be shaping and constraining the emotional lives of depressed individuals and outlining how treatment aimed at alleviating emotional problems in depression may benefit from targeting bodily dysfunction.
Optimal functioning after psychopathology is understudied. We report the prevalence of optimal well-being (OWB) following recovery after depression, suicidal ideation, generalized anxiety disorder, bipolar disorder, and substance use disorders. Using a national Canadian sample ( N = 23,491), we operationalized OWB as absence of 12-month psychopathology, coupled with scoring above the 25th national percentile on psychological well-being and below the 25th percentile on disability measures. Compared with 24.1% of participants without a history of psychopathology, 9.8% of participants with a lifetime history of psychopathology met OWB. Adults with a history of substance use disorders (10.2%) and depression (7.1%) were the most likely to report OWB. Persons with anxiety (5.7%), suicidal ideation (5.0%), bipolar I (3.3%), and bipolar II (3.2%) were less likely to report OWB. Having a lifetime history of just one disorder increased the odds of OWB by a factor of 4.2 relative to having a lifetime history of multiple disorders. Although psychopathology substantially reduces the probability of OWB, many individuals with psychopathology attain OWB.
Treatments for depression have improved, and their availability has markedly increased since the 1980s. Mysteriously the general population prevalence of depression has not decreased. This “treatment-prevalence paradox” (TPP) raises fundamental questions about the diagnosis and treatment of depression. We propose and evaluate seven explanations for the TPP. First, two explanations assume that improved and more widely available treatments have reduced prevalence, but that the reduction has been offset by an increase in: 1) misdiagnosing distress as depression, yielding more “false positive” diagnoses; or 2) an actual increase in depression incidence. Second, the remaining five explanations assume prevalence has not decreased, but suggest that: 3) treatments are less efficacious and 4) less enduring than the literature suggests; 5) trial efficacy doesn't generalize to real-world settings; 6) population-level treatment impact differs for chronic-recurrent versus non-recurrent cases; and 7) treatments have some iatrogenic consequences. Any of these seven explanations could undermine treatment impact on prevalence, thereby helping to explain the TPP. Our analysis reveals that there is little evidence that incidence or prevalence have increased as a result of error or fact (Explanations 1 and 2), and strong evidence that (a) the published literature overestimates short- and long-term treatment efficacy, (b) treatments are considerably less effective as deployed in “real world” settings, and (c) treatment impact differs substantially for chronic-recurrent cases relative to non-recurrent cases. Collectively, these 4 explanations likely account for most of the TPP. Lastly, little research exists on iatrogenic effects of current treatments (Explanation 7), but further exploration is critical.
To what extent does a suicide attempt impair a person’s future well-being? We estimated the prevalence of future well-being (FWB) among suicide attempt survivors using a nationally representative sample of 15,170 youths. Suicide attempt survivors were classified as having high FWB if they reported 1) a suicide attempt at Wave I; 2) no suicidal ideation or attempts over the past year at Wave III (seven years after); 3) a well-being profile at or above the top quartile of non-suicidal peers. 75 of 574 suicide attempt survivors (∼ 13%) met criteria for FWB at Wave III, compared to 26% of non-suicidal peers. Wave I well-being levels, not depressive symptoms, predicted the likelihood of FWB at Wave III (OR = 1.23; 95% CI: 1.05-1.44; p < 0.05). In conclusion, a non-fatal suicide attempt reduced but did not preclude FWB in a large national sample. The observation that a segment of the population of suicide attempt survivors achieves FWB carries implications for the prognosis of suicidal behavior and the value of incorporating well-being into investigations of suicide-related phenomena.
Psychiatric genomics is providing insights into the nature of psychiatric conditions that in time should identify new drug targets and improve patient care. Less attention has been paid to psychiatric pharmacogenomics research, despite its potential to deliver more rapid change in clinical practice and patient outcomes. The pharmacogenomics of treatment response encapsulates both pharmacokinetic (“what the body does to a drug”) and pharmacodynamic (“what the drug does to the body”) effects. Despite early optimism and substantial research in both these areas, they have to date made little impact on clinical management in psychiatry. A number of bottlenecks have hampered progress, including a lack of large-scale replication studies, inconsistencies in defining valid treatment outcomes across experiments, a failure to routinely incorporate adverse drug reactions and serum metabolite monitoring in study designs, and inadequate investment in the longitudinal data collections required to demonstrate clinical utility. Nonetheless, advances in genomics and health informatics present distinct opportunities for psychiatric pharmacogenomics to enter a new and productive phase of research discovery and translation.
There are few studies on the predictors of long-term course of major depressive disorder (MDD) with an onset in childhood and adolescence. Studies have relied on variable-centered methods, utilizing psychosocial and clinical characteristics to predict depression outcomes. However, fewer studies have used person-centered approaches that rely on profiles of functioning to predict course and outcomes of depression. This study examined the long-term course and outcome of early onset depression as a function of profiles of psychosocial and clinical characteristics in adolescence. Participants from the Oregon Adolescent Depression Project with a history of MDD by study entry (Mage = 16.29 years) and who had follow-up assessments at age 30 were included (n = 215). Psychosocial and clinical constructs, including domains of internalizing problems, externalizing problems, correlates of internalizing problems, adolescent stress, and social support, were assessed in adolescence. Latent profile analyses found a 3-class solution with Low Negative Cognitive Style (LNCS; 27.9%); Internalizing and High Negative Cognitive Style (INT/HNCS; 53.9%); and Internalizing and High Negative Cognitive Style plus Poor Interpersonal Functioning and High Stress (INT/HNCS+ ; 18.1%). Overall, classes differed in depression morbidity, such that the INT/HNCS+ class had the greatest depression morbidity across follow-up assessments. Social adjustment differed between all classes, with the INT/HNCS+ class showing the worst functioning, the LNCS class showing the best functioning, and the INT/HNCS class falling in the middle. Patterns of clinical and psychosocial functioning were differentially associated with long-term depression and social adjustment among youth with depression.
When perceived changes in course occur, individuals can be left feeling disconnected from who they were in the past. This sensation of being “off-course” in life is an individual difference we call derailment. In this paper, we review derailment’s unique contribution to the psychological literature, the role of perceived self and identity change in mental health, and the nuanced association between derailment and depression. While depression has been emphasized in research to date, we argue for derailment’s role in other types of mental illness, motivating several exciting directions for future work. For the pervasiveness of identity in our everyday lives, the study of derailment confers opportunities for better understanding the experience of psychopathology and approaching its treatment.
Early detection of and intervention in psychoses prior to their first episode is presently based on the symptomatic ultra-high risk and the basic symptom criteria. Current models of symptom development assume that basic symptoms develop first, followed by attenuated and, finally, frank psychotic symptoms, though interrelations of these symptoms are yet unknown. Therefore, we studied for the first time their interrelations using a network approach in 460 patients of an early detection service (mean age=26.3 years, SD=6.4; 65% male; n=203 clinical high-risk (CHR), n=153 first-episode psychosis, and n=104 depression). Basic, attenuated and frank psychotic symptoms were assessed using the Schizophrenia Proneness Instrument, Adult version (SPI-A), the Structured Interview for Psychosis-Risk Syndromes (SIPS), and the Positive And Negative Syndrome Scale (PANSS). Using the R package qgraph, network analysis of the altogether 86 symptoms revealed a single dense network of highly interrelated symptoms with five discernible symptom subgroups. Disorganized communication was the most central symptom, followed by delusions and hallucinations. In line with current models of symptom development, the network was distinguished by symptom severity running from SPI-A via SIPS to PANSS assessments. This suggests that positive symptoms develop from cognitive and perceptual disturbances included basic symptom criteria. Possibly conveying important insight for clinical practice, central symptoms and symptoms ‘bridging’ the association between symptom subgroups may be regarded as the main treatment targets, in order to prevent symptomatology from spreading or increasing across the whole network.
Background
Most studies examining predictors of the onset of depression focus on variable centered regression methods that focus on the effects of multiple predictors. In contrast, person-centered approaches develop profiles of factors and these profiles can be examined as predictors of onset. Here, we developed profiles of adolescent psychosocial and clinical functioning among adolescents without a history of major depression.
Methods
Data come from a subsample of participants from the Oregon Adolescent Depression Project who completed self-report measures of functioning in adolescence and completed diagnostic and self-report measures at follow-up assessments up to approximately 15 years after baseline.
Results
We identified four profiles of psychosocial and clinical functioning: Thriving; Average Functioning; Externalizing Vulnerability and Family Stress and Internalizing Vulnerability at the baseline assessment of participants without a history of depression at the initial assessment in mid-adolescence. Classes differed in the likelihood of onset and course of depressive disorders, experience of later anxiety and substance use disorders, and psychosocial functioning in adulthood. Moreover, the predictive utility of these classes was maintained when controlling for multiple other established risk factors for depressive disorders.
Conclusions
This work highlights the utility of examining multiple factors simultaneously to understand risk for depression.
Major depressive disorder (MDD), also known as unipolar depression, is one of the leading causes of disability and disease worldwide. The signs and symptoms are low self‑esteem, anhedonia, feeling of worthlessness, sense of rejection and guilt, suicidal thoughts, among others. This review focuses on studies with molecular-based approaches involving MDD to obtain an integrated, more detailed and comprehensive view of the brain changes produced by this disorder and its treatment and how the Central Nervous System (CNS) produces neuroplasticity to orchestrate adaptive defensive behaviors. This article integrates affective neuroscience, psychopharmacology, neuroanatomy and molecular biology data. In addition, there are two problems with current MDD treatments, namely: 1) Low rates of responsiveness to antidepressants and too slow onset of therapeutic effect; 2) Increased stress vulnerability and autonomy, which reduces the responses of currently available treatments. In the present review, we encourage the prospection of new bioactive agents for the development of treatments with post-transduction mechanisms, neurogenesis and pharmacogenetics inducers that bring greater benefits, with reduced risks and maximized access to patients, stimulating the field of research on mood disorders in order to use the potential of preclinical studies. For this purpose, improved animal models that incorporate the molecular and anatomical tools currently available can be applied. Besides, we encourage the study of drugs that do not present “classical application” as antidepressants, (e.g., the dissociative anesthetic ketamine and dextromethorphan) and drugs that have dual action mechanisms since they represent potential targets for novel drug development more useful for the treatment of MDD.
Background:
To investigate whether usage of treatment-acquired regulatory skills is associated with prevention of depressive relapse/recurrence.
Method:
Remitted depressed outpatients entered a 24-month clinical follow up after either 8 weekly group sessions of cognitive therapy (CT; N = 84) or mindfulness-based cognitive therapy (MBCT; N = 82). The primary outcome was symptom return meeting the criteria for major depression on Module A of the SCID.
Results:
Factor analysis identified three latent factors (53% of the variance): decentering (DC), distress tolerance (DT), and residual symptoms (RS), which were equivalent across CT and MBCT. Latent change score modeling of factor slopes over the follow up revealed positive slopes for DC (β = .177), and for DT (β = .259), but not for RS (β = -.017), indicating posttreatment growth in DC and DT, but no change in RS. Cox regression indicated that DC slope was a significant predictor of relapse/recurrence prophylaxis, Hazard Ratio (HR) = .232 90% Confidence Interval (CI) [.067, .806], controlling for past depressive episodes, treatment group, and medication. The practice of therapy-acquired regulatory skills had no direct effect on relapse/recurrence (β = .028) but predicted relapse/recurrence through an indirect path (β = -.125), such that greater practice of regulatory skills following treatment promoted increases in DC (β = .462), which, in turn, predicted a reduced risk of relapse/recurrence over 24 months (β = -.270).
Conclusions:
Preventing major depressive disorder relapse/recurrence may depend upon developing DC in addition to managing residual symptoms. Following the acquisition of therapy skills during maintenance psychotherapies, DC is strengthened by continued skill utilization beyond treatment termination. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
For decades, researchers and practitioners have theorized psychological disorder and health as opposite ends of a single continuum. We offer a more nuanced, data driven examination into the various ways that people with psychological disorders experience well-being. We review research on the positive emotions, meaning and purpose in life, and social relationships of people diagnosed with major depressive disorder, bipolar disorder, social anxiety disorder, schizophrenia, and trauma-related disorders. We also discuss when and how friends, family members, and caregivers of these people are adversely impacted in terms of their well-being. Throughout, we highlight important, often overlooked findings that not all people with mental illness are devoid of well-being. This review is meant to be illustrative as opposed to comprehensive, synthesizing existing knowledge and inspiring explorations of unclear or undiscovered territory.
Multiple informants - compared to single informants - better inform the clinical assessment and the diagnosis of psychopathology. The Operations Triad Model (OTM; De Los Reyes et al. 2013a) provides researchers with a conceptual framework for integrating information from multiple informants into research settings. We simplified this model by: 1) identifying context and insight as the critical factors necessary for determining if multiple informants improve diagnostic accuracy and 2) providing decision-making heuristics for determining when and how to use multiple informants in clinical research and practice. We focused on how symptoms can vary across situations (i.e., context) and how individuals can lack the awareness to accurately report symptoms (i.e., insight) to improve interpretations of informant discrepancies.
The goal of this study was to evaluate the relationship between early change in psychosocial function independent of depression severity and longer-term symptomatic remission. Participants of Combining Medications to Enhance Depression Outcomes trial were randomly selected for model selection (n = 334) and validation (n = 331). Changes in psychosocial function (Work and Social Adjustment Scale, WSAS) from baseline to week 6 were assessed and two data-driven sub-groups of WSAS change were identified in the randomly selected model selection half. Results of analyses to predict symptomatic remission at 3 and 7 months were validated for these sub-groups in the second half (validation sample). From baseline to week 6, psychosocial function improved significantly even after adjusting for depression severity at each visit and select baseline variables (age, gender, race, ethnicity, education, income, employment, depression onset before age 18, anxious features, and suicidal ideation), treatment-arm, and WSAS score. The WSAS change patterns identified two (early improvement and gradual change) subgroups. After adjusting for baseline variables and remission status at week 6, participants with early improvement in the second half (validation sample) had greater remission rates than those with gradual change at both 3 (3.3 times) and 7 months (2.3 times) following acute treatment initiation. In conclusion, early improvement in psychosocial function provides a clinically meaningful prediction of longer-term symptomatic remission, independent of depression symptom severity.
Disordered sleep is strongly linked to future depression, but the reasons for this link are not well understood. This study tested one possibility – that poorer sleep impairs emotion regulation (ER), which over time leads to increased depressive symptoms. Our sample contained individuals with a wide range of depression symptoms (current depression, N = 54, remitted depression, N = 36, and healthy control, N = 53), who were followed clinically over six months and reassessed for changes in depressive symptom levels. As predicted, maladaptive ER mediated both cross-sectional and prospective relationships between poor sleep quality and depression symptoms. In contrast, an alternative mediator, physical activity levels, did not mediate the link between sleep quality and depression symptoms. Maladaptive ER may help explain why sleep difficulties contribute to depression symptoms; implications for interventions are discussed.
We propose a novel developmentally informed framework to push research beyond a focus on comorbidity between discrete diagnostic categories and to move toward research based on the well-validated dimensional and hierarchical structure of psychopathology. For example, a large body of research speaks to the validity and utility of the internalizing and externalizing spectra as organizing constructs for research on common forms of psychopathology. The internalizing and externalizing spectra act as powerful explanatory variables that channel the psychopathological effects of genetic and environmental risk factors, predict adaptive functioning, and account for the likelihood of disorder-level manifestations of psychopathology. As such, our proposed theoretical framework uses the internalizing and externalizing spectra as central constructs to guide future psychopathology research across the life span. The framework is particularly flexible, because any of the facets or factors from the dimensional and hierarchical structure of psychopathology can form the focus of research. We describe the utility and strengths of this framework for developmental psychopathology in particular and explore avenues for future research.
Decades of research have shown that positive life events contribute to the remission and recovery of depression; however, it is unclear how positive life events are generated. In this study, we sought to understand if personality strengths could predict positive life events that aid in the alleviation of depression. We tested a longitudinal mediation model where gratitude and meaning in life lead to increased positive life events and, in turn, decreased depression. The sample consisted of 797 adult participants from 43 different countries who completed online surveys at five timepoints. Higher levels of gratitude and meaning in life each predicted decreases in depression over 3 and 6 months time. Increases in positive life events mediated the effects of these personality strengths on depression over 3 months; however, not over 6 months. Goal pursuit and positive emotions are theorized to be the driving forces behind gratitude and meaning in life’s effects on positive life events. We used the hedonic treadmill to interpret the short-term impact of positive life events on depression. Our findings suggest the potential for gratitude and meaning in life interventions to facilitate depression remission.
This review summarizes the current meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders. A search of the literature resulted in a total of 16 methodologically rigorous meta-analyses. Our review focuses on effect sizes that contrast outcomes for CBT with outcomes for various control groups for each disorder, which provides an overview of the effectiveness of cognitive therapy as quantified by meta-analysis. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger, childhood somatic disorders, and chronic pain were in the moderate range. CBT was somewhat superior to antidepressants in the treatment of adult depression. CBT was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. Large uncontrolled effect sizes were found for bulimia nervosa and schizophrenia. The 16 meta-analyses we reviewed support the efficacy of CBT for many disorders. While limitations of the meta-analytic approach need to be considered in interpreting the results of this review, our findings are consistent with other review methodologies that also provide support for the efficacy CBT.
Background:
Trials evaluating efficacy of omega-3 highly unsaturated fatty acids (HUFAs) in major depressive disorder report discrepant findings.
Aims:
To establish the reasons underlying inconsistent findings among randomised controlled trials (RCTs) of omega-3 HUFAs for depression and to assess implications for further trials.
Method:
A systematic bibliographic search of double-blind RCTs was conducted between January 1980 and July 2014 and an exploratory hypothesis-testing meta-analysis performed in 35 RCTs including 6665 participants receiving omega-3 HUFAs and 4373 participants receiving placebo.
Results:
Among participants with diagnosed depression, eicosapentaenoic acid (EPA)-predominant formulations (>50% EPA) demonstrated clinical benefits compared with placebo (Hedge's ITALIC! G= 0.61, ITALIC! P<0.001) whereas docosahexaenoic acid (DHA)-predominant formulations (>50% DHA) did not. EPA failed to prevent depressive symptoms among populations not diagnosed for depression.
Conclusions:
Further RCTs should be conducted on study populations with diagnosed or clinically significant depression of adequate duration using EPA-predominant omega-3 HUFA formulations.
Background and objectives:
Impaired cognitive processing is a key feature of depression. Biases in autobiographical memory retrieval (in favour of negative and over-general memories) directly impact depression symptoms, but also influence downstream cognitive factors implicated in the onset and maintenance of the disorder. We introduce a novel cognitive intervention, MemFlex, which aims to correct these biases in memory retrieval and thereby modify key downstream cognitive risk and maintenance factors: rumination, impaired problem solving, and cognitive avoidance.
Method:
Thirty eight adults with remitted Major Depressive Disorder completed MemFlex in an uncontrolled clinical trial. This involved an orientation session, followed by self-guided completion of six workbook-based sessions over one-month. Assessments of cognitive performance and depression symptoms were completed at pre- and post-intervention.
Results:
Results demonstrated medium-sized effects of MemFlex in improving memory specificity and problem solving, and decreasing rumination, and a small effect in reducing cognitive avoidance. No significant change was observed in residual symptoms of depression.
Limitations:
This study was an uncontrolled trial, and has provided initial evidence to support a larger-scale, randomized controlled trial.
Conclusions:
These findings provide promising evidence for MemFlex as a cost-effective, low-intensity option for reducing cognitive risk associated with depression.
Judging other people’s personality is a widespread social phenomenon early on in the acquaintance process. The accuracy of these interpersonal impressions colors the way we select, shape, and maintain our social environments. In this chapter, we give an overview of the state of the art in research on the accuracy of personality judgments. First, we describe and discuss existing methodological alternatives (variable- vs. person-centered approaches; choice of accuracy criteria; individual vs. aggregated perceiver approaches). Second, we tackle the question of how well humans can judge the personality of unknown others summarizing the wealth of existing studies across a large variety of contexts. Third, following a lens model approach, we discuss the cue-expression and cue-perception processes that mediate the amount of judgmental accuracy and summarize initial empirical process insights. Fourth, based on a process-understanding we describe domains of moderators that influence how well perceivers can judge others personalities (e.g., good trait, good judge, good target, good information). Finally, we highlight a set of issues we deem as important challenges for future research on the accuracy of personality judgments.
In this review we argue in favour of further integration between the disciplines of positive and clinical psychology. We argue that most of the constructs studied by both positive and clinical psychology exist on continua ranging from positive to negative (e.g., gratitude to ingratitude, anxiety to calmness) and so it is meaningless to speak of one or other field studying the " positive " or the " negative ". However, we highlight historical and cultural factors which have led positive and clinical psychologies to focus on different constructs; thus the difference between the fields is more due to the constructs of study rather than their being inherently " positive " or " negative ". We argue that there is much benefit to clinical psychology of considering positive psychology constructs because; (a) constructs studied by positive psychology researchers can independently predict wellbeing when accounting for traditional clinical factors, both cross-sectionally and prospectively, (2) the constructs studied by positive psychologists can interact with risk factors to predict outcomes, thereby conferring resilience, (3) interventions that aim to increase movement towards the positive pole of well-being can be used encourage movement away from the negative pole, either in isolation or alongside traditional clinical interventions, and (4) research from positive psychology can support clinical psychology as it seeks to adapt therapies developed in Western nations to other cultures.
People respond to stressful events in different ways, depending on the event and on the regulatory strategies they choose. Coping and emotion regulation theorists have proposed dynamic models in which these two factors, the person and the situation, interact over time to inform adaptation. In practice, however, researchers have tended to assume that particular regulatory strategies are consistently beneficial or maladaptive. We label this assumption the fallacy of uniform efficacy and contrast it with findings from a number of related literatures that have suggested the emergence of a broader but as yet poorly defined construct that we refer to as regulatory flexibility. In this review, we articulate this broader construct and define both its features and limitations. Specifically, we propose a heuristic individual differences framework and review research on three sequential components of flexibility for which propensities and abilities vary: sensitivity to context, availability of a diverse repertoire of regulatory strategies, and responsiveness to feedback. We consider the methodological limitations of research on each component, review questions that future research on flexibility might address, and consider how the components might relate to each other and to broader conceptualizations about stability and change across persons and situations.
© The Author(s) 2013.
Systematic reviews, such as meta-analyses, are highly valued within scientific, professional, and lay communities because they provide an easily digestible aggregate of a large body of work. A recently published meta-analysis of positive psychology interventions concluded that these interventions have small effects and argued for the use of these interventions in diverse populations (Bolier et al., 2013). We caution researchers against drawing conclusions from this study because of the unusual definition of what is (and is not) a positive psychological intervention. Bolier and colleagues (2013) define their area of inquiry as “pure positive psychology interventions” and limit their sample to studies conducted within the years following the formal founding of the positive psychology movement. This decision – while well intentioned, as it provides specificity to their criteria for inclusion – is, in our view, too narrow, excluding a host of studies that use the same intervention strategies and target the same outcomes but do not explicitly reference “positive psychology”. The inclusion criteria of a systematic review directly impact its findings and conclusions. Using the criterion of papers that explicitly reference positive psychology creates an arbitrary boundary that reflects neither the research nor practice of the field; the best practitioners prioritize effectiveness and efficiency over explicit ties to “positive psychology”. Arbitrary boundaries hinder science and impair the ability of researchers, clinicians, and the general public to draw accurate conclusions from the findings. It also limits the meta-analyst’s ability to conduct moderation analysis that can help drive the field forward by answering research questions that are difficult to address in a single study. Positive psychology and psychology more generally would benefit from definitions of terms that are conceptually-based and thus meta-analyses that are theoretically sound.
Growing popular interest in positive psychology may have important implications for the measurement of well-being. Five studies tested the prediction that well-being ratings are influenced by desirability bias. In Study 1, participants (N = 176) instructed to fake good endorsed higher well-being; those instructed to fake bad endorsed lower well-being, compared to controls. In Studies 2 and 3 (N’s = 111, 121), control participants endorsed higher levels of well-being compared to those attached to a bogus pipeline. These differences were mediated by desirability bias. In Study 4 (N = 417), instruction manipulations did not affect well-being levels, but presenting a desirability measure prior to well-being measures attenuated the correlations between them. In Study 5 (N = 391), however, this order effect did not replicate. We discuss the importance of continued vigilance for desirability bias in well-being research as a ready solution to this clear problem remains elusive.
Major depression is the commonest psychiatric disorder and in the U.S. has the greatest impact of all biomedical diseases on disability. Here we review evidence of the genetic contribution to disease susceptibility and the current state of molecular approaches. Genome-wide association and linkage results provide constraints on the allele frequencies and effect sizes of susceptibility loci, which we use to interpret the voluminous candidate gene literature. We consider evidence for the genetic heterogeneity of the disorder and the likelihood that subtypes exist that represent more genetically homogenous conditions than have hitherto been analyzed.
Importance
Many people meditate to reduce psychological stress and stress-related health problems. To counsel people appropriately, clinicians need to know what the evidence says about the health benefits of meditation.
Objective
To determine the efficacy of meditation programs in improving stress-related outcomes (anxiety, depression, stress/distress, positive mood, mental health–related quality of life, attention, substance use, eating habits, sleep, pain, and weight) in diverse adult clinical populations.
Evidence Review
We identified randomized clinical trials with active controls for placebo effects through November 2012 from MEDLINE, PsycINFO, EMBASE, PsycArticles, Scopus, CINAHL, AMED, the Cochrane Library, and hand searches. Two independent reviewers screened citations and extracted data. We graded the strength of evidence using 4 domains (risk of bias, precision, directness, and consistency) and determined the magnitude and direction of effect by calculating the relative difference between groups in change from baseline. When possible, we conducted meta-analyses using standardized mean differences to obtain aggregate estimates of effect size with 95% confidence intervals.
Findings
After reviewing 18 753 citations, we included 47 trials with 3515 participants. Mindfulness meditation programs had moderate evidence of improved anxiety (effect size, 0.38 [95% CI, 0.12-0.64] at 8 weeks and 0.22 [0.02-0.43] at 3-6 months), depression (0.30 [0.00-0.59] at 8 weeks and 0.23 [0.05-0.42] at 3-6 months), and pain (0.33 [0.03- 0.62]) and low evidence of improved stress/distress and mental health–related quality of life. We found low evidence of no effect or insufficient evidence of any effect of meditation programs on positive mood, attention, substance use, eating habits, sleep, and weight. We found no evidence that meditation programs were better than any active treatment (ie, drugs, exercise, and other behavioral therapies).
Conclusions and Relevance
Clinicians should be aware that meditation programs can result in small to moderate reductions of multiple negative dimensions of psychological stress. Thus, clinicians should be prepared to talk with their patients about the role that a meditation program could have in addressing psychological stress. Stronger study designs are needed to determine the effects of meditation programs in improving the positive dimensions of mental health and stress-related behavior.
Happiness is generally considered a source of good outcomes. Research has highlighted the ways in which happiness facilitates the pursuit of important goals, contributes to vital social bonds, broadens people's scope of attention, and increases well-being and psychological health. However, is happiness always a good thing? This review suggests that the pursuit and experience of happiness might sometimes lead to negative outcomes. We focus on four questions regarding this purported "dark side" of happiness. First, is there a wrong degree of happiness? Second, is there a wrong time for happiness? Third, are there wrong ways to pursue happiness? Fourth, are there wrong types of happiness? Cumulatively, these lines of research suggest that although happiness is often highly beneficial, it may not be beneficial at every level, in every context, for every reason, and in every variety.
© The Author(s) 2011.
The relationship between the fields of humanistic and positive
psychology has been marked by continued tension and
ambivalence. This tension can be traced to extensive differences
in the philosophical grounding characterizing the
two perspectives within psychology. These differences exist
with respect to (a) ontology, including the ways in which
human nature is conceptualized regarding human potentials
and well-being; (b) epistemology, specifically, the
choice of research strategies for the empirical study of
these concepts; and (c) practical philosophy, particularly
the goals and strategies adopted when conducting therapy
or undertaking counseling interventions. Because of this
philosophical divide, adherents of the two perspectives may
best be advised to pursue separately their shared desire to
understand and promote human potentials and well-being.
We compared Seligman’s PERMA model of well-being with Diener’s model of subjective well-being (SWB) to determine if the newer PERMA captured a type of well-being unique from the older SWB. Participants were 517 adults who completed self-report measures of SWB, PERMA, and VIA character strengths. Results from four analytic techniques suggest the factor underlying PERMA is capturing the same type of well-being as SWB. Confirmatory factor analysis yielded a latent correlation of r = 0.98 between SWB and PERMA. Exploratory structural equation modeling found two highly related factors (r = 0.85) that did not map onto PERMA and SWB. SWB and PERMA factors showed similar relationships with 24 character strengths (average correlation difference = 0.02). Latent profile analyses yielded subgroups of people who merely scored high, low, or mid-range on well-being indicators. Our findings suggest that while lower-order indicators SWB and PERMA have unique features, they converge onto a single well-being factor.
Objective:
In a randomized clinical trial, we compared the efficacy of cognitive-behavioral therapy (CBT) and psychodynamic therapy for adult outpatient depression on measures of psychopathology, interpersonal functioning, pain, and quality of life.
Method:
There were 341 Dutch adults (70.1% female, mean age = 38.9, SD = 10.3) meetingDiagnostic and Statistical Manual for Mental Disorders-Fourth Edition(DSM-IV) criteria for a major depressive episode and with a Hamilton Depression Rating Scale (HAM-D) score ≥14, who were randomized to 16 sessions of individual manualized CBT or short-term psychodynamic supportive psychotherapy. Severely depressed patients (HAM-D >24) received additional antidepressant medication according to a protocol. Outcome measures included the Brief Symptom Inventory, Beck Anxiety Inventory, Outcome Questionnaire, a visual analogue scale for pain, and EuroQol. Data were analyzed with mixed model analyses using intention-to-treat samples. Noninferiority margins were prespecified as Cohen's d = -0.30.
Results:
Across treatment conditions, 45-60% of the patients who completed posttreatment assessment showed clinically meaningful change for most outcome measures. We found no significant differences between the treatment conditions on any of the outcome measures at both posttreatment and follow-up. Noninferiority of psychodynamic therapy to CBT was shown for posttreatment and follow-up anxiety measures as well as for posttreatment pain and quality of life measures, but could not be consistently demonstrated for the other outcomes.
Conclusions:
This is the first study that shows that psychodynamic therapy can be at least as efficacious as CBT for depression on important aspects of patient functioning other than depressive symptom reduction. These findings extend the evidence-base of psychodynamic therapy for depression, but replication is needed by means of rigorously designed noninferiority trials. (PsycINFO Database Record
Objective:
We conducted a randomized controlled trial to determine whether IRISS (Intervention for those Recently Informed of their Seropositive Status), a positive affect skills intervention, improved positive emotion, psychological health, physical health, and health behaviors in people newly diagnosed with HIV.
Method:
One-hundred and fifty-nine participants who had received an HIV diagnosis in the past 3 months were randomized to a 5-session, in-person, individually delivered positive affect skills intervention or an attention-matched control condition.
Results:
For the primary outcome of past-day positive affect, the group difference in change from baseline over time did not reach statistical significance (p = .12, d = .30). Planned secondary analyses within assessment point showed that the intervention led to higher levels of past-day positive affect at 5, 10, and 15 months postdiagnosis compared with an attention control. For antidepressant use, the between group difference in change from baseline was statistically significant (p = .006, d = -.78 baseline to 15 months) and the difference in change over time for intrusive and avoidant thoughts related to HIV was also statistically significant (p = .048, d = .29). Contrary to findings for most health behavior interventions in which effects wane over the follow up period, effect sizes in IRISS seemed to increase over time for most outcomes.
Conclusions:
This comparatively brief positive affect skills intervention achieved modest improvements in psychological health, and may have the potential to support adjustment to a new HIV diagnosis. (PsycINFO Database Record
Background Major depression occurs more frequently among people of lower socioeconomic status (SES) and among females. Although the focus of considerable investigation, the development of SES and sex differences in depression remains to be fully explained. In this study, we test the hypotheses that low childhood SES predicts an increased risk of adult depression and contributes to a higher risk of depression among females.
Methods Participants were 1132 adult offspring of mothers enrolled in the Providence, Rhode Island site of the US National Collaborative Perinatal Project between 1959 and 1966. Childhood SES, indexed by parental occupation, was assessed at the time of participants' birth and seventh year. A lifetime history and age at onset of major depressive episode were ascertained via structured interviews according to diagnostic criteria. Survival analyses were used to model the likelihood of first depression onset as a function of childhood SES.
Results Participants from lower SES backgrounds had nearly a twofold increase in risk for major depression compared to those from the highest SES background independent of childhood sociodemographic factors, family history of mental illness, and adult SES. Analyses of sex differences in the effect of childhood SES on adult depression provided modest support for the hypothesis that childhood SES contributes to adult sex differences in depression.
Conclusions Low SES in childhood is related to a higher risk of major depression in adults. Social inequalities in depression likely originate early in life. Further research is needed to identify the pathways linking childhood conditions to SES differences in the incidence of major depression.
This paper presents the development and validation of a new well-being questionnaire: the Scales of General Well-Being (SGWB). A review of current measures identified fourteen common constructs as lower-order indicators of well-being: happiness, vitality, calmness, optimism, involvement, self-awareness, self-acceptance, self-worth, competence, development, purpose, significance, self-congruence and connection. Three studies were then conducted. In study 1, the item pool was developed and the adequacy of its content to assess each of the fourteen constructs was evaluated by consulting a panel of six subject expert academics. In study 2, the dimensionality was assessed in an adult North American sample (N = 560). The results supported the hierarchical factor structure. In study 3, further evidence confirmed the factor structure, and provided support for the measure's internal and test-retest reliability, measurement invariance across gender, age and a longitudinal period of 5 weeks, and criterion validity in an adult North American sample (N = 1101). The SGWB promises to be a useful research tool that provides both a global measure of well-being as well as a collection of fourteen individual health-related scales.
Certain clinical traits (e.g., ruminative response style, self-criticism, perfectionism, anxiety sensitivity, fear of negative evaluation, and thought suppression) increase the risk for and chronicity of emotional disorders. Similar to traditional personality traits, they are considered dispositional and typically show high temporal stability. Because the personality and clinical-traits literatures evolved largely independently, connections between them are not fully understood. We sought to map the interface between a widely studied set of clinical and personality traits. Two samples (N = 385 undergraduates; N = 188 psychiatric outpatients) completed measures of personality traits, clinical traits, and an interview-based assessment of emotional-disorder symptoms. First, the joint factor structure of these traits was examined in each sample. Second, structural equation modeling was used to clarify the effects of clinical traits in the prediction of clinical symptoms beyond negative temperament. Third, the incremental validity of clinical traits beyond a more comprehensive set of higher-order and lower-order personality traits was examined using hierarchical regression. Clinical and personality traits were highly correlated and jointly defined a 3-factor structure-Negative Temperament, Positive Temperament, and Disinhibition-in both samples, with all clinical traits loading on the Negative Temperament factor. Clinical traits showed modest but significant incremental validity in explaining symptoms after accounting for personality traits. These data indicate that clinical traits relevant to emotional disorders fit well within the traditional personality framework and offer some unique contributions to the prediction of psychopathology, but it is important to distinguish their effects from negative temperament/neuroticism. (PsycINFO Database Record
In this review we argue in favour of further integration between the disciplines of positive and clinical psychology. We argue that most of the constructs studied by both positive and clinical psychology exist on continua ranging from positive to negative (e.g., gratitude to ingratitude, anxiety to calmness) and so it is meaningless to speak of one or other field studying the “positive” or the “negative”. However, we highlight historical and cultural factors which have led positive and clinical psychologies to focus on different constructs; thus the difference between the fields is more due to the constructs of study rather than their being inherently “positive” or “negative”. We argue that there is much benefit to clinical psychology of considering positive psychology constructs because; (a) constructs studied by positive psychology researchers can independently predict wellbeing when accounting for traditional clinical factors, both cross-sectionally and prospectively, (2) the constructs studied by positive psychologists can interact with risk factors to predict outcomes, thereby conferring resilience, (3) interventions that aim to increase movement towards the positive pole of well-being can be used encourage movement away from the negative pole, either in isolation or alongside traditional clinical interventions, and (4) research from positive psychology can support clinical psychology as it seeks to adapt therapies developed in Western nations to other cultures.
The present study examined the efficacy of two evidence-based group treatments for significant psychopathology in university students. Fifty-four treatment-seeking participants were randomized to a semester-long dialectical behavior therapy (DBT) or positive psychotherapy (PPT) group treatment. Mixed modeling was used to assess improvement over time and group differences on variables related to symptomatology, adapative/maladaptive skill usage, and well-being/acceptability factors. All symptom and skill variables improved over the course of treatment. There were no statistically significant differences in rate of change between groups. The DBT group evidenced nearly all medium to large effect sizes for all measures from pre-to post-treatment, with mostly small to medium effect sizes for the PPT group. There was a significant difference in acceptability between treatments, with the DBT group demonstrating significantly lower attrition rates, higher attendance, and higher overall therapeutic alliance. While both groups demonstrated efficacy in this population, the DBT group appeared to be a more acceptable and efficacious treatment for implementation. Results may specifically apply to group therapy as an adjunctive treatment because a majority of participants had concurrent individual therapy.
Researchers and clinicians assume a strong, positive correlation between anxiety symptoms and functional impairment. That assumption may be well-justified since diagnostic criteria typically include functional impairment. Still, the relationship remains largely unavailable in any systematic review. Our aim with this paper was to provide empirical evidence for this assumed relationship and to document the observed correlations between anxiety symptom measures and functional impairment measures. Correlations existed for symptoms of six anxiety disorders (Panic Disorder, Agoraphobia, Social Anxiety Disorder, Post-Traumatic Stress Disorder, Generalized Anxiety Disorder, Obsessive Compulsive Disorder) across four functional domains (global, social, occupational, and physical). Overall, the mean of 497 correlations across all disorders and functional domains was modest (r=.34); since the variability between disorders and functional domains tended to be rather large, we explored these correlations further. We presented these results and the potential explanations for unexpected findings along with the clinical and research implications.
A large international sample was used to test whether hedonia (the experience of positive emotional states and satisfaction of desires) and eudaimonia (the presence of meaning and development of one's potentials) represent 1 overarching well-being construct or 2 related dimensions. A latent correlation of .96 presents negligible evidence for the discriminant validity between Diener's (1984) subjective well-being model of hedonia and Ryff's (1989) psychological well-being model of eudaimonia. When compared with known correlates of well-being (e.g., curiosity, gratitude), eudaimonia and hedonia showed very similar relationships, save goal-directed will and ways (i.e., hope), a meaning orientation to happiness, and grit. Identical analyses in subsamples of 7 geographical world regions revealed similar results around the globe. A single overarching construct more accurately reflects hedonia and eudaimonia when measured as self-reported subjective and psychological well-being. Nevertheless, measures of eudaimonia may contain aspects of meaningful goal-directedness unique from hedonia. (PsycINFO Database Record
This article summarizes and scrutinizes the growth of the development of clinically relevant and psychometrically sound approaches for determining the clinical significance of treatment effects in mental health research by tracing its evolution, by examining modifications in the method, and by discussing representative applications. Future directions for this methodology are proposed.
This Viewpoint discusses the promise of personalized or precision medicine compared with its achievements to date.
Personalized or precision medicine maintains that medical care and public health will be radically transformed by prevention and treatment programs more closely targeted to the individual patient. These interventions will be developed by sequencing more genomes, creating bigger biobanks, and linking biological information to health data in electronic medical records (EMRs) or obtained by monitoring technologies. Yet the assumptions underpinning personalized medicine have largely escaped questioning. In this Viewpoint, we seek to stimulate a more balanced debate by posing 7 questions for the advocates of personalized medicine.
Differential risk factors for the onset of depression were prospectively examined in a community-based sample of adolescents (N = 1,709), some of whom had a history of major depressive disorder (MDD; it = 286) and some of whom did not (n = 1,423). From the theories of J. Teasdale (1983, 1988) and R. Post (1992) concerning the etiology of initial versus recurrent episodes of depression, the authors hypothesized that (a) dysphoric mood and dysfunctional thinking styles would be correlated more highly among those with a previous history of MDD than among those without a history of MDD; (b) dysphoric mood or symptoms and dysfunctional thinking would be a stronger predictor of onset of recurrent episodes (n = 43) than of first onsets (n = 70); and (c) major life stress would be a stronger predictor of first onsets of MDD than of recurrent episodes. The results provide support for the 3 hypotheses and suggest that distinct processes are involved in the onset of first and recurrent episodes of MDD.
• The course of illness of 431 subjects with major depression participating in the National Institute of Mental Health Collaborative Depression Study was prospectively observed for 5 years. Twelve percent of the subjects still had not recovered by 5 years. There were decreasing rates of recovery over time. For example, 50% of the subjects recovered within the first 6 months, and then the rate of recovery declined markedly. Instantaneous probabilities of recovery reflect that the longer a patient was ill, the lower his or her chances were of recovering. For patients still depressed, the likelihood of recovery within the next month declined from 15% during the first 3 months of follow-up to 1 % to 2% per month during years 3, 4, and 5 of this follow-up. The severity of current psychopathology predicted the probability of subsequent recovery. Subjects with moderately severe depressive symptoms, minor depression, or dysthymia had an 18-fold greater likelihood of beginning recovery within the next week than did subjects who were at full criteria for major depressive disorder. Many subjects who did not recover continued in an episode that looked more like dysthymia than major depressive disorder.
Objective:
As npart of the National Institute of Mental Health Collaborative Study of the Psychobiology of Depression, the comparative course of manic depressive (bipolar) and primary unipolar patients was assessed.
Design:
Systematic evaluation using structured instruments every 6 months for a period of 5 years with the recording of remissions, new episodes, and subsequent hospitalizations.
Patients:
The number of subjects varied somewhat depending on the analyses conducted. For a comparison of course in bipolar patients and unipolar patients, 148 bipolars were compared with 172 unipolar patients.
Results:
Both unipolar and bipolar patients were more likely to have episodes if they had episodes prior to index admission. Likewise, prior hospitalizations predicted multiple hospitalizations in follow-up. Chronicity was significantly more prevalent among unipolar depressives but in both unipolar and bipolar patients, chronicity diminished over time. Bipolar patients were more likely than unipolar patients to have multiple episodes at the 2-year and 5-year follow-ups. In bipolar patients, there was no difference in the number of episodes in follow-up between males and females but in unipolar patients, females were significantly more likely to have subsequent hospitalizations and episodes than males. Treatment variables did not relate to these differences. A family history of mania or schizoaffective mania predicted multiple episodes in bipolar patients but not in primary unipolar depressives. A family history of all affective illness (mania, schizoaffective mania, bipolar II illness, and depression) did not predict a multiple-episode course in either bipolar or unipolar illness. In unipolar patients, the independent variables leading to multiple-episode course in follow-up are being female, an early age of onset, and prior episodes.
Conclusions:
As a result of this systematic follow-up study, new data add to the distinction between bipolar and primary unipolar patients both as regards number of episodes in follow-up and also as regards risk factors that are associated with the multiple-episode course.
The systematic study of the natural course of affective disorders originated with the pioneer work of Kraepelin1 and has continued until recently. However, with the advent of lithium and its widespread use in the prophylaxis of affective disorders, naturalistic data on the course of the illness has become increasingly unavailable. While reviewing the literature on the subject, one is struck by the discrepancies in the reported results and particularly the disparities concerning the proportion of patients with a single episode or those who experience several episodes during the observation period. It is our working assumption that methodological and population differences account for most, if not all, of the reported inconsistencies. For the purpose of this paper, we reviewed ten of the largest and most frequently quoted studies conducted over the past half century, largely in the predrug era, and concerning the natural course of affective illness. After presenting a
Although the chemical imbalance theory is the dominant causal explanation of depression in the United States, little is known about the effects of this explanation on depressed individuals. This experiment examined the impact of chemical imbalance test feedback on perceptions of stigma, prognosis, negative mood regulation expectancies, and treatment credibility and expectancy. Participants endorsing a past or current depressive episode received results of a bogus biological but credible test demonstrating their depressive symptoms to be caused, or not caused, by a chemical imbalance in the brain. Results showed that chemical imbalance test feedback failed to reduce self-blame, elicited worse prognostic pessimism and negative mood regulation expectancies, and led participants to view pharmacotherapy as more credible and effective than psychotherapy. The present findings add to a growing literature highlighting the unhelpful and potentially iatrogenic effects of attributing depressive symptoms to a chemical imbalance. Clinical and societal implications of these findings are discussed.
Development of a composite index for use in treatment outcome research with social phobia is described. The index consists of a number of individual outcome measures, and the cutoff scores are based on the performance of a normal control group. Treatment sensitivity of the index was assessed, and the change in classification of social phobics treated with behavioral or drug treatment was determined. At posttreatment, outcome measures revealed significant changes over treatment, and distribution of social phobics on the composite index was more similar to that of normals than at pretreatment. The results are discussed in terms of the usefulness of composite indexes in treatment outcome research and the necessity for such measures to be based on normative data.
Most of our knowledge in psychology and allied social sciences is based on observing consequences and seeking antecedents. The statistical analysis of such retrospective knowledge thus involves conditioning on consequences. This article demonstrates that given the common conditions of investigating "unusual" consequences, the degree of statistical contingency between a single consequence and a single antecedent is greater when conditioning on the consequence than when conditioning on the antecedent--which is, of course, necessary for prediction. Moreover, this asymmetry is exacerbated when the investigator is free to search for antecedents in a situation involving multiple potential antecedents. This asymmetry is exacerbated to an even greater extent when the investigator relies on memory rather than recorded observations in this search. Thus, if we identify the degree of statistical contingency in prediction with the degree we find in retrospection, we seriously overestimate. Our subsequent disappointment in our deficient predictive abilities can easily lead to rejecting variables and analyses that are in fact predictive in favor of those of unknown validity.
Brain disease models of psychopathology, such as the popular chemical imbalance explanation of depression, have been widely disseminated in an attempt to reduce the stigma of mental illness. Ironically, such models appear to increase prejudicial attitudes among the general public toward persons with mental disorders. However, little is known about how biochemical causal explanations affect the perceptions of individuals seeking mental health treatment. Ninety undergraduate students participated in a thought experiment in which they were asked to imagine feeling depressed, seeking help from a doctor who diagnosed them with major depressive disorder, and receiving, in counterbalanced order, a chemical imbalance and biopsychosocial explanation for their symptoms. Ratings of each explanation's credibility and perceptions of self-stigma (e.g., blame), prognosis, and treatment expectancies were obtained. Compared to the biopsychosocial model, the chemical imbalance model was associated with signifi antly less self-stigma but also significantly lower credibility, a worse expected prognosis, and the perception that psychosocial interventions would be ineffective. The chemical imbalance explanation appears to reduce blame at the cost of fostering pessimism about recovery and the efficacy of nonbiological treatments. Research is needed on how the chemical imbalance model affects the clinical response of patients receiving mental health treatment.
Reviews the literature since 1967 on subjective well-being (SWB [including happiness, life satisfaction, and positive affect]) in 3 areas: measurement, causal factors, and theory. Most measures of SWB correlate moderately with each other and have adequate temporal reliability and internal consistency; the global concept of happiness is being replaced with more specific and well-defined concepts, and measuring instruments are being developed with theoretical advances; multi-item scales are promising but need adequate testing. SWB is probably determined by a large number of factors that can be conceptualized at several levels of analysis, and it may be unrealistic to hope that a few variables will be of overwhelming importance. Several psychological theories related to happiness have been proposed; they include telic, pleasure and pain, activity, top–down vs bottom–up, associanistic, and judgment theories. It is suggested that there is a great need to more closely connect theory and research. (7 p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Reigning measures of psychological well-being have little theoretical grounding, despite an extensive literature on the contours of positive functioning. Aspects of well-being derived from this literature (i.e., self-acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth) were operationalized. Three hundred and twenty-one men and women, divided among young, middle-aged, and older adults, rated themselves on these measures along with six instruments prominent in earlier studies (i.e., affect balance, life satisfaction, self-esteem, morale, locus of control, depression). Results revealed that positive relations with others, autonomy, purpose in life, and personal growth were not strongly tied to prior assessment indexes, thereby supporting the claim that key aspects of positive functioning have not been represented in the empirical arena. Furthermore, age profiles revealed a more differentiated pattern of well-being than is evident in prior research. (PsycINFO Database Record (c) 2012 APA, all rights reserved)