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Optimal Well-Being After Major Depression
Abstract
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.
... Preliminary findings indicate that higher levels of well-being may be uniquely protective against future depression and anxiety (Keyes et al., 2010). Among people diagnosed with depression, higher well-being at baseline was associated with a higher probability of achieving higher well-being and symptomatic recovery at a 10-year follow up (Panaite et al., 2021;Rottenberg et al., 2019). ...
... Early data indicate that although major psychopathology reduces the likelihood of OWB, many persons with psychopathology achieve OWB. In a nationally representative U.S. adult sample, 10% of persons with studydocumented depression satisfied OWB criteria 10 years later, compared with 21% of nondepressed persons meeting the same standard (Rottenberg et al., 2019). In other words, depression reduced the probability of achieving OWB by approximately 50%. ...
... Although this is a new area of investigation, we expected that rates of OWB after depression and generalized anxiety disorder in Canada would be similar to those observed in the United States Rottenberg et al., 2019). Given that this was the first study to ascertain OWB rates after bipolar and substance use disorders, we did not have expectations for these disorders. ...
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.
... Meta-analyses find that psychiatric symptoms correlate only modestly with functional impairment (McKnight and Kashdan, 2009;Mcknight et al., 2016), suggesting that current symptomatic endpoints provide incomplete assessments of functioning. Studies also find that incorporating information about well-being into diagnostic endpoints can improve the prediction of mental health outcomes, above and beyond psychiatric symptoms alone (Keyes et al., 2010;Rottenberg et al., 2019). Perhaps most important is that many patients with anxiety disorders have treatment goals that go beyond abatement of symptoms, like forming meaningful relationships, experiencing personal growth, and improving attitudes towards oneself (Holtforth et al., 2009) -all of which are components of well-being. ...
... In general, data suggest that 50-70% individuals with Major Depressive Disorder (MDD) recover within one year and only 6-15% experience a chronic course (Richards, 2011). Using a nationally representative sample, our team found that 10% of individuals with a previous MDD diagnosis were not only symptom-free 10 years later, but also experienced OWB: well-being levels akin to the top 25% of non-depressed adults in the United States (Rottenberg et al., 2019). We hypothesized that rates of OWB would be even higher for anxiety disorders for four reasons. ...
... Moving from descriptive to predictive models, our goal was to predict the likelihood of OWB from information acquired at their intake assessment 10 years earlier (baseline). We tested a prediction model in people with GAD or PD that was previously supported for participants with MDD (Rottenberg et al., 2019): whether anxious individuals who experienced higher well-being at baseline would be more likely to be symptom-free and achieve optimal levels of psychological well-being 10 years later. ...
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.
... Meta-analyses find that psychiatric symptoms correlate only modestly with functional impairment (McKnight and Kashdan, 2009;Mcknight et al., 2016), suggesting that current symptomatic endpoints provide incomplete assessments of functioning. Studies also find that incorporating information about well-being into diagnostic endpoints can improve the prediction of mental health outcomes, above and beyond psychiatric symptoms alone (Keyes et al., 2010;Rottenberg et al., 2019). Perhaps most important is that many patients with anxiety disorders have treatment goals that go beyond abatement of symptoms, like forming meaningful relationships, experiencing personal growth, and improving attitudes towards oneself (Holtforth et al., 2009) -all of which are components of well-being. ...
... In general, data suggest that 50-70% individuals with Major Depressive Disorder (MDD) recover within one year and only 6-15% experience a chronic course (Richards, 2011). Using a nationally representative sample, our team found that 10% of individuals with a previous MDD diagnosis were not only symptom-free 10 years later, but also experienced OWB: well-being levels akin to the top 25% of non-depressed adults in the United States (Rottenberg et al., 2019). We hypothesized that rates of OWB would be even higher for anxiety disorders for four reasons. ...
... Moving from descriptive to predictive models, our goal was to predict the likelihood of OWB from information acquired at their intake assessment 10 years earlier (baseline). We tested a prediction model in people with GAD or PD that was previously supported for participants with MDD (Rottenberg et al., 2019): whether anxious individuals who experienced higher well-being at baseline would be more likely to be symptom-free and achieve optimal levels of psychological well-being 10 years later. ...
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.
... 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). To assess psychological well-being, researchers may consider scales such as the Psychological Well-Being Scale (Ryff & Keyes, 1995) and the Scale of Positive and Negative Experience (Diener et al., 2010). ...
... How high must well-being be to be considered OWB? We suggest a norm-based approach, which highlights healthy functioning based on the distribution of well-being in the general population (Rottenberg et al., 2019;Turner et al., 1993). One reasonable benchmark for a conservative threshold is the well-being profile met by the top quartile (25%) of the nonsuicidal population. ...
... To our knowledge, there are no credible population estimates of OWB among people who attempt suicide and survive. One possible benchmark comes from related work on optimal high functioning after depression (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.
... 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). This work also uncovered that people with depression vary in their global reports of psychological well-being, and that these variations predicted long-term outcomes (Rottenberg et al, 2019). ...
... 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). This work also uncovered that people with depression vary in their global reports of psychological well-being, and that these variations predicted long-term outcomes (Rottenberg et al, 2019). A clear next step in this research program is to clarify what aspects of well-being are important for long-term positive outcomes. ...
... Our data potentially offer greater specificity than prior reports where overall well-being at one time point was predictive of depression at a future time point (Keyes, Dhingra, &, Simoes, 2010;Wood & Joseph, 2010;Rottenberg et al., 2019). Notably, in our dataset, better hedonic functioning captured through daily experiences of PA and positive events were related to more benign depression outcomes over the long term. ...
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.
... Using this three-part definition in a representative sample of the U.S. population (3,487 adults), we estimated how common it was for people to thrive 10 years after a diagnosis of depression. Nearly 10% of adults with documented depression thrived 10 years later-as indicated by the absence of major depression symptoms along with a well-being score profile superior to that of 75% of their nondepressed peers (Rottenberg et al., 2019). Depression, far from precluding thriving, only reduced it by about half (relative to individuals without a diagnosed mental-health condition). ...
... 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.
... L. Keyes et al., 2010;Wood & Joseph, 2010) as well as recover more explicitly from existing psychiatric disorders, above and beyond psychological symptoms (D. J. Disabato et al., 2021;Iasiello et al., 2019;Rottenberg et al., 2019). Researchers have offered frameworks that include well-being and symptoms/distress as related but nonoverlapping dimensions (e.g., flourishing vs. languishing; C. L. Keyes, 2005). ...
Prior research suggests variability of positive affect (PA), or the degree to which an individual’s experience of PA is variable rather than stable, is associated with worse psychological health. However, it is unclear whether different aspects of PA variability serve different psychological functions. One possibility is that changes in PA in response to rewarding contexts, or PA reactivity, serve a healthy function, while general instability of PA from one moment to the next serves an unhealthy function. The current investigation separated out PA reactivity to pleasant activities from general PA instability. We tested associations in three experience-sampling studies collected between 2012 and 2020 (N = 323). An internal meta-analysis revealed a significant association between PA reactivity to pleasant activities and less well-being. Moderation by average levels of PA was present but inconsistent across studies. We discuss how PA reactions to rewarding contexts may not necessarily reflect healthy emotion regulation and consider that “mood brightening” effects in daily life may indicate ill-being rather than well-being. Caution is warranted when interpreting the primary findings, as the indirect effect of PA reactivity was significant in only one of the three individual studies, and the effect was only found for the outcome of well-being and not distress. Results can be most confidently generalized to White adults living in the Midwest region of the United States. Future research should test not only the intensity of PA reactivity to rewarding contexts but also how long a person can sustain elevated PA—in relation to psychological health.
... Longitudinal studies have demonstrated that low levels of eudaimonia or its absence represent a risk factor for depression that would develop years later [5,6]. However, when psychologically distressed individuals were subjected to therapeutic or community programs that are enriched with eudaimonic elements, withdrawal of psychological disturbances was observed [7], and this newly acquired state of functioning would persist even 10 years later [8]. Antonovsky's work on the sense of coherence also demonstrated the importance of eudaimonia through its component of meaningfulness, seen as the most important element for resilience trajectory [9]. ...
Cultivating an eudaimonic lifestyle benefits mental health. However, it is not known under which circumstances the benefits of eudaimonia are the most pronounced. This cross-sectional study aimed to examine psychological needs (autonomy, competence, and relatedness) as the moderators of the effects eudaimonia has on mental health (general mental health, positive and negative mental health). In total, 328 young adults took part in this study, of which 36.6% were males, whose ages ranged between 18 and 30, with a median of 19 years (SD = 1.32). Questionnaires were used to measure eudaimonia (The Eudaimonia Scale from The Hedonic and Eudaimonic Motives for Activities), psychological needs (The Basic Psychological Needs Scale), and mental health (The Mental Health Inventory). To analyze the data, hierarchical regression analyses and analyses of variance have been performed. The results revealed that of all psychological needs, only the need for relatedness moderated the relationship between eudaimonia and general mental health and eudaimonia and negative mental health. Individuals with high eudaimonia and a highly satisfied need for relatedness had good general mental health and fewer mental health disturbances. The findings suggest that if one practices meaningful behaviors, the positive change in the mental health domain is greatest when those actions benefit not only this individual but others as well.
... What about recoverycan people achieve optimal well-being and thrive after major depression? Rottenberg et al. (2019) found that 10% of adults with documented depression in MIDUS were thriving 10 years later, assessed as the presence of multiple aspects of psychological well-being. These findings suggest that clinicians should consider collecting metrics of well-being to better monitor progress of patients over the long term. ...
Purpose
The purpose of this article is to examine synergies between a eudaimonic model of psychological well-being (Ryff, 1989) and mental health practice. The model grew out of clinical, developmental, existential and humanistic perspectives that emphasized psychological strengths and capacities, in contrast to the focus on emotional distress and dysfunction in clinical psychology.
Design/methodology/approach
Conceptual foundations of the eudaimonic approach are described, along with the six components positive functioning that are used to measure well-being. These qualities may be important in facilitating the recovery experiences, which are of interest in Mental Health and Social Inclusion .
Findings
Four categories of empirical evidence about eudaimonia are reviewed: how it changes with aging, how it matters for health, what are its biological and neurological underpinnings and whether it can be promoted. Major contemporary forces against eudaimonia are also considered, including ever-widening inequality, the enduring pandemic and world-wide strife. In contrast, encounters with the arts and nature are put forth as forces for eudaimonia. The relevance of these ideas for mental health research and practice is considered.
Practical implications
Enormous suffering defines our contemporary world. Such realities call for greater attention to factors that undermine as well as nurture the realization of human potential, the core of eudaimonic well-being.
Originality/value
Mental health is often defined as the absence of mental illness. The novelty of the eudaimonic approach is to define mental health as the presence of well-being, assessed with different components of positive functioning.
... We computed multimorbidity for all subjects in the Biomarker Project. Additionally, we examined multimorbidity in mental health, a binary variable indicating whether having two or more of the psychiatric and addictive conditions including depression (Rottenberg, Devendorf, Panaite, Disabato, & Kashdan, 2019), anxiety disorder (Disabato et al., . CC-BY-NC-ND 4.0 International license available under a (which was not certified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. ...
Multimorbidity, co-occurrence of two or more chronic conditions, is one of the top priorities in global health research and has emerged as the gold standard approach to study disease accumulation. As aging underlies the development of many chronic conditions, surrogate aging biomarkers are not disease-specific and capture health at the whole person level, having the potential to improve our understanding of multimorbidity. Biological age has been examined in recent years as a surrogate biomarker to capture the process of aging. However, relatively few studies have investigated the relationship between biological age and multimorbidity. More research is needed to quantify biological age using a broad range of biological markers and multimorbidity based on a comprehensive set of chronic conditions. Brain age estimated by neuroimaging data and machine learning models is another surrogate aging biomarker predictive of a wide range of health outcomes. Little is known about the relationship between brain age and multimorbidity. To answer these questions, our study investigates whether elevated biological age and accelerated brain age are associated with an increased risk of multimorbidity using a large dataset from the Midlife in the United States (MIDUS) Refresher study. Ensemble learning is utilized to combine multiple machine learning models to estimate biological age using a comprehensive set of biological markers. Brain age is obtained using convolutional neural networks and neuroimaging data. Our study is the first to examine the relationship between accelerated brain age and multimorbidity and presents the first effort to test whether sex moderates the relationship between these surrogate aging biomarkers and multimorbidity. Furthermore, it is the first attempt to explore how biological age and brain age are related to multimorbidity in mental health. Our findings hold the potential to advance the understanding of the accumulation of physical and mental health conditions, which may contribute to new strategies to improve the treatment of multimorbidity and detection of at-risk individuals.
... We highlight evidence from the Midlife in the United States (MIDUS) Survey, the Health and Retirement Study (HRS), and the English Longitudinal Study of Ageing (ELSA) to underscore these points. A proliferation of recent findings have documented the protective influence of eudaimonic aspects of well-being, particularly purpose in life, in reducing risk for major depression (Keyes, 2002;Rottenberg, Devendorf, Panaite, Disabato, & Kashdan, 2019), multiple disease outcomes (Boyle, Buchman, & Bennett, 2010;Kim, Sun, Park, Kubzansky, & Peterson, 2013;, and extending length of life (Hill & Turiano, 2014;Steptoe, Deaton, & Stone, 2015). Intervening biological and brain-based mechanisms have also been explicated (Hafez et al., 2018;Heller et al., 2013;Morozink, Friedman, Coe, & Ryff, 2010;Schaefer et al., 2013;Zilioli, Slatcher, Ong, & Gruenewald, 2015). ...
We question use of the term “well-being” to encompass notably distinct phenomena (objective indicators of socioeconomic status and health, subjective indicators of psychological experience) and dispute characterization of the field of well-being as relatively new. We also call for greater interplay between government surveys and multiuse cohort studies, both of which increasingly focus on well-being. The MIDUS study is presented as an example of how to negotiate distinct disciplinary priorities in broad-based studies of well-being and health, including those that take context seriously. We conclude with explanations for why we do not endorse any of the measurement recommendations (single-item measures, 4- to 6-item measures, multi-item assessments) put forth in the preceding chapter, arguing that the ultra-short assessments ignore extensive prior science documenting the complex, multifaceted nature of well-being, while the proposed longer assessment (Comprehensive Inventory of Thriving) suffers from multiple problems including a questionable conceptual foundation, inadequate evidence of validity and reliability, and highly redundant items.
... Moreover, the internalization of public stigma can increase distress and diminish morale and hope for recovery among attempt survivors (Carpinello and Pinna, 2017). Past work documenting the possibility of positive outcomes in the wake of mental health problems has proven constructive in decreasing stigma and facilitating hope for positive outcomes (e.g., schizophrenia; Andreasen et al., 2005;Warner, 2009;depression;Rottenberg et al., 2019). In a similar vein, the VA recently transitioned from traditional models of health care focused on symptom reduction to recovery-oriented models, emphasizing the (re)establishment of positive functioning (VA, 2008). ...
Background
Most people who survive suicide attempts neither re-attempt suicide nor die by suicide. Research on suicide attempt survivors has primarily focused on negative endpoints (e.g., increased suicide risk) rather than positive outcomes. One important outcome is psychological well-being (PWB), defined as positive functioning across emotional, intrapersonal, and interpersonal domains. We compared PWB among US military veterans with (i.e., attempt survivors) and without (i.e., non-attempters) a history of suicide attempt(s) using data from three nationally representative cohorts.
Methods
Each US veteran cohort (Cohort1: N = 3148; Cohort2: N = 1474; Cohort3: N = 4042) completed measures of suicidality (e.g., attempt history), character strengths (e.g., curiosity, optimism), psychological symptoms (e.g., depression), and indicators of PWB (e.g., happiness). t-Tests were conducted to examine group differences in PWB; hierarchical regressions were conducted to examine suicide attempt status as a predictor of PWB controlling for symptoms and demographics. Multivariable regressions were conducted to identify predictors of PWB among attempt survivors.
Results
In each cohort, reported PWB was markedly lower among suicide attempt survivors than non-attempters (ds = 0.9–1.2), even after adjusting for mental health symptoms. Individual differences in PWB were observed, with a subset of suicide attempt survivors reporting higher PWB levels than non-attempters (1.4–7.4 %). Curiosity and optimism were positively associated with PWB among suicide attempt survivors (rs = 0.60–0.78).
Limitations
Data were cross-sectional, limiting inferences about causation and directionality of associations.
Conclusions
Findings highlight diminished PWB as an important and understudied concern among veteran attempt survivors. Collectively, our findings underscore the importance of considering PWB in the research, assessment, and treatment of suicidality.
... Historically, the study of anxiety and mood disorders has attended to gloomy outcomes, including symptom chronicity and high rates of relapse (e.g., Richards, 2011;Ten Have et al., 2021). Researchers recently discovered that a sizable number of once depressed adults (approximately 10%) not only recover but show evidence of high levels of well-being on multiple outcomes a decade later (for the exact criteria, see: Rottenberg et al., 2019). In another study, 13% of adults with a prior suicide attempt not only survived but showed evidence of high levels of well-being a decade later (compared with the 23% prevalence rate of high well-being reported by those without suicidality; Tong et al., in press). ...
Much has been discovered about well-being since 1998, when positive psychology entered the lexicon. Among the wide range of areas in positive psychology, in this commentary we discuss recent discoveries on (1) distinctions between meaning in life, a sense of purpose, and happiness, (2) psychological or personality strengths and the benefits of particular combinations, and (3) resilience after exposure to adversity. We propose a series of questions about this literature with the hope that well-being researchers and practitioners continue to update their perspectives based on high-quality scientific findings and revise old views that rely on shaky empirical ground.
... Specifically, for those depressed people who reported higher PA over the course of the study, PA on days with a stressor was related to lower next day NA. This is our second contribution; current findings add to accumulating work on the value of investigating depression heterogeneity in understanding long term positive outcomes in depression (Panaite et al., 2021;Rottenberg et al., 2019). ...
Can positive events and positive emotions reduce the impact of a stressful event in people with depression? In previous research, studies have found that positive events and positive affect (PA) that co-occur with daily stressors can reduce – or offset – the emotional impact of the stressors. However, this effect has not been examined in people with depression, an emotional disorder characterized by higher levels of negative affect (NA) and lower levels of PA. This study examined whether depression is an individual difference variable in affective offset through testing whether depression reduces or eliminates affective offset. Using a nationally representative sample with daily assessments across eight days, we examined reports of positive events, stressors, and PA and NA from 121 adults with a depression diagnosis versus 839 adults with no depression symptoms. For depressed persons, when a stressor occurred, same day number of positive events, but not PA, offset next day NA. At the same time, depressed participants who reported higher average daily PA also reported lower NA the day after a stressor occurred. Our study provides evidence that some depressed persons exhibit affective offset and some depressed persons do not. We offer several explanations for the heterogeneous reactions of depressed individuals.
... Maintaining and thriving for psychological well-being after recovering from depression is crucial, given that depression is recurrent. Thankfully, Rottenberg et al. (2019) had reported that nearly 10% of those who were depressed managed to attain optimal well-being ten years later. Those depressed individuals with a higher level of well-being at the initial stage of study are found to have a greater chance of thriving (30% probability) after recovery. ...
This qualitative study explored the healing process of depression survivors among emerging adults with effective coping strategies utilised by them. A semi-structured interview was conducted on participants aged between 18-28 years old. A theme narrating the experience of the depression survivors were identified: The journey of healing - Crawling out of the quicksand. The survivors emphasised that to achieve healing, everything starts from within the self, and they had been putting in a lot of their extra efforts in helping themselves heal. They all went beyond recovery, where their efforts illustrated their focus on healing, thriving, and achieving optimal well-being upon recovery. Significantly, the relevance and applicability of the building blocks of Seligman’s PERMA model of well-being towards those efforts taken were revealed in the study. .
... An individual with a high level of subjective well-being can control their emotion and cope with various phenomena in their life, whereas those with a low level of subjective well-being view their life worthless, and they view the problems they face as heart-rending properly. Accordingly, an individual with a low subjective well-being often experiences negative emotion such as restlessness, depression (Rottenberg, Devendorf, Panaite, Disabato, & Kashdan, 2019;Wood & Joseph, 2010;Yüksel & Bahadir-Yilmaz, 2019), and anger (Haase, Seider, Shiota, & Levenson, 2012;Phillips, Henry, Hosie, & Milne, 2006;Weathersby, King, Fox, Loret, & Anderson, 2019). ...
The present study aimed to discover the effect of social support on single mothers’ subjective well-being. This study employed a correlational approach. One hundred fifty nine single-mothers in Bantul regency, Special Region of Yogyakarta, Indonesia were involved in this study, determined using quota sampling. The data were collected using social support and subjective well-being scales. Simple linear regression was used to analyze the data. The present study exhibited that social support significantly affects single mothers’ subjective well-being. This study can be used as a reference proving that social support is much needed by a single-mother to obtain subjective well-being. Therefore, a service in the form of a psychoeducational group is required in the community to enhance social support on single-mother. It can also be in the form of psychoeducational group and counseling services for single-mother to enhance her subjective well-being.
Abstrak: Penelitian ini bertujuan untuk mengetahui pengaruh dukungan sosial terhadap subjective well-being ibu tunggal. Penelitian ini menggunakan pendekatan korelasional. Subjek dalam penelitian ini adalah 159 ibu tunggal di Kabupaten Bantul, Daerah Istimewa Yogyakarta, Indonesia. Pemilihan subjek ditentukan menggunakan quota sampling. Data dikumpulkan dengan menggunakan skala dukungan sosial dan skala subjective well-being. Analisis data yang digunakan yaitu regresi linier sederhana. Penelitian ini menunjukkan bahwa dukungan sosial secara signifikan memengaruhi subjective well-being ibu tunggal. Studi ini dapat digunakan sebagai referensi yang membuktikan bahwa dukungan sosial sangat dibutuhkan oleh seorang ibu tunggal untuk mendapatkan subjective well-being. Oleh karena itu, layanan dalam bentuk kelompok psikoedukasi diperlukan di masyarakat untuk meningkatkan dukungan sosial pada ibu tunggal. Kelompok psikoedukasi dan layanan konseling, juga dapat digunakan untuk meningkatkan subjective well-being ibu tunggal.
... Optimal well-being is defined as having a positive emotion and the absence of negative emotions (Burns et al., 2015). According to Rottenberg et al. (2019), people with depression may achieve optimal well-being with the help of mental health professionals. An excellent communication with the professional's care team can enhance the recovery process and achieve the optimal of individual well-being. ...
... Fortunately, our study suggests that recovery presentations are common among videos that imply a course. Not only are these messages consistent with community-based epidemiological studies (Eaton et al., 2008;Mattisson, Bogren, Horstmann, Munk-Jörgensen, & Nettelbladt, 2007;Moffitt et al., 2010;Rottenberg, Devendorf, Panaite, Disabato, & Kashdan, 2019), but burgeoning research shows recovery messages decrease public and self-stigma (Yanos, Lucksted, Drapalski, Roe, & Lysaker, 2015). ...
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.
Background
Previous research papers have suggested that with each successive episode of depression or anxiety disorder the chance of recurrence significantly increases. However, the causes of such recurrences have been less well studied. Indeed, studies often report multiple, often conflicting, risk factors. The current review aimed to systematically collate recent literature on this topic to both estimate the likelihood of recurrence after an initial episode of depression or generalised anxiety disorder and elucidate factors which make recurrence more or less likely.
Methods
In May 2022, searches were conducted across four electronic databases: Medline, Global Health, PsycInfo and Embase for records published in English since 2018 in peer-reviewed journals reporting on the prevalence of recurrence of depressive/anxiety disorders, or risk factors for recurrence of depressive/anxiety disorders.
Results
A total of 2,173 citations were screened and 36 papers were included in the review. Recurrence rate reported in the retained papers ranged from 11.6–91.8%, with a mean and median recurrence rate of 42%. There was limited consensus on factors associated with recurrence, but previous experience of trauma, especially during childhood, was found to be the most predictive.
Limitations
Grey literature was not included within this review which may have resulted in a loss of potentially important studies.
Conclusion
We found no evidence that disease-related factors were predictive of relapse. Instead, our results also showed that, other than exposure to prior trauma, there was no clear consensus as to what risk factors impacted risk of recurrence. Suggestions for future research are suggested.
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.
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.
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.
Background: First-episode psychosis typically has its onset during adolescence. Prolonged deficits in social functioning are common in FEP and yet often variance in functioning remains unexplained. Developmental psychology frameworks may be useful for understanding these deficits. Eudaimonic well-being (EWB), or positive self-development, is a developmental psychology construct that has been shown to predict mental health outcomes across multiple populations but has not been systematically reviewed in FEP.
Aim: Our aim was to systematically review the evidence for: the predictors of EWB, the effectiveness of EWB interventions, and to examine the quality of this research in FEP.
Methods: Selected studies measured either composite or components of EWB. A systematic search produced 2,876 abstracts and 122 articles were identified for full screening which produced 17 final papers with 2,459 participants.
Results: Studies comprised six RCTs, eight prospective follow-up studies, and three case-controlled studies. Self-esteem and self-efficacy were the most commonly measured components. A meta-analysis of RCTs revealed no statistically significant effect of interventions on self-esteem. The extant research indicates that character strengths may be associated with higher EWB. Self-esteem may be lower in FEP compared with age matched controls but not different from ultra-high risk patients. Self-esteem appears to be associated with poorer insight and improved therapeutic alliance. Significant problems with both external and internal validity of reviewed studies were apparent.
Conclusions: The hypotheses that lowered EWB is a risk factor for both onset of FEP and for poorer functional outcomes warrant further investigation. There is currently no evidence for effective interventions for EWB in FEP.
Background
Studies have consistently demonstrated a positive cross-sectional association between depressive symptoms and derailment, or the sense of being “off-course” in life. Still unknown is whether all symptoms of depression similarly relate to derailment. Given that depressive symptoms do not weigh equally in the prediction of other important outcomes, this study aimed to bridge the gap between these novel findings and emerging perspectives focused on the impact of individual depressive symptoms.
Methods
The study was preregistered prior to data collection. The analytic sample contained 1,457 adults (Mage = 37.46 years, 54.22% female) recruited from Amazon's Mechanical Turk. Participants self-reported on depression using the Patient Health Questionnaire-9, and perceived changes in identity and self-direction using the Derailment Scale.
Results
All symptoms of depression shared positive unadjusted associations with derailment. Feelings of failure, fatigue, and sleep problems shared positive unique associations with derailment, and represented the top three contributors to the explained variance in derailment.
Limitations
This study relied on self-report methods, making results vulnerable to bias (e.g., social desirability, errors in memory, interpretation).
Conclusions
As work understanding the association between depressive symptoms and derailment continues to unfold, this study has provided markers for researchers and clinicians by suggesting that those who feel like they have failed, are fatigued, or report sleep problems may be the most likely to feel off-course and disconnected from their past selves. This work helps establish the utility of considering identity within the context of mental health, and future directions stemming from these findings are discussed.
The Chi-square statistic is a non-parametric (distribution free) tool designed to analyze group differences when the dependent variable is measured at a nominal level. Like all non-parametric statistics, the Chi-square is robust with respect to the distribution of the data. Specifically, it does not require equality of variances among the study groups or homoscedasticity in the data. It permits evaluation of both dichotomous independent variables, and of multiple group studies. Unlike many other non-parametric and some parametric statistics, the calculations needed to compute the Chi-square provide considerable information about how each of the groups performed in the study. This richness of detail allows the researcher to understand the results and thus to derive more detailed information from this statistic than from many others.
The Chi-square is a significance statistic, and should be followed with a strength statistic. The Cramer’s V is the most common strength test used to test the data when a significant Chi-square result has been obtained. Advantages of the Chi-square include its robustness with respect to distribution of the data, its ease of computation, the detailed information that can be derived from the test, its use in studies for which parametric assumptions cannot be met, and its flexibility in handling data from both two group and multiple group studies. Limitations include its sample size requirements, difficulty of interpretation when there are large numbers of categories (20 or more) in the independent or dependent variables, and tendency of the Cramer’s V to produce relative low correlation measures, even for highly significant results.
Objectives:
We investigated whether positive mental health predicts all-cause mortality.
Methods:
Data were from the Midlife in the United States (MIDUS) study (n = 3032), which at baseline in 1995 measured positive mental health (flourishing and not) and past-year mental illness (major depressive episode, panic attacks, and generalized anxiety disorders), and linked respondents with National Death Index records in a 10-year follow-up ending in 2005. Covariates were age, gender, race, education, any past-year mental illness, smoking, physical inactivity, physical diseases, and physical disease risk factors.
Results:
A total of 6.3% of participants died during the study period. The final and fully adjusted odds ratio of mortality was 1.62 (95% confidence interval [CI] = 1.00, 2.62; P = .05) for adults who were not flourishing, relative to participants with flourishing mental health. Age, gender, race, education, smoking, physical inactivity, cardiovascular disease, and HIV/AIDS were significant predictors of death during the study period.
Conclusions:
The absence of positive mental health increased the probability of all-cause mortality for men and women at all ages after adjustment for known causes of death.
Theory and research on major depression have increasingly assumed a recurrent and chronic disease model. Yet not all people who become depressed suffer recurrences, suggesting that depression is also an acute, time-limited condition. However, few if any risk indicators are available to forecast which of the initially depressed will or will not recur. This prognostic impasse may be a result of problems in conceptualizing the nature of recurrence in depression. In the current paper we first provide a conceptual analysis of the assumptions and theoretical systems that presently structure thinking on recurrence. This analysis reveals key concerns that have distorted views about the long-term course of depression. Second, as a consequence of these theoretical problems we suggest that investigative attention has been biased toward recurrent forms of depression and away from acute, time-limited conditions. Third, an analysis of how these theoretical problems have influenced research practices reveals that an essential comparison group has been omitted from research on recurrence: people with a single lifetime episode of depression. We suggest that this startling omission may explain why so few predictors of recurrence have as yet been found. Finally, we examine the reasons for this oversight, document the validity of depression as an acute, time-limited disorder, and provide suggestions for future research with the goal of discovering early risk indicators for recurrent depression.
We sought to describe the prevalence of mental health and illness, the stability of both diagnoses over time, and whether changes in mental health level predicted mental illness in a cohort group.
In 2009, we analyzed data from the 1995 and 2005 Midlife in the United States cross-sectional surveys (n = 1723), which measured positive mental health and 12-month mental disorders of major depressive episode, panic, and generalized anxiety disorders.
Population prevalence of any of 3 mental disorders and levels of mental health appeared stable but were dynamic at the individual level. Fifty-two percent of the 17.5% of respondents with any mental illness in 2005 were new cases; one half of those languishing in 1995 improved in 2005, and one half of those flourishing in 1995 declined in 2005. Change in mental health was strongly predictive of prevalence and incidence (operationalized as a new, not necessarily a first, episode) of mental illness in 2005.
Gains in mental health predicted declines in mental illness, supporting the call for public mental health promotion; losses of mental health predicted increases in mental illness, supporting the call for public mental health protection.
Multivariate Imputation by Chained Equations (MICE) is the name of software for imputing incomplete multivariate data by Fully Conditional Speci cation (FCS). MICE V1.0 appeared in the year 2000 as an S-PLUS library, and in 2001 as an R package. MICE V1.0 introduced predictor selection, passive imputation and automatic pooling. This article presents MICE V2.0, which extends the functionality of MICE V1.0 in several ways. In MICE V2.0, the analysis of imputed data is made completely general, whereas the range of models under which pooling works is substantially extended. MICE V2.0 adds new functionality for imputing multilevel data, automatic predictor selection, data handling, post-processing imputed values, specialized pooling and model selection. Imputation of categorical data is improved in order to bypass problems caused by perfect prediction. Special attention to transformations, sum scores, indices and interactions using passive imputation, and to the proper setup of the predictor matrix. MICE V2.0 is freely available from CRAN as an R package mice. This article provides a hands-on, stepwise approach to using mice for solving incomplete data problems in real data.
Previous research in psychiatry has focused on how negative personality traits and impaired well-being form risk factors for depression. This study presents the first longitudinal test of whether the absence of positive well-being forms an additional unique risk factor for depression.
A large cohort of 5566 people completed a survey at two time points, aged 51-56 at Time 1 and 63-67 at Time 2. Positive psychological well-being included measures self-acceptance, autonomy, purpose in life, positive relationships with others, environmental mastery, and personal growth. Personality was measured as extraversion, neuroticism, agreeableness, conscientiousness, and openness to experience. Depression was measured with the CES-D scale.
People with low positive well-being were 7.16 times more likely to be depressed 10-years later. After controlling for personality, negative functioning, prior depression, demographic, economic, and physical heath variables, people with low positive well-being were still over twice as likely to be depressed.
All measures were self-report, rather than based on peer-report or physician diagnosis. An aging population was studied; replication is needed in younger populations.
The absence of positive well-being forms a substantial risk factor for depression, independent of the presence of negative functioning and impaired physical health. Older people with low PWB are very likely to become depressed over 10 years, and preventative intervention and monitoring of these individuals are indicated.
Numerous empirical studies from various populations and settings link patient treatment adherence to physician-patient communication. Meta-analysis allows estimates of the overall effects both in correlational research and in experimental interventions involving the training of physicians' communication skills.
Calculation and analysis of "r effect sizes" and moderators of the relationship between physician's communication and patient adherence, and the effects of communication training on adherence to treatment regimens for varying medical conditions.
Thorough search of published literature (1949-August 2008) producing separate effects from 106 correlational studies and 21 experimental interventions. Determination of random effects model statistics and the detailed examination of study variability using moderator analyses.
Physician communication is significantly positively correlated with patient adherence; there is a 19% higher risk of non-adherence among patients whose physician communicates poorly than among patients whose physician communicates well. Training physicians in communication skills results in substantial and significant improvements in patient adherence such that with physician communication training, the odds of patient adherence are 1.62 times higher than when a physician receives no training.
Communication in medical care is highly correlated with better patient adherence, and training physicians to communicate better enhances their patients' adherence. Findings can contribute to medical education and to interventions to improve adherence, supporting arguments that communication is important and resources devoted to improving it are worth investing in. Communication is thus an important factor over which physicians have some control in helping their patients to adhere.
A theoretical model of psychological well-being that encompasses 6 distinct dimensions of wellness (Autonomy, Environmental Mastery, Personal Growth, Positive Relations with Others, Purpose in Life, Self-Acceptance) was tested with data from a nationally representative sample of adults (N = 1,108), aged 25 and older, who participated in telephone interviews. Confirmatory factor analyses provided support for the proposed 6-factor model, with a single second-order super factor. The model was superior in fit over single-factor and other artifactual models. Age and sex differences on the various well-being dimensions replicated prior findings. Comparisons with other frequently used indicators (positive and negative affect, life satisfaction) demonstrated that the latter neglect key aspects of positive functioning emphasized in theories of health and well-being.
To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of "usual care" by the primary care physician.
A randomized controlled trial among primary care patients with major depression or minor depression.
Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were randomized, with 91 patients meeting criteria for major depression and 126 for minor depression.
Intervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment (visits 1 and 3 with a primary care physician, visits 2 and 4 with a psychiatrist) and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. Patient education in these visits was supplemented by videotaped and written materials.
Primary outcome measures included short-term (30-day) and long-term (90-day) use of antidepressant medication at guideline dosage levels, satisfaction with overall care for depression and antidepressant medication, and reduction in depressive symptoms.
In patients with major depression, the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more (75.5% vs 50.0%; P < .01), were more likely to rate the quality of the care they received for depression as good to excellent (93.0% vs 75.0%; P < .03), and were more likely to rate antidepressant medications as helping somewhat to helping a great deal (88.1% vs 63.3%; P < .01). Seventy-four percent of intervention patients with major depression showed 50% or more improvement on the Symptom Checklist-90 Depressive Symptom Scale compared with 43.8% of controls (P < .01), and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls (P < .004). In patients with minor depression, the intervention group had significantly greater adherence than controls to adequate dosage of antidepressant medication for 90 days or more (79.7% vs 40.3%; P < .001) and more often rated antidepressant medication as helping somewhat to helping a great deal (81.8% vs 61.4%; P < .02). However, no significant differences were found between the intervention and control groups in the percentage of patients who were satisfied with the care they received for depression (94.4% vs 89.3%), in the percentage who experienced a 50% or more decrease in depressive symptoms, or in the decrease of depressive symptoms over time.
A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist, intensive patient education, and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression. It improved satisfaction with care and resulted in more favorable depressive outcomes in patients with major, but not minor, depression.
The goal of this study was to investigate psychosocial disability in relation to depressive symptom severity during the long-term course of unipolar major depressive disorder (MDD).
Monthly ratings of impairment in major life functions and social relationships were obtained during an average of 10 years' systematic follow-up of 371 patients with unipolar MDD in the National Institute of Mental Health Collaborative Depression Study. Random regression models were used to examine variations in psychosocial functioning associated with 3 levels of depressive symptom severity and the asymptomatic status.
A progressive gradient of psychosocial impairment was associated with a parallel gradient in the level of depressive symptom severity, which ranges from asymptomatic to subthreshold depressive symptoms to symptoms at the minor depression/dysthymia level to symptoms at the MDD level. Significant increases in disability occurred with each stepwise increment in depressive symptom severity.
During the long-term course, disability is pervasive and chronic but disappears when patients become asymptomatic. Depressive symptoms at levels of subthreshold depressive symptoms, minor depression/ dysthymia, and MDD represent a continuum of depressive symptom severity in unipolar MDD, each level of which is associated with a significant stepwise increment in psychosocial disability.
Well-being is a complex construct that concerns optimal experience and functioning. Current research on well-being has been derived from two general perspectives: the hedonic approach, which focuses on happiness and defines well-being in terms of pleasure attainment and pain avoidance; and the eudaimonic approach, which focuses on meaning and self-realization and defines well-being in terms of the degree to which a person is fully functioning. These two views have given rise to different research foci and a body of knowledge that is in some areas divergent and in others complementary. New methodological developments concerning multilevel modeling and construct comparisons are also allowing researchers to formulate new questions for the field. This review considers research from both perspectives concerning the nature of well-being, its antecedents, and its stability across time and culture.
Although experts in the treatment of depression have suggested that achieving remission is the primary goal of treatment, questions remain about how remission should be defined. In antidepressant efficacy trials, remission is defined according to scores on symptom severity scales. Normalization of functioning is often mentioned as an important component of remission, although it is not used to identify patients with remission in treatment studies. The authors' goal was to determine what depressed patients consider important in defining remission from depression.
A brief questionnaire was distributed to 535 psychiatric outpatients who were being treated for DSM-IV major depressive episode. They were asked to rate the importance of 16 statements in determining whether depression is in remission.
The three items most frequently judged to be very important in determining remission were the presence of features of positive mental health such as optimism and self-confidence; a return to one's usual, normal self; and a return to usual level of functioning. The patients endorsed a statement about absence of symptoms with nearly similar frequency.
Patients aspire to a range of outcomes from the treatment of their depression.
Selective serotonin reuptake inhibitors (SSRIs) are widely used to treat depression, but the rates, timing, and baseline predictors of remission in "real world" patients are not established. The authors' primary objectives in this study were to evaluate the effectiveness of citalopram, an SSRI, using measurement-based care in actual practice, and to identify predictors of symptom remission in outpatients with major depressive disorder.
This clinical study included outpatients with major depressive disorder who were treated in 23 psychiatric and 18 primary care "real world" settings. The patients received flexible doses of citalopram prescribed by clinicians for up to 14 weeks. The clinicians were assisted by a clinical research coordinator in the application of measurement-based care, which included the routine measurement of symptoms and side effects at each treatment visit and the use of a treatment manual that described when and how to modify medication doses based on these measures. Remission was defined as an exit score of <or=7 on the 17-item Hamilton Depression Rating Scale (HAM-D) (primary outcome) or a score of <or=5 on the 16-item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR) (secondary outcome). Response was defined as a reduction of >or=50% in baseline QIDS-SR score.
Nearly 80% of the 2,876 outpatients in the analyzed sample had chronic or recurrent major depression; most also had a number of comorbid general medical and psychiatric conditions. The mean exit citalopram dose was 41.8 mg/day. Remission rates were 28% (HAM-D) and 33% (QIDS-SR). The response rate was 47% (QIDS-SR). Patients in primary and psychiatric care settings did not differ in remission or response rates. A substantial portion of participants who achieved either response or remission at study exit did so at or after 8 weeks of treatment. Participants who were Caucasian, female, employed, or had higher levels of education or income had higher HAM-D remission rates; longer index episodes, more concurrent psychiatric disorders (especially anxiety disorders or drug abuse), more general medical disorders, and lower baseline function and quality of life were associated with lower HAM-D remission rates.
The response and remission rates in this highly generalizable sample with substantial axis I and axis III comorbidity closely resemble those seen in 8-week efficacy trials. The systematic use of easily implemented measurement-based care procedures may have assisted in achieving these results.
The Lundby Study is a longitudinal cohort study on a geographically defined population consisting of 3563 subjects. Information about episodes of different disorders was collected during field investigations in 1947, 1957, 1972 and in 1997. Interviews were carried out about current health and past episodes since the last investigation; for all subjects information was also collected from registers, case-notes and key informants. This paper describes the course and outcome of 344 subjects who had their first onset of depression during the follow-up.
In this study individuals who had experienced their first episode of depression were followed up. Their course was studied with regard to recurrence of depression related to duration of follow-up, transition to other psychiatric disorders including alcohol disorders, as well as incidence and risk factors of suicide.
Median age at first onset of depression was around 35 years for individuals followed up for 30-49 years. The recurrence rate was about 40% and varied from 17% to 76% depending on length of follow-up. Transition to diagnoses other than depression was registered in 21% of the total sample, alcohol disorders in 7% and bipolar disorder in 2%. Five per cent committed suicide; male gender and severity of depression were significant risk factors.
The low rates of recurrence and suicide suggest a better prognosis for community samples than for in- and out-patient samples.
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.
Objective.
—To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of "usual care" by the primary care physician.Design.
—A randomized controlled trial among primary care patients with major depression or minor depression.Patients.
—Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were randomized, with 91 patients meeting criteria for major depression and 126 for minor depression.Interventions.
—Intervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment (visits 1 and 3 with a primary care physician, visits 2 and 4 with a psychiatrist) and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. Patient education in these visits was supplemented by videotaped and written materials.Main Outcome Measures.
—Primary outcome measures included short-term (30-day) and long-term (90-day) use of antidepressant medication at guideline dosage levels, satisfaction with overall care for depression and antidepressant medication, and reduction in depressive symptoms.Results.
—In patients with major depression, the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more (75.5% vs 50.0%; P<.01), were more likely to rate the quality of the care they received for depression as good to excellent (93.0% vs 75.0%; P<.03), and were more likely to rate antidepressant medications as helping somewhat to helping a great deal (88.1% vs 63.3%; P<.01). Seventy-four percent of intervention patients with major depression showed 50% or more improvement on the Symptom Checklist—90 Depressive Symptom Scale compared with 43.8% of controls (P<.01), and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls (P<.004). In patients with minor depression, the intervention group had significantly greater adherence than controls to adequate dosage of antidepressant medication for 90 days or more (79.7% vs 40.3%; P<.001) and more often rated antidepressant medication as helping somewhat to helping a great deal (81.8% vs 61.4%; P<.02). However, no significant differences were found between the intervention and control groups in the percentage of patients who were satisfied with the care they received for depression (94.4% vs 89.3%), in the percentage who experienced a 50% or more decrease in depressive symptoms, or in the decrease of depressive symptoms over time.Conclusion.
—A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist, intensive patient education, and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression. It improved satisfaction with care and resulted in more favorable depressive outcomes in patients with major, but not minor, depression.(JAMA. 1995;273:1026-1031)
Data are reported on a series of short-form (SF) screening scales of DSM-III-R psychiatric disorders developed from the World Health Organization's Composite International Diagnostic Interview (CIDI). A multi-step procedure was used to generate CIDI-SF screening scales for each of eight DSM disorders from the US National Comorbidity Survey (NCS). This procedure began with the subsample of respondents who endorsed the CIDI diagnostic stem question for a given disorder and then used a series of stepwise regression analyses to select a subset of screening questions to maximize reproduction of the full CIDI diagnosis. A small number of screening questions, between three and eight for each disorder, was found to account for the significant associations between symptom ratings and CIDI diagnoses. Summary scales made up of these symptom questions correctly classify between 77% and 100% of CIDI cases and between 94% and 99% of CIDI non-cases in the NCS depending on the diagnosis. Overall classification accuracy ranged from a low of 93% for major depressive episode to a high of over 99% for generalized anxiety disorder. Pilot testing in a nationally representative telephone survey found that the full set of CIDI-SF scales can be administered in an average of seven minutes compared to over an hour for the full CIDI. The results are quite encouraging in suggesting that diagnostic classifications made in the full CIDI can be reproduced with excellent accuracy with the CIDI-SF scales. Independent verification of this reproduction accuracy, however, is needed in a data set other than the one in which the CIDI-SF was developed. Copyright © 1998 Whurr Publishers Ltd.
Most information about the lifetime prevalence of mental disorders comes from retrospective surveys, but how much these surveys have undercounted due to recall failure is unknown. We compared results from a prospective study with those from retrospective studies.
The representative 1972-1973 Dunedin New Zealand birth cohort (n=1037) was followed to age 32 years with 96% retention, and compared to the national New Zealand Mental Health Survey (NZMHS) and two US National Comorbidity Surveys (NCS and NCS-R). Measures were research diagnoses of anxiety, depression, alcohol dependence and cannabis dependence from ages 18 to 32 years.
The prevalence of lifetime disorder to age 32 was approximately doubled in prospective as compared to retrospective data for all four disorder types. Moreover, across disorders, prospective measurement yielded a mean past-year-to-lifetime ratio of 38% whereas retrospective measurement yielded higher mean past-year-to-lifetime ratios of 57% (NZMHS, NCS-R) and 65% (NCS).
Prospective longitudinal studies complement retrospective surveys by providing unique information about lifetime prevalence. The experience of at least one episode of DSM-defined disorder during a lifetime may be far more common in the population than previously thought. Research should ask what this means for etiological theory, construct validity of the DSM approach, public perception of stigma, estimates of the burden of disease and public health policy.
Outcomes in depression treatment research include both changes in symptom severity and functional impairment. Symptom measures tend to be the standard outcome but we argue that there are benefits to considering functional outcomes. An exhaustive literature review shows that the relationship between symptoms and functioning remains unexpectedly weak and often bidirectional. Changes in functioning often lag symptom changes. As a result, functional outcomes might offer depression researchers more critical feedback and better guidance when studying depression treatment outcomes. The paper presents a case for the necessity of both functional and symptom outcomes in depression treatment research by addressing three aims-1) review the research relating symptoms and functioning, 2) provide a rationale for measuring both outcomes, and 3) discuss potential artifacts in measuring functional outcomes. The three aims are supported by an empirical review of the treatment outcome and epidemiological literatures.
While clinical diagnoses are the primary criteria for differential indication in psychotherapy, treatment-goal themes may provide additional information on diagnosis-specific and extra-diagnostic aspects of treatment motivation. It is hypothesized that the goals of anxiety patients focus on symptom relief, while the goals of depression patients are thematically more heterogeneous. Additionally, it is hypothesized that patients with various specific anxiety disorders can be differentiated on their treatment-goal themes.
To obtain a sufficiently large number of diagnostically non-comorbid patients, a sample of 328 patients with non-comorbid anxiety and depression patients was merged from two subsamples: 255 outpatients from a university-based clinic in Germany and 73 outpatients from a comparable clinic in German-speaking Switzerland.
The treatment-goal themes of the 328 outpatients were coded using the Bern inventory of treatment goals.
Patients with non-comorbid diagnoses of depression or anxiety differed as hypothesized. Anxiety patients' treatment goals predominantly focused on symptom relief, while depression patients' treatment goals were thematically more heterogeneous. In addition, patients with various specific anxiety disorders differed in their treatment-goal themes.
Implications for clinical assessment and treatment planning are discussed.
To ascertain whether the quality of physician-patient communication makes a significant difference to patient health outcomes.
The MEDLINE database was searched for articles published from 1983 to 1993 using "physician-patient relations" as the primary medical subject heading. Several bibliographies and conference proceedings were also reviewed.
Randomized controlled trials (RCTs) and analytic studies of physician-patient communication in which patient health was an outcome variable.
The following information was recorded about each study: sample size, patient characteristics, clinical setting, elements of communication assessed, patient outcomes measured, and direction and significance of any association found between aspects of communication and patient outcomes.
Of the 21 studies that met the final criteria for review, 16 reported positive results, 4 reported negative (i.e., nonsignificant) results, and 1 was inconclusive. The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control.
Most of the studies reviewed demonstrated a correlation between effective physician-patient communication and improved patient health outcomes. The components of effective communication identified by these studies can be used as the basis both for curriculum development in medical education and for patient education programs. Future research should focus on evaluating such educational programs.
The recurrence of an affective disorder in people who initially recover from major depressive disorder was characterized by using the unique longitudinal prospective follow-up data from the National Institute of Mental Health Collaborative Program on the Psychobiology of Depression-Clinical Studies.
Up to 15 years of prospective follow-up data on the course of major depressive disorder were available for 380 subjects who recovered from an index episode of major depressive disorder and for 105 subjects who subsequently remained well for at least 5 years after recovery. Baseline demographic and clinical characteristics were examined as predictors of recurrence of an affective disorder. The authors also examined naturalistically applied antidepressant therapy.
A cumulative proportion of 85% (Kaplan-Meier estimate) of the 380 recovered subjects experienced a recurrence, as did 58% (Kaplan-Meier estimate) of those who remained well for at least 5 years. Female sex, a longer depressive episode before intake, more prior episodes, and never marrying were significant predictors of a recurrence. None of these or any other characteristic persisted as a predictor of recurrence in subjects who recovered and were subsequently well for at least 5 years. Subjects reported receiving low levels of antidepressant treatment during the index episode, which further decreased in amount and extent during the well interval.
Few baseline demographic or clinical characteristics predict who will or will not experience a recurrence of an affective disorder after recovery from an index episode of major depressive disorder, even in persons with lengthy well intervals. Naturalistically applied levels of antidepressant treatment are well below those shown effective in maintenance pharmacotherapy studies.
Depression and anxiety are common in medical patients and are associated with diminished health status and increased health care utilization. This article presents a quantitative review and synthesis of studies correlating medical patients' treatment noncompliance with their anxiety and depression.
Research on patient adherence catalogued on MEDLINE and PsychLit from January 1, 1968, through March 31, 1998, was examined, and studies were included in this review if they measured patient compliance and depression or anxiety (with n>10); involved a medical regimen recommended by a nonpsychiatrist physician to a patient not being treated for anxiety, depression, or a psychiatric illness; and measured the relationship between patient compliance and patient anxiety and/or depression (or provided data to calculate it).
Twelve articles about depression and 13 about anxiety met the inclusion criteria. The associations between anxiety and noncompliance were variable, and their averages were small and nonsignificant. The relationship between depression and noncompliance, however, was substantial and significant, with an odds ratio of 3.03 (95% confidence interval, 1.96-4.89).
Compared with nondepressed patients, the odds are 3 times greater that depressed patients will be noncompliant with medical treatment recommendations. Recommendations for future research include attention to causal inferences and exploration of mechanisms to explain the effects. Evidence of strong covariation of depression and medical noncompliance suggests the importance of recognizing depression as a risk factor for poor outcomes among patients who might not be adhering to medical advice.
Depression is an illness that frequently starts early in life, tends
to run a chronic course, and produces substantial disability. According to
the World Health Organization, depression is the leading global cause of years
of life lived with disability and the fourth leading cause of disability-adjusted
life-years, a measure that takes premature mortality into account.1 Depression is not only widespread and common, it may
be fatal; an estimated 90% of suicides are associated with mental illness,
most commonly depression.2 There were nearly
30 000 suicides in the United States in 1999, almost twice the number
of homicides.3 Suicide has become the third
leading cause of death in individuals aged 15 to 24 years.4
Depression is an important public-health problem, and one of the leading causes of disease burden worldwide. Depression is often comorbid with other chronic diseases and can worsen their associated health outcomes. Few studies have explored the effect of depression, alone or as a comorbidity, on overall health status.
The WHO World Health Survey (WHS) studied adults aged 18 years and older to obtain data for health, health-related outcomes, and their determinants. Prevalence of depression in respondents based on ICD-10 criteria was estimated. Prevalence values for four chronic physical diseases--angina, arthritis, asthma, and diabetes--were also estimated using algorithms derived via a Diagnostic Item Probability Study. Mean health scores were constructed using factor analysis and compared across different disease states and demographic variables. The relation of these disease states to mean health scores was determined through regression modelling.
Observations were available for 245 404 participants from 60 countries in all regions of the world. Overall, 1-year prevalence for ICD-10 depressive episode alone was 3.2% (95% CI 3.0-3.5); for angina 4.5% (4.3-4.8); for arthritis 4.1% (3.8-4.3); for asthma 3.3% (2.9-3.6); and for diabetes 2.0% (1.8-2.2). An average of between 9.3% and 23.0% of participants with one or more chronic physical disease had comorbid depression. This result was significantly higher than the likelihood of having depression in the absence of a chronic physical disease (p<0.0001). After adjustment for socioeconomic factors and health conditions, depression had the largest effect on worsening mean health scores compared with the other chronic conditions. Consistently across countries and different demographic characteristics, respondents with depression comorbid with one or more chronic diseases had the worst health scores of all the disease states.
Depression produces the greatest decrement in health compared with the chronic diseases angina, arthritis, asthma, and diabetes. The comorbid state of depression incrementally worsens health compared with depression alone, with any of the chronic diseases alone, and with any combination of chronic diseases without depression. These results indicate the urgency of addressing depression as a public-health priority to reduce disease burden and disability, and to improve the overall health of populations.
There are no studies of the natural history of major depressive disorder that lack prevalence and clinic biases.
To estimate risk factors for first lifetime onset and parameters of chronicity following the first episode, including duration, recovery, and recurrence, and to search for predictors of each parameter.
Prospective population-based cohort study with 23 years of follow-up.
East Baltimore, Maryland, an urban setting.
Probability sample of 3481 adult household residents in 1981, including 92 with first lifetime onset of major depressive disorder during the course of the follow-up, and 1739 other participants followed up for at least 13 years.
Diagnostic Interview Schedule and Life Chart Interview.
Female participants showed higher risk of onset of disorder, longer duration of episodes, and a nonsignificant tendency for higher risk of recurrence. Sex was not related to recovery. The median episode length was 12 weeks. About 15% of 92 individuals with first episodes did not have a year free of episodes, even after 23 years. About 50% of first episode participants recovered and had no future episodes. The evolution of the course was relatively stable from first to later episodes. Individuals with 1 or 2 short alleles of the serotonin transporter gene were at higher risk for an initial episode, but experienced episodes of shorter duration. There were few strong predictors of recovery or recurrence.
Major depressive disorder is unremitting in 15% of cases and recurrent in 35%. About half of those with a first-onset episode recover and have no further episodes.
Diagnostic and statistical manual of mental disorders
American Psychiatric Association. (1986). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington,
DC: Author.
The John D. and Catherine T. MacArthur foundation series on mental health and development. Studies on successful midlife development. How healthy are we? A national study of well-being at midlife (pp 1-34)
- O G Brim
- C D Ryff
- R C Kessler
Brim, O. G., Ryff, C.D., & Kessler, R. C. (2004). The MIDUS
National Survey: An overview. In O. G. Brim, C. D. Ryff,
& R. C. Kessler (Eds.), The John D. and Catherine T.
MacArthur foundation series on mental health and development. Studies on successful midlife development. How
healthy are we? A national study of well-being at midlife
(pp 1-34). Chicago, IL: University of Chicago Press.