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

An integrative analysis of potential mechanisms of reduced positive affect in daily life in depression: an ESM study

Decreased levels of positive affect (PA) are a hallmark of depression. Current models propose as potential main mechanisms a dysfunctional use of emotion regulation (ER) strategies (i.e. dampening, positive rumination), and a maladaptive activation of pro-hedonic goals. However, the role of these mechanisms in PA in daily life remains understudied. We used a 10-day ESM design to assess how these mechanisms influence each other and contribute to depressive symptomatology-related low momentary PA in 139 individuals. Higher depressive symptoms were associated with lower PA, pro-hedonic goals, more frequent use of positive rumination, and higher use of dampening. Further, experiencing higher levels of PA predicted lower following time point use of dampening in individuals with higher symptoms. Finally, using positive rumination was more beneficial (i.e. predicted higher PA increases one moment later) for individuals with higher symptomatology. Our findings suggest that moment-to-moment changes in PA daily life are affected by, and have an effect on, both pro-hedonic goals and the use of dampening and positive rumination, highlighting specific cognitive-affective mechanisms that should be considered when designing interventions aimed at improving low PA characterising depression symptomatology.

Well-Being After Psychopathology: A Transformational Research Agenda

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.

Future Well-Being Among U.S. Youth Who Attempted Suicide and Survived

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 (a) a suicide attempt at Wave I, (b) no suicidal ideation or attempts over the past year at Wave III (7 years after), and (c) a well-being profile at or above the top quartile of nonsuicidal peers. Seventy-five of 574 suicide attempt survivors (∼13%) met criteria for FWB at Wave III, compared to 26% of nonsuicidal 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 < .05). In conclusion, a nonfatal 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.

Longitudinal reciprocal associations between depression, anxiety, and substance use disorders over three decades of life

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.

Major Depression and Its Recurrences: Life Course Matters

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.

More treatment but no less depression: The treatment-prevalence paradox

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 a-c 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.

Pharmacogenomics: A road ahead for precision medicine in psychiatry

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.

Future Well-Being Among People Who Attempt Suicide and Survive: Research Recommendations

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 nonfatal 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 reduce the stigma associated with suicide-related behaviors.

Optimal well-being in the aftermath of anxiety disorders: A 10-year longitudinal investigation

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.

Latent Class Analysis of Adolescent Psychosocial Functioning and Course of Major Depression

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 (M_age = 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.

Derailment within the landscape of psychopathology

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 article, 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. Although 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.

Profiles of psychosocial and clinical functioning in adolescence and risk for later depression and other outcomes

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.

Change processes underlying "good outcome": A qualitative study on recovered and improved patients' experiences in psychotherapy for major depression

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.

Redefining Therapeutic Outcomes of Depression Treatment

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 in 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 is to discover 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.

Habits as Building Blocks for the Resilience of Vulnerable Populations: Two Positive Deviance Case Studies From the U.S.–Mexico Border Region

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.

The Differential Role of Central and Bridge Symptoms in Deactivating Psychopathological Networks

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.

Molecular aspects of depression: A review from neurobiology to treatment

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.

Optimal Well-Being after Major Depression

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 (MIDUS) study. To count as thriving after depression, a person had to exhibit no evidence of major depression, and had to exceed cut offs across nine facets of psychological well-being that characterize the top 25% of US nondepressed adults. Overall, nearly 10% of adults with study documented depression were thriving ten 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.

The Effectiveness of Mindfulness-Based Cognitive Therapy (MBCT) in Real-World Healthcare Services

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.