Twenty-four years ago, as a young adult, I was brought to my knees by a severe depression that for years refused to budge, and almost took my life.
Getting back on my feet was a halting process of trial and error: I went on leave from my graduate school program in history, I tried medications, underwent psychotherapy, spent time in the hospital.
For a long time, nothing worked.
Just when I thought I would be stuck in a chronic depression forever, I started to get better. Very slowly, but surely, I improved. Eventually I became functional, and then fully regained my health and happiness.
What had changed?
Was it getting married to my high school sweetheart? Starting a family, and raising my daughter? A career change from history to psychology? A change of scenery from Florida to California? A new and more vigorous exercise routine?
I couldn’t be certain of the explanation, and my uncertainty led me to want to better understand more about the rise and fall of depression.
According to the World Health Organization, major depressive disorder is the most burdensome disease in the world. Three aspects of depression help explain why this is so:
- Depression is a common problem.
- People have trouble functioning during episodes of depression.
- Episodes of depression often recur over the life course.
Long-term follow-up studies of people treated for depression also paint a gloomy picture of its long-term prognosis. It’s a condition that is often difficult to shake, and can be resistant to treatment.
But hidden in this gloom is a more optimistic story about depression. Since recovering from depression, I’ve been fully invested in studying mood disorders, and became an author and advocate for those who struggle with depression.
And I’ve found that there are people out there who buck these trends — who, like me, not only recover fully from depression, but even thrive after it for long periods of time.
Until now, research hasn’t focused on these individuals, and so we have only hints about who functions well after depression and why.
What defines high functioning after depression?
It’s hard to study high functioning after depression without a clear definition of who fits this description.
A straightforward, three-part definition is a person with a history of depression who:
1. Has become almost completely symptom-free. Being symptom free is important not just because it’s a positive outcome, but also because long-term research studies show that even relatively minor symptoms of depression make it more than four times likely that full-scale depression will return.
2. Demonstrates good psychosocial functioning. Good psychosocial functioning refers to a person doing well across a number of areas, including in their job, in their relationships, and in how they cope with adversity. Even though it may sound obvious that these factors would be important in shaping who stays well after depression, only about 5 percent of treatment studies measure psychosocial functioning at all.
This is unfortunate given findings showing that change in this area can be a decisive factor in predicting who will get well and who stays well.
3. Has a high-functioning well period that lasts for longer than six months. A well period of this duration is important because it may set in motion an “upward spiral” of thoughts and behaviors that can block depression from returning over much a longer period of time (for decades or even a lifetime).
How common is high functioning after depression?
We won’t know precisely how common high functioning after depression is until researchers do studies using the three-part definition. But there are clues that good outcomes in depression may be more common than previously thought.
Two major comprehensive long-term studies that followed people for decades found that from 50 percent to 60 percent of people who had a first episode of depression never had another one. Findings such as these point to the chance that a substantial subset of people has experienced depression and has managed to put it completely behind them.
I am happy to say that personally, I’ve now managed to avoid depression for almost two decades. I seemed to have beaten the odds, which is wonderful.
Still, I am left with nagging questions: Was my good outcome unusual? How does this happen? Is there one main path to high functioning after depression? Or are there a variety of them? If there are many paths, which path is the most common? The easiest to find?
What predicts high functioning after depression?
We don’t yet know systematically what predicts high functioning after depression. At this point, there are two main ideas based on what is known about other depression-related outcomes.
One idea is that some aspect of the depression itself can offer clues about who has the greatest chance of breaking free from it. For example, high functioning after depression might be more likely if a person:
- has less severe symptoms
- has had fewer episodes
- first had depression later in life
A second idea is that the factors that surround the depression, including how a person reacts to it, will predict high functioning afterward. In this case, high functioning is more likely if a person:
- was functioning well before the first episode of depression struck
- has more resources available, such as friends and money
- makes beneficial change in their daily routine, job, beliefs, or friends as a result of the depression
Why more research is crucial
Besides advancing knowledge, the main reason to learn more about why some people function well after depression is to help more people achieve these good outcomes.
Specifically, if there are particular thoughts and behaviors that predict wellness after depression, the hope would be that these thoughts and behaviors can be collected, codified, and taught to others, and even applied to formal mental health treatment.
People living with depression are hungry for this information. When asked on surveys about their goals for disease management, patients responded that regaining confidence and achieving their previous level of functioning were high on their list of priorities.
In fact, these types of positive outcomes ranked higher than the goal of becoming symptom free.
Interestingly, professional guidelines in psychiatry and clinical psychology have long said that becoming symptom free, or an asymptomatic status, should be the highest goal for depression treatment.
But it seems that people who struggle with depression (not to mention their loved ones) want to aim even higher — to emerge from depression strong, wise, and more resilient, better versions of their previous self.