Back from the Black: Why Do Early Improvers Improve?

I recently posted about the early improvers, the roughly 1/3 of people in a depressive episode who show a rather substantial and early improvement in their depression, We should care about this lucky third. Not only do they get relief quicker but their improvements hold up fairly well. Although early improvement by itself never puts a person completely in the clear, and many early improvers have the symptoms return later, early improvement can be an important stepping stone to fuller recovery. Early improvers appear to have superior long-term outcomes relative to those who have more gradual improvement.

We don't have a lot of research specifically on what foretells this early improvement in depression. Here are my 4 (actually 4 and a half) best hunches about the early improvers based on the general outcome literature for depression and our knowledge of what drives the mood system.

Hunch #1: Early improvers don't have as many or as complicated problems as the average depressed person. The predicament of the mood system is that it has to integrate across all available threats and opportunities and push behavior in the right direction, and when, necessary, pause. We can see how a discrete problem like the breakup of an intense relationship might benefit from a cocoon of low mood--as a place to analyze the past and develop solutions: whether it's deciding to date a man with different characteristics or deciding to take a break from dating to focus on other priorities. Surely, some of the early improvers are people who have arrived at reasonable solutions to life's solvable problems.

But what about when many different problems arrive simultaneously? Depressions come with other psychiatric and medical difficulties -with anxiety piled on top - with substance abuse piled on top- with chronic pain piled on top - and with serious health problems piled on top. New stressors may pile up even after depression starts - the depressed person may lose their job, have new financial difficulties, or have friends and support desert them. With each new problem, the mood system is facing a longer and more complex equation with more unknown terms. When there are no easy solutions, we should expect only sluggish improvement at best.

Hunch #2: Early improvers do the right things. Based on what we know to be helpful in bringing depression to heel, we can surmise that early improvers try to exercise, keep active, and maintain a normal schedule if they can. If they are in treatment, they keep their appointments and comply with the doctor's requests. They try to make full use of their social networks of support rather than immediately withdrawing from them. The early improver may be aided by an innate resilience that helps them to do the right things. A study by Geschwind and colleagues found intriguing signs of nimbleness in the mood system of early improvers. They gave depression patients pagers and prompted them to report on their emotions several times a day as they started a drug treatment. Some patients demonstrated a very early improvement in positive mood states during the first week of treatment. Mind you, these patients still had depression symptoms like concentration problems, guilt, insomnia, and a sad mood. What had changed is that they were now also able to experience signs of enthusiasm and cheer. This shift in mood foretold that the patient was likely to achieve remission on the drug by the sixth week. In fact, patients with early signs of positive mood improvement had a 34 times higher chance of achieving eventual remission than those who did not. How did the early shift in mood bring about the extinction of depression? One possibility is that mood shift picked out the people who were unusually receptive to the pharmacological effect of the drug. But another perhaps more interesting hypothesis is that this shift in positive mood feeds an upward spiral of behavior - a small amount of positive mood allowed patients to begin to do the right things to re-engage with their environment, to seek out rewards again, and to benefit when good things happen.

Hunch #3: Early improvers enjoy usually good fortune. If rotten fortune, and having tangled problems interfere with improvement, a brilliant turn of luck at the start of a depression could be enough to stop depression in its tracks. Leenstra and colleagues found positive life changes increased in number during the 3 months prior to recovery in primary care patients with depression and anxiety. George Brown and Tiril Harris have shown that events that provide an injection of hope into a situation of ongoing deprivation --what they call fresh start events-- can bend the course of depression in an upward direction.

Hunch #4: Early improvers have miraculous treatment responses. Treatment may have been the first thing that popped into your head when I said I had hunches about rapid improvement. Treatment is probably less important here than we think it is. It's worth mentioning that we see the same segment of early improvers among patients who take placebo pills, among patients on waiting lists, and among people in the community who are not in treatment of any kind. We may attribute rapid improvement at the start of a treatment to the treatment when it is not actually a product of the treatment at all.

Hunch #4 and a half: Early improvers have an X factor. This hunch concerns the possibility that early improvers have discovered secret weapons in their struggles against depression that account for their sucess. These weapons may or may not work well for others. These weapons may or may not overlap with what happens in established therapies. We don't know. The first step is learning more about what worked for the lucky third, to shed light on what they used to come into the light.

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Did you experience early improvement? Did you have a secret weapon against depression?

Write me at chartingthedepths@gmail.com