Improvement in Depression: Now or Never?

We know quite a bit about why and how people fall into depression. From negative thinking to stressful environments to poor ways of coping to gloomy temperaments, falling in is no great mystery. But why and how do people pull out of depression?

We know that most people do pull out. With many years of follow-up, nearly every single person in a group of depressed people will eventually remit. Some experts even describe depression as a self-limited condition, like a storm that eventually spins out to sea and dies. We also have extensive research on treatment, procedures designed to accelerate this recovery process. Fortunately, some treatments are empirically supported, meaning that there is systematic data to show many people substantially improve as a result. So we know that most depression ends and that several treatments -- whether medication or psychologically based -- are clearly better than nothing.

Our knowledge of how and why people pull out of depression is primitive. But primitive as it is, we can build on two big facts. Fact One: We know from epidemological research that for most who suffer, depression will improve slowly, with gains uneven, halting, and fragile. And ultimately, about two-thirds of those who partially recover will fall back into an episode of depression. Thus, a key research question is why is improvement so slow for most, with gains often reversing.

Fact Two is in many ways more curious and interesting. In study after study, it's those who improve early --often about 1/3 of those studied-- who retain and often expand upon their gains. For example, Szegedi and colleagues reported in 2009 an analysis of over six thousand patients who had been enrolled in drug trials: improving early --in the first two weeks-- was an extremely strong predictor of ever improving. This apparently robust finding runs against the longstanding idea in pharmacology that antidepressants take many weeks before their clinical action in the brain can manifest itself. But perhaps what is most curious of all is that it does not appear to matter what kind of therapy it is -- the importance of early improvement has been shown for cognitve therapy, drug therapy, and even for placebo pills. If you get better early, you have a good chance to get well. The finding has also been extended to severely depressed inpatients in a hospital. Those who do best in the first two weeks do best in the long run.

The flip side, the implication, is scary: It suggests that improvement in depression is often now or never. We must build upon our knowledge of what is special about those who respond now to shrink the pool of nevers, the propoprtion of those who will have to suffer for a very long time before even partial relief arrives. If we could predict who would respond to what beforehand - and assign accordingly, we would be well on the road to containing depression. As it stands, starting a treatment for depression is like spinning the roulette wheel -- some will win for sure; but more will need to try their luck again.

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What is the first thing you noticed when you started to get better?

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