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Depression has many phases. It comes on. It rages. It remits. It recurs.
In many ways, the most awkward phase of depression is when the worst has passed, when a depressed person is better, but not fully well. The continuing dominance of the disease model of depression stunts our thinking about this phase. Depression is, first and foremost, the disease in full bloom, the acute phase. But when depression is in its twilight, when it slowly fades into an ordinary bad mood, that's a kind of conceptual limbo.
Residual depression is a state of limbo in other ways.
The first limbo is being part way back in your life. This is a confusing place to be. Uncertain whether depression is really and truly gone, there's no script for how to act. As author and journalist Tracy Thomson put it, "I yearned to get better; I told myself I was getting better. In fact, the depression was still there, like a powerful undertow. Sometimes it grabbed me, yanked me under; other times I swam free." After hospitalization for depression, she returned to her job at the Washington Post, but cognitively she was only there intermittently. "I wrote long memos to remind myself of what I was doing, sometimes only to find a similar memo I'd written several days before."
There is also a social limbo. A depressed person in the throes of an episode is relatively easy to make allowances for. But what about when the worst is over? A spouse, a boss, or friend, who was sympathetic when depression was disclosed or first treated may lose patience with allowances. So, too, the sufferer may be done with depression well before depression is done with them. The price of saying, "enough already!" is walking around bruised and battered without getting the proper support. After the worst is over, there's an incentive to pretend that everything is back to normal even when it is not. Limbo is too complicated to explain.
Clinical practice likewise leaves people with residual symptoms in limbo. They are in a fog zone. Part of this stems from treatment researchers focusing their energies on the acute phase of depression. While this is understandable, it is telling that in clinical trials the main yardsticks of success are defined in terms of reductions in depression symptoms. By convention, one yardstick is a response, which is conventionally defined as 50 percent or greater symptom reduction. Another yardstick is remission, defined when depression falls below a standardized symptom cutoff, most often below a 7 on a symptom measure called the Hamilton. Using these as the sole yardsticks implies that no consequential depression remains when they are met. But this is not the case. In one representative study, 80 percent of people who were treated with Prozac for 8 weeks and who met the study criteria for full remission (i.e., Hamilton ≤ 7) still had one or more symptoms. Is it true that these remaining symptoms aren't worth bothering with?
Recently, there's a growing recognition that these yardsticks set the bar of success too low. Residual depression is a potentially dangerous state, worthy of treatment in its own right. Over time, small amounts of residual depression have surprisingly bad effects. For example, Paykel and colleagues found that among those who had improved substantially, residual symptoms tripled the risk for subsequent early relapse. Relapse occurred in 76% of those with residual symptoms and only 25% of those without. Likewise, a large cohort study found that people who had residual symptoms at recovery relapsed much much faster -- on average three times faster -- than people who were asymptomatic at recovery. These same patterns are seen over time when people with a first lifetime major depressive episode were followed for up to a dozen years. People who have residual depressive symptoms during recovery have more severe and chronic future courses, with deep depression recurring faster and more often. In these respects, almost better is worse than you might think. In fact. it's not too big a stretch to say that one big reason we are not winning the fight against depression is that our available treatments leave so many people in limbo.
Millions of people remain in limbo states for long periods of time. This is a call to recognize the importance of this phase of depression and to raise our sights for it. The aftermath of depression is often a tough slog, like a long hangover -- for almost better to become completely well, we need to provide more attention, support, guidance, and yes, even treatment for people who find themselves in this phase.
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