Mental disorders afflict humanity on a vast scale. The World Health Organization estimates that half a billion people struggle with depression and anxiety. Those who have a mental illness suffer great distress – whether it’s the crippling fear of a panic attack, the angst of remembered trauma, or the horror of compulsive rituals. Collectively, mental health problems account for more than a fifth of all years lived with disability.
As important and compelling as these statistics are, however, the story they tell overlooks the other side of the coin – the reality that some percentage of people with mental illness recover and even thrive. The story of Kevin Hines is one notable example of this possibility. After years of suffering from depression, delusions and paranoia, Hines attempted suicide by jumping off the Golden Gate Bridge in San Francisco. Immediately after leaving the railing, he felt regret as he plunged 240 feet into the waters below. Miraculously, Hines survived. His mental health has since improved, and he is now a prominent public speaker on suicide prevention, and the author of the book Cracked, Not Broken: Surviving and Thriving After a Suicide Attempt (2013).
While one story cannot represent every person’s experience, it does raise important questions about mental illness. What are the chances that someone with a mental health problem such as depression, anxiety or suicidal impulses will recover from these difficulties to live a happy life? Are mental health disorders so horrible, so corrosive and so destructive to wellbeing that instances of thriving after mental illness are too rare to enumerate? Or is the transition from mental illness to wellness a realistic possibility for many? The psychiatry, psychology and public health establishment has hesitated to tackle these important questions.
Mental health fields have invested their energy into tracking symptoms or disorders as endpoints. In practical terms, this means that those who formally evaluate treatment typically consider the extent to which treatments reduce the symptoms of mental illness rather than the extent to which they lead to a state of high wellbeing. This distinction is non-trivial, as insights from positive psychology have shown us that the absence of symptoms does not equal the presence of good functioning – ridding oneself of anxiety is not the same as creating joy, meaning and satisfaction with life.
This focus on symptom reduction has led to mixed advancements. A symptom-driven approach has helped to generate empirically supported therapies and medications for disorders such as depression, panic disorder and phobias. However, many treatments using this approach have plateaued in their effectiveness – and residual symptoms, relapse and recurrence are common outcomes for clients who discontinue treatment. The overall situation remains frustrating for therapists and clients alike.
Contrary to the idea that thriving after psychopathology is rare, 10 per cent of those who’d had depression met the wellbeing standard
All therapists know of at least some clients who have done extraordinarily well. And the public is widely aware of stories about those who overcame mental health adversity and developed a life full of purpose and happiness, including outspoken celebrities like Dwayne ‘the Rock’ Johnson (who suffered from depression) and Ariana Grande (who has dealt with depression and PTSD). Yet the scientific fields at the forefront of improving mental health have not collected systematic data on positive outcomes after psychopathology.
Our research group – the Mood and Emotion Lab at the University of South Florida – has started to remedy the situation with a series of studies that offer first estimates of thriving after common mental health problems. To obtain these estimates, we made two practical decisions. First, we needed a way to measure thriving with pre-existing, valid assessments. We embraced psychological wellbeing – which encompasses aspects such as overall life satisfaction, self-acceptance, a sense of purpose, and positive relationships – as a widely accepted concept with established measures. These include questionnaires on which individuals rate their agreement with statements such as: ‘In general, I feel confident and positive about myself’ and ‘I know that I can trust my friends, and they know they can trust me,’ among many others.
Second, we took advantage of the size and representativeness of national datasets that allowed us to calculate wellbeing norms among people who did not experience psychopathology – and then assess how many people with a history of psychopathology met those same norms. The standard we used to determine that someone was ‘thriving’ after psychopathology required a person to no longer be diagnosable, and also to meet or exceed the level of wellbeing met by the top 25 per cent of the normative sample.
Our first analysis used the MIDUS dataset, derived from a longitudinal study of nearly 3,500 midlife adults in the US. In this analysis, we asked: what was the chance that people who were diagnosed with depression during the first part of the study would, 10 years later, be recovered from the disorder and report the level of wellbeing met by the top quarter of nondepressed people? Contrary to the idea that thriving after psychopathology is rare, we found that 10 per cent of those who’d had depression earlier in the study met this wellbeing standard (compared with 21 per cent of those who had not had depression). Rather than eliminating the chance of future high wellbeing, depression only halved it. We observed a similar pattern of data in a national sample of adolescents, focusing on non-fatal suicide attempts: those who had survived a suicide attempt were about half as likely to report high levels of psychological wellbeing at a seven-year follow-up compared with nonsuicidal peers.
Objectively, having depression does not foreclose the possibility of future happiness
When analysing data from the 2012 Canadian Community Health Survey (a national sample of 25,000 adults in Canada), we again found a similar pattern. In Canada, about 10 per cent of people with a history of psychopathology in their lifetime met our thriving criteria, compared with 24 per cent of those without a history of psychopathology. Thriving rates did vary by the type and presentation of psychopathology, however. For example, rates of thriving were lower in people with a history of bipolar disorder (3 per cent) than in people with a history of substance use disorders (10 per cent), depression (7 per cent) or generalised anxiety disorder (6 per cent). Although some of these numbers are low, it should be noted that our thriving criteria were relatively strict; they may not have captured people who you could say were ‘doing well, but not thriving’. In our study, 67 per cent of people with any past mental illness had reached symptomatic recovery, meaning they no longer met the diagnostic criteria for a particular illness.
Our findings show that psychopathology does not impose absolute limits on human potential. This might sound abstract, but it hits both of us personally. Like many who study depression, we have had periods during which we struggled with the condition. During these struggles, we have been told that depression is invariably chronic, recurrent and something you must learn to live with. Such messages were disheartening to hear – and, in light of these data, it seems that they were also incorrect. We can only wonder how much it would have helped if a provider presented us with this basic fact of prognosis: that, objectively, having depression does not foreclose the possibility of future happiness.
While we are not spokespeople for all patients, we are also not alone. Survey data show that patient groups value the presence of elements of wellbeing – whether that’s satisfaction with life, personal growth or positive relations with others – as much or more than the absence of symptoms. Going forward, disseminating accurate prognosis information that conveys the full range of outcomes – both the possibility of chronicity and disability, and the possibility of thriving – would be a great service to millions of people who struggle with their mental health and worry about the future.
Thriving, as a long-term goal, could also be integrated more widely into mental health care. This could take several forms, including measuring various proxies of thriving before and during treatment to better understand the process of change, and it could involve routinely including thriving measures as an outcome. We know many real-world therapists who want their clients to thrive one day. But only by collecting systematic data – and by prioritising positive functioning as much as negative functioning – will our field start to understand which treatments lead to thriving and which don’t.
People with more financial resources are more likely to thrive after mental illness
Ideally, therapists and their clients will work collaboratively to develop a shared understanding of thriving. We recognise that patients vary in their goals and what they find most meaningful. For one person it might be functioning well on the job; for another it might be finding intimacy with their partner; for others it could be active participation in the local community or finding ways to build upon personal strengths. Our hope is that an enhanced focus on wellbeing will spark a broader conversation that encourages providers to better align patient care with patient goals.
It may be possible to increase the number of people who thrive after psychopathology. As more data emerge, we will want to learn more about what differentiates thrivers from other people. Is it the kind of treatment, the specific diagnosis, or the level or kinds of support and resources around the person? Our early findings suggest that people with multiple conditions throughout their lifetime, and those who experience longer episodes of conditions like depression and anxiety, have decreased chances of thriving over time. We also found that people with more financial resources, measured by household income bracket, are more likely to thrive after mental illness.
Our default assumption is that there are multiple pathways to wellness. We expect that some pathways to thriving might be more fixed (eg, one’s genetic or financial endowment), whereas other pathways will be more readily within human control (habits or routines, or strategies for self-regulation). Finding controllable pathways that could lead to increased odds of thriving is a particularly exciting prospect. Our current estimates are just snapshots of the present; they do not tell us what will be possible in the future.
The consideration of thriving as a mental health outcome arrives at a moment when mental health care is already being reimagined. The COVID-19 pandemic has spotlighted urgent unmet mental health needs and the inadequacy of traditional mental health service delivery to meet those needs. As we ponder new models for delivering mental health care, such as telehealth, peer models or text-based therapy, the moment is also ripe for rethinking the goals of treatment.