Hope In Recovery: Good News for Teens in Depression Treatment

We have some good news for teens in depression treatment. It works.

Three New Studies Show Treatment is Headed in the Right Direction

When we read about mental health issues in the news these days, almost everything we encounter is negative. Headline and stories are filled with dire warnings about the precarious state of teen mental health in 2022. Troubling trends in the prevalence of depression and anxiety combined with the increase in teen suicide that began before the coronavirus pandemic – and was then exacerbated by the pandemic – make all these stories and warnings warranted.

Our teens are in a precarious spot. They are at increased risk of mental health disorders, psychological issues, emotional disturbances, and behavioral problems. The stress and grief of the past two years can manifest in various ways, and many teens are, indeed, feeling that stress and grief manifest in the form of mental health disorders like depression.

However, not all of the news is bad or scary.

Along with the increase in mental health issues among teens, what we also see – nationwide, for children, teens, and adults alike – is an unprecedented willingness to acknowledge mental health issues and talk about them in public.

In the context of all this troubling data, this is a huge step.

Stepping Up, Opening Up: It Makes a Difference

In the past two years, we’ve seen athletes in the National Football League (NFL) open up about depression, suicidal ideation, and anxiety. That’s right: in what might be the most macho milieu on earth outside the military, we see grown men crying and asking for help. According to the American Psychological Association (APA), several NFL teams now have full-time therapists on staff year-round, solely for the purpose of supporting the mental health needs of their players. We can see the ripple effect of the NFL approach in commercials, advocacy campaigns, and public efforts to normalize mental health care and remove the stigma from speaking up and seeking help.

That’s not all.

In the summer of 2021, we watched the best gymnast on earth – maybe the best gymnast ever – take a step back and say to the world “My mental health, psychological well-being, and physical safety is more important than a gold medal.” That’s not a quote, but that was the content of her message. Contrast that to twenty-six years ago, when we watched a 19-year-old gymnast perform a dangerous event with a severely injured ankle – risking her physical health, her future, and her personal wellbeing so the USA could win a team gold – and we can judge how far we’ve come.

We’ve come a long way.

We still have a long way to go – but it looks like we’re headed in the right direction.

We’ll narrow the focus of this article to a discussion of depression. Three articles published recently have our attention. One shows that treatment for depression can be effective, long-lasting, and allow people with depression to manage their symptoms and thrive. The others present evidence on two relatively new components of depression treatment – diet and exercise – that foreground the importance of a holistic approach to treatment.

Let’s look at the study on the relationship between diet and depression first.

Healthy Eating and Depression Treatment: What’s the Connection?

Most of us know what healthy eating means. Here’s the common knowledge:

1. We need whole grains and plenty of fresh fruits and vegetables.
2. It’s best to cut back on our sugar intake.
3. We need to avoid processed foods and fast foods whenever possible.
4. We need to eat three health meals a day.
5. It’s okay to break the rules once in a while.

With regards to that last point, what matters is that more of our meals are healthy than not healthy. We know that changing our eating habits might take some time, but we also know that when we do shift that balance to favor healthy foods, we can see dramatic improvements in our overall health.

This new study shows us that a change in diet can lead to changes in our mental health, as well.

Published in 2022, the study “The Effect of A Mediterranean Diet On The Symptoms Of Depression In Young Males” examined the effect of diet on a group of young men with moderate to severe depression. Researchers recruited a group of 72 young males and split them into two groups: a control group who received a traditional approach to psychotherapy called befriending therapy, and an experimental group whose treatment involved a change in diet only, and no psychotherapy. They assessed symptoms of depression at baseline, six weeks, and twelve weeks.

We’ll share what they found, but first, here’s a quick description of the Mediterranean diet as published by the Mayo Clinic:

• Meals revolve around vegetables, beans, and whole grains, as opposed to meat.
• Fish is a common part of meals, and included in at least two meals per week.
• Olive oil is preferred to butter or other types of cooking oil.
• Desserts revolve around fresh fruit.

Now let’s take a look at those results.

The Effect of Diet vs. Therapy on Depression in Young Males

• Participants in the diet group (MD) adhered to treatment – i.e. stayed and finished – in higher rates than the therapy group (BT).
• At 12 weeks, the MD group showed greater improvement on the Beck Depression Inventory Scale than the BT group.
• At 12 weeks, the MD group showed greater improvement on a Quality of Life (QoL) assessment than the BT group.

That’s important news, which we include here to support our claim in the beginning of this article that, in our opinion, depression treatment is heading in the right direction by embracing the holistic model of treatment. In addition to traditional therapy and medication, the holistic approach includes lifestyle changes like diet, i.e. healthy eating. Another component of a lifestyle change common to a holistic approach to depression treatment is exercise.

That’s what the next study examined.

Let’s take a look at what the researchers found.

Traditional Approaches to Depression Treatment in Teens and Adults: A Quick Review

For years, the standard treatment for depression was a combination of therapy and medication. While a wide variety of approaches to psychotherapy are effective for depression treatment in teens and adults, the general consensus is that modes of therapy based on cognitive behavioral therapy (CBT) work best for the most people. When indicated, CBT in combination with anti-depressant medication can help people who don’t respond well to therapy alone manage their depressive symptoms and lead a full and fulfilling life.

Types of therapy based on CBT include:

• Mindfulness based cognitive behavioral therapy (MBCBT)
• Dialectical behavior therapy (DBT)
• Acceptance and commitment therapy (ACT)

There are others, but those are the most common. Types of medication for depression include:

• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin and noradrenaline reuptake inhibitors (SNRIs)
• Tricyclic antidepressants (TCAs)
• Monoamine oxidase inhibitors (MAOIs)
• Norepinephrine and dopamine reuptake inhibitors (NDRIs)

Again, there are others, but those are the most common.

This combination approach works very well for a large majority of people diagnosed with MDD. However, this approach does not work for everyone. Studies published over the past twenty years show that for some people, exercise is as effective as psychotherapy for depression – but there’s a problem.

The symptoms of depression often create a substantial barrier to full participation in an exercise program. Low mood, low motivation, and fatigue can prevent people with depression from engaging in healthy exercise consistently.

This begs a question: is there a way to remove those barriers and get people with depression to adhere to an exercise protocol?

Combined Exercise and Cognitive Behavioral Therapy for Depression: A Novel Approach

This new study took an approach designed to mitigate the problem of adherence by combining exercise and cognitive behavioral therapy in a unified program that required participants to exercise before engaging in CBT sessions. Here’s how they did it: they recruited 58 people diagnosed with MDD and divided them into two groups. One group exercised for half an hour before their CBT session – researchers labeled this the ActiveCBT group. One group did not exercise, but engaged in regular activities before their CBT session – researchers labeled this the CalmCBT group.

At baseline, two months, and three months post-treatment, researchers analyzed the following dimensions/outcomes of ActiveCBT and CalmCBT:

• Treatment acceptability (Will they do it?)
• Treatment adherence (Did they do it?)
• State Anhedonia (Do they feel better after treatment?)
• Depressive symptoms (Did treatment reduce depressive symptoms)

Let’s take a look at their results.

Exercise and CBT (ActiveCBT)  v. CBT Alone (CalmCBT)

• Treatment acceptability (Will they do it?):
  • Participants in both groups reported the protocols sounded reasonable and agreed to participate fully
• Treatment adherence (Did they do it?)
  • Participation and completion of the protocols in both groups were high:
    • 100% for the active group
    • 90% for the calm group
  • State Anhedonia (Do they feel better?)
    • Compared to the CalmCBT group, participants in the ActiveCBT group reported less anhedonia on a visual scale called the Visual Anhedonia Scale (VAS), which measures overall sense of pleasure on a device using a manual slider.
    • Compared to the CalmCBT group, participants in the ActiveCBT group reported less anhedonia on a scale called the Dimensional Anhedonia Rating Scale (DARS), which measures the sense of pleasure “right now” with a 17-point questionnaire
  • Depressive symptoms (Did treatment reduce depressive symptoms?)
    • At two months, the end of the study period:
      • The ActiveCBT group and the CalmCBT group showed remission rates of 60%
    • At three months post-treatment:
      • The ActiveCBT group showed a remission rate of 40%
      • The CalmCBT group showed a remission of 25%

Those results are interesting: they show that after a CBT session, people in the active group report less anhedonia, and also reported decreases in overall anhedonia. With regards to remission of depressive symptoms, there was no difference in the groups at the end of treatment. Three months later, however, the ActiveCBT group showed significantly greater remission of symptoms. One way to interpret this is that exercise, as a habit, is a durable and effective lifestyle change that can support remission of depressive symptoms – in combination with CBT skills – longer than psychotherapy alone.

That’s another dataset that supports the holistic approach to depression treatment.

Now it’s time to switch gears to a more general – and possibly more important – question:

Can people with mental illness recover and lead a life with high levels of wellbeing, functioning, and life satisfaction?

Mental Health Disorders, Treatment, and Lifelong Recovery

This gets to the core of the entire discussion about mental health treatment. People with depression – children, teenagers, and adults – and their families want answers to two questions:

1. Does treatment work?
2. Does it last?

The answer to the first question is yes. However, not every person with a mental illness achieves remission.

The answer to that question is the subject of the last study we discuss in this article. In a paper published in the journal Clinical Psychological Science called “Optimal Well-Being After Psychopathology: Prevalence and Correlates,” a group of researchers in Canada reported the results of data analysis on the wellbeing – the optimal well-being – of people who received a clinical diagnosis for any of the following diagnoses:

• Depression
• Suicidal ideation
• Generalized anxiety disorder
• Bipolar disorder
• Substance use disorder

Here’s how the primary author of the study summarizes the report:

“Research on mental illness has historically focused on adverse outcomes, while overlooking a potentially important group of people who thrive following recovery after mental illness. We discovered that a sizable group of people experience long-term thriving in response to common mental illnesses, including depression, anxiety, and substance use disorders.”

In the study, researchers examined the records of 23,491 Canadians diagnosed at some point in their lives with one or more of the disorders listed above. To determine their current level of well-being, they defined a category they called optimal well-being, which they defined as “full recovery from psychopathology, coupled with high levels of psychological well-being and low levels of functional disability.”

Let’s take a look at what they found.

Optimal Well-Being After Mental Health/Substance Use Disorder Diagnosis

1. Optimal well-being means:
   • No mental illness symptoms for 12 months
   • High scores on measures of life satisfaction
   • Low level of functional disability
2. In the general population, among people without no mental health or substance use diagnosis ever:
   • 24% meet criteria for optimal well-being.
3. Among people with at least one diagnosed mental health disorder, who make up 33% of the total population:
   • 10% meet criteria for optimal well-being (58% report diagnostic recovery)
4. Optimal wellness by disorder:
   • SUD: 10% (68% report diagnostic recovery)
     • Alcohol: 11% (71% report diagnostic recovery)
     • Cannabis/Other drugs: 4% (73% report diagnostic recovery
   • Depression: 7% (50% report diagnostic recovery)
   • Generalized Anxiety Disorder: 6% (64% report diagnostic recovery)
   • Bipolar I & II: 3% (30% report diagnostic recovery)

Let’s interpret that data, because it’s not immediately obvious why we think those numbers are cause for hope. First, the criteria for optimal wellness are high, which is demonstrated by the fact that only 24 percent of the never-diagnosed population are considered optimally well. What that means is that 76 percent of them are not optimally well. Applying that point of view to people with a history of mental health disorders, we learn that, compared to people with a history of mental health disorder, only 14 percent more people with no history of mental health disorder are considered optimally well.

This refutes the notion that a person diagnosed with a mental health disorder cannot live a fulfilling life and thrive in recovery. Now let’s look at the set of numbers we place in parentheses: the percentage of people in the sample who meet the criteria for diagnostic recovery.

To Recover, To Live, To Thrive

In the context of this study, diagnostic recovery means the absence of clinical symptoms of a diagnosed mental health disorder for 12 consecutive months.

When we look at the diagnostic recovery data, that’s where we see real hope. As the numbers show, optimal wellness is elusive. Only 24% of people without any history of mental health disorder say that meet criteria for optimal wellness.

However, for people with depression, anxiety, or substance use disorder, the fact that diagnostic recovery rates are 50, 64, and 73 percent respectively means that they have a very good chance of achieving diagnostic recovery. That’s a big deal, because most of us think of mental health disorders as chronic conditions that never really fully go away, an idea which is reinforced by the mantra recovery is a lifelong journey.

That’s true: recovery is a lifelong journey, but recovery is not synonymous with optimal well-being. A person diagnosed with a mental health disorder who receives evidence-based treatment can achieve a full diagnostic recovery, which gives them an honest chance at optimal well-being, which we’ll call thriving. The numbers say remission and recovery are achievable in a practical sense. Thriving is another story. The hope that we want people with depression, anxiety, or a substance use disorder to take from this article is the this:

When they enter treatment, they learn the practical tools to recover from mental illness or substance abuse. To live and thrive in recovery is the next step. Living and thriving depend on who they are and on their personal vision of happiness and success. Recovery takes them to the door: what this study shows is that a mental health diagnosis does not prevent them from opening that door, but rather prepares them to open it and walk right through.