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When Is Depression Cured?

No endpoint has been defined for the treatment of depression, making it hard for patients to know if they have been cured.

Over fifteen years of experience with reasonably safe drug treatments for depression has given the mental health world a new understanding of the disorder, a more accurate sense of its true course and a new set of goals. It's no longer enough merely to be treated for depression; it's necessary to be cured completely.

Increasingly, the aim of treatment is not to make patients better but to make them well. In the absence of complete remission from an episode of depression, the disorder tends to recur, even to settle in more or less permanently. What's more, studies now show that the longer patients remain sick, the harder it is to ever make them completely well.

Improvement is not enough. The existence of even low-level symptoms can have deleterious effects on the brain itself, not simply increasing the likelihood of subsequent episodes but actually accelerating their occurrence.

Experts find that complete remission requires treatment for a minimum of nine months—and that's for an acute first episode. Beyond the disappearance of symptoms patients should experience a minimum of two months of well-being before treatment is stopped.

Guidelines drawn up by psychiatrists themselves state that people who have chronic depression—an episode lasting two years or more— need to be treated for two years after full remission has occurred. And if you have recurrent depression, marked by multiple depressive episodes, treatment should last indefinitely. Just as with chronic disorders like hypertension and diabetes, maintenance treatment is necessary.

But here's the rub. Few patients now take antidepressants in a way that gives them a shot at curing the condition. The average duration of a prescription is about 100 days.

According to a national study of depression, 40% of sufferers get no treatment at all for their condition. And a scant 22% get anything resembling adequate care.

Unfortunately, that shifts onto patients themselves the responsibility for seeing that the treatment they get is adequate. Buyer beware.

Over time it has become clear that people who don't achieve full remission are at high risk for relapse and for doing poorly. Even if they don't have a full relapse of depression they don't fare well in terms of social and occupational function.

And for some people, returning to "normal" isn't good enough."Twenty-five percent of depressive episodes are preceded by dysthymia," a more or less chronic low-grade mood disturbance, observes Martin Keller, M.D., chairman of psychiatry at Brown University. "These people need to do better than return to their normal self. The differences are dramatic between those who are asymptomatic and functioning well and those with some symptoms."

It may be that the future will bring indicators of remission that more precisely reflect the subtleties of neurobiologic disturbance that underlie the disorder. Researchers know that multiple brain areas go awry in depression, and following even successful treatment it takes an extended period of time for brain circuitry to reset itself, leaving patients vulnerable to relapse well after overt symptoms disappear.

But for now, no unambiguous end-point of treatment has been defined and no specific test of cure exists. The most reliable indicators of remission are the disappearance of manifest symptoms, complete resumption of roles you enjoyed both inside and outside the home, and the subjective sense of return to well-being.

Although it sounds vague, what social scientists call your level of "psychosocial functioning" provides what is probably the most sensitive sign of recovery. This includes your ability to work efficiently and well, the absence of friction in relationships with spouse, friends and colleagues, your physical health, and the overall quality of your life. Improvements in social adjustment, ability to concentrate and to work productively seem to take the longest, as can a sense of clear-headedness.

Dr. Keller suggests that during periods of depression you keep a list of the particular symptoms you are experiencing. Then as you undergo treatment and begin to feel better, go through the symptom list and monitor how well you are doing on each element.