young woman getting therapy for depression

Over the course of our lives, the intensity and range of our emotions and moods can change, depending a variety of factors that are often beyond our control: but if we experience persistent sadness and low mood, can we exercise some level of control by seeking early treatment – i.e. before we receive a clinical diagnosis – and prevent mild, non-clinical depression from escalating to major depression and a diagnosis of major depressive disorder (MDD)?

A new study published by The Lancet: Psychiatry called “Psychological Interventions to Prevent the Onset Of Major Depression In Adults: A Systematic Review And Individual Participant Data Meta-Analysis” addresses this exact question.

This is an important topic to address for several reasons:

  1. Rates of mental illness, including depression, show increases both in the U.S. and worldwide over the past decade
  2. Evidence-based treatment for depression is safe and effective
  3. Stigma around treatment and support is slowly fading, which means people may be willing to seek support without a diagnosis
  4. The earlier a person with any kind of mental, emotional, or behavioral challenges receives professional support, the better the outcome

That last point is what we want to focus on in this article. We know, for instance, that treatment for depression for people diagnosed with depression can reduce symptoms of depression. That’s the whole point of treatment. We also know that for people with a diagnosis of depression, early treatment can prevent depression from escalating in severity.

But what we don’t know, or rather, don’t have evidence for, is whether early treatment for subclinical depression – with approaches we use for clinical MDD – can prevent it from crossing the threshold to clinical depression.

How We Treat Depression Now

The current process for a person who thinks they have depression generally follows a pattern like this:

  1. They experience depressive symptoms, or a loved one notices changes in behavior that may indicate mental health challenges.
  2. Depending on how severe the symptoms are, they may seek outside support – from a family member, a guidance counselor at school, a peer support group, or a professional healthcare provider – a psychiatrist, a psychotherapist, or a primary care provider.
  3. If they receive a screening for depression from a primary care provider or a specialist, they may receive a diagnosis for mild, moderate, or severe major depressive disorder.
  4. However, if they don’t meet clinical threshold for major depressive disorder (MDD), they may not receive a referral for professional support in the form or therapy or counseling. And in the absence of a diagnosis, they won’t – or shouldn’t – receive a prescription for antidepressant medication.

Unlike other areas of healthcare, in mental/behavioral health, there’s no real formal process or standard of care for people with subclinical symptoms. What most patients with subclinical depressive symptoms receive is advice about things like self-care and work-life balance, but they won’t receive an official intervention designed to address their depressive symptoms.

We’ll elaborate on this point further. For instance, a person can be prediabetic, and receive specific instructions to improve their condition and prevent escalation from prediabetes to full-blown diabetes. Likewise, it’s possible for physicians to identify precancerous cells in people and recommend a course of therapy to prevent them from escalating to precancerous to cancerous.

In mental health treatment, there’s a diagnostic category called prodromal psychosis, where patients display early signs of psychosis and receive appropriate treatment.

But we don’t have analogous diagnoses for the most common mental health disorders.

There’s no clinical diagnosis called pre-anxiety. Nor is there a diagnosis called pre-depression. Which means there’s no standard of care for people with symptoms that don’t meet or exceed the clinical threshold.

The Current Facts on Depression in the U.S.

We gathered the following facts and figures from the 2023 National Survey on Drug Use and Health (2023 NSDUH). The NSDUH is a vital resource in behavioral health, primarily because of its consistency and its size. It’s published annually and includes data from more than 70,000 people. That means we can us the NSDUH to arrive at population-level conclusions that enable both policymakers and providers to understand the current state of affairs, make plans, and advocate resources accordingly.

Here’s the latest data on depression among adults.

Major Depressive Episode (MDE): Adults 18+

MDE:

  • Total: 8.5% (21.9 million)
  • 18-25: 17.5% (5.9 million)
  • 26-49: 10.2% (22.6 million)
  • 50+: 4.5% (5.4 million)

MDE With Severe Impairment:

  • Total: 5.9% (15.3 million)
  • 18-25: 12.9% (4.3 million)
  • 26-49: 7.4% (1.9 million)
  • 50+: 2.7% (3.3 million)

Here’s something to think about. Every single one of those people experienced symptoms of depression before receiving a diagnosis for depression. That begs the question implied in the title of this article: if they had received early treatment, could they have prevented their depression from escalating to clinical depression?

Let’s look at another set of statistics – this time on mental illness, in general. We offer this information to provide context for the data we share and the topic we address. Again, we’ll point out that every person represented in the bullet points below experienced symptoms before receiving a diagnosis.

Mental Illness Among Adults 18+

Any Mental Illness

  • Total: 22.8% (58.6 million)
  • 18-25: 33.8% (11.5million)
  • 26-49: 29.2% (47.1 million)
  • 50+: 14.1% (16.9 million)

Serious Mental Illness

  • Total: 5.7% (14.6 million)
  • 18-25: 9.2% (1.1 million)
  • 26-49: 7.9% (8.2 million)
  • 50+: 2.4% (2.9 million)

And, like the first set of data we shared, we wonder how many of those millions of people could have addressed their mental health symptoms early and prevented the escalation of symptoms from mild to moderate, or moderate to serious.

Let’s look to this new study and learn what they found.

Early Treatment to Prevent Depression From Escalating

In this study, the research team recognized a new trend in depression treatment. For adults with depressive symptoms that don’t reach a clinical threshold, providers are considering psychological interventions as a strategy to prevent the worsening of symptoms, and the transition from subclinical to clinical depression.

Here’s how they summarize this research effort:

“In this individual participant data meta-analysis, we quantify the effect of preventive interventions against control on MDD onset and explore effect modifiers.”

Here’s a quick summary of the study participants:

  • Total: 7201 participants with depressive symptoms who received early intervention, and 3504 control subjects with depressive symptoms who did not receive early intrvention
  • By Gender: 30.9% male, 68.9% female, 0.2% preferred not to say
  • Average age: 49.9

Here’s a quick summary of the interventions examined for early treatment for depression:

  • Cognitive behavioral therapy (CBT)
  • Problem solving therapy
  • Behavioral activation
  • Stepped care
  • Other types

Providers administered interventions in three modes:

  • In person
  • Conference calls
  • Other (virtual, text, individual call)

To determine whether early treatment for mild or early depression prevents or has any impact on transition to more serious or severe depression, the research team examined rates of depressive symptoms using standard psychiatric metrics at baseline, six months after treatment initiation, 12 months after treatment initiation, and 24 months after treatment initiation.

Let’s take a look at the results.

Mild Symptoms, Early Treatment, And Depression: The Results

Here’s what the research team found:

Early Treatment for Depression: Is it Effective?

Early treatment for depression was associated with:

  • Significantly reduced MDD diagnosis at 6 months:
    • 42% reduced incidence, compared to control group
  • Significantly reduced MDD diagnosis at 12 months
    • 33% reduced incidence, compared to control group
  • No reduction in MDD diagnosis at 24 months, compared to control group

Now let’s look at the data on the various factors that may have impacted the interventions, which researchers call modifiers.

Early Treatment for Depression: Which Modifiers Affected Outcomes?

Previous treatment:

  • The impact of early treatment was more significant for people with no previous history of psychotherapy

Baseline Depression and Anxiety:

  • Patients with higher initial depressive symptoms showed greater reduction in MDD risk
  • Patients with higher initial anxiety symptoms showed greater reduction in MDD risk
  • Treatment delivered via conference call was as effective as in-person or virtual treatment

Here’s how the research team characterizes their results:

“Our findings support guidelines recommending psychological interventions as a treatment option in the management of subthreshold persistent depressive symptoms. Moreover, our results underscore the importance of public health messaging that emphasizes the effectiveness of preventive psychological interventions for depression, contributing to de-stigmatization and encouraging engagement in mental health practices.”

This research clearly demonstrates the value of early intervention for people with depressive symptoms that don’t meet a clinical threshold for MDD diagnosis. The study sheds light on this specific subset of th population.

Since they’re not in crisis, and their depressive symptoms don’t cause serious disruption – they often fly under the radar. Now we know we should increase our awareness of their needs, an include them in our efforts to reduce barriers to care for all people.

How This Study Helps

In addition to clarifying the fact that early treatment for mild, subthreshold depression can reduce or prevent conversion to major depressive disorder (MDD), this study helps by showing us the methods that work are standard approaches that we’re familiar with and are widely available.

In fact, the primary mode – and most effective – treatment modality was cognitive behavioral therapy (CBT), which is the most common type of psychotherapy. The benefits of CBT go beyond reducing depressive symptoms. CBT can help patients:

  • Identify and and evaluate their thoughts
  • Identify whether their thoughts are associated with positive or negative feelings or behaviors
  • Define personal goals
  • Learn practical skills that help achieve their goals
  • Develop/improve communication skills
  • Develop/improve mindfulness skills
  • Learn stress tolerance skills

CBT, and other forms of psychotherapy that can help people with depression, empower patients with the skills they need to become self-managing after their time in formal treatment. Now we know that CBT may also empower patients before their symptoms reach a clinical threshold, and give them the emotional awareness and cognitive skills to manage depressive symptoms, and in some cases, prevent conversion of subthreshold depression to clinical major depressive disorder (MDD).