Incurable?

Recently, I started re-reading from the beginning a fanfiction series about therapy that I had been following for several years.  Even if, as I described in a previous post, a recent chapter had left me worrying that depression is genetic and inevitable, the story overall is about recovery.  The author takes a tragic hero who has a short, lonely and misunderstood life in canon, and gives him a chance to survive, get some much-needed help, and find happiness and love.  I had found the story deeply inspiring.

However, re-reading it, I noticed that in an early chapter, when the hero goes to his first therapy session, his therapist warns him that most mental illness can be treated but not exactly cured, and so treatment focuses on learning to function with it and minimise the symptoms.

It struck me that if I were the hero, I would think at that point, ‘I’ve already “functioned” well enough to do my job for the past 17 years and help defeat an evil wizard, and I’ve hated every day of it.  If that’s the best I can hope for – if I can never cease to be depressed and anxious and wish I was dead and hate anyone who reminds me of someone who’s hurt me – then what’s the point in getting therapy?  I’ve achieved my goal and the world doesn’t need me any more, so why can’t I just die?’

Of course, in practice the therapist is going to be focusing on helping him learn to overcome past trauma and find more hopeful ways of thinking about life.  So when I read this chapter, I thought she was presenting the situation in an overly pessimistic way, which might make someone who isn’t familiar with medical terminology and the distinction between ‘treatment’ and ‘cure’ feel unduly discouraged. 

Obviously, in the fanfic, the hero doesn’t give up, because he’s tougher than I am.  And in this fanfic, the author intends things to work out well for him.  But worrying that depression might be incurable in real life made me feel despairing enough that I could barely get through work the next day greeting customers cheerily without bursting into tears.

I tried reminding myself, ‘Oh, come on, this is just a character in a fanfic speaking!’  After all, I had been reading enough about neuroplasticity over the past half-year to know that the human brain develops throughout life, and psychotherapy and practising mindfulness can help to make real changes in our neural pathways, so that people really can recover.  So I decided to look up the real statistics on recovery from depression when I got home.

When I did, I really began to despair, to the point where the following week I couldn’t face going to work at all.  Most medical sites talked about ‘remission’ from depression rather than recovery.  This suggested to me that depression is usually an inescapable degenerative disease (as if it was a physical condition like cancer or Alzheimer’s) from which therapy can at best buy a few years of feeling a bit better before you’re back to feeling as bad as when you started, or worse – and are now older, poorer, more tired and more disappointed because you now know that in the long term, trying to escape didn’t work.

A site called Anxiety to Zen noted that ‘Out of 258 analyzed patients, it was found that approximately 80% recovered within five years; however, 50% of those who recovered experienced a recurrence. The risk of relapse is notably high, with percentages increasing over time—36% after one year, 40% after two years, and reaching 65% after a decade.’  Even more worryingly for someone with long-term depression, it added that ‘Following the first depressive episode, roughly half of patients will relapse, with increasing risks for subsequent episodes—70% after the second and 90% after the third.’

According to The Lancet, ‘25–40% of patients who recover after treatment will have another depressive episode within 2 years, 60% after 5 years, and 85% after 15 years.’  (I’m not sure what ‘after’ means in this context, but I suspect it means that after 5 years, 60% will have had a relapse at some point within that time.  If it meant that 60% are fine for 5 years and have a relapse some time after that, and 85% are okay for 15 years and then have a relapse, the figures don’t make sense.

Even a report on Cognitive Behavioural Therapy as a particularly effective intervention only reported that ‘Over the course of 46 months, 43 per cent of those who had received CBT had improved, reporting at least a 50 per cent reduction in symptoms of depression, compared with 27 per cent who continued with their usual care alone.’  When less than half of people showing 50% improvement for slightly under four years is an exceptional result, it isn’t very encouraging.

Most of the thoughts that had held me back from making progress in therapy in the past – particularly worrying that God wanted me to be depressed and that it was a sin to want to be healthy and happy – were beliefs that I knew were untrue.  But this seemed medically conclusive, and this thought made me more depressed than ever (and harder than ever for PDB11 to live with).  If depression is incurable, why throw thousands of pounds away on temporary relief?

Also, I thought, could it do more harm than good in the long run?  What if someone experiencing remission got married and had children, only to revert when his children were toddlers to hating himself and everyone around him and wishing he could die, and resenting his family for tying him to life?  How could that not traumatise his children?  I don’t plan to have children, but what would be the good of looking for a more responsible job than working part-time in a shop, if I can’t be stable for long?

When I thought about it a bit more, it occurred to me that these statistics on relapse were about the probability of someone getting one more depressive episode at some point in the years following the study.  They didn’t suggest that after therapy, most people go back to being routinely depressed, or at least having a depressive episode for about one week per month, or that depression will be as severe as before.  If I could get better for a year, let alone several years, shouldn’t that be likely to change my habits of thought enough that I’d be less likely to go back to my current state? 

Yes, there is a higher risk of relapse for people who have had numerous depressive episodes – but this could be simply because they have more factors causing depression, or more ingrained habits of thinking in a depressive way to unlearn, not that they aren’t getting better overall.  After all, a friend of mine who has been trying to get clear of drug addiction for the past twenty years has had numerous relapses, but as time goes on he’s got much better, not just at staying off drugs, but at living more healthily and finding positive interests in his life.

As PDB11 said, we really need to ask a therapist’s advice about what it is or isn’t reasonable to hope for.  However, of the various therapists we have found online and contacted, most are currently busy or don’t work with couples, so it could take a few months to find someone.

In the meantime, I posted questions on Quora which received a number of answers, mostly helpful and encouraging, with only one accusing me of being stupid (and this was from someone who accuses everyone of being either stupid or a chatbot):

If most depression is incurable, does that mean I'm stuck with feeling this way forever? I'm not asking whether I will sometimes get a depressive episode again, but whether I will inevitably go on having depressive episodes every few weeks. 

I've read that most people in therapy for depression relapse within a few years, but does therapy make a difference to frequency and severity of depressive episodes, or just buy a brief period of feeling better before depression resumes as before? 

In particular, Blake Christiansen’s answer explained that I might or might not relapse, but that therapy would give me the tools I needed to take control over my life so if I did get further depressive episodes, they wouldn’t destroy me.  Similarly, an answer by Michaela Silver to another person’s question explained that a therapist isn’t someone who takes away pain, but a teacher, like a fitness coach, who helps you to realise that although you can’t now lift a heavy weight, when your muscles aren’t strong enough and you are recovering from an injury, you can train to the point where you can lift it.

However, what encouraged me the most was when ShadowAceSeverus, the fanfiction author whose stories had sent me down this track of worrying, wrote back to me.  He hadn’t updated his stories or replied to my comments for a while, and I had wondered whether he had blocked me because he was fed up with my being so negative when he was aiming to write a hopeful but realistic and honest story about recovery, or whether I had even put him off writing fanfiction (or whether he was just busy with his new job).

However, when I had posted a comment that wasn’t even so much commenting on his story as listing my worries about mental health and whether therapy was even worth it, he wrote a long, encouraging reply about why therapy is thoroughly worth it even for people with severe long-term problems that never go away.  He described his own experiences with problems much more severe than mine, including trauma, anxiety, recurring nightmares and OCD, and how much better things are for him now than seven years ago.  And then, with astonishing generosity, he invited me to chat with him privately by email or on Zoom.

So I emailed him, and he wrote back, and I wrote back.  He even sent pictures of his cats, including the family of kittens he has been fostering, who were the reason he hasn’t had time to write much lately.  (I was relieved to hear that it wasn’t because of me.)  I don’t know whether we’ll become friends who communicate often,  but the fact that he was willing to write to me meant a lot.

It even cheered me up so much that within a couple of days, I was able to sleep through the night without taking the quetiapine antipsychotic that I’m not supposed to be on any more, meaning that in the morning I could take the sertraline antidepressant that I am meant to be taking daily.  This felt like a tremendous victory – being sufficiently non-depressed that I could take an antidepressant!

And things have gone on getting better over the past few days.  Admittedly, last night I didn’t sleep more than a couple of hours – but at least instead of lying awake worrying, I was just awake wanting to write.  So I came downstairs and wrote this.