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The earlier, the better

Many times in my professional career I’ve met someone coming to therapy for the first time with depression. Often, they might be in middle age. In our first session I’d ask how long they had felt depressed. Typically, they’d tell me they’d been stressed for the last while, but they’d become down in the last few months. At this point, I often ask: “That sense of feeling down; where do you feel that in your body?”. The person will often describe a feeling in their chest or throat, a feeling of tearfulness or tension in their head. Then, I ask: “Have you ever felt this before?”. Initially, someone may say no, but on reflection, will say something like: “Actually, ten years ago, we were going through a really hard time at work, and I felt it a lot at that stage”. We’ll reflect for a while longer, and they may notice that following a relationship break-up in their twenties they felt like that for months.

As we go back through their life, they’ll often notice that they have felt this way a variety of times since adolescence. Something which seemed like it had emerged in the last few months, had in fact, been recurring intermittently throughout their life. This is often the nature of mental health problems. They can start off mild, or at least we can manage them, but they recur. And each time they recur, they impact the practical aspect of our lives and the quality of our lives.

From a clinical perspective, this is known as the Duration of Untreated Illness (DUI) or the Duration of Untreated Episode (DUE): the length of time someone has had an illness or an episode of an illness without treatment or support. There are some conditions where this is very well studied. In physical health, we know short periods of untreated cancers for instance, are very closely related to good outcomes. In mental health, we know that low DUI and DUE predict better social, personal, and symptom outcomes for people in their first year of illness all the way to twenty years later.

The evidence is so strong in the area of psychosis it has led to a change in the organisation of psychosis services internationally towards early intervention and prevention strategies. In Ireland, this has led to the development of the National Clinical Programme for Early Intervention in Psychosis.

Surprisingly, the DUI and DUE of depression have remained understudied. The only systematic review in the area took place in 2014. The authors found only ten studies which looked at DUI and DUE in depression worldwide. The authors concluded that DUI and DUE significantly impacted individuals’ responses to antidepressant therapy, remission, and changes in their overall well-being, but that, actually, we haven’t asked the question properly.

Because there hasn’t been sufficient research in the area, services for depression haven’t adapted to an early intervention model. We have another option. We can take an ‘earlier is better’ strategy. Historically, we often viewed mental illness as something which was rare, severe, and largely untreatable. We know now depression is the second most common illness in the world. Only back pain is more common. Think about all the people in your social circle. Think about how many give out about their backs! Almost as many will experience depression in their lives. In fact, mental illness is common, mild, and highly treatable, at least initially. The longer mental health problems continue without support, the more likely they are to become severe, harder to treat, and have a greater impact on our lives.

This year, we can adopt an ‘earlier is better’ strategy. We can do this through educating ourselves on the signs and symptoms of mental health problems, intervening early to support ourselves and to gain the support we need, and advocating for healthcare structures and public policy which look to provide timely, evidence-based treatment for the mental health difficulties one-in-three of us will experience in our lives.

This blog is by Dr Keith Gaynor for Aware Mental Health Week 2023. Dr Gaynor is Associate Professor in Clinical Psychology at University College Dublin. 

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