A Current Look at Chronic Depression

A Current Look at Chronic Depression

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A chronic form of depression, dysthymia is characterized by depressed mood on most days for at least two years. On some days individuals may feel relatively fine or even have moments of joy. But the good mood usually lasts no longer than a few weeks to a few months. Other signs include low self-esteem, plummeting energy, poor concentration, hopelessness, irritability and insomnia.

Dysthymia — also known as dysthymic disorder — is typically described as a mild depression. But the data show a different story: Dysthymia is often a serious and severe disorder, said David J. Hellerstein, M.D., professor of clinical psychiatry at Columbia University and a research psychiatrist at New York State Psychiatric Institute. Experts refer to dysthymia as a paradoxical condition because it appears mild day to day but becomes brutal long-term, he said.

Epidemiological studies reveal that dysthymia frequently has a devastating impact on people’s lives. Individuals with dysthymia are more likely to receive government assistance, have high healthcare costs and have elevated rates of unemployment. If they do work, they typically work part-time or report under-achieving because of emotional problems. They also tend to be single because depression can make relationships more challenging.

People with dysthymia also are at increased risk for more severe episodes of depression. In fact, as many as 80 to 90 percent will get major depression, according to Dr. Hellerstein, who’s also author of the book Heal Your Brain: How the New Neuropsychiatry Can Help You Go from Better to Well. “It’s like if you have asthma, you are more likely to get bronchitis and pneumonia because you have this baseline condition all the time,” he said.

There’s evidence that dysthymia boosts the risk for suicidal behavior. One seven-year study found that the rates of suicidal behavior in dysthymia were similar to the rates in major depression.

Comorbidity with anxiety disorders also is common. And dysthymia tends to co-occur with alcohol problems and attention deficit hyperactivity disorder, Hellerstein said.

Dysthymia still largely goes undiagnosed and untreated. As many as three percent of Americans struggle with dysthymia, while less than half ever seek treatment. Part of the problem is that many people mistake the symptoms for their personality, Hellerstein said. They may assume that they’re just pessimistic or self-conscious or moody. After struggling for so many years, people come to view the fog of depression as their normal functioning. If people do seek treatment, it’s usually for other concerns, such as vague physical aliments or relationship problems, he said. As a result, these individuals rarely get evaluated for a mood disorder.

Learn more: Dysthmic disorder symptoms

There’s a common myth that a look on the bright side cures depression. That if you think positively enough, you’ll simply snap out of it. But individuals can’t snap out of depression any more than they can will themselves out of chronic asthma.

Another misconception is that dysthymia doesn’t require treatment. Lifestyle changes, exercise, and social support are usually enough to improve short-term mild depression, Hellerstein said. But this doesn’t work for dysthymia. Most people with dysthymia have typically tried modifying their lifestyle; yet their depression doesn’t disappear, he said.

Fortunately, people greatly improve with treatment. Unfortunately, the data on dysthymia are still limited, Hellerstein said. Only about 20 pharmacological studies have compared medication to placebo. Most studies show that antidepressants are effective in minimizing symptoms. The response to placebo tends to be low — lower than in major depression research — which speaks to the stubbornness of the condition, Hellerstein said.

As with major depression, the first line of pharmacological treatment is selective serotonin reuptake inhibitors or SSRIs. Wellbutrin and serotonin-norepinephrine reuptake inhibitors (SNRIs) also show improvements. Other classes of antidepressants such as tricyclics and MAO inhibitors also work, but have more side effects. The deciding factor is usually tolerability, Hellerstein said.

He recommends dysthymia patients take medication for two years and taper off very gradually (with monitoring from a psychiatrist). Once depressive symptoms have responded to treatment, there is an opportunity to make lifestyle changes, whether that means looking for a good job, finishing a degree, starting a romantic relationship or establishing healthy routines, Hellerstein said.

If individuals are hesitant to take medication, Hellerstein suggested trying psychotherapy first. But if there’s little improvement after several months, medication might be necessary.

The literature on psychotherapy also is scant. Still, it appears that cognitive-behavioral therapy, interpersonal therapy and behavior activation therapy are helpful for treating dysthymia. These therapies work on challenging maladaptive thoughts and adopting healthier behaviors.

People with chronic depression frequently develop avoidance behaviors, such as procrastinating and ruminating, which only perpetuate symptoms and stress, Hellerstein said. The above therapies help patients take an active approach for solving their problems and achieving their goals, he said. Patients not only feel better but also have the psychological tools to improve their lives and cope effectively with stress.

If you think you might have dysthymia, it’s important to get an accurate assessment, he said. Teaching hospitals or facilities affiliated with a medical school are the best places to find practitioners, because they tend to be especially up-to-date on the latest research.

As Hellerstein underscored, dysthymia is not a hopeless condition. “[With treatment] I see a lot of people who go through an accelerated process of psychological development,” he said. They’re able to return to work, pursue their education, enjoy healthy relationships and lead fulfilling lives.

Learn more: Dysthymia Treatment

Current Diagnosis and Treatment of Anxiety Disorders

Anxiety disorders are the most prevalent mental health conditions. Although they are less visible than schizophrenia, depression, and bipolar disorder, they can be just as disabling. The diagnoses of anxiety disorders are being continuously revised. Both dimensional and structural diagnoses have been used in clinical treatment and research, and both methods have been proposed for the new classification in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-5). However, each of these approaches has limitations. More recently, the emphasis in diagnosis has focused on neuroimaging and genetic research. This approach is based partly on the need for a more comprehensive understanding of how biology, stress, and genetics interact to shape the symptoms of anxiety.

Anxiety disorders can be effectively treated with psychopharmacological and cognitive�havioral interventions. These inter ventions have different symptom targets thus, logical combinations of these strategies need to be further studied in order to improve future outcomes. New developments are forthcoming in the field of alternative strategies for managing anxiety and for treatment-resistant cases. Additional treatment enhancements should include the development of algorithms that can be easily used in primary care and with greater focus on managing functional impairment in patients with anxiety.

1. Introduction

Chronic pain is usually defined as any persistent or intermittent pain that lasts more than 3 months, which can be categorized along a variety of dimensions, including one of the most important divisions, neuropathic versus nociceptive pain [1, 2]. Neuropathic pain is induced by a lesion or disease involving the nervous system [3], and nociceptive pain occurs as a consequence of actual or threatened damage to nonneural tissue [4]. Chronic pain is a major public health problem, with epidemiological studies reporting that in the USA and Europe, approximately one fifth of the general population are affected [5]. Additionally, as one of the most common and disabling mental disorders, depression has been reported to be the third leading contributor to the global disease burden [6, 7]. Clinical studies have revealed that chronic pain, as a stress state, often induced depression [8�] and that up to 85% of patients with chronic pain are affected by severe depression [11, 12]. Patients suffering from chronic pain-induced depression exhibit a poorer prognosis than those with chronic pain only and chronic pain and depression are closely correlated in terms of occurrence and development and are able to mutually promote their own severity progress [13].

To date, neither the corresponding pathophysiological mechanisms of chronic pain and depression nor their mutual correlation has been identified, which poses a huge challenge for the treatment of pain accompanied by depression. However, in recent years, studies have revealed considerable overlaps between pain- and depression-induced neuroplasticity changes and neurobiological mechanism changes. Such overlaps are vital to facilitating the occurrence and development of chronic pain-induced depression. In particular, injury sensory pathways of body pains have been shown to share the same brain regions involved in mood management, including the insular cortex, prefrontal cortex, anterior cingulate, thalamus, hippocampus, and amygdala, which form a histological structural foundation for the coexistence of pain and depression [14]. Furthermore, the volumes of the prefrontal cortex (PFC) and hippocampus have been reported in many studies to be significantly smaller in depressed patients and to be closely related to depression severity [15�]. In addition, individuals with depression in postmortem studies have also been observed to have a significantly reduced number of PFC synapses, which thus decreases synaptic functions [18]. Meanwhile, the effect of PFC on pain development via the nucleus accumbens has also been verified [19], thus indicating that the occurrence and development of pain and depression may be associated with some identical neuroplasticity changes. Furthermore, maladaptive plasticity changes, which refer to the plasticity in the nervous system that leads to a disruption of the function and may be considered a disease state, have also been indicated in a large number of clinical trials and animal studies [20]. Additionally, these maladaptive plasticity changes may also occur in sensory conduction pathways from the peripheral to the central nervous system and participate in the occurrence, development, and maintenance of chronic pain [3]. In summary, chronic pain and depression may be based on common neuroplasticity mechanism changes, which are a potentially important route for the onset and aggravation of chronic pain and depression. Reviewing the role of neuroplasticity in chronic pain and depression, this paper explores the influence of analgesic drugs and antidepressants with different pharmacological effects on neuroplasticity as well as their contribution to individualized application strategies in the treatment of chronic pain-induced depression.

4 Examples of Hope

1. Realistic Hope

Realistic hope is hope for an outcome that is reasonable or probable (Wiles, Cott, & Gibson, 2008). In this sense, an individual suffering from chronic pain might hope for a small reduction in pain, knowing that complete eradication is unrealistic.

According to Eaves, Nichter, & Ritenbaugh (2016) being realistic is a way of hoping that allows individuals to observe and understand their situation while still maintaining openness toward the possibility of positive change.

2. Utopian Hope

This way of hoping is a collectively oriented hope that collaborative action can lead to a better future for all. According to (Webb, 2013) the utopian hoper critically negates the present and is driven by hope to affirm a better alternative. Consider utopian hope presented by a political movement a movement that effectively articulates the hopes of a social group to expand the horizons of possibility.

3. Chosen Hope

Hope not only helps us live with a difficult present but also with an uncertain future. In addition to physical suffering, a diagnosis of a serious or terminal illness is a major contributor to psychiatric syndromes and distress. Understandably, multiple factors such as grief, fear, and concerns about loved ones can contribute to experiences of hopelessness within this population.

In the palliative care context, for instance, chosen hope is critical to the management of despair and its accompanying paralysis of action. Garrard & Wrigley (2009) suggested that hope for even the most restricted range of goals within the limits of a life is essential to the regulation of negative emotions.

4. Transcendent Hope

According to Eaves, Nichter, & Ritenbaugh (2016), transcendent hope encompasses three types of hope, namely:

  1. Patient Hope – a hope that everything will work out well in the end.
  2. Generalized Hope – hope not directed toward a specific outcome.
  3. Universal Hope – a general belief in the future and a defense against despair in the face of challenges.

Also referred to as existential hope, transcendent hope describes a stance of general hopefulness not tied to a specific outcome or goal put simply, it is the hope that something good can happen.

An Adaptive Syndrome or Maladaptive Response? Genetics and Evolutionary Theories

In contrast to an idiographic functional analysis of depression, the medical disease model posits that depression is a syndrome or multiple syndromes and one inherits risk for this syndromal response. The model relies to a considerable degree on research indicating at least some genetic involvement in depression (Wallace, Schneider, & McGuffin, 2002). However, the family, twin, and adoption studies on which this conclusion is based point to a larger environmental contribution than genetic contribution in all but the most severe cases of depression (Wallace et al., 2002). Furthermore, researchers and theorists from a variety of perspectives have highlighted methodological flaws and unsubstantiated assumptions of this research (Ceci & Williams, 1999 Hayes, 1998 Turkheimer, 1998) that have the collective effect of lowering heritability estimates even further as well as questioning their very basis. Nonetheless, it seems likely that some inherited vulnerability to depression exists in some cases, and a full behavior-analytic account can include this possibility.

A typical behavioral argument against the medical disease model of depression is to accept that depression is a syndrome but posit that it is adaptive, the product of contingencies of survival (Skinner, 1953). In fact, many evolutionary explanations for depression have been offered (e.g., Bowlby, 1980 Gilbert, 1992 Leahy, 1997 Price, Sloman, Gardner, Gilbert, & Rohde, 1994 P. J. Watson & Andrews, 2002 see McGuire & Troisi, 1998, for a review), and such evolutionary accounts are important to consider and are consistent with behavioral theory (Corwin & O'Donohue, 1995). There are three broad themes under which these theories fall: resource conservation, social competition, and attachment (Allen & Badcock, 2003).

Theories of resource conservation posit that depression permits the conservation of resources and disengagement from unsuccessful goal-directed activity by decreasing appetite, energy levels, and motivation (Leahy, 1997 Nesse, 2000). For instance, when in a new environment with unknown contingencies, such as traveling to a foreign country, one is more likely to be functioning in a way to avoid negative reinforcement or punishment while trying to learn the rules of the new environment. If one were to engage in a goal-directed activity, such as trying to obtain a job, one would likely not be successful. Social-competition theories view depression as a deescalation or yielding reaction to a defeat. This is said to be adaptive because it signals submission to the victor and allows acceptance of social subordination and the avoidance of unnecessary conflict (Price, 1967, 1998 Price et al., 1994). An example of this can be seen in a boxing match, when one fighter is knocked down for a full 10 counts. The loser typically displays behaviors including sloped posture, decreased eye contact, and avoidance (all depressed behaviors) as opposed to getting back up and continuing to fight. Finally, attachment theories of the adaptive nature of depression claim that a depressive reaction is an adaptive response to the loss of interpersonal relationships that helps to maintain the proximity of caregivers or reestablish an attachment by signaling a need for assistance from others and eliciting that assistance (Averill, 1968 Bowlby, 1980 Frijda, 1994). This can easily be seen by a lost boy in a busy mall. When the child begins to cry, passersby typically attend to him, try to find the boy's parents, and comfort him during the search.

We suggest that depression is neither a syndrome nor adaptive. Any theory of depression as an adaptive syndrome has to overcome two primary hurdles inherent in the phenomenon. First, given the variability in symptom profiles in depression, one has to pick which set of symptoms of depression comprises the syndrome, or alternately posit multiple syndromes with different symptom sets (M. C. Keller & Nesse, 2006). For example, are both melancholic and atypical depression adaptive syndromes? Given that some of symptoms associated with melancholic depression (insomnia and loss of appetite) are the opposite of those associated with atypical depression (hypersomnia and increased appetite), it is impossible for the same theory to account for both presentations.

Second, the nature and chronicity of depressive symptoms seem to be maladaptive. For example, a transient sad mood in response to a loss certainly seems adaptive in that it elicits empathy and evokes helping behaviors in others. If this is true, then such an affective respondent reaction may have evolved due to contingencies of survival. It would be expected to have certain losses as antecedents and to resolve when support is acquired. However, in clinical depression the sad mood is often chronic and unresponsive to helping behaviors. In fact, although the evolutionary account suggests that the response should garner social support, research is clear that depressive behaviors result in decreased social support (Coyne, 1976 Gotlib & Lee, 1989 Joiner & Metalsky, 2001) and worse psychosocial functioning in general (Barnett & Gotlib, 1988). Suicide is another example. Although suicidal gestures may be seen as operant attempts to garner support (Linehan, 1993), completed suicide is difficult to conceive of as an operant (i.e., learned) behavior (Hayes, Strosahl, & Wilson, 1999) and is clearly not adaptive in terms of survival.

A more likely scenario is that depression itself is not adaptive, but the core experience represents a variation of an adaptive affective response (Nettle, 2004 also see Nesse, 2000). In other words, the capability to experience moderate low mood or sadness in appropriate situations (but not become clinically depressed) may have many of the same short-term benefits that have been used to support the claim that depression is adaptive. Support for this view comes from personality researchers, who have posited the temperamental trait of negative affectivity as a trait that is selected for and normally distributed (Nettle, 2004 D. Watson & Clark, 1984), and considerable research suggests that this trait may be a vulnerability factor for both depression and anxiety (L. A. Clark & Watson, 1991 L. A. Clark, Watson, & Mineka, 1994).

Although the notions of temperament or traits are unnecessary, it is reasonable to suggest that there may be a range in the duration and magnitude of affective reactions that are adaptive. A depressed individual could represent a deviation from that range in that he or she experiences negative affect longer and to a greater extent in response to an environmental event. In other words, the propensity to experience mild and appropriate levels of negative affect may be adaptive and thus appear on a continuum those at one of the extreme ends of this continuum may be quite sensitive to fluctuations in reinforcement contingencies, suffer from chronic negative affect, and be at risk for clinical depression.

It is important to remember that we are proposing a scenario in which there is a genetic contribution to the likelihood of the core affective experience in depression but the remaining symptoms are potentially free to vary and should be described in terms of antecedents and consequences. Of course, there may be an adaptive, normally distributed range in the sensitivity of these additional behaviors (e.g., sleep) to environmental stimuli that represent separate inherited vulnerabilities. This view of depression is consistent with recent biological findings that suggest that depression is likely a product of multiple genes and a complex gene𠄾nvironment interaction (Wallace et al., 2002), as well as neuroscientific findings of mixed and variable structural and functional abnormalities in several brain regions, with few depressed individuals displaying the complete package of deficits, leading researchers to conclude that depression refers to a heterogeneous group of disorders as well (Davidson, Pizzagalli, Nitschke, & Putnam, 2002). Thus, other scientific fields are taking tentative steps away from a syndromal view of depression and toward an idiographic analysis.

What is Clinical Depression?

Clinical depression is also known as major depressive disorder. This is regarded as one of the commonest depressive disorders. The main obstacle that a person with clinical depression faces is the inability to go one with his daily routine. The person has difficulty in working, sleeping, eating and enjoying his life. The person usually feels depressed most of the time of the day, and this occurs almost every day. Some of the common symptoms that can be diagnosed are suicidal thoughts, weight gain or weight loss, lack of energy, feelings worthless, difficulty in concentrating and difficulty to sleep.

Psychologists advise that if at least five of the symptoms are visible for a period of two weeks or more the individual requires medical attention.

10 Benefits of VR-Based Therapy

While VR should be seen as a tool rather than the answer to every mental health challenge faced by a client, it does offer several advantages (Boeldt et al., 2019 Bohil et al., 2011 Maples-Keller et al., 2017):

    A high degree of ecological validity. The environments within such a digital reality are increasingly complex and believable.

Ultimately patients have reported high levels of satisfaction with VR treatment, probably due to the sense of control it offers and its effectiveness as a therapy (Maples-Keller et al., 2017).

The potential for VR in therapy is incredible and exciting. Success using such immersive technology has the potential to help the lives of those experiencing (Bohil et al., 2011 Maples-Keller et al., 2017):

    Phobias – through controlled exposure to the feared object or situation

The above list only tells part of the story. While further work and exploration of the benefits continue in all the above areas of mental health, research breaks new ground in schizophrenia, autism, eating pathology, promoting cardiovascular health, and the mental health benefits of exercise (Zeng et al., 2018).

What Chronic Conditions Trigger Depression?

Although any illness can trigger depressed feelings, the risk of chronic illness and depression gets higher with the severity of the illness and the level of life disruption it causes. The risk of depression is generally 10-25% for women and 5-12% for men. However, people with a chronic illness face a much higher risk -- between 25-33%. Risk is especially high in someone who has a history of depression.

Depression caused by chronic disease often makes the condition worse, especially if the illness causes pain and fatigue or it limits a person's ability to interact with others. Depression can intensify pain, as well as fatigue and sluggishness. The combination of chronic illness and depression might lead you to isolate yourself, which is likely to make the depression even worse.

Research on chronic illnesses and depression indicates that depression rates are high among patients with chronic conditions:

    : 40%-65% experience depression (without heart attack): 18%-20% experience depression
  • Parkinson's disease: 40% experience depression : 40% experience depression
  • Stroke: 10%-27% experience depression
  • Cancer: 25% experience depression : 25% experience depression syndrome: 30%-54% experience depression

How to cope with a depressive episode

A depressive episode in the context of a major depressive disorder is a period characterized by low mood and other depression symptoms that lasts for 2 weeks or more. When experiencing a depressive episode, a person can try to make changes to their thoughts and behaviors to help improve their mood.

Symptoms of a depressive episode can persist for several weeks or months at a time. Less commonly, depressive episodes last for over a year.

According to the Anxiety and Depression Association of America, approximately 16.1 million adults in the United States experienced at least one major depressive episode in 2015.

Read on to learn more about the symptoms of a depressive episode and 12 tips for coping with one.

Share on Pinterest Symptoms of a depressive episode may include anxiety, frustration, feeling hopeless, fatigue, and a loss of interest in things once enjoyed.

Symptoms of a depressive episode are more extreme than normal periods of low mood and may include:

  • feeling sad, hopeless, or helpless
  • feeling guilty or worthless
  • irritability or frustration or low energy
  • restlessness
  • changes in appetite or weight
  • loss of interest in things once enjoyed, including hobbies and socializing
  • trouble concentrating or remembering
  • changes in sleep patterns
  • moving or talking more slowly than usual
  • loss of interest in living, thoughts of death or suicide, or attempting suicide
  • aches or pains that do not have an obvious physical cause

For a diagnosis of depression, people must experience several of these symptoms for most of the day, almost every day, for at least 2 weeks.

Tackling depression as soon as symptoms develop can help people recover more quickly. Even those who have experienced depression for a long time might find that making changes to the way they think and behave improves their mood.

The following tips may help people deal with a depressive episode:

1. Track triggers and symptoms

Keeping track of moods and symptoms might help a person understand what triggers a depressive episode. Spotting the signs of depression early on may help them avoid a full-blown depressive episode.

Use a diary to log important events, changes to daily routines, and moods. Rate moods on a scale of 1 to 10 to help identify which events or activities cause specific responses. See a doctor if symptoms persist for 14 days or more.

2. Stay calm

Identifying the onset of a depressive episode can be scary. Feeling panicked or anxious is an understandable reaction to the initial symptoms of depression. However, these reactions may contribute to low mood and worsen other symptoms, such as loss of appetite and disrupted sleep.

Instead, focus on staying calm. Remember that depression is treatable and the feelings will not last forever.

Anyone who has experienced depressive episodes before should remind themselves that they can overcome these feelings again. They should focus on their strengths and on what they have learned from previous depressive episodes.

Self-help techniques, such as meditation, mindfulness, and breathing exercises can help a person learn to look at problems in a different way and promote a sense of calmness. Self-help books and phone and online counseling courses are available.

3. Understand and accept depression

Learning more about depression can help people deal with the condition. Depression is a widespread and genuine mental health disorder. It is not a sign of weakness or a personal shortcoming.

Accepting that a depressive episode may occur from time to time might help people deal with it when it does. Remember, it is possible to manage symptoms with treatments, such as lifestyle changes, medication, and therapy.

4. Separate yourself from the depression

A condition does not define a person they are not their illness. When depression symptoms begin, some people find it helpful to repeat: “I am not depression, I just have depression.”

A person should remind themselves of all the other aspects of themselves. They may also be a parent, sibling, friend, spouse, neighbor, and colleague. Each person has their own strengths, abilities, and positive qualities that make them who they are.

5. Recognize the importance of self-care

Self-care is essential for good physical and mental health. Self-care activities are any actions that help people look after their wellbeing.

Self-care means taking time to relax, recharge, and connect with the self and others. It also means saying no to others when overwhelmed and taking space to calm and soothe oneself.

Basic self-care activities include eating a healthful diet, engaging in creative activities, and taking a soothing bath. But any action that enhances mental, emotional, and physical health can be considered a self-care activity.

6. Breathe deeply and relax the muscles

Deep breathing techniques are an effective way to calm anxiety and soothe the body’s stress response. Slowly inhaling and exhaling has physical and psychological benefits, especially when done on a daily basis.

Anyone can practice deep breathing, whether in the car, at work, or in the grocery store. Plenty of smartphone apps offer guided deep breathing activities, and many are free to download.

Progressive muscle relaxation is another helpful tool for those experiencing depression and anxiety. It involves tensing and relaxing the muscles in the body to reduce stress. Again, many smartphone apps offer guided progressive muscle relaxation exercises.

We have reviewed some meditation apps that can help with depression and anxiety.

7. Challenge negative thoughts

Cognitive behavioral therapy (CBT) is an effective therapy for those with depression and other mood disorders. CBT proposes that a person’s thoughts, rather than their life situations, affect their mood.

CBT involves changing negative thoughts into more balanced ones to alter feelings and behaviors. A qualified therapist can offer CBT sessions, but it is also possible to challenge negative thoughts without seeing a therapist.

Firstly, notice how often negative thoughts arise and what these thoughts say. These may include “I am not good enough,” or “I am a failure.” Then, challenge those thoughts and replace them with more positive statements, such as “I did my best” and “I am enough.”

8. Practice mindfulness

Take some time every day to be mindful and appreciate the present moment. This may mean noticing the warmth of sunlight on the skin when walking to work, or the taste and texture of a crisp, sweet apple at lunchtime.

Mindfulness allows people to fully experience the moment they are in, not worrying about the future or dwelling on the past.

Research suggests that regular periods of mindfulness can reduce symptoms of depression and improve the negative responses that some people with chronic or recurrent depression have to low mood.

9. Make a bedtime routine

Sleep can have a huge impact on mood and mental health. A lack of sleep can contribute to symptoms of depression, and depression can interfere with sleep. To combat these effects, try to go to bed and get up at the same time each day, even at weekends.

Establish a nightly routine. Start winding down from 8 pm. Sip chamomile tea, read a book, or take a warm bath. Avoid screen time and caffeine. It may also be helpful to write in a journal before bed, especially for those whose racing thoughts keep them up.

10. Exercise

Exercise is extremely beneficial for people with depression. It releases chemicals called endorphins that improve mood. An analysis of 25 studies on exercise and depression reports that exercise has a “large and significant effect” on symptoms of depression.

11. Avoid alcohol

Alcohol is a depressant, and alcohol use can trigger episodes of depression or make existing episodes worse. Alcohol can also interact with some medications for depression and anxiety.

12. Record the positives

Often, depressive episodes can leave people focusing on the negatives and discounting the positives. To counteract this, keep a positivity journal or gratitude journal. This type of journal helps to build self-esteem.

Before bed, write down three good things from the day. Positives include regular meditation, going for a walk, eating a healthful meal, and so much more.

Positive Psychology Goes to War

W e are in a golden age for institutional leaders hoping to apply the findings of psychology to improve their organizations. Research psychology has, in recent decades, produced a glut of exciting new interventions, often delivered via best-selling books, viral TED Talks, and the like.

The problem is that it’s difficult for someone untrained in a given area to evaluate claims within that area, even if they are otherwise quite competent. This idea is sometimes referred to as “unskilled intuition” — I might have a strong feeling that the guy fixing my car is trying to rip me off, but since I can barely understand the terms he is using to describe my steering-wheel issue, I’m really just feeling around in the dark. I’m a professional writer, not a mechanic.

Few areas of behavioral science better exemplify the danger of unskilled intuition than the increasingly popular endeavor of positive psychology, one of the newest established subfields of psychology and one that has successfully sold questionable theories to many institutions, most notably the U.S. Army, for very large sums.

Positive psychology was founded by Martin Seligman, a legendary researcher at the University of Pennsylvania (Mihaly Csikszentmihalyi also played a key role and co-wrote a pathbreaking 2000 article with Seligman). Marty, as he is known to everyone in his orbit, is an iconic, divisive figure in the world of academic psychology. If you looked only at the early part of his career, you’d be surprised that he ended up being one of the godfathers of a field dedicated to positivity. That early work was, well, dark. Through experiments that involved shocking dogs in different ways, Seligman developed the extremely important psychological concept of learned helplessness. It refers to a situation in which an organism’s lack of control over its surroundings prompts it to stop engaging in standard acts of self-preservation.

But later in his career, Seligman shifted focus dramatically. He came to realize, as he would explain in many speeches and interviews, that psychology was too focused on pathology, on fixing broken people, and less on cultivating strengths and helping people who were otherwise basically healthy to maximize their potential. Seligman wanted to transform American psychology, and the best way to do that would be as president of its flagship organization, the American Psychological Association. Seligman was elected in 1996 — “by the largest vote in modern history,” his faculty page notes — and when he took office in 1998, he made positive psychology the theme of his presidency.

This new, highly marketable subfield arrived at an important juncture for the broader discipline of psychology. As Barbara Ehrenreich explained in her 2009 critique of the positive-thinking movement, Bright-Sided: How the Relentless Promotion of Positive Thinking Has Undermined America:

Positive psychology provided a solution to the mundane problems of the psychology profession. Effective antidepressants had become available at the end of the 1980s, and these could be prescribed by a primary care physician after a ten-minute diagnostic interview, so what was left for a psychologist to do? In the 1990s, managed care providers and insurance companies turned against traditional psychotherapy, effectively defunding those practitioners who offered lengthy courses of talk therapy. The Michigan Psychological Association declared psychology “a profession at risk” and a California psychologist told the San Francisco Chronicle that “because of managed care, many clinical psychologists aren’t being allowed to treat clients as they believe they should. They still want to work in the field of helping people, so they’re moving out of therapy into coaching.” If there was no support for treating the sick, there were endless possibilities in coaching ordinary well people in the direction of greater happiness, optimism, and personal success.

In this view, positive psychology enabled professional psychology to greatly expand its market, allowing psychologists to advertise themselves as coaches to companies, schools, and other organizations.

At root, positive psychology claims that there are reliable ways to make people happier and more optimistic and that these changes bring with them benefits like increased mental health and longevity. But the underlying science is controversial. As Daniel Horowitz writes in his excellent 2018 cultural and scientific history of the field, Happier? The History of a Cultural Movement That Aspired to Transform America, “Virtually every finding of positive psychology under consideration remains contested, by both insiders and outsiders . Major conclusions have been challenged, modified, or even abandoned.”

In a highly cited 2005 article, for example, the positive psychologist Sonja Lyubomirsky and her colleagues argued that 50 percent of the variance in human happiness is accounted for by genetics, 10 percent by circumstance, and 40 percent by factors within individuals’ control, the result of choices they make. This encouraging “happiness pie” concept went viral, leading to book contracts, speaking engagements, and other professional rewards for Lyubomirsky. Seligman transformed it into a “happiness formula” in his own work: H = S + C + V. That is, happiness, H, equals S (genetic set point) plus C (circumstances) plus V (things under the individual’s voluntary control). In part on the basis of Lyubomirsky’s finding, he argued that there was a great deal of potential for the average person to become significantly happier.

Remarkably, it appears to have taken almost a decade and a half for anyone to critically evaluate Lyubomirsky’s sunny claim in a peer-reviewed journal. But when Nicholas J.L. Brown and Julia M. Rohrer did, for an April 2020 article published in the Journal of Happiness Studies, they found many statistical problems. Among others, “there is only very limited evidence to place the figure for the heritability of well-being as low as (precisely) 50%. Consequently, there is little reason to believe that 40% is a reliable estimate of the variance in chronic happiness attributable to intentional activity — for example, if Lyubomirsky et al. had chosen a different (but, in our view, at least equally plausible) set of estimates, they might just as easily have concluded that as little as [5 percent] of variance in chronic happiness can be attributed to volitional activities.” Suffice it to say that there is a massive difference between 5 percent and 40 percent of an individual’s level of happiness being within their control — a difference with obvious ramifications for the usefulness of positive psychology’s books and interventions.

It’s little surprise, in light of all this, that both external and internal critics have argued that positive psychology has made unwarranted claims. “The first data on rigorously tested positive psychology have only recently begun to show up in journals,” wrote the positive psychologists Todd B. Kashdan and Michael F. Steger in 2011, “yet people have been offering to ‘apply’ positive psychology for several years already. What kind of message does this convey about the scientific endeavor of positive psychology? Is it any wonder that positive psychology is often dismissed as ‘happiology’ or the equivalent of accepting a Dixie cup of Kool-Aid from Jim Jones?” As Horowitz writes in Happier?, a primary concern of some positive psychologists “involved the dangers of popularization,” of polishing rough claims to make them look smoother for marketing purposes.

But these serious questions surrounding the field’s rigor haven’t stopped positive psychology from quite successfully selling its wares to the public. One key player in that economy is Seligman’s Positive Psychology Center at the University of Pennsylvania. Founded in 2003, the center has been good, from both a public-relations and a financial standpoint, for the university that hosts it. In his center’s annual reports, Seligman regularly notes that “the PPC is financially self-sustaining and contributes substantial overhead to Penn.”

The PPC’s s most important client is probably the U.S. Army. That’s thanks to the fact that in 2008 the Army turned to Seligman to help it solve a crisis involving PTSD and suicide among soldiers, rewarding him and his academic home base with what would become many millions of dollars’ worth of military contracts. To a keen observer of the Positive Psychology Center’s offerings and promotional style, it might have come across as a questionable bet. On multiple occasions, Seligman and his center have made impressive claims about interventions that outpace the available evidence.

One example is the so-called Strath Haven Positive Psychology Curriculum, which is named for the suburban Philadelphia high school where it was piloted. Its “major goals . . . are 1) to help students identify their signature character strengths and 2) to increase students’ use of these strengths in day-to-day life,” write Seligman and some of his colleagues in an article in the Oxford Review of Education. The researchers explain that 347 ninth graders were assigned to either a class that included the curriculum or a control group in which the school day was business as usual. “Students, their parents and teachers completed standard questionnaires before the programme, after the programme, and through two years of follow-up,” write the authors. “Questionnaires measured students’ strengths (e.g., love of learning, kindness), social skills, behavioural problems and enjoyment of school. In addition, we examined students’ grades.”

Strikingly, even though these researchers were given almost $3 million to run a randomized controlled evaluation of their intervention, they never published one in comprehensive form. The Oxford Review article’s brief discussion of the program provides some provisional results, but few of the statistical details one would expect in a full-blown published evaluation. The authors make a somewhat vague claim about improved grades being seen in one subgroup (and presumably not others), but provide no statistics to back it up. It’s clear, though, that the general results were disappointing: “The positive psychology programme did not improve other outcomes we measured, such as students’ reports of their depression and anxiety symptoms, character strengths, and participation in extracurricular activities.”

And yet if a school administrator curious about Seligman’s track record visited the “Resilience Training for Educators” section of his Penn website, they’d find a rosier assessment: There, Seligman claims that the Strath Haven program “builds character strengths, relationships, and meaning, as well as raises positive emotion and reduces negative emotion.”

Seligman’s tendency to overclaim can also be seen in the case of the Penn Resilience Program, or PRP. PRP is one of the Positive Psychology Center’s biggest “hits” it has been purchased by schools all over the world and adapted to various noneducational settings as well.

PRP, which was first created by Jane Gillham in the 1990s, is geared to 10- to 14-year-olds, and its goal is to improve these students’ mental-health outcomes, particularly by making them more resistant to depression. The trainings are usually conducted not by licensed mental-health professionals but by others (usually teachers) who can, in theory, be quickly trained up to the task: As Gillham and her colleagues write, the program’s leaders “typically participate in a 4- or 5-day training workshop, where they first apply PRP skills in their own lives and then learn to deliver the curriculum to groups of late-elementary and middle school students.”

The program is delivered to groups of six to 15 students over the course of about 20 hours, total, though the number and length of individual sessions can vary. The primary purpose is to help the children and early adolescents better understand basic cognitive behavioral principles, including the potential harms of negative self-talk (I failed this test I really am just worthless) and catastrophizing (My mom was supposed to be home by now she must have gotten into a horrible accident). The goal is to instill, in healthy young people, cognitive habits and skills that will prevent depression and anxiety in the long run (though there are also variants geared at groups of kids already exhibiting mental-health warning signs).

The Positive Psychology Center clearly views the Penn Resilience Program as one of its premier offerings. In a talk he gave at the 2009 annual conference of the American Psychological Association, Seligman presented the results of a review of 19 PRP studies conducted over 20 years. The accompanying APA press release noted that “based on the students’ assessments of their own feelings, the researchers found that PRP increased optimism and reduced depressive symptoms for up to a year. The program also reduced hopelessness and clinical levels of depression and anxiety. Additionally, the PRP worked equally well for children from different racial/ethnic backgrounds.”

Unfortunately, Seligman doesn’t appear to have ever published this review of the literature anywhere (I did ask him about this directly in an email, and in response he pointed me to other research instead), so it’s unclear how impressive the effects he found were, what criteria he used to include or exclude given studies, and so forth. But another, more formally conducted review of the literature — a meta-analysis co-written by Gillham herself — came to a different conclusion.

That meta-analysis, led by Steven Brunwasser and published in 2009, examined 17 controlled evaluations of the PRP — that is, studies that compared the outcomes of a PRP group and a control group. It found that while the PRP did appear to reduce depressive symptoms among students exposed to it, those reductions were small, statistically speaking. “Future PRP research should examine whether PRP’s effects on depressive symptoms lead to clinically meaningful benefits for its participants, whether the program is cost-effective, . and whether PRP is effective when delivered under real-world conditions,” the authors concluded.

This is not an impressive evaluation, referring as it did to a program already being sold to schools on the basis of its supposedly impressive evidence base. And in 2016, the Journal of Adolescence delivered an even harsher verdict about PRP in another meta-analysis. “No evidence of PRP in reducing depression or anxiety and improving explanatory style was found,” the authors wrote. “The large scale roll-out of PRP cannot be recommended.”

Seligman, for his part, pointed me to a 2015 meta-analysis conducted by researchers in Australia and New Zealand that appears to show that PRP has some effectiveness. But a close look reveals that that meta-analysis doesn’t tell an appreciably different story from the one told by Brunwasser and Gillham’s evaluation, especially when it comes to the specific “flavor” of PRP that makes the program so attractive on the grounds of potential cost-effectiveness — one in which the intervention is delivered to (mostly) healthy students by laypeople who can be quickly trained for that task. In fact, the researchers from Australia and New Zealand themselves write that “Our results are consistent with another review of the PRP” — and cite the underwhelming meta-analysis by Brunwasser and Gillham.

Whatever the reasons for PRP’s shortcomings, as of 2020 many of the Positive Psychology Center’s clients around the world don’t appear to have gotten the message they keep purchasing it. In fact the program’s purview has expanded beyond schools. The PPC’s 2018 annual report touts the fact that the center received a two-year grant from the Department of Justice to adapt PRP for law-enforcement personnel, as well as contracts to develop similar programs for the medical schools at Yale and Penn, among myriad other clients. Over all, notes Seligman in his report, “Since 2007, we have delivered more than 270 Penn Resilience Programs to more than 50,000 people.” The fact that these are adult contexts adds a whole other layer of uncertainty given that PRP was designed for kids.

The Positive Psychology Center has had a substantial impact on education around the country, but the adoption of its ideas by the U.S. military may be more consequential still. It is here that what Daniel Horowitz calls the “dangers of popularization” come most clearly into focus.

A round 2007 the U.S. Army realized it had a full-blown mental-health crisis on its hands. The wars in Iraq and Afghanistan had stretched personnel thin, to the point where, in order to keep numbers up, the Pentagon was forced to revise longstanding rules about the length of combat deployments. This led to more and longer deployments, with less time off between them, and to increasing numbers of National Guard and U.S. Army Reserve personnel — individuals who had, in many cases, signed up imagining their service would entail “one weekend a month, two weeks a year” of peacetime drills and perhaps occasional domestic disaster relief, as one slogan for the National Guard put it — being sent repeatedly to active combat zones.

Soldiers in both Iraq and Afghanistan, like their predecessors in Vietnam, became occupiers of lands where they mostly didn’t speak the language, often couldn’t tell friend from foe, and were beset by threats that came seemingly out of nowhere. The results were staggering: about 15.7 percent of deployed veterans and 10.9 percent of non-deployed veterans screened positive for PTSD during this era, according to a major study, compared with a lifetime prevalence of about 6.8 percent in the general population. In 2002, a terrifying uptick in suicides among Army soldiers, who bore the brunt of the conflicts, began, and many of those deaths appeared to be directly connected to PTSD symptoms. There was also a series of horrible killings and other violent crimes committed by soldiers who had been exposed to trauma — these were less common but appeared to get far more media attention.

In October 2007, Col. Jill W. Chambers, an energetic survivor of the 9/11 attack on the Pentagon who had herself been diagnosed with PTSD, was handed the monumental task of figuring out how to solve this problem. Adm. Michael Mullen, who had just arrived at the Pentagon as the new chair of the Joint Chiefs of Staff, named her “Special Assistant to the Chairman for Returning Warrior Issues” and gave her a simple imperative, as she described it to me: “Jill, go forth, get away from the Pentagon — get out there and start talking to people and find out what it is that’s causing our service members so many problems.” Chambers took on her new role with gusto. “For the next eight months, I was out and about all over the world,” she explained. She had contacts throughout the armed forces, so she traveled all over the country to have conversations with those who were shouldering the heaviest load of the ongoing wars. “It got to be, Jill’s coming in, she’s cool, please get your guys to talk with her,” Chambers explained with evident pride. Over and over, soldiers back from Iraq and Afghanistan would tell Chambers stories of trauma tinged with stigma.

One said he had been sleeping in his garage because he kept waking up to find himself choking his terrified wife. He was scared of his own behavior, but also scared of speaking about it aloud. “Look, if you tell anybody about this, I’m going to deny it,” he told Chambers. This was a crisis, and it was clear the military needed to do something. That something arrived via a coincidence. One day, Chambers was on a flight from Washington, D.C., to Boston with her husband, the country musician Michael Peterson, and he nudged her. He was reading a book called Learned Optimism: How to Change Your Mind and Your Life, written by a psychologist named Martin Seligman. It seemed relevant to Chambers’s current work Peterson’s key takeaway from Learned Optimism, as Chambers explained it, was that “you can really prime your pump before you face adversity to actually get yourself prepared for it.” Could there be a way to instill in soldiers a sense of resilience and optimism that would help them both during combat and after, that would effectively inoculate them against the worst psychological ravages of war? “Why don’t you just call Marty Seligman?” Peterson asked Chambers. So she did.

In August 2008, Chambers and Peterson met with Seligman in the garden of his Philadelphia home and came away very impressed. A few more calls and meetings later — and some pushback from Army higher-ups who wanted to sweep the problem under the rug but whom Chambers could brush off because of her direct mandate from Mullen (“Four stars beat any of those two- and three-star generals,” as she put it) — and Seligman had earned a meeting with Gen. George W. Casey Jr., chief of staff of the Army, to whom Mullen had delegated the task of vetting him.

Casey proved a quick convert. “He put his fist down and he said, By golly, we have a problem, and we are going to start talking about post-traumatic stress,” Chambers recalled. Seligman, armed as he was with what appeared to be reams of research and impressively rigorous books supporting his approach, emerged from the meeting as the Army’s go-to guy for addressing this newly acknowledged crisis. “Who else out there had a resilience-building program, right?” said Carl Castro, a retired colonel who was involved in multiple Army mental-health initiatives and who is currently an associate professor of social work at the University of Southern California. “Who else had a validated program, some data, any data around building resilience? And if you go back and look in the literature, there was only one person.”

And that’s how the Comprehensive Soldier Fitness program, or CSF, was born. Soon, it was a mandatory part of Army life for every soldier: more than a million in all. It would become one of the largest mental-health interventions geared at a single population in the history of humanity, and possibly the most expensive.

Comprehensive soldier fitness is a hybrid consisting of three different components: One is a set of online-learning modules geared at boosting mental health adapted from Battlemind, an existing military mental-health program. Another is a mandatory annual survey, the Global Assessment Tool, or GAT, which was cobbled together from a number of different instruments. All soldiers are required to take the GAT every year and to complete a set number of hours of the online modules.

But the centerpiece of CSF, at least when it came to how it was advertised to the public, was the Master Resilience Training program. MRT, as it is known, is a train-the-trainer program closely modeled after the PRP. Like the online-learning modules and the GAT, it is mandatory for all soldiers. It was also the main reason Seligman’s Positive Psychology Center won its initial $31 million from the Army, in the form of a 2010 no-bid contract, as well as the funding that would follow. That initial contract contained common Pentagon budgeting language indicating that the recipient is the only provider of a particular service: “There is only one responsible source due to a unique capability provided, and no other supplies or services will satisfy agency requirements.” It’s clear, from Seligman’s account of the early days of CSF in his book Flourish, as well as various statements from others, that the military’s claims about “unique capability” stemmed from the supposedly strong evidence base for PRP.

Seligman’s argument was that Comprehensive Soldier Fitness could help reduce PTSD and suicidality, and it’s worth pausing here to reflect on how many steps removed this claim is from the initial goals and scope of the Penn Resilience Program. When the PRP began, it was novel and untested, given that it was attempting to prevent depression and anxiety with tools that had only been validated for treating those conditions. But still, it was premised on a reasonable theory in light of cognitive behavioral therapy’s solid base of evidence, and all it was claiming was that it could prevent anxiety and depression in some students.

Comprehensive Soldier Fitness was founded on a more radical claim: that an adapted version of the PRP could prevent PTSD and therefore suicide. “That’s why we instituted the Comprehensive Soldier Fitness program,” General Casey told a Senate appropriations subcommittee in 2010, “to give the soldiers and family members and civilians the skills they need on the front end to be more resilient and to stay away from suicide to begin with. It’s a long-term program, but I think that is the only way that we are ultimately going to begin to reduce this.”

PRP itself, though, was never designed for anything remotely like that no one associated with it, until Seligman linked up with the Army, appears to have ever claimed it could prevent PTSD or suicide, and such an idea wasn’t even on the radar of the program’s designers as they built it. And yet in one paper, Seligman, his Penn Positive Psychology peer Karen Reivich, and Sharon McBride of the Army wrote of the Penn Resilience Program — which by that time had been shown in a meta-analysis not to be particularly effective in reducing depression among 10- to 14-year-olds — that “the preventive effects of the PRP on depression and anxiety are relevant to one of the aims of the MRT course, preventing post-traumatic stress disorder (PTSD), since PTSD is a nasty combination of depressive and anxiety symptoms.”

But just because PTSD can cause depression or anxiety doesn’t mean that treating depression and anxiety cures PTSD, or that preventing depression and anxiety prevents PTSD. Having a cold might make you cough, but simply curing the cough may fail to address the underlying illness.

As the researcher and data sleuth Nick Brown (who helped debunk the happiness pie concept) wrote in a critical review of Comprehensive Soldier Fitness published in the open-access online academic journal The Winnower, “Much of PTSD consists of symptoms whose prevention is not addressed by the PRP, or indeed anything else that comes under the umbrella of positive psychology.” He delivered an unflinchingly harsh verdict about the chain of causal claims Seligman had sold to the Army: “The idea that techniques that have demonstrated, at best, marginal effects in reducing depressive symptoms in school-age children could also prevent the onset of a condition that is associated with some of the most extreme situations with which humans can be confronted is a remarkable one that does not seem to be backed up by empirical evidence.”

Stretching things even further, Seligman and his colleagues didn’t merely adapt PRP to a new and unfamiliar context they also bolstered the Master Resilience Training program with components taken from other corners of positive psychology, many of them involving attempts to make people a bit more optimistic in general. “Resilient people bounce, not break,” reads one slide from an MRT session. Under that, two images: “You” over a tennis ball, “Not you” over a cracked egg with yolk oozing out. A bit later in that same slide deck, an in-class exercise: “Discuss resilience using the quotes [from earlier slides], your personal experiences, and what we’ve discussed so far in the course. Create a list of the strengths, skills, and abilities that you believe are critical for resilience.” Later still, the module promises that resilience “can be developed: Everyone can enhance his or her resilience by developing the MRT competencies.” Elsewhere, soldiers are instructed to “hunt the good stuff” — that is, to remain optimistic by thinking of the good things in life. (This had become somewhat infamous among some of the critics of Comprehensive Soldier Fitness with whom I spoke: Before sending a 20-year-old into an urban-combat hellhole, you’re reminding him to “hunt the good stuff.”)

Other aspects of positive psychology were shoehorned into the CSF curriculum as well, such as the aforementioned theory about finding and cultivating character strengths, which does not appear to have ever been tested as an anti-PTSD or anti-suicide measure in any context. These materials were not from PRP as it was originally conceived, and they have a far weaker evidence base than interventions premised on cognitive behavioral principles. In an email, Gillham, after cautioning that she was unfamiliar with CSF itself, noted that “the original PRP did not include positive psychology activities. I personally don’t consider the original PRP a positive psychology intervention.”

Over all, there was no evidence PRP itself could prevent PTSD or suicide in its existing form Seligman and his colleagues then padded it with elements that are, according to the available evidence (or lack thereof), even less suited to that task.

T here are effective treatments for PTSD. One of them is called cognitive processing therapy, and it was developed by Patricia A. Resick of Duke University, a leading trauma researcher. CPT is itself premised on a cognitive behavioral approach, but it is both more targeted and more intense than anything positive psychology attempts: It helps patients with PTSD rewire how they conceive of the traumas and tragedies they have experienced. A soldier might be hung up on the idea that he did something wrong, leading to a buddy’s death, for example. So a therapist might in turn help gently lead him to better understand that war really is chaotic, random, and unfair, and that therefore he shouldn’t hold himself responsible for such a horrible event. CPT is focused on ameliorating cognitive distortions, but, crucially, it can do so only among those who are already afflicted with PTSD, because the approach depends upon untangling the specific thought patterns and experiences of a given sufferer.

CPT is considered a “gold standard” PTSD treatment by the Pentagon. Another such treatment is prolonged exposure, or PE, therapy. Developed by the Israeli researcher Edna Foa, who is based (as fate would have it) at the University of Pennsylvania’s Perelman School of Medicine, PE therapy entails helping patients to face down and process their trauma and its triggers, rather than fall victim to the avoidance strategies that so often cut them off from other people and stymie their ability to integrate their trauma into a recuperated sense of self. Neither of these treatments is perfect, and both have their critics. But the available research strongly suggests that the average veteran with PTSD would benefit from a course of PE therapy or CPT.

The problem, though, is that the military has long had a serious problem getting veterans to enter and stick with these treatments.

The numbers are stark: A 2017 paper found that only 56 percent of returned veterans from Iraq and Afghanistan who screened positive for PTSD had any subsequent engagement with mental-health services, and over the years the rates at which veterans with PTSD have partaken of therapies like PE or CPT have hovered at just about a third. Research suggests that veterans’ obstacles to treatment range from logistics — some are simply unable to get to a VA center or other treatment facility on a regular basis — to stigma against open discussion of trauma symptoms.

So at the time the U.S. military faced its burgeoning PTSD crisis, there was one rather obvious approach to take: expanding access to scientifically validated treatment for veterans, and seeking to better understand why they often shied from or felt cut off from it. But that wasn’t what happened.

The Army’s leadership appears to have been particularly drawn to PTSD interventions that would piggyback on its institutional fixation with “resilience” and prevention. It’s understandable why: First, the prospect of preventing PTSD rather than having to treat it after the fact was likely irresistible to many who understood how bad the situation had gotten. “Build resilience, prevent PTSD” was too good a promise to refuse, because if kept it would forestall a tremendous amount of human suffering, and to the unskilled layperson there did appear to be evidence supporting this approach, in the form of Seligman’s impressive claims about PRP. But CSF also fit neatly with the Army’s beliefs in self-possession and self-efficacy, meaning that it could be pitched to Army bigwigs in a language they were already fluent in. On top of all that, for the Army to introduce a sweeping new program rather than bolstering or tweaking existing ones would bring with it obvious PR opportunities, such as videos of soldiers participating in an exciting, novel mental-health initiative (which were indeed shot and disseminated to the public).

The adoption of Comprehensive Soldier Fitness was not driven by PTSD experts. Neither the Pentagon staffer initially tasked with narrowing down the Army’s range of potential options for addressing the PTSD crisis (Chambers) nor the general who became CSF’s arguably fiercest advocate (Casey) was an actual expert on PTSD, nor was Seligman himself. “We were never asked to consult on prevention of PTSD, or whether this program would work, or whether it should be funded,” said Resick. Those who did have expertise in the relevant areas did not find the CSF storyline credible. “When I first heard about it I was more or less floored,” George A. Bonanno, a clinical psychologist at Columbia University and leading resilience researcher, told the journalist and American studies scholar Daniel DeFraia for a 2019 article he published in The War Horse, a military-focused journalism outlet. “I’ve been studying resilience for 20 years, and I don’t know of any empirical data that shows how to build resilience in anybody.” But the Army personnel who were convinced “Marty” was their man encountered a reasonable-sounding explanation for how CSF would resolve the issue of Army PTSD and suicidality via resilience boosting. None of this is particularly surprising in light of how human institutions work.

R ichard J. McNally, a Harvard psychologist and leading PTSD expert, told me he was invited to an early meeting with Seligman, Brig. Gen. Rhonda Cornum (another major figure in the development of CSF), and others at the Positive Psychology Center to discuss the nascent program. There, he tried to emphasize just how little evidence there was that the adapted-PRP approach would successfully address PTSD. “That’s why my suggestion to Marty and to General Cornum was, ‘Why don’t you pilot this first, and then you can tweak it, improve it, et cetera, et cetera, until you can get a good sense of whether this is going to work prior to disseminating it throughout the entire Army?’” he recalled. “That was my issue, because there was not a great deal of evidence on this.”

With pilot testing, the idea is to roll out a smaller-scale version of the program in question on a subset of the population for which it’s designed — not only to test for evidence of its efficacy, but also to ensure it has no adverse effects. But General Casey, besotted as he was with Seligman’s ideas, would have none of this pilot-test talk. During a key exchange recounted in Flourish, Seligman described what happened when he and Cornum asked Casey for an initial pilot test to see how their program performed. “Hold on,” the general “thundered,” as Seligman put it. “I don’t want a pilot study. We’ve studied Marty’s work. They’ve published more than a dozen replications. We are satisfied with it, and we are ready to bet it will prevent depression, anxiety, and PTSD. This is not an academic exercise, and I don’t want another study. This is war. General [Cornum], I want you to roll this out to the whole Army.”

This is a veritable carnival of unskilled intuition and exaggerated storytelling, a striking example of how science can be adulterated and misunderstood by an organization seeking to apply it. “They’ve published more than a dozen replications”: Well, but when those and other studies were meta-analyzed, PRP didn’t seem to do much, and those studies were conducted on kids, anyway. “We are satisfied with it, and we are ready to bet it will prevent depression, anxiety, and PTSD”: No published literature on PRP claimed it could prevent PTSD, because that wasn’t what it was designed for.

Unsurprisingly, the Army never produced any real evidence CSF works. While it did publish four “technical papers,” none of them peer-reviewed, that purported to show the effectiveness of CSF (“Study concludes Master Resilience Training effective,” touted the Army’s website), these analyses don’t survive close scrutiny. The psychologists Roy Eidelson and Stephen Soldz, for example, published a working paper showing that the Army’s evaluations were riddled with cherry-picking and basic methodological errors in one instance, for example, the outcomes for soldiers who hadn’t been deployed were compared with those for soldiers who had, introducing a mega-confound that renders the comparison meaningless, because it would be impossible to know whether any differences between the groups should be attributed to CSF or to deployment itself.

The Institute of Medicine, an august branch of the National Academy of Sciences, came to the same conclusion in a major 2014 report that evaluated the military’s various efforts for improving the psychological well-being of service members and their families: “Although evaluations that were conducted by CSF staff and were not subject to peer review have demonstrated statistically significant improvement in some GAT subscale scores, the effect sizes have been very small, with no clinically meaningful differences in pre- and post-test scores. Accordingly, it is difficult to argue there has been any meaningful change in GAT scores as a result of participation.” In addition, the institute’s report notes, the one attempt the Army made to evaluate CSF on the basis of actual diagnoses among service members found “no difference in diagnosis among those receiving the [CSF] intervention” and those who had not participated in it.

None of this was cheap. There’s some fuzziness to the numbers, but in 2017 the Army told Daniel DeFraia that CSF cost $43.7 million the previous year. This tracks, roughly speaking, with the USA Today journalist Gregg Zoroya’s estimate that as of 2015 the program had been a six-year, $287-million enterprise (like DeFraia, Zoroya is one of the few journalists who has dug deeply into the program). Of course from a military perspective this is peanuts: A single F-35 costs about $100 million. But if, as the numbers suggest, CSF has cost the Army somewhere in the neighborhood of half a billion dollars since it was launched more than a decade ago (and has cost the Pentagon even more if you include the funds spent on the Air Force version, Comprehensive Airman Fitness, which launched in 2011), that’s still a tremendous amount of money, absolutely speaking, when one considers the good it could do in helping get soldiers the mental-health care they need. There may be no other single mental-health intervention in the history of humanity that has cost this much, and the Army has almost nothing to show for it.

The absence of evidence that the Penn Resilience Program and Comprehensive Soldier Fitness actually work as anti-PTSD interventions — as well as evidence that other approaches do, on average, work (at least as far as treating trauma that has already been inflicted) — was right there in the literature all along. The trauma and anxiety researchers Patricia Resick, Richard McNally, and Edna Foa could have told anyone who asked, and in some cases did tell those who asked, that what the Army was rolling out was based on no one’s expert understanding of PTSD. But it didn’t matter: The program slid too effortlessly into military ideals, and was such a big, important-seeming, attention-getting response to the crisis that it attained a formidable internal momentum and quickly snowballed on the basis of its own overheated promises.

Or, phrased differently: Imagine Marty Seligman and Patricia Resick competing for the same giant military contract. During Seligman’s presentation, he explains how his idea, Comprehensive Soldier Fitness, will help reinforce values the Army already holds dear: self-possession, hard work, respect for and trust in authority. The trainings can slot right into soldiers’ other responsibilities. Soldiers can be trained up as Master Resilience Trainers. A relatively simple, universal intervention will make the military stronger in an easy, convenient way that won’t interfere with anything. It will save lives. Best of all, adopting this program will allow the Army to broadcast out to America inspiring scenes of soldiers receiving life-enhancing training, and of Master Resilience Trainers fanning out throughout the Army, imparting these messages at the unit level. And as a result, countless tragedies will be averted this is a remarkable, revolutionary opportunity to nip Army PTSD and suicidality in the bud, en masse.

Then Resick gets up to make the case that the grant should go to her and to her cognitive-processing therapy approach. This is actually less straightforward than what Marty just posited, she explains. Post-traumatic stress disorder isn’t about a lack of optimism, or about a failure to “hunt the good stuff.” It’s much more complicated than that, and there’s no evidence it can really be prevented, and treating it involves carefully unpacking soldiers’ thought patterns and, in many cases, undoing the military’s very own teachings. At the end of the day, if you send young soldiers into deadly situations and allow terrible things to happen to them, you need to approach the aftermath in a careful, responsible, evidence-based way. There’s no simple solution here, no quick fix. Trauma is trauma, and it’s ugly and takes time to unpack. And, if she’s being honest, she can’t really claim, as Marty did, that beefing up the Army’s investment in cognitive-processing therapy will bring with it PR opportunities. These stories aren’t inspiring they involve young men sitting with a therapist talking about the worst days of their lives and their lingering feelings of guilt and anger about what happened on those days. Sometimes they’re crying. It’s hardly ever photogenic.