Specificity in the pursuit of euthymia
Authors: Jesse H. Wright
Journal: World Psychiatry (2020)

In their incisive paper, Fava and Guidi1 argue that therapies, in addition to relief of symptoms or distress, should have the more ambitious goal of helping patients achieve a euthymic state that includes psychological well-being, positive affects, and flexibility. In a way, they are proposing that therapies go beyond the “gold standard” of remission to a “platinum standard” that could convey greater benefits in terms of quality of life and relapse prevention. There is evidence from two investigations on well-being therapy (WBT) for depression that a focus on achieving well-being can lead to better relapse prevention than observed with clinical management or standard cognitive behavior therapy (CBT)2. But the only direct comparison of WBT and CBT for depression that measured well-being found significant improvements in one (personal growth) of the six domains in the Psychological Well-Being (PWB) scales for WBT and two domains (purpose in life and self-acceptance) for CBT2. Another small study comparing WBT with CBT for generalized anxiety disorder reported advantages for WBT in all six domains of the PWB scales. In addition to WBT, Fava and Guidi note that two other evidence-based psychotherapies have features that may be useful in reaching states of euthymia. Mindfulness-based cognitive therapy (MBCT) includes methods intended to promote mindful, non-judgmental mentation that can help persons achieve a good life. Acceptance and commitment therapy (ACT) utilizes mindfulness and awareness to promote flexibility and acceptance. WBT, MBCT and ACT each have appeal for pursuit of euthymia, because their proposed mechanisms of action and goals go beyond symptom relief. These therapies, especially WBT, have enriched our options for treatment by providing well-articulated methods for enhancing well-being. But it is not known whether treatments with specific methods for promoting well-being are required if the goals extend to achieving the “platinum standard” of euthymia. A meta-analysis3 of studies that employed either the PWB scales or the Mental Health Continuum – Short Form, assessing the six domains of well-being1, found an overall moderate effect size for psychotherapies, of which the most common were WBT, mindfulness and ACT. However, the studies in this meta-analysis did not include several of the most widely used psychiatric treatments (e.g., pharmacotherapy, CBT and interpersonal psychotherapy), because investigations on these approaches have not utilized the above-mentioned scales. Psychiatry and psychology have been driven largely by a “disease bias” . Thus, outcome assessments in most treatment studies have focused heavily, or solely, on measuring symptom change – not on elements of psychological well-being. Yet, there is some evidence that approaches other than WBT, mindfulness and ACT may impact functions described by Fava and Guidi in their definition of euthymia. For example, a meta-analysis of trials of antidepressants in patients with fibromyalgia4 found a moderate effect size for pharmacotherapy on measures of well-being. Other studies of antidepressants have reported positive changes in well-being after treatment with sertraline, levomilnacipran ER, venlafaxine and desvenlafaxine. These studies used a variety of scales to measure components of well-being, none of which were as comprehensive as the PWB scales. However, improvements in functions such as vitality, interpersonal functioning, and overall well-being suggest that antidepressants can yield benefits in addition to symptom relief. There have been several studies suggesting that psychotherapies other than WBT, MBCT and ACT might be useful for reaching euthymia. In one such investigation, Iranian mourners treated with CBT had significantly greater improvements in spiritual well-being (defined as “stability in life, peace, balance and harmony, and feeling a close relationship with self, God, and the environment”)5. Another study on CBT found greater benefit than an active control on emotional well-being6, while research on CBT in HIV+ women documented significant increases in psychological and spiritual well-being compared to a psychoeducational control group7. Digital delivery of CBT also has been shown to improve well-being. Significant advantages versus control treatments were observed on Warwick-Edinburgh Mental Well-being Scale scores in an online CBT computer program for insomnia8. Logotherapy, a treatment focused primarily on helping patients find a sense of meaning in life, has been investigated rarely in randomized, controlled trials. But there is evidence that it can improve well-being. Purpose in life was enhanced in an investigation of individual logotherapy for paralyzed inpatients9. Occupational therapy, a treatment with a very different proposed mechanism of action, is another approach that may have benefit in reaching states of euthymia. A large investigation of this therapy versus a no-treatment control reported significant benefits in promoting well-being, including vitality, social functioning, and life satisfaction10. It is difficult to compare results of studies on well-being, because different designs and measures have been employed. Fava and Guidi's definitions of well-being and euthymia, and their measurement by the PWB scales, encompass more domains and functions than typically have been assessed in other studies. However, available evidence suggests that therapies that do not posit a specific mechanism of action for enhancing well-being may have some ability to help patients move toward euthymia. Several explanations for lack of specificity in promoting well-being are possible. Symptoms of an illness such as depression interfere with experiences of well-being, so that any treatment that reduces symptoms may have potential for improving well-being. Furthermore, diverse treatment methods could enhance well-being by operating through common pathways such as effecting the neurobiological processes that underlie subjective experiences of psychological well-being. Unspecified or unmeasured therapeutic influences may be operative in improving well-being (e.g., positive placebo effect, behavioral activation, non-specific elements of all effective psychotherapies). Although there has been insufficient research to support or refute these possible explanations, there are indications from earlier studies that specific hypothesized mechanisms of action may not be required to convey specific benefits. For example, antidepressants have been found to have a strong influence on negative thinking, a presumed purview of CBT, while CBT improves energy, interest and other symptoms that are targets for antidepressants. Fava and his associates have been leaders in the development of WBT and in helping clinicians and researchers understand the importance of well-being as a treatment goal. Now, with their call for the pursuit of euthymia, they challenge us to significantly broaden our conceptualization of psychiatric treatment and to search for ways to assist patients in maximizing their functioning in domains such as personal growth, self-acceptance, and purpose in life. WBT, MBCT and ACT offer considerable promise for reaching such treatment goals. But it is possible that other approaches also could promote well-being and the “platinum standard” of euthymia. Shouldn't all psychiatric treatments pursue euthymia as Fava and Guidi have defined it?