Euthymia: why it really does matter
Authors: Andrew MacLeod
Journal: World Psychiatry (2020)

Few would argue against the value of a life of positive emotions, meaning and purpose, competence, achievements, and quality relationships with others. Such a life is obviously worth living and worth striving for. A reasonable question to ask, though, is whether directly promoting such a life falls under the provenance of psychiatry and other mental health professions. The alternative view is that mental health services should focus on treating disorders that act as obstacles getting in the way of such a life being realized, rather than promoting it directly. Fava and Guidi1, in this issue of the journal, argue for the former view, organizing their approach around the central concept of euthymia. I would like to endorse their stance and elaborate on some reasons why. First, some mental health problems might benefit from being conceptualized as having essential components of low well-being. For example, suicidal thinking has often been talked about as a negative view of the future, but recent attempters high in suicide ideation consistently show a lack of anticipated positive personal events in their future, without showing an excess of future negative thoughts2. Furthermore, self-reported hopelessness correlates with lack of positive future thoughts, and shows no significant correlation with negative future thoughts3. In other words, those who are suicidal specifically suffer from the absence of a component of a good life – looking forward to positive things in the future, both in the short and long term. The understanding of suicidal thinking could, therefore, be enhanced by a greater focus on the positive well-being component of future-thinking, normally present but absent when people feel suicidal. It is not that traditional approaches do not appreciate this kind of point at all – anhedonia is a good example, where the absence of a pleasure response is recognized as central to depression – but there is enormous scope for further work exploring how the understanding of different psychiatric conditions can be enhanced by the application of well-being frameworks. Second, it is a disappointing but well established fact that some mental disorders, even when responsive to initial treatment, prove to be relapsing or recurring. Fava and Guidi point to the example of depression, where 50% of those successfully treated after a first episode experience at least one further episode, with the risk increasing further after subsequent episodes4. What is the role of a well-being approach here? Consider the following analogy. A young girl is playing in a park but does not notice a large hole; she falls down the hole and cannot get herself out; her father hears her cries and comes and pulls her out. After soothing her, does her father go off to what he was doing before and leave the child to play at the edge of the hole? Of course he does not. He takes her to a part of the park far away from the hole, where she will not fall in again. By getting people to a reduced level of symptoms or distress that takes them out of "the hole" and then leaving them there, we are doing the equivalent of leaving the child to play by the hole after rescuing her. If we do not want people to relapse, we need to find ways to get them as far away from the hole as possible, and it is not necessarily safe to assume that they will be able to do that by themselves. It is here that more well-being focused approaches can come into their own, by both reducing residual symptoms and building well-being resources5. Given that residual symptoms are one of the strongest predictors of relapse4, approaches such as well-being therapy6 that target those symptoms would seem to be particularly valuable. Third, many mental health problems are unfortunately long lasting or even chronic, whether in full or in a reduced form. Symptoms may not respond well to traditional treatment approaches, or residual symptoms may persist to a significant degree. Recovery-oriented practices7 are based on the idea that personal recovery can occur even in the absence of clinical recovery. The use of the term "recovery" in this personal context is somewhat confusing, referring as it does to people being able to live satisfying and meaningful lives even in the ongoing presence of illness symptoms. Once again, traditional approaches do recognize the value of not simply focusing on symptoms. However, it is fair to say that recovery-focused approaches do not seem well connected to the extensive psychological well-being literature that might inform them. There is great scope for marrying mainstream well-being models with service provision for mental health problems. This could help in providing a fuller framework within which to understand the goals of those continuing to suffer the effects of mental health problems, and also to help them to think of how to attain those goals, using a structured approach such as well-being therapy. It is here that Fava and Guidi, in drawing on the model of Ryff8 from the mainstream psychological literature, provide an excellent example of how such a marriage can work. The discussion on relapse/recurrence and chronicity highlights an interesting area that requires further clarification. Recovery-based approaches have an underlying assumption that well-being is at least partially independent of illness/distress, such that a life of well-being can be fostered even as someone continues to be symptomatic. This is different from the relapse prevention discussion of moving a person further away from disorder by enhancing his/her well-being. The relapse discussion and the analogy of the hole in the park is based on the simpler idea of a single underlying dimension, with well-being at one end and illness/distress at the other, one in which they are incompatible with each other because they are opposites. There is some debate about which of these approaches best fits the data9, and it is likely the case that both views have some merit. A full understanding of this issue is yet to be reached. One way that this understanding will be progressed is by talking about specifics rather than broad classes. In some cases, the relationship will be more like a single dimension: for example, having a life full of positive emotions and being depressed seem incompatible and more like two ends of a single dimension. In other cases a two-dimensional framework will fit better: someone could hear voices but also live a life that is purposeful and meaningful. In other words, it depends on which aspects of illness and which aspects of well-being are being talked about. However, the important point for the discussion here is that, whether within a single- or a two-dimensional framework, there is value in promoting euthymia. Much work remains to be done on all of these issues, but there is exciting potential for advances in assessment and intervention in this area.