World Psychiatry OFFICIAL JOURNAL OF THE WORLD PSYCHIATRIC ASSOCIATION (WPA)

WPA Volume 19, Number 1 February 2020

EDITORIAL Euthymia and disabling health conditions 58 B.P. NIERENBERG Euthymia: why it really does matter 1 A. MACLEOD The pursuit of euthymia: are cultural factors 59 relevant? SPECIAL ARTICLES S.K. CHATURVEDI, S. PARAMESHWARAN Economics and mental health: the current scenario 3 RESEARCH REPORTS M. KNAPP, G. WONG Dopamine and glutamate in schizophrenia: 15 20-year follow-up study of physical morbidity 61 biology, symptoms and treatment and mortality in relationship to antipsychotic R.A. MCCUTCHEON, J.H. KRYSTAL, O.D. HOWES treatment in a nationwide cohort of 62,250 patients with schizophrenia (FIN20) PERSPECTIVES H. TAIPALE, A. TANSKANEN, J. MEHTÄLÄ ET AL Metformin add-on vs. antipsychotic switch vs. 69 Gender competence and mental health promotion 34 continued antipsychotic treatment plus healthy J. FISHER lifestyle education in overweight or obese youth Engagement of ethnic minorities in mental health 35 with severe mental illness: results from the care IMPACT trial M. ALEGRIA, I. FALGAS-BAGUE, H. FONG C.U. CORRELL, L. SIKICH, G. REEVES ET AL Leveraging collaborative care to improve access 36 The interplay among psychopathology, personal 81 to mental health care on a global scale resources, context-related factors and real-life J. UNÜTZER, A.D. CARLO, P.Y. COLLINS functioning in schizophrenia: stability in The role of new technologies in monitoring the 38 relationships after 4 years and differences evolution of psychopathology and providing in network structure between recovered and measurement-based care in young people non-recovered patients I.B. HICKIE S. GALDERISI, P. RUCCI, A. MUCCI ET AL A network meta-analysis of the effects 92 FORUM – THE EVOLVING SCIENCE of psychotherapies, pharmacotherapies and OF EUTHYMIA: CONCEPTS, ASSESSMENT their combination in the treatment of adult AND INTERVENTIONS depression The pursuit of euthymia 40 P. CUIJPERS, H. NOMA, E. KARYOTAKI ET AL G.A. FAVA, J. GUIDI INSIGHTS Commentaries Constructing a liberated and modern mind: 51 Beyond depression: the expanding role 108 six pathways from pathology to euthymia of inflammation in psychiatric disorders S.C. HAYES A.H. MILLER Specificity in the pursuit of euthymia 52 Inflammation affects social experience: 109 J.H. WRIGHT implications for mental health N.I. EISENBERGER, M. MOIENI Why the field of moral philosophy must guide 53 any discussion on well-being The synaptic pruning hypothesis of 110 A.M. WOOD, A.T. DAVIDSON schizophrenia: promises and challenges M. KESHAVAN, P. LIZANO, K. PRASAD Euthymic suffering and wisdom psychology 55 M. LINDEN Gut microbiota: a missing link in psychiatry 111 Understanding mood in mental disorders 56 T.G. DINAN, J.F. CRYAN G. HASLER The untapped power of allostasis promoted 57 LETTERS TO THE EDITOR 113 by healthy lifestyles B.S. MCEWEN WPA NEWS 122

IMPACT FACTOR: 34.024 ISSN 1723-8617 FORUM – THE EVOLVING SCIENCE OF EUTHYMIA: CONCEPTS, ASSESSMENT AND INTERVENTIONS

The pursuit of euthymia

Giovanni A. Fava1, Jenny Guidi2 1Department of Psychiatry, University at Buffalo, State University of New York, Buffalo, NY, USA; 2Department of Psychology, University of Bologna, Bologna, Italy

Psychiatrists often consider the positive characteristics displayed by a patient in their clinical judgment, yet current assessment and treatment strat­ egies are shifted on the side of psychological dysfunction. Euthymia is a transdiagnostic construct referring to the presence of positive affects and psychological well-being, i.e., balance and integration of psychic forces (flexibility), a unifying outlook on life which guides actions and feelings for shaping future accordingly (consistency), and resistance to stress (resilience and tolerance to anxiety or frustration). There is increasing evidence that the evaluation of euthymia and its components has major clinical implications. Specific instruments (clinical interviews and questionnaires) may be included in a clinimetric assessment strategy encompassing macro-analysis and staging. The pursuit of euthymia cannot be conceived as a therapeutic intervention for specific mental disorders, but as a transdiagnostic strategy to be incorporated in an individualized therapeutic plan. A number of psychotherapeutic techniques aiming to enhance positive affects and psychological well-being (such as well-being therapy, mindfulness-based cognitive therapy, and acceptance and commitment therapy) have been developed and validated in randomized controlled clinical trials. The findings indicate that flourishing and resilience can be promoted by specific interventions leading to a positive evaluation of one’s self, a sense of continuing growth and development, the belief that life is purposeful and meaningful, satisfaction with one’s relations with others, the capacity to manage effectively one’s life, and a sense of self-determination.

Key words: Euthymia, psychological well-being, resilience, mental health, clinimetrics, positive psychology, well-being therapy, mindfulness- based cognitive therapy, acceptance and commitment therapy

(World Psychiatry 2020;19:40–50)

About sixty years ago, M. Jahoda pub- This questionnaire disclosed that ill-being full recovery can be reached only through lished an extraordinary book on posi- (e.g., major depressive disorder) and well- interventions which facilitate progress to- tive mental health1. She denied that “the being were independent although inter- ward restoration or enhancement of psy- concept of mental health can be usefully related dimensions3,4. This means that chological well-being. defined by identifying it with the absence some individuals might have high levels A third converging development oc- of a disease. It would seem, consequently, of both ill-being and well-being, while curred as the concept of positive mental to be more fruitful to tackle the concept of others might have major mental disorders health became the target of an increasing mental health in its more positive conno- and poor psychological well-being, and amount of research10. Its domains were tation, noting, however, that the absence further individuals might have no major very broad, such as the presence of mul- of disease may constitute a necessary, mental disorders and high levels of psy- tiple human strengths (rather than the but not sufficient, criterion for mental chological well-being. absence of weaknesses), including ma- health.”1 Further, the naive conceptualization of turity, dominance of positive emotions, She outlined criteria for positive men­ well-being and distress as mutually exclu- subjective well-being, and resilience10. tal health: autonomy (regulation of behav- sive (i.e., well-being is lack of distress and Yet, probably the strongest input to the ior from within), environmental mastery, should result from removal of distress) was consideration of psychological well-being satisfactory interactions with other peo- challenged by clinical research. Patients came from the positive psychology move- ple and the milieu, the individual’s style with a variety of mental disorders who ment initiated by the American Psycho- and degree of growth, development or were judged to have remitted on symp- logical Association in the year 200011, self-actualization, and the attitudes of an tomatic grounds still presented with im- which had a huge impact on psychology individual toward his/her own self (self- pairment in psychological well-being com­ and the society in general in a very short perception/acceptance). The book indi­ pared to healthy control subjects5,6. time. The movement can be credited with cated that mental health research was Second, impairments in psychological delivering the message that psychology dramatically weighted on the side of psy- well-being were found to be a substantial needs to consider the positive as well as chological dysfunction1. risk factor for the onset and recurrence of the negative, an issue that was much later It took a long time before such imbal- mental disorders, such as depression7,8. extended to psychiatry12. Yet, this move- ance started being corrected, as a result of Psychological well-being thus needs to be ment attracted considerable criticism13,14. several converging developments that oc- incorporated in the definition of recovery9. Positive psychology developed outside curred in the late 1990s. There has been growing recognition that the clinical field and, not surprisingly, its First, C. Ryff2 introduced a method for interventions that bring the person out of oversimplified approach (happiness and the assessment of Jahoda’s psychologi- negative functioning may not involve a full optimism, the more the better) was likely cal dimensions based on the self-rating recovery, but the achievement of a neutral to clash with the complexities of clinical Psychological Well-Being (PWB) scales. position9. Jahoda1 had postulated that a reality13,14.

40 World Psychiatry 19:1 - February 2020 Despite these developments, consider- well-being, and, indeed, scales describing­ er, encompasses four different meanings: ation of psychological well-being has had well-being were found to be more sensi- life energy; feelings and passions; will, a limited impact so far on general prac- tive to medication effects than those de- desire and inclination; thought and intel- tice. The aim of this review is to illustrate scribing symptoms17. In turn, changes in ligence. Interestingly, the corresponding that clinical attention to psychological well-being may affect the intensity of verb (euthymeo) means both “I am hap- well-being requires an integrative frame- symptomatology­ 18,19. py, in good spirits” and “I make other peo- work, which may be subsumed under the Excessively elevated levels of positive ple happy”, “I reassure and encourage”. concept of euthymia15, as well as specific emotions can also become detrimental13, The definition of euthymia is generally assessment and treatment strategies. Such and are more connected with mental dis­ ascribed to Democritus: one is satisfied an approach may unravel innovative and orders and impaired functioning than with what is present and available, taking promising prospects both in clinical and with psychological well-being. little heed of people who are envied and preventive settings. Optimal balanced well-being can be admired and observing the lives of those different from person to person, according who suffer and yet endure21. It is a state of to factors such as personality traits, social quiet satisfaction, a balance of emotions EUTHYMIA AS AN INTEGRATIVE roles, cultural and social context. Table 1 that defeats fears. FRAMEWORK outlines the bipolar nature of Jahoda-Ryff’s The Latin philosopher Seneca translat- dimensions20. Appraisal of positive cogni- ed the Greek term euthymia by tranquil­ In 1991, Garamoni et al16 suggested tions and affects thus needs to occur in the litas animi (a state of internal calm and that healthy functioning is characterized setting of an integrative framework, which contentment) and linked it to psycho- by an optimal balance of positive and neg- may be provided by the concept of euthy- logical well-being as a learning process. ative cognitions and affects, and that psy- mia. Happiness is not everything, and what chopathology is marked by deviations This term has a Greek origin and results is required is felicitatis intellectus, the from this balance. Treatment of psychiat- from the combination of eu, well, and­ awareness of well-being. Plutarch, who ric symptoms may induce improvement of thymos, soul. The latter element, howev- attempted a synthesis of Greek and Latin

Table 1 The spectrum of dimensions of psychological well-being

IMPAIRED LEVEL BALANCED LEVEL EXCESSIVE LEVEL

Environmental mastery The person feels difficulties in managing everyday The person has a sense of competence in managing The person is looking for difficult situations to be affairs; he/she feels unable to improve things the environment; he/she makes good use of sur- handled; he/she is unable to savoring positive around; he/she is unaware of opportunities. rounding opportunities; he/she is able to choose emotions and leisure time; he/she is too engaged what is more suitable to personal needs. in work or family activities.

Personal growth The person has a sense of being stuck; he/she lacks The person has a sense of continued development; The person is unable to elaborate past negative expe- sense of improvement over time; he/she feels he/she sees one’s self as growing and improving; riences; he/she cultivates illusions that clash with bored and uninterested in life. he/she is open to new experiences. reality; he/she sets unrealistic standards and goals.

Purpose in life The person lacks a sense of meaning in life; he/she The person has goals in life and feels there is mean- The person has unrealistic expectations and hopes; has few goals or aims and lacks sense of direction. ing to present and past life. he/she is constantly dissatisfied with perfor- mance and is unable to recognize failures.

Autonomy The person is over-concerned with the expectations The person is independent; he/she is able to resist The person is unable to get along with other peo- and evaluations of others; he/she relies on judg- to social pressures; he/she regulates behavior ple, to work in team, to learn from others; he/ ment of others to make important decisions. and self by personal standards. she is unable to ask for advice or help.

Self-acceptance The person feels dissatisfied with one’s self; he/she The person accepts his/her good and bad qualities The person has difficulties in admitting his/her is disappointed with what has occurred in past and feels positive about past life. own mistakes; he/she attributes all problems to life; he/she wishes to be different. others’ faults.

Positive relations with others The person has few close, trusting relationships with The person has trusting relationships with others; he/ The person sacrifices his/her needs and well-being others; he/she finds difficult to be open. she is concerned about welfare of others; he/she for those of others; low self-esteem and sense of understands give and take of human relationships. worthlessness induce excessive readiness to forgive.

World Psychiatry 19:1 - February 2020 41 cultures, criticized the concept of euthy- display consistency in one’s behavior and as having quality ties to others affect the mia involving detachment from current deeply held values. The absence of flexibil- physiological substrates of health32. The events, as portrayed by Epicurus, and un- ity is linked to depression, anxiety and the concept of subjective incompetence (a feel- derscored the learning potential of mood general tendency to experience negative ing of being trapped or blocked because of alterations and adverse life situations. emotions more frequently, intensely and a sense of inability to plan or start actions In the psychiatric literature, the term readily, for longer periods of time, in what toward goals) stands as opposite to that euthymia essentially connotes the lack of has been subsumed under the rubric of neu­ of resilience33. Individuals who perceive significant distress. When a patient, in the roticism30. themselves as incompetent are uncertain longitudinal course of mood disturbances, Resilience has been defined as the ca- and indecisive as to their directions and no longer meets the threshold for a dis- pacity to maintain or recover high well-be- aims. order such as depression or mania, as as- ing in the face of life adversity31. Looking Fava and Bech15 defined a state of eu- sessed by diagnostic criteria or by cut-off for the presence of wellness following ad- thymia as characterized by the following points on rating scales, he/she is often versity involves a more demanding and rig- features (Figure 1): labelled as euthymic. Patients with bipo- orous conception of resilience than the lar disorder spend about half of their time absence of illness or negative behavior­ •• Lack of mood disturbances that can be in depression, mania or mixed states22. al outcomes, the usual gold standards. subsumed under diagnostic rubrics. If The remaining periods are defined as eu- Examples are provided by life histories the subject has a prior history of mood thymic23-27. However, considerable fluc- of persons regaining high well-being fol- disorder, he/she should be in full re- tuations in psychological distress were lowing depression, or the ability to sustain mission. If sadness, anxiety or irritable recorded in studies with longitudinal psychological well-being during serious mood are experienced, they tend to be designs, suggesting that the illness is still or chronic illness. Resilience is thus con- short-lived, related to specific situa- active in those latter periods, even though ceptualized as a longitudinal and dynamic tions, and do not significantly affect ­ev its intensity may vary28. It is thus ques- process, which is related to the concept eryday life. tionable whether subthreshold sympto- of flourishing. Issues such as leading a •• The subject has positive affects, i.e., matic periods truly represent euthymia28. meaningful and purposeful life as well feels cheerful, calm, active, interested Similar considerations apply to the use of the term euthymia in unipolar depres- sion and dysthymia. Again, euthymia is of- ten defined essentially in negative terms29, as a lack of a certain intensity of mood symptoms, and not as the presence of specific positive features that characterize recovery9. Jahoda1 outlined a characteristic that is very much related to the concept of eu- thymia. She defined it as integration: the individual’s balance of psychic forces (flex- ibility), a unifying outlook on life which guides actions and feelings for shaping future accordingly (consistency), and re- sistance to stress (resilience and tolerance to anxiety or frustration). It is not simply a generic (and clinically useless) effort of avoiding excesses and extremes. It is how the individual adjusts the psychological di- mensions of well-being to changing needs. In the past decades, there has been an increasing interest in the concepts of flex- ibility and resilience portrayed by Jahoda1. Psychological flexibility has been viewed30 as the ability to: recognize and adapt to var­ious situational demands; change one’s paradigms when these strategies compro­ mise personal or social functioning; main- tain balance among important life domains; Figure 1 The concept of euthymia

42 World Psychiatry 19:1 - February 2020 in things, and sleep is refreshing or re- tegrative way, we need a clinimetric per­ depressed mood most of the day, nearly storative. spective39-41. The term “clinimetrics” in­ every day, for the diagnosis of major de­ •• The subject manifests psychological dicates a domain concerned with the pression. Psychiatrists also weigh the in­ well-being, i.e., displays balance and measurement of clinical issues that do tensity of positive emotions and their bor­ integration of psychic forces (flexibil- not find room in customary clinical tax- ders with elation and behavioral activa- ity), a unifying outlook on life which onomy. Such issues include the types, tion to determine the bipolar characteris- guides actions and feelings for shaping severity and sequence of symptoms; rate tics of a mood disorder. However, current future accordingly (consistency), and of progression in illness (staging); sever- formal assessment strategies fail to cap­ resistance to stress (resilience and tol- ity of comorbidity; problems in functional ture most of this information49. Table 2 erance to anxiety or frustration). capacity; reasons for medical decisions outlines the Clinical Interview for Euthy- (e.g., treatment choices), and many other mia (CIE), that covers such missing areas. This definition of euthymia, because aspects of daily life, such as well-being The first five items explore the contents of of its intertwining with mood stability, is and distress39-43. positive affects, as depicted by the WHO- substantially different from the concept of 547. eudaimonic well-being, that has become increasingly popular in positive psychol- Positive affects ogy34. Indeed, research on psychological Psychological well-being well-being can be summarized35 as falling While there have been considerable ef- in two general groups: the hedonic view- forts to quantify and qualify psychological There are several instruments to assess point focuses on subjective well-being, distress44, much less has been done about psychological well-being states and di- happiness, pain avoidance and life sat- assessing positive affects such as feeling mensions45,46. isfaction, whereas the eudaimonic view- cheerful, calm, active, interested in things, The PWB scales have been used exten- point, as portrayed by Aristotle, focuses on friendly45,46. sively in clinical settings6. They encompass meaning and self-realization and defines Self-rating scales and questionnaires 84 items and six dimensions (environ- well-being in terms of degree to which a have been the preferred method of evalu- mental mastery, personal growth, pur- person is fully functioning or as a set of ation, and there are several instruments pose in life, autonomy, self-acceptance, wellness variables such as self-actualiza- available45,46. Two instruments stand out and positive relations with others)2. The tion and vitality. However, the two view- for their clinimetric properties: the World questionnaire, because of its length, may points are inextricably linked in clinical Health Organization-5 Well-Being Index be problematic to use in a busy clinical situations, where they also interact with (WHO-5)47 and the Symptom Question- setting. A shorter version, the 6-item part mood fluctuations14. The eudaimonic per­ naire (SQ)17. of the PsychoSocial Index50,51, has been spective ignores the complex balance of The WHO-5 scale consists of five items developed and submitted to clinimetric positive and negative affects in psycho- that cover a basic life perception of a dy- validation: it was found to be a sensitive logical disturbances13,16. namic state of well-being. Such items have measure of well-being, yet it does not al- Whether an individual meets the criteria been incorporated in the Euthymia Scale15, low differentiation of the various dimen- of euthymia or not, it is important to evalu- that has been found to entail clinimetric sions. A structured interview based on the ate its components in clinical practice and validity and reliability48. The Symptom PWB scales2 has also been devised14. to incorporate them in the psychiatric ex- Questionnaire is a self-rating scale with A 10-item self-rating scale, the Accept- amination. There is, in fact, extensive evi- 24 items referring to relaxation, content- ance and Action Questionnaire (AAQ-II), dence that positive affects and well-being ment, physical well-being and friendli- is available to measure psychological flex- represent protective factors for health and ness, and 68 items referring to anxiety, ibility52,53. Yet, flexibility is only one com- increase resistance to stressful life situa- depression, somatization and hostility-ir- ponent of euthymia. tions6,32,36-38. ritability17. Extensive clinical research has Further, both the PWB scales and de- documented its sensitivity to change and rived indices and the AAQ-II provide as- ability to discriminate between different sessment of the impaired and optimal CLINICAL ASSESSMENT OF populations45. levels, but do not yield information about POSITIVE AFFECTS AND In their clinical practice, psychiatrists excessive levels. Such information is in- PSYCHOLOGICAL WELL-BEING weigh positive affects to evaluate the over­ cluded in the CIE (Table 2). Items 6 to 17 all severity and the characteristics of a dis- of the interview assess both polarities of Clinical assessment is aimed to explor- order. For instance, in order to discrimi- psychological well-being dimensions de- ing the presence of positive affects and nate depression from sadness, psychia- veloped by Jahoda1 and measured by the psychological well-being, as well as their trists look for instances of emotional well- PWB scales2. The interview also allows to interactions with the course and char­ being that interrupt depressed mood and collect information about flexibility, re- acteristics of symptomatology. In or­der for reactivity to environmental factors. In- silience and consistency (items 18 to to analyze these characteristics in an in- deed, the DSM-5 requires the presence of 22).

World Psychiatry 19:1 - February 2020 43 Table 2 The Clinical Interview for Euthymia (CIE)

POSITIVE AFFECTS 1. Do you generally feel cheerful and in good spirits? YES NO 2. Do you generally feel calm and relaxed? YES NO 3. Do you generally feel active and vigorous? YES NO 4. Is your daily life filled with things that interest you? YES NO 5. Do you wake up feeling fresh and rested? YES NO

DIMENSIONS OF PSYCHOLOGICAL WELL-BEING Environmental mastery 6. In general, do you feel that you are in charge of the situation in which you live? YES NO 7. Are you always looking for difficult situations and challenges? YES NO

Personal growth 8. Do you have the sense that you have developed and matured a lot as a person over the years? YES NO 9. Do you often fail to understand how things go wrong and/or set standards that you are unable to reach? YES NO

Purpose in life 10. Do you enjoy making plans for the future and working to make them a reality? In doing this, do you get a sense of direction in your life? YES NO 11. Are you constantly dissatisfied with your performance? YES NO

Autonomy 12. Is it more important for you to stand alone on your own principles than to fit in with others? YES NO 13. Are you able to ask for advice or help if needed? YES NO

Self-acceptance 14. In general, do you feel confident and positive about yourself? YES NO 15. Do you have difficulties in admitting your own mistakes, and/or attribute all problems to other people? YES NO

Positive relations with others 16. Do you have many people who want to listen when you need to talk and share your concerns, that is, do you feel that you get a lot out of your friendships? YES NO 17. Do you tend to sacrifice your needs and well-being to those of others? YES NO

FLEXIBILITY AND CONSISTENCY 18. If you become sad, anxious or angry, is it for a short time? YES NO 19. Do you keep on thinking of negative experiences? YES NO 20. Are you able to adapt to changing situations? YES NO 21. Do you try to be consistent in your attitudes and behaviors? YES NO 22. Are you able to handle stress most of the times? YES NO

Integration with psychiatric does not reflect the complex situations and after” into the lives of patients, con- symptomatology that are encountered in clinical practice54. sidering the “stressful life circumstances It needs to be integrated with positive af­ that have surrounded the onset of illness, In most instances of diagnostic rea- fects and psychological well-being, as the premorbid personality and its Achilles soning in psychiatry, the process ends well as with a broad range of further el­ heels, the historical record of the patient’s with the identification of a disorder, ac- ements, including stress, lifestyle, sub- development, adjustment in childhood, cording to a diagnostic system. Such a di- clinical symptoms, illness behavior and the relationship with parents, sexual life agnosis (e.g., major depressive disorder), social support, in a longitudinal perspec- within and out of marriage, his achieve- however, encompasses a wide range of tive54. ments and ambitions, his interpersonal manifestations, comorbidity, severity, prog­ This approach is in line with the tra- relationships, his adaptation in various nosis and responses to treatment54. The ditional psychopathological assessment, roles and the strength or brittleness of his exclusive reliance on diagnostic criteria as outlined by M. Roth55: “looking before self-esteem”55.

44 World Psychiatry 19:1 - February 2020 Two technical steps may facilitate the stagnation), and low self-acceptance (e.g., medications59. The planning of treatment integration of the assessments of psycho- dissatisfaction with herself). As depicted thus requires determination of the symp- logical well-being and distress. in Figure 2, macro-analysis helps to iden- tomatic target of the first line approach The first technical step involves the cli­ tify the main problem areas in this specific (e.g., pharmacotherapy), and tentative nimetric use of macro-analysis42,54,56. This situation. identification of other areas of concern method starts from the assumption that in Macro-analysis can be supplemented to be addressed by subsequent treatment most cases of mental disorders there are by micro-analysis, which may consist of di- (e.g., psychotherapy)59. functional relationships with other more mensional measurements, such as observ- or less clearly defined problem areas, and er- or self-rating scales to assess positive that the targets of treatment may vary dur­ affects and psychological well-being42,54,56. PSYCHOTHERAPEUTIC ing the course of disturbances. For in- The choice of these instruments is dictated TECHNIQUES stance, let us consider the case of a woman by the clinimetric concept of incremen- with a recurrent major depressive disorder tal validity54: each aspect of psychological Every successful psychotherapy, regard­ whose current episode has only partially measurement should deliver a unique in- less of its target, is likely to improve subjec- remitted (see Figure 2). Clinical interview- crease in information in order to qualify for tive well-being and to reduce symptoma­tic ing focused on symptoms may disclose the inclusion. distress60. Many psychotherapeutic tech- presence of residual symptoms (e.g., sad- The second technical step requires ref- niques aimed to increase psychological ness, diminished interest in things, guilt, erence to the staging method, whereby a well-being have been developed, although irritability), problems in the family (e.g., disorder is characterized according to se- only a few have been tested in clinical set- interpersonal frictions with her mother, re- verity, extension and longitudinal devel- tings61-63. current thoughts regarding the loss of her opment57,58. The clinical meaning linked A specific psychotherapeutic strategy father two years before) and unsatisfactory to the presence of dimensions of psycho- has been developed according to Jahoda’s interpersonal relationships (e.g., repeated logical well-being varies according to the concept of euthymia1. Well-being therapy failures in romantic relationships). Clini- stage of development of a disorder, wheth- (WBT) is a manualized, short-term psy- cal interviewing focused on euthymia may er prodromal, acute, residual or chronic54. chotherapeutic strategy that emphasizes disclose low levels of autonomy (e.g., lack Further, certain psychotherapeutic strate- self-observation, with the use of a struc- of assertiveness in many situations) and gies can be deferred to a residual stage of tured diary, homework and interaction personal growth (e.g., strong feelings of psychiatric illness, when state-dependent between patient and therapist14,20,64. It can dissatisfaction with her life and a sense of learning has been improved by the use of be differentiated from positive psychology

CBT

Residual symptoms

Frictions with mother Loss of father

Romantic failures

Low personal growth

Low autonomy

Low self-acceptance

WBT WBT WBT

Figure 2 Macro-analysis of a partially remitted patient with recurrent major depressive disorder with therapeutic targets. CBT – cognitive be- havior therapy, WBT – well-being therapy

World Psychiatry 19:1 - February 2020 45 interventions62 on the basis of the follow- APPLICATIONS This design was subsequently used in a ing features: a) patients are encouraged to number of randomized controlled trials identify episodes of well-being and to set The pursuit of euthymia in a clinical and was found to entail significant ben- them into a situational context; b) once setting cannot be conceived as a therapy efits in a meta-analysis72. the instances of well-being are properly for specific mental disorders, but as a trans­ The sequential model is an intensive, recognized, the patient is encouraged diagnostic strategy to be incorporated in two-stage approach, where one type of to identify thoughts and beliefs leading a therapeutic plan. Psychotherapeutic in- treatment (psychotherapy) is applied to to premature interruption of well-being terventions aimed at psychological well- improve symptoms which another type of (automatic thoughts), as is performed being are not suitable for application as treatment (pharmacotherapy) was unable in cognitive behavior therapy (CBT) but a first line treatment of an acute psychi- to affect. The rationale for this approach is focusing on well-being rather than dis- atric disorder20,64. However, most patients to use psychotherapeutic strategies when tress; c) the therapist may also reinforce seen in clinical practice have complex they are most likely to make a unique and and encourage activities that are likely to and chronic disorders54. It is simply wish- separate contribution to patient’s well- elicit well-being; d) the monitoring of the ful thinking to believe that one course of being and to achieve a more pervasive course of episodes of well-being allows treatment will be sufficient for yielding recovery by addressing residual symp- the therapist to identify specific impair- lasting and satisfactory remission. The use tomatology. The sequential design is dif- ments or excessive levels in well-being of psychotherapeutic strategies aimed at ferent from maintenance strategies for dimensions according to Jahoda’s con- euthymia should thus follow clinical rea- prolonging clinical responses obtained ceptual framework1; e) patients are not soning and case formulation facilitated by by therapies in the acute episodes, as well simply encouraged to pursue the highest the use of macro-analysis and staging. as from augmentation or switching strat- possible levels of psychological well-being The treatment plan should be filtered egies addressing lack of response to the in all dimensions, as is the case in most by clinical judgment taking into consider- first line of treatment71,72. positive psychology interventions, but ation a number of clinical variables, such Three independent randomized con- also to achieve a balanced functioning15. as the characteristics and severity of the trolled trials using the sequential combi- Another psychotherapeutic strategy in­ psychiatric episode, co-occurring symp- nation of cognitive therapy and WBT were tended to increase psychological well- tomatology and problems (not necessar- performed in Italy73,74, Germany75 and being is mindfulness-based cognitive ily syndromes), medical comorbidities, the US76. In other trials that took place in therapy (MBCT)65, which is built on the patient’s history, and levels of psychologi- Canada77 and the Netherlands78, some Buddhist philosophy of a good life. Its cal well-being54. Such information should principles of WBT were used in addition to main aim is to reduce the impact of po- be placed among other therapeutic ingre- standard cognitive therapy. Further, there tentially distressing thoughts and feelings, dients, and will need to be integrated with have been several investigations79-87 in but it also introduces techniques such as patient’s preferences70. which MCBT was applied to the residual mindful, non-judgmental attention and In the following sections, we illustrate a stage of depression after pharmacother- mastery, and pleasure tasks that may be number of applications of strategies for en- apy. geared to a good life66. However, the good hancing and/or modulating psychological From the available studies, we are una- life that is strived for is a state involving well-being. All these indications should be ble to detect whether the pursuit of psycho- detachment, as portrayed by Epicurus, and seen as tentative since, even when efficacy logical well-being was a specific effective not necessarily euthymia, as depicted by is supported by randomized controlled tri- ingredient and what was the mechanism Plutarch. als, the specific role of strategies modulat- decreasing the likelihood of relapse. None- Acceptance and commitment therapy ing well-being in determining the outcome theless, the clinical results that have been (ACT)67 is aimed to increase psychological cannot be elucidated with certainty, be- obtained are impressive, and the sequen- flexibility53. It consists of an integration of cause they are incorporated within more tial model seems to be a strategy that has behavioral theories of change with mind- traditional approaches and a dismantling enduring effects in the prevention of the fulness and acceptance strategies. Unlike analysis is rarely implemented. vexing problem of relapse in depression. WBT, ACT argues that attempts at chang- It is conceivable, and yet to be tested, that ing thoughts can be counterproductive, similar strategies may involve significant and encourages instead awareness and Relapse prevention advantages in terms of relapse rates also in acceptance through mindfulness prac- other psychiatric disorders. tice. In 1994, a randomized controlled trial There are also further psychothera- introduced the sequential design in de- peutic approaches, such as Padesky and pression71. Depressed patients who had Increasing the level of recovery Mooney’s strengths-based CBT68 and responded to pharmacotherapy were ran­ forgiveness therapy69, that have been sug- domly assigned to CBT or to clinical man- The studies that used a sequential design gested to increase well-being, but await agement, while antidepressant med­i­ clearly indicated that the level of remission adequate clinical validation66. cations were tapered and discontinued. obtained by successful pharmacotherapy

46 World Psychiatry 19:1 - February 2020 could be increased by a subsequent psy- disorder or mania. Suicidal behavior chotherapeutic treatment72. Clinicians Patients with cyclothymic disorder were and researchers in clinical psychiatry often randomly assigned to the sequential com- The relationship between future-direct- confound response to treatment with full bination of CBT and WBT or clinical man- ed thinking (prospection) and suicidality recovery9. A full recovery can be reached agement. At post-treatment, significant has been recently analyzed94, and a poten- only through interventions which facilitate differences were found in outcome meas- tial innovative role for well-being enhanc- progress toward restoration or enhance- ures, with greater improvements in the ing psychotherapies has been postulated. ment of psychological well-being1. CBT/WBT group. Therapeutic gains were Working on dimensions such as purpose In a randomized controlled trial, pa- maintained at 1- and 2- year follow-up. in life may counteract suicidal behavior. tients with mood or anxiety disorders The results thus indicated that WBT may Indeed, positive mental health was found who had been successfully treated by be­ address both polarities of mood swings to moderate the association between sui- havioral (anxiety disorders) or phar­ma­ and is geared to a state of euthymia15. Can cidal ideation and suicide attempts95. cological (mood disorders) methods were the target of euthymia decrease vulner- An issue that is not sufficiently appre­ assigned to either WBT or CBT for residual ability to relapse in bipolar spectrum dis- ciated is also the experience of mental symptoms18. Both WBT and CBT were as- orders91? This is an important area that pain that many suicidal patients may pre­ sociated with a significant reduction of deserves specific studies. sent. ACT was found to significantly re- those symptoms, but a significant advan- duce suicidal ideation as well as mental tage of WBT over CBT was detected by pain compared to relaxation in adult sui- observer-rated methods. WBT was associ- Treatment resistance cidal patients96. ated also with a significant increase in PWB scores, particularly in the personal growth A considerable number of patients fail to scale18. respond to appropriate pharmacotherapy Discontinuing psychotropic drugs A dismantling study in generalized anxi- and/or psychotherapy54. In a randomized ety disorder19 suggested that an increased controlled trial, MBCT was compared to Psychotropic drug treatment, particu­ level of recovery could indeed be obtained treatment-as-usual (TAU) in treatment-re- larly when it is protracted in time, may with the addition of WBT to CBT. Patients sistant depression92. MBCT was significant- cause various forms of dependence97. With­ were randomly assigned to eight sessions ly more efficacious than TAU in reducing drawal symptoms do not necessarily wane of CBT, or to CBT followed by four ses- depression severity, but not the number of after drug discontinuation and may build sions of WBT. Both treatments were as- cases who remitted. into persistent post-withdrawal disorders98. sociated with a significant reduction of A subsequent study93 investigated the These symptoms may constitute a iatro- anxiety. However, significant advantages effectiveness of MBCT + TAU versus TAU genic comorbidity that affects the course of the CBT/WBT sequential combination only for chronic, treatment-resistant de- of illness and the response to subsequent over CBT were observed, both in terms pressed patients who had not improved treatments97. of symptom reduction and psychological during not only previous pharmacother- Discontinuation of antidepressant med­ well-being improvement19. apy but also psychological treatment (i.e., ications such as selective serotonin reup- While the clinical benefits of WBT in CBT or interpersonal psychotherapy). At take inhibitors, duloxetine and venlafaxine increasing the level of recovery have been post-treatment, MBCT + TAU had sig- represents a major clinical challenge99,100. documented in depression64 and gener- nificant beneficial effects in terms of- re A protocol based on the sequential combi- alized anxiety disorder19, this appears to mission rates, quality of life, mindfulness nation of CBT and WBT in post-withdraw- be a possible target for a number of other skills, and self-compassion, even though al disorders has been devised101 and tested mental health problems. Indeed, the issue the intent to treat (ITT) analysis did not in case reports102. of personal growth is attracting increasing reveal a significant reduction in depres- interest in psychoses88, and a role for WBT sive symptoms. in improving functional outcomes as an A number of case reports have suggest- Post-traumatic stress disorder additional ingredient to CBT in psychotic ed that WBT may provide a viable alterna- disorders has been postulated89. tive when standard cognitive techniques There has been growing awareness of based on monitoring distress do not yield the fact that traumatic experiences can any improvement or even cause sympto- also give rise to positive developments, Modulating mood matic worsening in depression, panic dis- subsumed under the rubric of post-trau- order, or anorexia nervosa64. These data matic growth103. Positive changes can be WBT has been applied in cyclothymic are insufficient to postulate a role for psy- observed in self-concept (e.g., new evalu- disorder90, a condition that involves mild or chotherapies enhancing or modulating ation of one’s strength and resilience), moderate fluctuations of mood, thoughts psychological well-being in these patient appreciation of life opportunities, social and behavior without meeting formal diag- populations, yet this approach may yield relations, hierarchy of values and priori- nostic criteria for either major depressive new insights into this area. ties, spiritual growth.

World Psychiatry 19:1 - February 2020 47 Well-being enhancing strategies may be risk factor for many of the most prevalent may be unsatisfactory not because techni- uniquely suited for facilitating the process medical and psychiatric diseases36,111. cal interventions are missing, but because of post-traumatic growth. Two cases have Lifestyle modification focused on weight our conceptual models, shifted on the side been reported on the use of WBT, alone or reduction, increased physical activity, of psychological dysfunction, are inad- in sequential combination with exposure, and dietary change is recommended as equate. for overcoming post-traumatic stress disor- first line therapy in a number of disorders, der, with the central trauma being discussed yet psychological distress and low levels 104 only in the initial history-taking session . of well-being are commonly observed REFERENCES among patients with chronic conditions 1. Jahoda M. 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50 World Psychiatry 19:1 - February 2020 COMMENTARIES

Constructing a liberated and modern mind: six pathways from pathology to euthymia

Traditional psychiatric nosology has In the area of affect, the negative change ing for competence is mismanaged by been largely based on the idea that human process of experiential avoidance pairs perfectionism,­ impulsivity or procrasti- psychological suffering reflects a latent with the positive process of experiential nation but is satisfied by the committed disease­ 1. As Fava and Guidi note in their acceptance; in the cognitive area, cogni- construction of larger and larger patterns paper­ 2, this conception has interfered with tive fusion and entanglement pairs with of values-based action. a more balanced and positive approach. It cognitive defusion; in attentional areas, In all of these pairs, the deep yearning is not just that the focus on psychological rigid attention to the past and future, via underneath pathological processes of distress has overwhelmed needed attention rumination and worry, pairs with flexi­ change is not the problem – pathology is to positive experience. It is also that the la- ble, fluid and voluntary attention to the just the wrong solution to the cor­rect hu- tent disease model underlying syndromal now; in the area of self, defense of a con­ man challenge. What draws peo­ple into diagnoses provides minimal clinical guid- ceptualized self is paired with a perspec­ pathology is the one-two punch of short- ance regarding the nature of psychological tive taking sense of self and ongoing self- term and more certain contingencies dom­ health. It is obvious that human thriving is awareness; in the motivational area, un- inating over longer-term and more proba- not merely the absence of distress. However, healthy forms of compliance, self-gratifi- bilistic ones, and an excessive reliance on without a more adequate approach, clini- cation, or aversive and avoidant rule-based the evolutionarily recent adaptation of sym­ cians are not given guidance about how to demands are paired with chosen values; in bolic thinking and problem solving. pivot their attention from pathology toward the overt behavioral area, perfectionism, Those general features are managed in psychological prosperity in a more mean- impulsivity or procrastination are paired ACT by the three remaining pairs of change ingful and ­coherent way. with committed and step-by-step acquisi­ processes in the PFM. By learning cogni- If a process-based diagnostic approach tion of broader patterns of values-based ac­ tive defusion skills, the yearning for un- is adopted, however, clear pathways arise tion. derstanding and coherence, that becomes from pathology to euthymia. More so than What is not usually noticed in these increasingly central as symbolic language eudaimonic detachment, euthymia de- pairings inside the PFM is that they are is acquired, can be met in a more generally notes the balanced satisfaction of human connected by deep human yearnings6. Con­ useful way. Instead of trying to achieve lit- needs and yearnings. Just as distressing sider those focused on by self-deter­mi­ eral coherence, in which all thoughts line ­human emotions reflect the frustration of nation theory, one of the best empir­ically up neatly in a coherent and consistent row, core yearnings, positive human emotions supported approaches to human needs: the person learns to step back from sym- and well-being reflect their accomplish- belonging, autonomy and competence7. bolic thinking processes and allow them ment. For that reason, we may be able to Entanglement with a conceptualized self to impact life choices based on functional use the core human yearnings reflected can be thought of as the mental misman- coherence – the wise understanding that inside pathological processes to provide a agement of a yearning to belong, in which comes from allowing useful thoughts to kind of roadmap for the creating of euthy- people attempt to gain group membership guide behavior based on their history of mia itself. and social connection or support by pres- workability over the longer term, while re- In an extended evolutionary approach entation of a persona that is especially able spectfully declining the mind’s invitation to process-based diagnosis, processes of or especially needy. Over time, the mental to comply with the rest. change link to variation, selection, reten- attachment to specialness undermines be- Similarly, instead of trying to satisfy an tion, and context sensitivity in at least six longing by fostering narcissistic pretense inborn yearning to feel by always “feeling psychological dimensions: affect, cogni- and avoidant/self-aggrandizing forms of good” – that is, by feeling only those events tion, attention, self, motivation, and overt “self-esteem” , or coercive presentations of that are cognitively evaluated as “good” or behavior3. As a set, these psychological di­ pathos. Either of these forms of adjustment “desirable” (which ultimately leads to a mensions are then nested in between so- lowers healthy connection and eventually reduced capacity to feel at all) – a more cial/cultural and genetic/physiological drives others away. Perspective taking and defused approach is taken to those evalu- levels of analysis. shared awareness, conversely, are known ations, allowing emotions to be explored The psychological flexibility model (PFM) to foster genuine connection, attachment and felt more openly and without need- that underlies acceptance and commitment­ and belonging. less defense. These acceptance skills satisfy therapy (ACT) contains six known patho- In a similar way, the yearning for au­ the yearning to feel, and allow the helpful logical processes of change that are paired tonomy or self-directed meaning is mis­ knowledge that emotions contain to be with six known positive processes of psy- managed by compliance, self-gratifica­ used, leading to more capacity for joy, ap- chological growth4,5. These six pairs line up tion and rule-based demands, but is sat­ preciation, love, and well-being. Finally, the with the six dimensions just listed. isfied by chosen values; while the yearn- yearning to be oriented can focus less on

World Psychiatry 19:1 - February 2020 51 the ruminated past or mentally constructed agement of social/cultural and physical/bi­ management of healthy yearnings lights a future, and more on a deeper connection ological health challenges. From the view­­ path toward euthymia, if we learn how to with what is actually present, inside and point of processes of change, psychopa- notice the presence of these yearnings in- out. thology itself contains much the same side pathology and pivot in the direction Pathological change processes can thus lesson in its evidence for sources of mis- of their healthy satisfaction. be thought of as mismanaged yearnings. management of these very same yearnings This mismanagement is caused by an evo- and challenges. Steven C. Hayes Department of Psychology, University of Nevada, Reno, lutionary mismatch between half a billion- Flexibility is based in part on the in- NV, USA year-old learning processes or even more creased and conscious context sensitiv- ancient genetic, epigenetic, perceptual, ity afforded by perspective taking and 1. Hofmann SG, Hayes SC. Clin Psychol Sci 2019; 7:37-50. sensory and neurobiological systems, and voluntary attentional control; consistency 2. Fava GA, Guidi J. World Psychiatry 2020;19:40- the dominance of symbolic reasoning and is fostered by the greater motivational 50. problem solving that is 200 to a thousand dominance of values, and the acquisition 3. Hayes SC, Hofmann SG, Stanton CE et al. Be- hav Res Ther 2019;117:40-53. times more recent, but that has been put of committed action skills; resilience is fos- 4. Hayes SC, Strosahl K, Wilson KG. Acceptance on steroids in the modern technological tered by greater emotional and cognitive and commitment therapy: the process and prac- era8. By focusing on what lies beneath pa- openness and their ability to incorporate tice of mindful change, 2nd ed. New York: Guil- ford, 2012. thology, however, a roadmap to euthymia both “negative” and “positive” experiences 5. Hayes SC. World Psychiatry 2019;18:226-7. is revealed. into a life worth living. Considered as a set, 6. Hayes SC. A liberated mind: how to pivot to- The flexibility, consistency and resil- these PFM skills foster euthymia, because ward what matters. New York: Avery, 2019. 7. Deci EL, Ryan RM. Psychol Inquiry 2000;11: ience that define euthymia are fostered by they allow us to do a better job of evolving 227-68. healthy management of yearnings for be- on purpose, supported by healthy psycho- 8. Hayes SC, Sanford B. J Exp Anal Behav 2014;101: longing, coherence, feeling, orientation, social forms of variation, selection, reten- 112-29. self-directed meaning, and competence, tion, and context sensitivity. DOI:10.1002/wps.20715 in turn fostering wise psychological man­ People in distress are not broken. The mis­­

Specificity in the pursuit of euthymia

In their incisive paper, Fava and Guidi1 reported advantages for WBT in all six do- Health Continuum – Short Form, as­sessing argue that therapies, in addition to relief mains of the PWB scales. the six domains of well-being1, found an of symptoms or distress, should have the In addition to WBT, Fava and Guidi note overall moderate effect size for psycho­ more ambitious goal of helping patients that two other evidence-based psychother- therapies, of which the most common were achieve a euthymic state that includes psy- apies have features that may be useful in WBT, mindfulness and ACT. However, the chological well-being, positive affects, and reaching states of euthymia. Mindfulness- studies in this meta-analysis did not in- flexibility. In a way, they are proposing that based cognitive therapy (MBCT) includes clude several of the most widely used psy­ therapies go beyond the “gold standard” methods intended to promote mindful, chiatric treatments (e.g., pharmacotherapy, of remission to a “platinum standard” that non-judgmental mentation that can help CBT and interpersonal psychotherapy), could convey greater benefits in terms of persons achieve a good life. Acceptance because investigations on these approach­ quality of life and relapse prevention. and commitment therapy (ACT) utilizes es have not utilized the above-mentioned There is evidence from two investiga­ mindfulness and awareness to promote scales. tions on well-being therapy (WBT) for de­ flexibility and acceptance. Psychiatry and psychology have been pression that a focus on achieving well- WBT, MBCT and ACT each have appeal driven largely by a “disease bias” . Thus, being can lead to better relapse prevention for pursuit of euthymia, because their pro- outcome assessments in most treatment than observed with clinical management posed mechanisms of action and goals go studies have focused heavily, or solely, on or standard cognitive behavior therapy beyond symptom relief. These therapies, measuring symptom change – not on ele- (CBT)2. But the only direct comparison of especially WBT, have enriched our options ments of psychological well-being. Yet, WBT and CBT for depression that measur­ for treatment by providing well-articulated there is some evidence that approaches ed well-being found significant improve- methods for enhancing well-being. But other than WBT, mindfulness and ACT ments in one (personal growth) of the six it is not known whether treatments with may impact functions described by Fava domains in the Psychological Well-Being specific methods for promoting well-being and Guidi in their definition of euthymia. (PWB) scales for WBT and two domains are required if the goals extend to achiev- For example, a meta-analysis of trials of (purpose in life and self-acceptance) for ing the “platinum standard” of euthymia. antidepressants in patients with fibromyal- CBT2. Another small study comparing WBT A meta-analysis3 of studies that em- gia4 found a moderate effect size for phar- with CBT for generalized anxiety disorder ployed either the PWB scales or the Mental macotherapy on measures of well-being.

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