When the summer was over, I went back to Padova and intended to become like George Engel and be knowledgeable of both internal medicine and psychiatry. In due course, however, I realized that one specialty was already more than I could handle and thus chose psychiatry, the field where most of the psychosomatic researchers came from.
Treating Depression
I started my residency training program in psychiatry in Padova, but my idea was to go back to Rochester to complete my training. Due to certain circumstances that in those days I judged to be unfavorable, I ended up instead in Albuquerque, New Mexico. My teacher and mentor was someone I had met at a psychosomatic conference, Robert Kellner. He had become a psychiatrist after several years as a primary care physician and thus shared something in common with George Engel. He really showed me how the psychosomatic approach could balance pharmacological and psychological therapies in psychiatric practice. Depression was the psychiatric disorder that attracted my attention the most. After 1 year in the southwestern US, I moved to Buffalo, New York, where I was asked to establish a depression unit. I was convinced that depression was essentially an episodic disorder, that there were powerful remedies against it (antidepressant drugs), and chronicity was essentially a consequence of inadequate diagnosis and treatment. Today when I look back on of my views then, I am surprised of my naiveté and clinical blindness. We have become aware that depression is essentially a chronic disorder with multiple acute episodes along its course [7]; however, back then my view was shared by almost every expert in the field.
Working in the US, I had essentially a cross-sectional view of the disorder (I was seeing and treating patients only in the hospital, with little follow-up). However, when I decided to go back to Italy and establish an outpatient clinic at the University of Bologna with opportunities for follow-up, I began to observe that patients I had personally treated with antidepressant drugs and whom I judged to have completely remitted relapsed into depression after some time. What was I missing?
The Concept of Recovery
I became more and more skeptical of the long-term effectiveness of antidepressant drugs to the point that in 1994 I introduced in the literature the hypothesis that these medications could be a cause for chronicity [8]. I was inspired by the ‘antibiotic paradox’: the best agents for treating bacterial infections are also the best agents for selecting and propagating resistant strains, which persist in the environment even when exposure to the drug is stopped [9]. On the basis of some data that were available, I postulated that long-term use of antidepressant drugs may worsen the long-term outcome and symptomatic expression of illness, decreasing both the likelihood of subsequent response to pharmacological treatment and duration of symptom-free periods [8]. Two decades later the evidence supporting this hypothesis is quite impressive [10], but in those days swimming against the tide of pharmaceutical propaganda was not easy. In Albuquerque, under the guidance of Robert Kellner, I had learned to practice cognitive behavior therapy (CBT). I used it with my depressed patients, whether associated with antidepressant drugs or not, but it did not seem to affect their long-term outcome, as also reported in the literature [7]. This was in striking contrast to the use of CBT in anxiety disorders, where positive and lasting effects could be observed [8].
Meanwhile, more and more studies were pointing to the fact that pharmacological treatment of depression was not solving all the problems and, despite substantial improvement, important residual symptoms were present [11]. Such symptoms included anxiety and irritability in particular, and were associated with impaired functional capacity. Most residual symptoms also occurred in the prodromal phase of illness and might progress to become prodromal symptoms of relapse [11]. As a result, the concept of recovery could not be limited to the abatement of certain symptoms [12]. As Engel indicated [2, 3], health is not simply the absence of disease, but also requires the presence of wellness. We knew how to bring people out of the negative functioning, but regaining psychological well-being was quite different and we did not have a clue about how to achieve it.
Psychological Well-Being
In the mid-1990s, I attended an international conference on psychiatry in Copenhagen, organized by my friend Per Bech, one of the most important and original researchers in psychological assessment of mood disorders [13]. When I met him, he recommended attending a session on quality of life. He explained that one of the speakers was an American developmental psychologist who had some interesting ideas. I went and, as on other occasions, he was right. The speaker was Carol Ryff, who gave an account of her model of psychological well-being, which was a synthesis of various contributions from the literature [14]. She remarked that well-being cannot be equated with happiness or life satisfaction. She had developed a questionnaire for measuring the various dimensions of psychological well-being, the Psychological Well-Being Scales (PWB), which she had applied to nonclinical populations in longitudinal studies [14]. She gave a brief description of each of its six dimensions.
I belong to the endangered species of clinician-researchers who do clinical research as well as assess and treat individual patients. When I examine research constructs, my starting point is always whether these constructs make sense with the patients I see. And Ryff's formulations were able to do this: autonomy (a sense of self-determination), environmental mastery (the capacity to manage effectively one's life), positive interpersonal relationships, personal growth (a sense of continued growth and development), purpose in life (the belief that life is purposeful and meaningful), and self-acceptance (a positive attitude toward self). After her presentation, I started thinking of many patients I had encountered who seemed to have these dimensions impaired or exaggerated with resulting clashes against everyday life. I was surprised that a developmental psychologist could have articulated such deeply clinical formulations.
Many years later I discovered that those dimensions had indeed a clinical root and were developed by Marie Jahoda, Professor of Social Psychology at New York University, in a fantastic book on positive mental health that was published in 1958 [15]. The book was waiting for me in an American library and became a further source of reflection and inspiration. Marie Jahoda had outlined six criteria for positive mental health. In 5 cases these criteria were only slightly different compared to those later outlined by Carol Ryff: autonomy (regulation of behavior from within), environmental mastery, satisfactory interactions with other people and the milieu, the individual's style and degree of growth, development and self-actualization (this was split by Ryff into the dimensions of personal growth and purpose in life), and the attitudes of an individual toward his/her own self (self-perception/acceptance). There was, however, a sixth important dimension whose formulation became particularly important to me at some later point in time: the individual's balance and integration of psychic forces, which encompass both outlook on life and resistance to stress.