Depression recovery: Emotional shifts often precede behavioral changes, study shows

Understanding how people recover from depression is key to improving treatments. A new study published in the Journal of Consulting and Clinical Psychology has found that emotional and cognitive changes often occur together during therapy, while behavioral improvements, like increased socializing and activities, tend to follow later.

Depression treatments, such as cognitive therapy or mindfulness-based approaches, aim to alleviate low mood and increase positive emotions by changing behaviors or challenging negative thought patterns. While these therapies are proven to be effective, the specifics of how and when these changes happen are not well understood. Does a shift in behavior or thinking trigger emotional improvement, or is it the other way around? This study sought to answer that question.

“I started studying the temporal order of change in negative thinking, depressive feelings, activities, and interactions because I was interested in the mechanisms of change underlying remission from depression,” said study author Evelien Snippe, a senior researcher at the University of Groningen.

“It may be an indication that changes in the way people think and act are the mechanisms underlying improvement in depressive feelings when you show that people change the way they think and act before they start to feel better. If we could show that, it may suggest that people suffering from depression could benefit from reducing their negative ways of thinking, increasing their activities, and engaging in more social interactions.”

The study included 32 adults diagnosed with major depressive disorder who were undergoing outpatient psychotherapy. Over a four-month period, the researchers collected real-time data on participants’ daily experiences using Ecological Momentary Assessment, a smartphone-based method that prompts individuals to record their mood, thoughts, and behaviors multiple times a day.

Participants rated their emotional state by indicating levels of sadness and happiness. They assessed their cognitive patterns by reporting how frequently they worried and the positivity or negativity of their self-thoughts. They also tracked their behaviors by reporting the number of social interactions and activities they engaged in. The data was analyzed using a statistical technique called change-point analysis, which identifies significant turning points in time-series data.

The findings highlighted that emotional and cognitive improvements often occurred around the same time during treatment. For example, participants frequently reported reductions in sadness or increases in happiness simultaneously with decreases in worrying or more positive self-reflection. This alignment suggests a close interdependence between mood and thought patterns, with changes in one domain likely influencing the other.

Conversely, behavioral changes, such as increased social interaction or activity engagement, tended to happen later, following emotional gains. This pattern indicates that individuals may first experience emotional relief before reengaging with their environment or taking on new activities.

“Our study suggests that depressive feelings and negative ways of thinking often start to improve around the same time during treatment of depression,” Snippe told PsyPost. “Thus, people start to feel better around the same time as they start to think less negatively. Another takeaway is that people often first start to feel better before they begin engaging in more activities and interactions with others.”

Interestingly, the results challenged the traditional assumption that behavioral or cognitive changes necessarily precede emotional improvement. Instead, the study suggested that emotional gains might initiate the broader process of recovery, potentially motivating individuals to engage more with life and take steps toward behavioral changes.

“We had expected that people would first start to engage in more activities and become more socially active before they began to feel better,” Snippe said. “The study showed that it was actually the other way around: people often first started to feel better and then engaged in more activities and interactions.”

The study sheds light on the interplay between emotions, thoughts, and behaviors during depression treatment. However, as with all research, there are some limitations. For instance, behavioral changes were less frequent and harder to measure, which might have affected the results. More detailed assessments of activities—such as their duration and effort level—could provide a clearer picture of how behavior evolves during treatment.

Future research could also explore whether different therapies produce unique patterns of emotional, cognitive, and behavioral change. For example, do mindfulness-based treatments lead to earlier improvements in mood compared to cognitive therapy? Additional studies could also investigate how antidepressant use interacts with therapy to influence the sequence of change.

“Our aim was to develop a method to study the temporal order of more long-term improvements in daily life experiences,” Snippe explained.

The study, “The temporal order of emotional, cognitive, and behavioral gains in daily life during treatment of depression,” was authored by Evelien Snippe, Timon Elmer, Eva Ceulemans, Arnout C. Smit, Wolfgang Lutz, and Marieke A. Helmich.