“It is said that ‘time heals all wounds’. But can time also heal depression? And if time can heal, is it as effective as psychotherapy? Can it be better, in some cases, not to seek treatment for mental health problems?”
A question that is harder to answer than it seems
A colleague submitted this question and asked if we could write about it. It is a difficult one that cannot be answered directly. One major complication is that we do not really know what happens when someone has a mental health problem and is willing to get treatment but does not receive it. As a result, it is largely unknown how many people with mental health problems get better without treatment, and how long that takes.
Why the answer is so hard to study
For most mental health problems, several evidence-based treatments are available, and treatment guidelines in primary care, specialized mental health care, and general medical care recommend them. This means that when a patient goes to a clinician, they will be offered treatment. That is good for patients — but it also means we can no longer examine what happens when these patients are not treated, and how many get better on their own.
There are also many people with mental health problems who do not seek treatment. In fact, most people with mental health problems never seek or receive an evidence-based treatment. In principle, we can examine what happens to them. But research shows that mental health problems tend to be substantially worse in people who do seek help than in those who do not, and there may be other differences too — for example, the social network may be stronger in those who do not seek help. This means that the outcomes of people who do not seek help cannot tell us much about how many people recover without treatment.
What the evidence does suggest
It is known that many people with mental health problems do get better without treatment. In one study (van Beljouw et al., 2010), people with depression and anxiety who perceived a need for care but did not get treatment had outcomes after one year that were comparable to those who did get treatment. But because the two groups still differed in important ways, this cannot be taken to mean that treatment has little added value.
So there are no good data on how well time alone can heal these wounds. However, outcome studies in psychotherapy can tell us a little. Because good outcome studies compare therapies with control conditions in which patients are not treated, we can estimate how many people improve without treatment.
The proportion of people who recover without treatment ranges from about 9 to 19% for common disorders such as depression, anxiety, and PTSD, and is somewhat lower for OCD (about 5%). Recovery with a first evidence-based treatment is considerably higher: about 42% for depression, between 32 and 38% for anxiety disorders, PTSD, and OCD, and about 25% for borderline personality disorder. “Getting better” here means that symptoms are reduced by at least 50% from the start to the end of the study.
These proportions should be read with caution, because they come from different types of control groups (waitlist, usual care, psychoeducation, and so on). And the “with treatment” figures reflect only the first treatment. If the first treatment does not work, clinicians usually offer to extend it, add medication, try another approach, or change therapist. Most people stay in treatment until they are better — which can happen quickly, with a single treatment, or take several.
Weighing the decision
It is also worth keeping in mind that treatment comes with costs. It requires time, effort, and a willingness to change, and — depending on the health care system — sometimes money. It can go quickly when the first treatment works, but it can also take a long time, it can have negative effects, and in some cases it may not work at all. And some people do get better without it.
Whether or not to seek treatment is a difficult decision that requires balancing the expected benefits against these costs.
The most important rule is this: when a mental health problem interferes substantially with your daily life, it is worth seeking treatment.
For example, when you can no longer work or go to school — or can only do so with great effort — or when it becomes very difficult to maintain your social or family life. You should also seek treatment if you have any thoughts of hurting yourself. When the problems interfere with your life, it is almost always worth the effort to get help.
- For how well psychotherapy actually works, see Does psychotherapy work?
- For the possible downsides of treatment, see Can psychotherapy have negative effects?
- For supporting someone who is reluctant to get help, see What to do when my partner does not want to get treatment?
Pim Cuijpers is professor emeritus of clinical psychology and scientific director of Metapsy. He has been involved in more than 1,100 scientific studies, mostly on psychological treatments of mental health problems. This is one of a series of evidence summaries in which Prof. Cuijpers tries to answer questions from patients and clinicians, based on what is known in science about treatments. The knowledge is mostly drawn from collective work of the Metapsy collaboration of at least 15 years. Do you have other questions you would like Prof. Cuijpers to discuss? Feel free to contact us.
Literature
- Whiteford HA, Harris MG, McKeon G, Baxter A, Pennell C, Barendregt JJ, Wang J. (2013). Estimating remission from untreated major depression: a systematic review and meta-analysis. Psychological Medicine, 43(8), 1569–1585.
- van Beljouw IM, Verhaak PF, Cuijpers P, van Marwijk HW, Penninx BW. (2010). The course of untreated anxiety and depression, and determinants of poor one-year outcome: a one-year cohort study. BMC Psychiatry, 10(1), 86.
- Cuijpers P, Miguel C, Ciharova M, Harrer M, Basic D, Cristea IA, de Ponti N, Driessen E, Hamblen J, Larsen SE, Matbouriahi M, Papola D, Pauley D, Plessen CY, Pfund RA, Setkowski K, Schnurr PP, van Ballegooijen W, Wang Y, Riper H, van Straten A, Sijbrandij M, Furukawa TA, Karyotaki E. (2024). Absolute and relative outcomes of psychotherapies for eight mental disorders: a systematic review and meta-analysis. World Psychiatry, 23, 267–275.
