Depression in young patients is associated with difficulty in taking action to avoid something unpleasant, while the ability to withdraw and not act remains intact, a study suggests.

“Clinically, this pattern is familiar,” study author Ryan Tomm, PhD candidate in psychology at the University of British Columbia in Vancouver, told Medscape Medical News. “A task that might seem simple, like returning a phone call, can feel disproportionately difficult for someone experiencing depression. Patients may recognize that acting would prevent negative consequences, but the effort and emotional load can feel overwhelming, leading to a tendency to withhold actions during avoidance.”

Similarly, he suggested, in work or social settings, people may know that in a particular situation, stepping in is the right move. But instead, they withdraw because inaction feels easier in the moment.

“These difficulties are not unique to depression,” Tomm noted. “They also occur in anxiety, obsessive-compulsive disorder, and schizophrenia, where motivational and avoidance processes are disrupted in different ways.”

The study was published online on September 1 in eNeuro.

Rewards Help

The researchers conducted two online studies to explore the relationship between depressive symptoms and avoidance behaviors. Study 1 involved 465 participants (undergraduates and online workers) who had to actively avoid an aversive sound either by taking a specific action (ie, making 3, 4, or 5 button presses on a computer) or not responding at all (inhibitory avoidance). About 60% of participants were women. The population had a wide range of symptom scores on the Beck Depression Inventory-II, ranging from low to severe.

In successful active-response trials, participants made the required response within the specified time (cue period), resulting in the avoidance of the aversive sound and the presentation of a safety signal. On failed active trials, an insufficient response or no response within the cue period triggered the aversive sound.

In inhibitory trials, participants were required to withhold their responses. In successful inhibitory trials, participants made no button presses during the cue period, resulting in the avoidance of the aversive sound and the presentation of a safety signal. In failed inhibitory trials, an erroneous button press triggered the aversive sound.

The researchers found that higher depressive scores were associated with poorer active-avoidance responses.

In a second study of 330 undergraduates (74% women), participants completed a version of the tasks that included receiving a reward (eg, points) when successful. In this situation, all participants with all levels of depressive symptoms showed higher accuracy for both active reward-seeking responses and inhibitory avoidance.

“These findings suggest that in young adults, depressive symptoms are associated with difficulty in overriding prepotent responses [ie, strong, unconscious, and often automatic reactions] to actively avoid aversive outcomes in the absence of reward,” the authors concluded.

“Several mechanisms may contribute to these difficulties,” Tomm said. “For some individuals, effortful actions may feel disproportionately costly, making it harder to engage. Others may become more focused on potential negative outcomes, so threats take on greater weight, and it becomes harder to shift from holding back to taking action.”

Still others may not recognize that certain behaviors can be helpful, as when patients struggle to accept the benefits of cognitive behavioral or other therapies.

“Each of these pathways points to distinct clinical targets: Helping patients gradually build active coping skills, while recognizing that initiating action may be especially difficult at the beginning; strengthening their ability to learn that certain behaviors bring safety or relief; and reducing the tendency to give disproportionate weight to negative outcomes,” Tomm said.

The limitations of the study include uncertainty about whether the results can be generalized to patients who are clinically diagnosed with depression, as well as high exclusion rates.

‘Default to Inaction’

Commenting on the study for Medscape Medical News, Peter Bieling, PhD, professor of psychiatry and behavioral neurosciences at McMaster University in Hamilton, Ontario, said, “The findings are consistent with what many of us see in practice: Depressed patients often struggle to mobilize effort, even when action would clearly reduce suffering. It isn’t that they don’t know what to do, but that the automatic tendency is inaction — a kind of freeze — and this study puts experimental weight behind that observation.”

“When you dig deeper, it can feel like a form of wishful thinking, that ‘if I wait long enough, the bad thing will maybe go away,’” said Bieling, who was not involved in the study. “That could be a thing people have learned in the past, or it could be an expression of a biological underpinning.”

Like the authors, Bieling noted that the study must be replicated in patients with major depression. “Also, there are lots of cognitive tasks where depressed people perform less well than nondepressed people. We’d need more research to explore whether this particular difference is a correlate or cause; does it exist before someone is depressed, or does it result from being depressed?”

The clinical takeaway, he said, “is that depressed patients often default to inaction, even when inaction has negative consequences. Lowering the effort barrier and reinforcing small acts of coping can help. For example, instead of tackling a whole pile of overdue bills, the first step might be simply opening one envelope and looking at the amount due.” 

In this example, he said, “It’s relatively easy to point out to the patient that these things will not simply go away or take care of themselves.” Good clinicians can also empathize by saying that they, too, wish certain things would simply go away on their own.

“You may also contrast how they are handling these annoying, but also small, unpleasant tasks now compared with when they were not depressed,” he suggested.

“And it’s useful to build in small rewards,” he added. If the patient opens the bills and makes a preliminary plan to get on top of them, they can reward themselves with a cup of tea, for example. Sometimes I call these biohacks,” he said. “They seem simple, and they’re also remarkably effective.”

The research was supported by the Natural Sciences and Engineering Research Council of Canada. Tomm and Bieling reported having no relevant financial relationships.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.