Elsewhere in JAMA Network Open, Vogt and colleagues report a novel study examining well-being as a possible protective factor associated with lower risk of posttraumatic stress disorder (PTSD) after trauma exposure. The investigators drew on data from the Veterans Metrics Initiative Study, a longitudinal investigation of a national sample of 9566 veterans who participated in survey assessments within 3 months of separation from military service as well as 5 subsequent assessments collected at 6-month intervals. Specifically, this report focused on the prospective association between 3 specific facets of well-being -- vocational, financial, and social -- and future PTSD at 3 separate prospective time points. Both domain-specific and overall levels of well-being were robustly associated with a lower risk of PTSD after trauma exposure at multiple follow-up points. Notably, these results held after controlling for other factors, such as prior trauma exposure, stress exposure, depression, and multiple demographic characteristics. From the authors' perspectives, these results underscore the value of monitoring well-being (particularly in vocational and social domains) as part of the overall surveillance of PTSD. By extension, interventions designed to enhance well-being could have utility for preventing PTSD, both among veterans and in the general population.

We think this report is noteworthy for 3 reasons. First, it exposes a large gap between the lip service paid to the importance of well-being both in clinical care and in public health conversations and the dearth of actual empirical studies of well-being in psychopathology. To our knowledge, the study by Vogt et al is virtually unique as a prospective investigation of the protective effects of well-being against the development of PTSD. Indeed, neglect of this topic is similar in other common mental health conditions, such as depression and anxiety disorders.

Second, when well-being has been studied in psychopathology, it has most typically been considered as an outcome, eg, in examinations of whether the effects of treatment extend beyond standard end points, such as symptomatic relief. While well-being is important to study as an outcome, Vogt et al draw our attention to the potential value of examining well-being as a predictor variable. In this case, the authors observed that several facets of well-being were quite meaningfully associated with future PTSD over a multiyear period. This is important, as clinical researchers should always be on the lookout for constructs that might improve course prediction. While these results need to be replicated, it is theoretically plausible that such protective effects would extend to other conditions beyond PTSD.

Third, this report highlights that well-being is a multifaceted construct that includes both factors that are located inside of a person, such as the experience of positive emotions, purpose, meaning, and autonomy, as well as factors that are more external, such as the presence of financial well-being, vocational well-being, or social well-being. The authors here found that these external aspects of well-being mitigated the development of PTSD. Although the different facets of well-being are intercorrelated, they each potentially explain unique variance. Thus, it would be useful for contributions of both internal and external aspects of well-being to be simultaneously evaluated. Ultimately, which aspects of well-being are most critical for explaining the course of mental health problems is an empirical question.

We hope this article will stimulate future inquiry, as this report provokes several key questions. First, why is well-being protective against psychopathology? Both our ability to describe and to intervene would be enhanced by developing a better mechanistic account of these effects. For example, while it is useful to know that the perception of adequate financial resources buffers against the development of PTSD, it would be even more valuable to know why this is the case. Relatedly, it will be critical to work through the logic for applications to intervention efforts, both for PTSD and other forms of psychopathology. Perhaps the most basic question of all is to document that well-being itself is subject to modification via systematic intervention in these populations. While there is increasing interest in interventions dedicated to altering well-being, the viability of such interventions almost certainly depends on what strategies are used, which facet of well-being is intervened upon, and which populations are tested. Finally, there is a need to clarify the downstream effects of a successful intervention on well-being on a variety of clinical end points, whether they be symptoms, disorder relapse, or functioning in various life domains.

There will doubtlessly be challenges in addressing these questions, as definitive answers will require well-resourced investigations that follow large samples of carefully diagnosed persons over time with multifaceted assessments of well-being. Nevertheless, we believe that chasing down these promising leads will serve clinical care. Increasingly, data suggest that patients and their families value the restoration of well-being and real life functioning as much as they value the traditional end points of reducing symptoms or disorders. In this regard, taking well-being seriously in clinical description and in intervention research is part and parcel of a research agenda that places patient concerns at the center.

Corresponding Author: Jonathan Rottenberg, PhD, Department of Psychology, Cornell University, 116 Reservoir Ave, Martha Van Rensselaer Hall, Ithaca, NY 14853 ([email protected]).