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PubMed1998

The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine.

BACKGROUND: Previous research has suggested that depressed patients, and particularly chronically depressed patients, have significant impairments in many areas of their lives. While previous studies suggested that these "psychosocial" impairments improve following pharmacologic treatment, no large scale definitive study using multiple measures of psychosocial functioning has been reported. METHOD: We assessed multiple domains of psychosocial functioning using interviewer-rated and self-report measures within the context of a 12-week acute treatment trial of sertraline and imipramine for patients with chronic depression (double depression and chronic major depression). We also compared the psychosocial functioning data of this sample before and after treatment with normative data available from published community samples. RESULTS: Chronically depressed patients manifested severe impairments in psychosocial functioning at baseline. After treatment with sertraline or imipramine, psychosocial functioning improved significantly. Significant improvements appeared relatively early in treatment (week 4). Despite these highly significant improvements in functioning during acute treatment, the study sample as a whole did not achieve levels of psychosocial functioning comparable to a comparator nondepressed community sample. However, patients who reached full symptomatic response (remission) during acute treatment did have levels of psychosocial functioning in most areas at endpoint that approached or equaled those of community samples. CONCLUSION: These results indicate that successful antidepressant treatment with sertraline or imipramine can alleviate the severe psychosocial impairments found in chronic depression.

Adaptation, Psychological↗
PubMed1999

Psychosocial processes underlying the maintenance and persistence of depression: implications for understanding chronic depression.

The three major theoretical perspectives on the maintenance and persistence of depression in the psychological literature are reviewed. Cognitive theorists, such as Teasdale and Nolen-Hoeksema, focus on how a reciprocal relationship between depressed mood and the individual's processing of, and response to, their symptoms maintains and prolongs the duration of depressive episodes. Interpersonal theorists, such as Lewinsohn and Coyne, hypothesize that the depressed person's interpersonal behavior elicits negative reactions from the social environment, leading to a downward spiral of persistent depression. Finally, recent studies have indicated that individuals who experienced childhood adversity are more susceptible to a chronic course of depression. Although these three perspectives vary somewhat in the degree of support they have accumulated, each exhibits some promise for helping to elucidate the maintenance and persistence of depression. However, much of the available empirical literature suffers from a number of critical limitations, including the lack of clinical samples, longitudinal studies, and adequate attention to confounding variables, such as the severity and duration of depression at baseline and comorbid psychopathology. We conclude by suggesting a number of ways in which cognitive and interpersonal factors and early adversity may interact to maintain and prolong depressive episodes.

Adaptation, Psychological↗
PubMed1988

The Newcastle Chronic Depression Study. Patient characteristics and factors associated with chronicity.

Chronic depression is defined as "symptomatic non-recovery for a period of 2 or more years". Chronic primary major depressives (n = 24) were compared retrospectively with a control group of primary major depressives (n = 20) who had recovered from their illness episode within 2 years. The former had a significantly higher familial loading for affective disorder and showed an increased incidence of independent undesirable life events during the 6 months prior to and 2 years after the onset of their illness. Female chronic depressives also had a significantly greater number of previous illness episodes and a more frequent history of thyroid dysfunction. Personality as measured on the EPO, psychiatric problems arising as secondary complications of the depressive illness, and developmental object loss did not differentiate chronic from non-chronic depressives.

Adult↗
PubMed2003

Diagnosis and treatment of chronic depression in children and adolescents.

Chronic unipolar depression is being increasingly recognized in general psychiatry as a particularly severe form of depressive illness that leads to significant symptomatology, prolonged suffering, and prolonged functional impairment in a variety of domains, including educational/vocational dysfunction as well as interpersonal impairment. Recent research on treatment interventions for adult patients with chronic depressions suggests that standard treatments for depressive illness may need modification to benefit patients with chronic illness. Little attention at this point has been given to the problem of chronic depression in children and adolescents. Many adults with chronic depressive disorders had onset of depression in their childhood or adolescence, making early identification of this form of illness a priority. The authors present a comprehensive review of emerging literature in the assessment, clinical course, and treatment of chronic forms of unipolar depression in youth. They then develop summary recommendations for the assessment and treatment of this type of mood disorder in youth, based on the currently available research and common sense clinical experience.

Journal Article↗
PubMed2002

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 2: Maintenance treatment of major depressive disorder and treatment of chronic depressive disorders and subthreshold depressions.

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of the complete spectrum of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). The first part of these WFSBP guidelines on unipolar depressive disorders covered the acute and continuation treatment of major depressive disorder (Bauer et al 2002). This second part of the guidelines covers the management of the maintenance-phase treatment of major depressive disorder, as well as the treatment of chronic and subthreshold depressive disorders (dysthymic disorder, double depression, minor depressive disorder and recurrent brief depression). These guidelines are primarily concerned with the biological treatment (including antidepressants, lithium, other psychopharmacological and hormonal medications, and electroconvulsive therapy) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Adolescent↗
PubMed2000

Late-life chronic depression: a 399-case study in private practice.

OBJECTIVE: Aims of the study were to find the prevalence of chronic depression in elderly patients compared with younger patients, and to compare chronic depression between elderly and younger patients, to find if there were clinical differences. A major feature of the study was the inclusion of a large number of bipolar II patients, usually not included in previous studies. METHODS: Three hundred and ninety-nine consecutive unipolar (N=200) and bipolar II (N=199) depression outpatients were interviewed with the Structured Clinical Interview for DSM-IV and depression rating scales in a private practice. RESULTS: Chronic depression was more common in elderly patients than in younger patients (53.6% vs 40.1%, p=0.0299). Late-life chronic depression patients had later age at onset, longer duration of illness, fewer bipolar II cases, more unipolar cases and more relapses than younger chronic depression patients. CONCLUSIONS: Results suggest that late-life depression is more likely to be chronic than depression in younger patients. The subtyping of chronic depression according to age seems supported by a different age at onset and some clinical differences.

Adult↗
PubMed2000

New strategies for treating chronic depression.

This article provides an update on the diagnosis of chronic depression subtypes, the clinical and public health significance of chronic depression, and a review of what is known about its treatment. The efficacy of antidepressant medications for pure dysthymia and double depression has been established, yet fewer than 50% of patients have achieved full remission with a single agent. Traditional antidepressant psychotherapies appear to have limited effectiveness for chronic depression. In one recent study, a combination of cognitive behavioral analysis system of psychotherapy and a newer antidepressant, nefazodone, yielded the highest response and remission rates ever reported in this population (73% response rate, 48% remission rate in an intent-to-treat sample). This combination merits further study for treatment of chronic depression.

Antidepressive Agents↗
PubMed1979

[Chronic depressions (author's transl)].

The definition of chronic depression necessarily calls for a review of the concept of recovery which in psychopathology is not clearly and univocally defined. The percentage of chronic evolution among depressive patients either as a persistence of depressive symptoms or as an impairment of social and professional role, ranges from 12 to 15%. Chronic depression raises psychopathologic and nosographic problems as well as clinical ones. In fact chronic depressives are often not correctly diagnosed, inadequately treated and destined to be affected by an over increasing inability. The chronic evolution of depression may result as a concurrence of several factors: a neurotic personality, an inadequate antidepressant maintenance treatment, an inappropriated use of minor tranquillizers as the only treatment. The occurrence of physical impairement, the continuous nature of depression and the resistance of antidepressant treatment may be also considered. Moreover the psychodynamic mechanisms aroused by the depressive experience and the secondary advantages of the illness may plan an effective role maintaining depressive symptomatology.

Bipolar Disorder↗
PubMed2003

Group comparisons of DSM-IV subtypes of chronic depression: validity of the distinctions, part 2.

The nosology of chronic depression in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV, American Psychiatric Association, 1994) is highly complex and requires clinicians to differentiate among several chronic course subtypes. This study replicates an earlier investigation (J. McCullough et al., 2000; see record 2000-05424-007) that found few differences among Diagnostic and Statistical Manual of Mental Disorders (3rd ed. rev.; DSM-III-R; American Psychiatric Association, 1987) categories of chronic depression. In the present study, 681 outpatients with chronic major depression, double depression, recurrent major depression without full interepisode recovery, and chronic major depression superimposed on antecedent dysthymia were compared. Few differences were observed on a broad range of demographic, clinical, psychosocial, family history, and treatment response variables. The authors suggest that chronic depression should be viewed as a single, broad condition that can assume a variety of clinical course configurations.

Adult↗
PubMed1996

Interpersonal improvement in chronically depressed patients treated with desipramine.

OBJECTIVE: Interpersonal difficulties of dysthymic patients are little studied. We used the Inventory of Interpersonal Problems (IIP) to assess baseline status and medication response in chronic depression. METHOD: 39 chronically depressed subjects answered the IIP at entry and after 10 weeks of desipramine (DMI). Seventeen DMI responders completed IIPs after a 16-week continuation phase. RESULTS: Mean scores improved on all six IIP subscales during acute treatment. Continuation phase IIP improved non-significantly, approaching normative scores. Baseline IIP score correlated inversely with treatment outcome. CONCLUSIONS: Findings replicate in greater interpersonal detail research demonstrating rapid social amelioration in chronically depressed responders to antidepressant medication. The IIP may be useful as a predictive and interpersonal sensitivity measure in treatment studies of chronic depression.

Adult↗
PubMed1998

Chronic depression: a case series of 203 outpatients treated at a private practice.

OBJECTIVE: To determine the prevalence of chronic depression among outpatients seen for depression. DESIGN: Case series. SETTING: Private practice. PATIENTS: Two hundred and three outpatients with mood disorders, excluding patients with comorbid substance abuse disorders and severe personality disorders. OUTCOME MEASURES: Prevalence rate and patient variables (diagnosis, age at baseline, age at onset, sex, number of previous episodes of depression, atypical features, psychiatric comorbidity, psychosis, duration of illness and baseline severity). RESULTS: The prevalence of chronic depression was 46.7%, which is higher than previously reported. The number of depressive episodes was higher, the presence of psychotic symptoms was more common and the duration of illness was longer in patients with chronic depression than in those with nonchronic depression. CONCLUSIONS: Chronic depression is more severe than nonchronic depression and is a prevalent illness in outpatients with depression seen in private practice.

Chronic Disease↗
PubMed1988

Imipramine treatment for chronic depression.

Antidepressant drugs in the treatment of chronic depressions have received little systematic study. We used a two-week, single-blind placebo washout followed by a six-week, double-blind comparison of imipramine hydrochloride and placebo in a sample of 76 outpatients with DSM-III dysthymic disorder entered into a trial at two centers. Subjects were preponderantly female, had insidious onset at an early age, and had depressions of moderate severity; 96% also met the DSM-III criteria for major depressive disorder at the time of presentation. Sixty percent had a history of persistent depressive symptoms sufficient to meet criteria for major depression for longer than two years. Markedly favorable responses occurred in 45% of imipramine-treated (n = 29) and 12% of placebo-treated (n = 25) patients and, respectively, 59% and 13% of those who completed the study. Imipramine produced significant advantage in measures of depressive symptoms, global severity of illness, and self-rated social and vocational function. Recovered patients experienced remission from both long-standing symptoms and deficits as well as more recently exacerbated aspects of their syndrome. Patients with pure dysthymic disorder of a mild, subsyndromal type were uncommon in these clinical settings. However, anti-depressant medication was effective for many moderately severe chronic depressions, which had previously been untreated or undertreated, presumably related to misdiagnosis.

Adult↗
PubMed2006

A step therapy algorithm for the treatment and management of chronic depression.

Depression is a chronic and progressive condition that, when not treated adequately, can lead to severe morbidity and mortality in patients and increased costs for health plans. Despite the significance of this disease state, the majority of patients are not treated adequately to the widely accepted goal of remission. Patients who do not achieve remission are at greater risk of relapse and recurrence, more chronic depressive episodes, and a shorter duration between depressive episodes. Modeled partially after the Sequenced Treatment Algorithm to Relieve Depression (STAR*D) trial and based on trial data and the consensus statements of a panel of clinical professionals, a step therapy algorithm is proposed in this supplement, including considerations for screening and intervention. The primary concepts in the development of this algorithm were the use of the same clinical tool for both screening and diagnosis and the incorporation of frequent follow-up visits or calls to continuously monitor progress in patients being treated. Also discussed are considerations for drug therapy choices when switching is deemed necessary. Switching to a drug from a different class of agents than the failed trial drug is recommended based on the differential mechanism of action between classes.

Algorithms↗
PubMed2002

Hypothalamic-pituitary-adrenal axis function in patients with chronic depression.

BACKGROUND: Hypothalamic-pituitary-adrenal (HPA) axis function in patients with chronic depression has previously been shown to be normal when measured using the dexamethasone suppression test (DST). We examined patients with chronic depression using the sensitive dexamethasone/corticotropin releasing hormone (dex/CRH) test and the dexamethasone suppression test (DST) to establish whether HPA axis abnormalities are present in this group. We also compared the sensitivity of the two tests and compared the results with previous studies in depression that have not specifically selected chronic patients. METHOD: Twenty-nine patients with the chronic subtype of major depressive disorder and 28 matched controls underwent examination of HPA axis function. RESULTS: Neither the cortisol response to the DST or the dex/CRH test differed significantly between the patient and control groups. There was a trend in favour of more patients than controls having an abnormal response to the dex/CRH test (P = 0.052). Neither the patients with an abnormally enhanced response, nor the magnitude of response could be predicted by any illness or demographic variable. CONCLUSION: The HPA axis is not overtly abnormal in chronic depression. This contrasts with previous findings in acute depression and bipolar disorder and may suggest that the HPA axis abnormalities present in acute depression resolve, but are not accompanied by symptom resolution. Alternatively, a subgroup of depressives with less HPA dysfunction may progress to chronicity. This has implications for treatment and prognosis. The dex/CRH is a more sensitive test of HPA axis function than the DST in patients with chronic depression.

Adult↗
PubMed2006

[A specific therapy for chronic depression. McCullough's Cognitive Behavioral Analysis System of Psychotherapy].

Chronic depression is a common disorder which causes significant impairment and enormous treatment costs. Traditional pharmacological and psychological treatment approaches have shown only modest success. The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) by James McCullough is the only therapy developed specifically for chronic depression. It integrates behavioral, cognitive, and interpersonal strategies. The approach is supported empirically and shown to be effective. This article presents the state of the art regarding research in psychotherapeutic treatment for chronic depression. In addition, the development of the approach and therapeutic strategies and techniques of CBASP are described.

Antidepressive Agents↗
PubMed2003

Cognitive therapy for chronic depression.

Recent literature indicates that there are important clinical differences between chronic and non-chronic depression. This article considers the implications of these differences when conducting cognitive therapy (CT) with chronically depressed patients. CT with chronic patients requires a greater emphasis on combating hopelessness, helplessness, and perfectionism, addressing early life-adverse experiences, and modifying maladaptive schemas. In addition, the effectiveness of CT may be enhanced by focusing on patients' poor social skills, ineffective reasoning skills, and their depressive identity. The case example presented illustrates CT with a chronically depressed patient.

Chronic Disease↗
PubMed2002

The search for determinants of chronic depression: a review of six factors.

While strides have been made in the classification, assessment and identification of chronic depression, there remains a limited understanding of the factors underlying chronicity. This review focuses on six putative determinants of chronic depression: developmental factors, personality and personality disorders, psychosocial stressors, comorbid disorders, biological factors and cognitive factors. The strongest support was found for the role of developmental factors in the chronicity of depression. Some support was found for the role of chronic stressors and certain personality features such as stress reactivity. Few other factors found support. The determinants of chronic depression do not differ qualitatively from acute depression. Rather, the development of chronic depression may involve increased levels of childhood adversity, protracted environmental stress and heightened stress reactivity. However, it is difficult to determine to what extent these putative determinants might reflect retrospective bias in data collection, or even parental reaction to children with subthreshold depressive traits. Detailed etiological models await further research attention to understudied areas and improved research designs. Suggestions for future research include greater specification of criteria for chronicity, use of more appropriate comparison groups and longer term prospective follow-up studies.

Brain↗