[Treatment-refractory depression(chronic depression)].
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Antidepressive Agents↗
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Algorithm for the treatment of chronic depression.
Chronic depression, which is marked by a course of illness lasting 2 years or more, encompasses 4 subtypes of depressive illness: (1) chronic major depressive disorder, (2) dysthymic disorder, (3) dysthymic disorder with major depressive disorder ("double depression"), and (4) major depressive disorder with poor interepisodic recovery (i.e., in incomplete remission). In the 1990s, chronic depression had a reported prevalence rate of 3% to 5% and accounted for 30% to 35% of all cases of depression in the United States. The authors present an algorithm modified from the Texas Medication Algorithm Project for patients with chronic depression. This treatment algorithm recommends a progression of steps or stages in treating chronic depression. The first stage is monotherapy with the selective serotonin reuptake inhibitors, nefazodone, bupropion sustained release, venlafaxine extended release, mirtazapine, or psychotherapy. Later options include combination therapy, electroconvulsive therapy, atypical antipsychotics, and novel treatments. Utilization of a comprehensive treatment algorithm for chronic major depression should encourage efficient, efficacious treatment.
Algorithms↗
Acute and maintenance treatment of chronic depression.
Chronic forms of depression account for approximately one third of all depressions. They are underrecognized and undertreated. This article defines the types of chronic depressions (dysthymic disorder, double depression, chronic major depression, and major depression in incomplete remission). A review of treatments for patients with these conditions is provided. The basic principles of treatment of chronic depression involve longer treatment and higher doses than are usually required for acute major depression. The impact of psychosocial disability and severity of depressive symptoms can be ameliorated with appropriate treatment. Newer treatments, such as the combination of psychotherapy and pharmacotherapy, may prove to be of greatest benefit for individuals with chronic mood disorders.
Adult↗
Strategies and tactics in the treatment of chronic depression.
Chronic depressions include major depressive disorder, recurrent, without full interepisode recovery; major depressive disorder, currently in a chronic (i.e., > or = 2 years) episode; double depression; dysthymic disorder; and those depressive disorders--not otherwise specified (NOS)--that are persistent or predictably recurrent with substantial disability. Strategic treatment decisions include (1) whether to treat with medication, psychotherapy, ECT, or other methods; (2) selection among specific agents with long-term efficacy and tolerability (preferably established by randomized controlled trials); (3) selection of the next treatment should the initial treatment fail or be found intolerable; and (4) deciding whether to provide maintenance treatment. Tactical decisions are those needed to optimally implement the strategies selected; for example, (1) how to optimally dose, (2) how long to continue an acute phase treatment trial, (3) how to measure outcome, and (4) how to identify and manage subsequent symptomatic breakthroughs or side effects (which may also require revisions in the initial strategies). Some antidepressant medications evidence efficacy and safety in acute phase treatment of the chronically depressed, but continuation and maintenance phase treatments for these patients are less well investigated and deserve further study. The clinical implications of what is known to date for managing these patients are discussed.
Antidepressive Agents↗
[Introduction to chronic depression and resistant depression].
Chronic depression actually covers several different nosographic entities. Among the predictive factors for chronicity, personality disorders raise the complex issue of the relationship between traits and depression. Some approaches favour the concept of premorbid personality, others in contrast insist more on personality disorders which complicate a depressive episode. In order to account for both stress factors and biological factors in the progression of depression towards chronicity, Post suggested in 1992 a bold integrative pattern. In this pattern, the premorbid period would be marked by secondary sensitization to repeated stress factors. These factors would cause not only short-term but also longer-term fragility by modifying the transcription of protein encoding, in particular for the C-fos oncogene. This would cause peptide alterations which originate a vulnerability to mood disorders. With time, an accumulation mechanism and a kindling phenomenon would cause the initial depressive episode to develop, and that in turn would constitute a new vulnerability factor for the new spontaneous occurrence of further depressive episodes. This model has the merit to underline the importance of early and durable treatment. It also suggests a promising approach for the future.
Brain↗
Improvement in subjective work performance after treatment of chronic depression: some preliminary results. Chronic Depression Study Group.
We analyzed the relationship between depression and patient-assessed or clinician-rated work performance among chronically depressed patients followed for 12 weeks in a large clinical trial. The data were collected in a double-blind design comparing sertraline, a selective serotonin reuptake inhibitor, with imipramine, a tricyclic antidepressant, in 12 academic centers nationwide. Incorporating work-related questions from a portfolio of rating scales used to assess depression, we constructed several measures of work performance, assessed at baseline and at Week 12 of the clinical investigation, and examined how they changed with improvement in depressive symptoms. As depressive symptoms subsided following treatment, patients reported substantial improvement in our measures of work performance. Eighty-six percent of the cohort reported some improvement from base-line to Week 12. The extent of improvement in work performance correlates highly with improvement in the depressive symptoms measured on the Hamilton Rating Scale for Depression. Treatment of depression with antidepressant medications resulted in substantial improvement in subjective work performance among the patients studied.
1-Naphthylamine↗
Breaking the myths: new treatment approaches for chronic depression.
BACKGROUND: Chronic depressive disorders are common, accounting for approximately one-third of all cases of depression and posing a major public health problem. In the past, chronic depression has been thought to be treatment-resistant, and evidence suggests that it is currently underdiagnosed, misdiagnosed, and suboptimally treated. OBJECTIVES: To review the subtypes of chronic depression and the evidence-base concerning their optimal treatment and to discuss some key clinical issues and areas of future research. METHODS: We identified key studies and randomized controlled trials (RCTs) by systematically searching electronic databases and hand searching specialist journals and bibliographies. RESULTS: Chronic depressive disorders respond well to standard pharmacologic interventions in the acute and maintenance phases of treatment. Standard psychotherapies alone may not be efficacious for chronic depression (especially dysthymia). Recent evidence suggests that treatment combining psychotherapy and medications may be superior to either treatment alone. CONCLUSIONS: Chronic depressive disorders are amenable to treatment, provided that intervention is both thorough and intensive. Although our knowledge about the optimal treatment of chronic depression has developed rapidly, changes in clinical practice have been slower to evolve. Further research is required to assess the effectiveness of multimodal interventions for chronic depression in more naturalistic settings.
Antidepressive Agents↗
Chronic depression.
Defining chronic depression as persistent symptoms for 2 or more years, a prevalence of chronic depression of 12-15% is found in the literature. A four-part classification of chronic depression is proposed: Chronic Primary Major Depression; Chronic Secondary Major Depression; Characterological or Chronic Minor Depression (Dysthymic Disorder); and 'Double Depression'. The literature indicates several factors predicting chronicity in primary major depression: more at risk are female patients, particularly those with premorbid neurotic personality traits, individuals with unipolar disorders, and those with higher familial loading for such disorders. Other factors are the adequacy and appropriateness of the treatment given, and the length of illness episode prior to treatment being received. Larger studies with well-matched controls are needed.
Adult↗
Chronic depression.
OBJECTIVE: Chronic depression has not been appreciated or studied as well as episodic mood disorders or other chronic psychiatric disorders. This review provides an overview of the clinical features, biology, and treatment of chronic depression and suggests additional areas for research. METHODS: The English-language literature was searched using MEDLINE. Additional references were selected from the bibliographies of recent publications. Studies of chronic nonbipolar depressed patients were selected; chronicity was defined as the persistence of depressive symptoms for at least two years or as a diagnosis of DSM-III or DSM-III-R dysthymia, "double depression," or chronic major depression. RESULTS AND CONCLUSIONS: Reported prevalence rates of chronic depression range from 3 to 5 percent in community samples and from 9 to 31 percent in clinical samples. Compared with patients with major depression, those with chronic depression have increased neurotic personality traits, adverse life events, health care utilization, and comorbid psychiatric and medical conditions, especially thyroid dysfunction. Biological and family studies support the relationship of chronic depression to the major mood disorders. Chronicity is also associated with inadequate treatment with anti-depressant drugs. Serotonergic or monoamine oxidase inhibitors may be more effective in treating chronic depression than tricyclic antidepressants. Psychosocial therapies need further study but may be especially useful in combination with drug treatment. Future research should investigate the clinical and biological correlates of subtypes of chronic depression, the response of the subtypes to different antidepressants, and the relative efficacy of combined antidepressant-psychosocial treatment.
Antidepressive Agents↗
"Double depression": superimposition of acute depressive episodes on chronic depressive disorders.
Although "double depression"--major depressive disorder superimposed on an underlying chronic depression--is a frequent phenomenon, the concept has not been well formulated clinically and has rarely been described in the research literature. The authors found that 1) 26% of l0l patients who met the criteria for major depressive disorder had an underlying chronic depressive disorder of at least 2 years' duration, 2) "recovery" rates for patients with superimposed depression differed greatly depending on whether recovery was defined as recovery from the major depressive disorder only or recovery from both disorders, and 3) patients with superimposed depression relapsed at a significantly higher rate immediately after recovery from the acute episode of depression than did patients without superimposed depression.
Acute Disease↗
Does anhedonia correlate with depression severity in chronic depression?
Anhedonia has been proposed as a psychological marker for biological depression. In this study, anhedonia was measured in a cohort of chronically depressed outpatients. Levels of anhedonia were similar to those reported in acutely depressed patients. Anhedonia was significantly correlated with morbid risk of depression in first-degree family members, neuroticism, introversion, and dysfunctional attitudes, but not with depression severity or hopelessness scores. In a naturalistic follow-up study over a 1-year period, while depression severity was significantly reduced, anhedonia scores remained constant. The study provides support for the view that in chronic depression anhedonia may have trait-like properties, and that the propensity toward anhedonic responses may occur irrespective of depressive severity.
Adult↗
Sertraline versus imipramine to prevent relapse in chronic depression.
BACKGROUND: Chronic depressions are common, disabling and under-treated, and long-term treatment is little studied. We report the continuation phase results from a long-term treatment study. METHODS: After 12 weeks of acute phase treatment in a double-blind, randomized, parallel-group, multi-center trial of sertraline or imipramine, patients with chronic depression (> or = 2 years in major depression, or major depression superimposed on dysthymia) continued study drug for 16 weeks. Initially, 635 patients were randomized to sertraline or imipramine in a 2:1 ratio. Nonresponders after 12 weeks entered a 12-week double-blind crossover trial of the alternate medication. Entry into continuation treatment required at least a satisfactory response (partial remission) to initial or crossover treatment. RESULTS: Of 239 acute or crossover responders to sertraline, 60% entered continuation in full remission and 40% with a partial remission. These proportions were identical for imipramine patients (n = 147). For both drug groups, over two-thirds of those entering in full remission retained it. For those entering in partial remission, over 40% achieved full remission. Patients requiring crossover treatment were less likely to maintain or improve their response during continuation treatment. The two drugs did not differ significantly in response distribution, drop out rates or discontinuation due to side effects during continuation treatment. LIMITATIONS: The absence of a placebo group constrains interpretation of our results, but chronic depressions have low placebo response rates. CONCLUSIONS: Most chronic depression patients who remit with 12 weeks of sertraline or imipramine treatment maintain remission during 16 weeks of continuation treatment. Most patients with a satisfactory therapeutic response (partial remission) after 12 weeks of treatment maintain it or further improve. Patients treated with imipramine experienced more side effects, but both drugs were well tolerated.
Adult↗
Lost human capital from early-onset chronic depression.
OBJECTIVE: Chronic depression starts at an early age for many individuals and could affect their accumulation of "human capital" (i.e., education, higher amounts of which can broaden occupational choice and increase earnings potential). The authors examined the impact, by gender, of early- (before age 22) versus late-onset major depressive disorder on educational attainment. They also determined whether the efficacy and sustainability of antidepressant treatments and psychosocial outcomes vary by age at onset and quantified the impact of early- versus late-onset, as well as never-occurring, major depressive disorder on expected lifetime earnings. METHOD: The authors used logistic and multivariate regression methods to analyze data from a three-phase, multicenter, double-blind, randomized trial that compared sertraline and imipramine treatment of 531 patients with chronic depression aged 30 years and older. These data were integrated with U.S. Census Bureau data on 1995 earnings by age, educational attainment, and gender. RESULTS: Early-onset major depressive disorder adversely affected the educational attainment of women but not of men. No significant difference in treatment responsiveness by age at onset was observed after 12 weeks of acute treatment or, for subjects rated as having responded, after 76 weeks of maintenance treatment. A randomly selected 21-year-old woman with early-onset major depressive disorder in 1995 could expect future annual earnings that were 12%-18% lower than those of a randomly selected 21-year-old woman whose onset of major depressive disorder occurred after age 21 or not at all. CONCLUSIONS: Early-onset major depressive disorder causes substantial human capital loss, particularly for women. Detection and effective treatment of early-onset major depressive disorder may have substantial economic benefits.
Adult↗
Social functioning in chronic depression: effect of 6 weeks of antidepressant treatment.
Social functioning was assessed in 189 nonmelancholically depressed outpatients. Patients were then treated for 6 weeks in a double-blind trial of phenelzine, imipramine, or placebo and functioning was reassessed. Before treatment, younger, more severely depressed, more chronically depressed patients and those with a DSM-III diagnosis of major depression plus dysthymic disorder were more functionally impaired than patients without these characteristics. Chronically depressed patients who responded to treatment reported significantly improved functioning while nonresponders did not. These results suggest that for some chronically depressed patients, impaired functioning results at least partly from the Axis I mood disorder instead of being entirely attributable to Axis II character pathology.
Adult↗
Chronic depression in women.
Chronic depression represents an important public health concern for women. It is underrecognized and undertreated and is associated with significant functional impairment and high rates of comorbidity. Moreover, recent research suggests that chronic depression may affect women more seriously than men; for example, women may experience illness onset at an earlier age and experience more severe psychosocial impairment compared with men. Recent studies have demonstrated the efficacy of both antidepressant medications and psychotherapy in treating chronic depression, with differential responsiveness to some treatments between women and men. Young women should be screened carefully and treated vigorously to prevent the serious consequences of this condition.
Adult↗
Family therapy and chronic depression.
Individuals with chronic depression report significant problems in multiple areas of their family functioning, suggesting the importance of combining family therapy with psychotherapy and pharmacotherapy in the treatment of their depression. We describe a model of family functioning (the McMaster model) and therapy (the Problem-Centered Systems Therapy of the Family) and its application in the treatment of a young woman with chronic depression. The key elements of the family treatment are a comprehensive assessment of the family, a systematic progression through defined treatment stages, an open, collaborative stance with the family, and a focus on the family's responsibility for change. Family therapy can aid the amelioration of depressive symptoms and improve the ability of family members to deal more effectively with the depression as well as a wider range of problems.
Adult↗
Chronic depression subtypes: a 257 case study.
The aim of the study was to compare Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) three subtypes of chronic depression (chronic major depressive episode [MDE] occurring in major depressive and bipolar II disorders, dysthymic disorder with MDE, and MDE without full interepisode recovery occurring in major depressive and bipolar II disorders) with each other, and with nonchronic depression, and to find if this subdivision was supported by clinical data. Two hundred and fifty seven consecutive MDE outpatients were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery Asberg Depression Rating Scale (MADRS), and the Global Assessment of Functioning (GAF) scale. Clinical variables (age, age at onset, duration of illness, severity, gender, recurrences, atypical and psychotic features, axis I comorbidity, bipolar II, and unipolar diagnoses) were compared among the chronic depression subtypes, and versus nonchronic depression. Chronic MDE had significantly less comorbidity than the other two chronic depression subtypes. All the other variables were not significantly different. Chronic depression subtypes had significantly longer duration of illness, less comorbidity, and more recurrences than nonchronic depression. These findings do not support the DSM-IV subtyping of chronic depression.
Ambulatory Care↗
Cognitive aspects of chronic depression.
Previous research on chronic depression has focused on its link with other mood disorders and Axis II personality disorders. However, there are few data examining whether the cognitive perspective applies to this condition. In this cross-sectional study, 42 outpatients with chronic depression were compared with 27 outpatients with nonchronic major depressive disorder and 24 never psychiatrically ill controls on cognitive variables thought to be related to vulnerability to depression (e.g., dysfunctional attitudes, attributional style, a ruminative response style, and maladaptive core beliefs). Both depressed groups were more elevated than a never-ill comparison group. However, chronically depressed individuals were generally more elevated on measures of cognitive variables than those with major depressive disorders even after controlling for mood state and personality disorder symptoms.
Adult↗