Chronic depression: Now, a treatable condition?
Q.Once thought to reflect an "unhappy temperament," chronic depression is now known to be a mood disorder amenable to drug treatment. The therapeutic implications are profound-particularly because many of these patients have been depressed for decades, if not for their entire adult lives.
A.In the 35 years since antidepressant medmcations first became available, acute major depression has been extensively studied and its impact characterized. While traditionally depression has been considered an acute, episodic condition, evidence gathered during the past two decades has shown increasingly that, more often than not, depression is a chronic, relapsing condition that may be lifelong. One 10-year prospective study of patients treated for acute depression found that * 12% were still symptomatic after 5 years * 7% experienced no remission of their symptoms during the entire course of the study * 28% of those treated successfully for an acute episode experienced a relapse with a year, while 62% had a relapse during 5 years, and 75% experienced a recurrence within the 10-year study period * Only 18% remained well for 10 years after an initial episode of major depression.1 Epidemiologic studies undertaken during the 1980s found a prevalence of 3% to 6% for chronic depression.2 Although chronic depression is sometimes referred to as "minor" depression, to differentiate it from its more florid, acute counterpart, its effects can hardly be characterized as minor. Many patients now being given this diagnosis have been significantly impaired for their entire adult lives, often more so than typically is seen with other chronic conditions such as diabetes, hypertension, and arthritis. The degree of impairment experienced by these patients is reflected in one study's findings that more than 20% of subjects with chronic depression were unemployed and that 31% were employed in jobs that were significantly below their education and training level.3 Comorbidity also figures prominently; many patients experience social phobias, panic disorder, and substance abuse. Strong family histories of affective disorders are typically found. In the early editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), chronic depression was classified as a personality disorder separate from major depression. This, of course, held major implications for treatment of the condition: Only long-term psychiatric treatment was considered suitable, with the goal of alteration of the abnormal personality characteristics. Antidepressant medications were not thought to be useful and were rarely prescribed. By the time DSM-III-R was published in 1987, researchers had found various types of physiologic evidence linking chronic depression more closely to its acute counterpart (see "Evolution of a diagnosis"). This shift in thinking has continued, and in DSM-IV chronic depression is classified as a mood disorder with 3 major subtypes: * Dysthymia, a condition in which symptoms of depression, less severe than those seen in acute major depression, persist for longer than 2 years * Chronic major depression, in which the severe symptoms that typify acute major depression persist for longer than 2 years * Double depression, when an episode of acute major depression is superimposed on an underlying dysthymic condition.
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