Clinical characteristics of outpatients with chronic major depression

doi:10.1016/0165-0327(94)00101-E

Journal of Affective Disorders

Volume 34, Issue 1, 16 April 1995, Pages 25-32

https://doi.org/10.1016/0165-0327(94)00101-E Get rights and content

Abstract

A cross-sectional evaluation of 243 unipolar, nonpsychotic outpatients with major depression was conducted. All subjects were diagnosed by RDC with SADS-L structured interviews. Diagnoses included RDC primary/secondary, RDC endogenous/nonendogenous and Winokur's family-history subtypes. Symptom severity was assessed by the 17-item Hamilton Rating Scale for Depression. Chronic depression was defined as the current episode of major depression lasting at least 2 years, corresponding to DSM-III-R and -IV criteria. Patients with chronic depression (n = 64) were compared with those with nonchronic depression (n = 179).

Chronicity was not related to gender, symptom severity, prior length of illness, age at onset of illness, RDC endogenous/nonendogenous, RDC primary/secondary or Winokur's family-history subtypes. Those with chronic depression were older and had fewer major depressive episodes than the nonchronic group. That the chronic group had fewer total episodes of depression than the nonchronic group, but a similar age at onset, is consistent with the notion that patients in a current chronic episode have characteristically longer depressive episodes throughout the course of their illness. Those with chronic episodes may be subject to psychological, biological and/or sociocultural factors that preclude an earlier episode remission for these individuals.

References (52)

H.S. Akiskal et al.
Chronic depressions — Part I. Clinical and familial characteristics in 137 probands
J. Affect. Disord
(1981)
M.J. Garvey et al.
Is chronic primary major depression a distinct depressive subtype?
Compr. Psychiatry
(1986)
D.E. Giles et al.
Polysomnographic findings and dexamethasone nonsuppression in unipolar depression: a replication and extension
Biol. Psychiatry
(1987)
P.W. Lavori et al.
Relapse affective disorders: a reanalysis of the literature using life table methods
J. Psychiat. Res.
(1984)
E. Szádóczky et al.
The role of psychosocial and biological variables in separating chronic and non-chronic major depression and early-late-onset dysthymia
J. Affect. Disord.
(1994)
H.S. Akiskal
Factors associated with incomplete recovery in primary depressive illness
J. Clin. Psychiatry
(1982)
H.S. Akiskal
Dysthymic disorder: psychopathology of proposed chronic depressive subtypes
Am. J. Psychiatry
(1983)
American Psychiatric Association
American Psychiatric Association
J. Angst et al.
The course of unipolar and bipolar affective disorders

A.T. Beck

Depression: Causes and Treatment

(1967)

O. Bratfos et al.

The course of manic-depressive psychosis: a follow-up investigation of 215 patients

Acta. Psychiatr. Scand

(1968)

W. Coryell et al.

Primary unipolar depression and the prognostic significance of delusions

Arch. Gen. Psychiatry

(1982)

W. Coryell et al.

Outcome in schizoaffective, psychotic and nonpsychotic depression. Course during a six to 24-month follow-up

Arch. Gen. Psychiatry

(1984)

S.L. Dubovsky et al.

Psychotic depression: advances in conceptualization and treatment

Hosp. Community Psychiatry

(1992)

J. Endicott et al.

A diagnostic interview: the schedule for affective disorders and schizophrenia

Arch. Gen. Psychiatry

(1978)

M. Hamilton

A rating scale for depression

J. Neurol. Neurosurg. Psychiatry

(1960)

R.M.A. Hirschfeld et al.

Psychosocial predictors of chronicity in depressed patients

Br. J. Psychiatry

(1986)

R.H. Howland

General health, health care utilization and medical comorbidity in dysthymia

Int. J. Psychiatry Med.

(1993)

G.I. Keitner et al.

Recovery and major depression: factors associated with twelve-month outcome

Am. J. Psychiatry

(1992)

M.B. Keller et al.

Long-term outcome of episodes of major depression: clinical and public health significance

JAMA

(1984)

M.B. Keller et al.

‘Double depression:’ two-year follow-up

Am. J. Psychiatry

(1983)

M.B. Keller et al.

The persistent risk of chronicity in recurrent episodes of non-bipolar major depressive disorder: a prospective follow-up

Am. J. Psychiatry

(1986)

T.A. Kerr et al.

The relationship between the Maudsley Personality Inventory and the course of affective disorders

Br. J. Psychiatry

(1970)

P. Kielholz

Diagnosis and therapy of the depressive states

Acta Psychosomat

(1959)

P. Kielholz

Zum Verlauf manisch-depressive Erkrankungen

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Research paperClinical characteristics of outpatients with chronic major depression

Abstract

J. Affect. Disord

Compr. Psychiatry

Biol. Psychiatry

J. Psychiat. Res.

J. Affect. Disord.

Factors associated with incomplete recovery in primary depressive illness

J. Clin. Psychiatry

Dysthymic disorder: psychopathology of proposed chronic depressive subtypes

Am. J. Psychiatry

The course of unipolar and bipolar affective disorders

Depression: Causes and Treatment

The course of manic-depressive psychosis: a follow-up investigation of 215 patients

Acta. Psychiatr. Scand

Primary unipolar depression and the prognostic significance of delusions

Arch. Gen. Psychiatry

Outcome in schizoaffective, psychotic and nonpsychotic depression. Course during a six to 24-month follow-up

Arch. Gen. Psychiatry

Psychotic depression: advances in conceptualization and treatment

Hosp. Community Psychiatry

A diagnostic interview: the schedule for affective disorders and schizophrenia

Arch. Gen. Psychiatry

A rating scale for depression

J. Neurol. Neurosurg. Psychiatry

Psychosocial predictors of chronicity in depressed patients

Br. J. Psychiatry

General health, health care utilization and medical comorbidity in dysthymia

Int. J. Psychiatry Med.

Recovery and major depression: factors associated with twelve-month outcome

Am. J. Psychiatry

Long-term outcome of episodes of major depression: clinical and public health significance

JAMA

‘Double depression:’ two-year follow-up

Am. J. Psychiatry

The persistent risk of chronicity in recurrent episodes of non-bipolar major depressive disorder: a prospective follow-up

Am. J. Psychiatry

The relationship between the Maudsley Personality Inventory and the course of affective disorders

Br. J. Psychiatry

Diagnosis and therapy of the depressive states

Acta Psychosomat

Zum Verlauf manisch-depressive Erkrankungen

Research paper
Clinical characteristics of outpatients with chronic major depression