Detection and Diagnosis
As noted, chronic depressions are frequently comorbid with other conditions. High rates of Axis I disorders—in particular the anxiety conditions—have been reported. For example, pronounced levels of anxiety were observed in the Keller sample. Although high baseline anxiety scores did not reduce overall response, they did delay the onset of response to antidepressant treatment. Axis II disorders are also common in chronic depression. Markowitz and colleagues, for example, reported that 85% of a sample of dysthymic patients presented with some form of concurrent personality disorder, particularly the avoidant, self-defeating, dependent, and borderline types. Finally, Axis III medical conditions are known to be highly prevalent in patients with acute depression and are likely to be even more common in chronic depression. There are few treatment studies that have specifically addressed comorbid conditions, but comorbid patients are likely to require longer, more intense, and multimodal therapies. Most previous studies of chronic depression have applied relatively strict exclusion criteria, such as the presence of comorbid Axis I and II disorders. Pragmatic, multidisciplinary trials are now required to ascertain how the more complex comorbid forms of chronic depression respond to treatment in naturalistic settings.
Detection rates for chronic depression appear to be poor, and the presence of comorbidity may exacerbate this problem. The mood disorder may be masked, for example, by a more florid Axis II disorder. Incomplete remission of MDD may be missed if symptom outcome measures are not used. For patients with double depression, return to baseline dysthymia is not an adequate treatment goal, since many of these patients can have full remission of symptoms, even with antidepressant treatment alone. In addition, once the chronicity of a depressive episode is identified, it may not be paramount to determine exactly which diagnostic subtype it represents, because the subtypes do not appear to differ greatly in terms of treatment response.
Mode of Treatment
The optimal management of chronic depression is likely to require that a range of treatment options be considered and that those selected often be implemented in a stepwise fashion. Treatment algorithms for chronic and refractory depression have been proposed, although their effectiveness in clinical settings has not yet been evaluated. There is little evidence to suggest that any single type of antidepressant is superior to another in the treatment of chronic depression, although more than one medication trial may be required before an optimal regimen is found. The long-term tolerability of a selected drug should be an important consideration, especially because lengthy or indeed indefinite maintenance treatment periods may be required. Given that many chronic depressions are treatment-refractory or show incomplete remission with treatment, augmentation and combination strategies may be required to optimize medication response. To our knowledge, no previous trials have addressed the effects of tailoring medication regimes in patients with chronic depression. Useful future research would focus upon the effectiveness of tailored pharmacologic management, with special emphasis on treatment tolerability, adverse effects, adherence to drug regimen, and frequent monitoring and reassessment. There may also be several other somatic treatment options, including light therapy, electroconvulsive therapy, or novel interventions such as vagus nerve stimulation or repetitive transcranial magnetic stimulation. The evidence concerning the efficacy of these options in treating chronic depression is, however, still scant.
There is insufficient evidence at present to judge whether psychotherapy in isolation is an effective treatment for chronic depression (and psychotherapy alone is not recommended for dysthymic disorder owing to evidence that it is not efficacious). Adding psychotherapy to pharmacotherapy is likely to be of significant benefit in the treatment of chronic depression. Psychotherapies shown to be effective include CBT, IPT, and the more specific CBASP. Early evidence indicates that patients with chronic and refractory depression may require a more intensive course of psychotherapy than is currently standard.
As previously noted, chronic depression is associated with marked impairment, and successful pharmacologic treatment appears to improve psychosocial functioning. Chronic depression also has profound effects upon occupational functioning, and preliminary evidence suggests that effective treatment improves subjective work performance. However, we are not aware of any studies that have examined the effects of systematically treating the occupational dysfunction associated with chronic depression. Occupational therapy may provide a useful adjunctive treatment by focusing upon improving the problem-solving skills, interpersonal skills, and coping mechanisms damaged by chronic illness.
Important gaps remain in our knowledge concerning the optimal maintenance treatment for chronic depression. Current evidence supports a multiyear maintenance phase, particularly in patients who have experienced previous episodes, where risk from relapse may be greater. However, there are no data available for the effectiveness of maintenance treatments beyond 2 years. The medication dosages that were effective in the acute-treatment phase should be maintained in the long-term treatment of chronic depression. Medication adherence is a significant issue in this maintenance period. Poor adherence has been related to worse outcome in the long-term management of depression in some, but not all studies. Ensuring patient adherence in the acute phases of treatment has proved challenging. Maintaining adherence in long-term treatment may be easier, because patients are likely to be feeling the benefits of treatment or experiencing fewer side effects as treatment regimens are tailored. Conversely, persuading patients to continue taking medication when they feel well holds its own challenges. Over and above simple education, it is likely to be beneficial to fully involve patients as collaborators in their treatment and to share decision making with them.
Maintenance psychotherapy may be important to maintain patients' feelings of motivation and self-efficacy, to prepare patients for setbacks should they occur, and to enhance medication adherence. However, maintenance-phase psychotherapy is only beginning to be studied; there is as yet no evidence available about the optimal "dosage" of maintenance psychotherapy for chronic depression.
Chronic depressive disorders are highly prevalent in both community and hospital populations and result in substantial disability for the individual and society. In the past, chronic depression was thought to be embedded in personality disorder, to have limited response to treatment, and to show a poor prognosis. As we currently understand it, chronic depression includes several diagnostic subtypes. A larger evidence base on treatment for chronic depression has accumulated (although "depressive personality disorder" is controversially being considered for inclusion in future editions of the DSM). While early work in this field was limited by methodological problems, several well-designed, systematic studies have now been performed. Broadly, these indicate that chronic depression responds favourably to antidepressants during the acute and maintenance phases of treatment, provided that the medication treatment is both thorough and intensive. An effective new approach to the treatment of chronic depression combines psychotherapy and antidepressants. Further research is now required to ascertain whether combined and individualized treatment regimens are effective in naturalistic clinical settings.
Although our knowledge concerning the treatment of chronic depression has developed rapidly, changes in clinical practice have been slower to evolve. Evidence indicates that chronic depressions remain poorly diagnosed and suboptimally treated. The challenge of the future is to dispel the myths that surround chronic depression and to implement this growing evidence base in clinical practice while continuing to address the gaps that remain in our understanding of its treatment. Only then can we begin to reduce the significant personal and societal burden that results from this highly prevalent condition.
- Lenhardt, Ann Marie & Bernadette McCourt; Adolescent unresolved grief in response to the death of a mother; Professional School Counseling; Feb 2000; Vol. 3; Issue 3.
Reflection Exercise #12
The preceding section contained information
regarding research results regarding the treatment of depression. Write
three case study examples regarding how you might use the content of this section
in your practice.
Online Continuing Education QUESTION
What two approaches does the "effective new approach" for treating chronic depression combine? Record the letter of the correct answer