Single episode of major depressive disorder

First episode of recurrent mood disorder or distinct subtype of late-onset depression?
  • Giovanni B. Cassano
  • Hagop S. Akiskal
  • Mario Savino
  • Adalgisa Soriani
  • Laura Musetti
  • Giulio Perugi
Original Articles


Of 687 consecutive inpatients and outpatients with primary major depressive illness, 213 (31%) were categorized as single episode (SE) by DSM-III-R criteria. Systematic evaluation of familial, sociodemographic, temperamental and symptomatological characteristics permitted the nearly equal division of SE into two categories: a. early-onset (<45 years) “first episode” superimposed on either depressive or hyperthymic temperaments (against a bipolar and unipolar familial background), more severe depression, higher rates of suicide attempts, greater anxiety-somatization and psychotic tendencies, and with the potential for recurrence; b. late-onset (≥45 years) isolated episode (against an unipolar familial background) with greater life stressors, pursuing a protracted course with less likelihood of recurrence. In most other respects, early-onset SE was intermediate between recurrent major depression and lateonset SE. The implications of these findings for the now largely abandoned category of “involutional melancholia” are discussed.

Key words

Late-onset depression Single-episode depression Hyperthymic and depressive temperaments 


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  1. Akiskal HS (1983a) The bipolar spectrum: New concepts in classification and diagnosis. In: Grinspoon L (ed) Psychiatry Update: The American Psychiatric Association Annual Review. American Psychiatric Press, Washington DC, pp 271–292Google Scholar
  2. Akiskal HS (1983b) Diagnosis and classification of affective disorders: new insights from clinical and laboratory approaches. Psychiatr Dev 1:123–160PubMedGoogle Scholar
  3. Akiskal HS, Akiskal K (1992) Cyclothymic, hyperthymic and depressive temperaments as subaffective variants of mood disorders. In: Tasman, A and Riba MB (Eds) American Psychiatric Association Review, American Psychiatric Press, Washington, DC, pp 43–62Google Scholar
  4. Akiskal HS, Akiskal K (1988) Re-assessing the prevalence of bipolar disorders: Clinical significance and artistic creativity Psychiatr. Psychobiol 3:29s-36sGoogle Scholar
  5. Akiskal HS, Bitar AH, Puzantian VR, Rosenthal TL, Walker PW (1978) The nosological status of neurotic depression: a prospective three-to four-year follow-up examination in light of the primary-secondary and unipolar-bipolar dichotomies. Arch Gen Psychiatry 35:756–766PubMedGoogle Scholar
  6. Akiskal HS, Cassano GB, Musetti L, Perugi G, Tundo A, Mignani V (1989) Psychopathology temperament, and past course in primary major depressions. 1. Review of evidence for a bipolar spectrum. Psychopathology 22:268–277PubMedGoogle Scholar
  7. Akiskal HS, Djenderedjian AM, Rosenthal RH, Khani MK (1977) Cyclothymic disorder: validating criteria for inclusion in the bipolar affective group. Am J Psychiatry 134:1227–1233PubMedGoogle Scholar
  8. Akiskal HS, Khani MK, Scott-Strauss A (1979) Cyclothymic temperamental disorders. Psychiatr Clin North Am 2:527–554Google Scholar
  9. Akiskal HS, Mallya G (1987) Criteria for the “soft” bipolar spectrum: treatment implications. Psychopharmacol Bull 23:68–73PubMedGoogle Scholar
  10. Akiskal HS McKinney WT Jr (1973) Depressive disorders: toward a unified hypothesis. Science 182:20–29PubMedGoogle Scholar
  11. Akiskal HS, Walker P, Puzantian VR, King D, Rosenthal TL, Dranon M (1983) Bipolar outcome in the course of depressive illness Phenomenologic, familial, and pharmacologic predictors. J Affect Dis 5:115–128CrossRefPubMedGoogle Scholar
  12. American Psychiatric Association (1987) Diagnostic and statistical manual of mental disorders, 3rd edn, revised. Washington, D.C.: American Psychiatric Association PressGoogle Scholar
  13. Andreasen NC, Endicott J, Spitzer RL, Winokur G (1977) The family history method using diagnostic criteria. Reliability and validity. Arch Gen Psychiatry 34:1229–1235PubMedGoogle Scholar
  14. Angst J (1973) The etiology and nosology of endogenous depressive psychoses. Foregin Psychiatry 2:1–108Google Scholar
  15. Angst J (1978) The course of affective disorders. II. Typology of bipolar manic-depressive illness. Arch Psychiatr Nervenkrankh 226:65–73CrossRefGoogle Scholar
  16. Astrup C, Fossum A, Holmboe R (1959) A follow-up study of 2780 patients with acute affective psychoses. Acta psychiatr Scand 34:7–62Google Scholar
  17. Berrios GE (1991) Affective disorders in old age: A conceptual history. Int J Geriatr Psychiatry 6:337–346CrossRefGoogle Scholar
  18. Bland RC, Newman SC, Orn H (1986) Recurrent and nonrecurrent depression. A family study. Arch Gen Psychiatry 43:1085–1089PubMedGoogle Scholar
  19. Cassano GB, Akiskal HS, Musetti L, Perugi G, Soriani A, Mignani V (1989) Psychopathology, temperament, and past course in primary major depressions. 2. Toward a redefinition of bipolarity with a new semistructured interview for depression. Psychopathology 22:278–288PubMedGoogle Scholar
  20. Cassano GB, Akiskal HS, Savino M, Musetti L, Perugi G, Soriani A (1992) Proposed subtypes of Bipolar II disorder: With hypomanic episodes and/or with hyperthymic temperament. J Affective Disord 26:127–140CrossRefGoogle Scholar
  21. Cassano GB, Musetti L, Perugi G, Mignani V, Soriani A, McNair DM, Akiskal HS (1987) Major depression subcategories: their potentiality for clinical research. In: Diagnosis and treatment of depression. “Quo Vadis?” Symposium, Sanofi Group, May 11–12, Montpellier, France, pp 91–103Google Scholar
  22. Cassano GB, Musetti L, Perugi G, Soriani A, Mignani V, McNair DM, Akiskal HS (1988) A proposed new approach to the clinical subclassification of depressive illness. Pharmacopsychiatry 2:19–23Google Scholar
  23. Dreyfus GL (1907) Die Melancholie. Ein Zustandsbild des Manisch-Depressiven Irreseins, G Fischer, JenaGoogle Scholar
  24. Goodwin FK, Jamison KR (1990) Manic-depressive illness. Oxford University Press, New YorkGoogle Scholar
  25. Hamilton M (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry 23:56–62PubMedGoogle Scholar
  26. Hamilton M (1967) Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol 6:278–296PubMedGoogle Scholar
  27. Keller MB, Lavori PW, Endicott J, Coryell W, Klerman GL (1983) “Double depression”: two-year-follow-up. Am J Psychiatry 140:689–694PubMedGoogle Scholar
  28. Kinkelin M (1954) Verlauf und Prognose des manischdepressiven Irreseins. Schweizer Archiv fur Neurologie und Psychiatrie (Zurich) 73:100–146Google Scholar
  29. Klein DN (1990) Depressive personality: reliability, validity, and relation to dysthymia. J Abnorm Psychol 99:412–421CrossRefPubMedGoogle Scholar
  30. Klein DN, Taylor EB, Harding K, Dickstein S (1988) Double depression and episodic major depression: demographic, clinical familial, personality, and socioenvironmental characteristics and short-term outcome. Am J Psychiatry 145:1226–1231PubMedGoogle Scholar
  31. Kraepelin E (1896) Psychiatrie. Ein Lehrbuch fur Studienierende und Aerzte, 5th edn. A Abel, LeipzigGoogle Scholar
  32. Kraepelin E (1921) Manic-depressive insanity and paranoia. Translated by RM Barclay, GM Robertson (eds) ES Livingstone, EdinburghGoogle Scholar
  33. Kraepelin E (1990) Psychiatry: a textbook for students and physicians, vol 2. Science History Publications, Canton, MaineGoogle Scholar
  34. Musetti L, Perugi G, Soriani A, Rossi VM, Cassano GB, Akiskal HS (1989) Depression before and after age 65. A re-examination. Br J Psychiatry 155:330–336PubMedGoogle Scholar
  35. Perris C (1968) The course of depressive psychoses. Acta Psychiatr Scand 44:238–248PubMedGoogle Scholar
  36. Perugi G, Musetti L, Simonini E, Piagentini F, Cassano GB, Akiskal HS (1990) Gender-mediated clinical features of depressive illness: The importance of temperamental differences. Br J Psychiatry 157:835–841PubMedGoogle Scholar
  37. Pichot P, Pull C (1981) Is there an involutional melancholia. Compr Psychiatry 22:2–10CrossRefPubMedGoogle Scholar
  38. Pichot P, Pull CB, Nowicka E, Pull MC, Frenckell R von (1979) [Involutional melancholia: IV. Comparison of the symptomatology of unipolar depressions with early onset and unipolar depressions with late onset]. Ann Med Psychol (Paris) 137:975–986Google Scholar
  39. Schneider K (1959) Clinical psychopathology. Grune and Stratton, New YorkGoogle Scholar
  40. Stenstedt A (1959) Involutional melancholia: A etiologic, clinical and social study of endogenous depression in later life, with special reference to genetic factors. Acta Psychiatr Neurol Scand (Suppl) 127Google Scholar
  41. Strober M, Carlson G (1982) Bipolar illness in adolescents with major depression: clinical, genetic, and psychopharmacologic predictors in a three — to four-year prospective follow-up investigation. Arch Gen Psychiatry 39:549–555PubMedGoogle Scholar
  42. Weissman MM (1979) The myth of involutional melancholia. J Am Med Assoc 242:742–744CrossRefGoogle Scholar
  43. Winokur G (1974) Genetic and clinical factors associated with course in depression. contributions to genetic aspects. Pharmakopsychiatr Neuro-Psychopharmakol 7:122–126Google Scholar
  44. Winokur G, Tsuang MT, Crowe RR (1982) The Iowa 500: affective disorder in relatives of manic and depressed patients. Am J Psychiatry 139:209–212PubMedGoogle Scholar
  45. Winokur G (1979) Unipolar depression: is it divisible into autonomous subtypes. Arch Gen Psychiatry 36:47–52PubMedGoogle Scholar
  46. Young RC, Abrams RC, Alexopoulos GS, Shindledecker R (1989) Sensation-Seeking Scale scores in treated geriatric depressives and controls. Biol Psychiatry 26:643–646CrossRefPubMedGoogle Scholar
  47. Zis AP, Grof P, Webster M (1980) Prediction of relapse in recurrent affective disorder. Psychopharmacol Bull 16:47–49Google Scholar

Copyright information

© Springer-Verlag 1993

Authors and Affiliations

  • Giovanni B. Cassano
    • 1
  • Hagop S. Akiskal
    • 2
  • Mario Savino
    • 1
  • Adalgisa Soriani
    • 1
  • Laura Musetti
    • 1
  • Giulio Perugi
    • 1
  1. 1.II Psychiatric Clinic, Institute of Clinical PsychiatryUniversity of PisaPisaItaly
  2. 2.University of California at San DiegoSan DiegoUSA

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