CNS Drugs

, Volume 5, Issue 5, pp 344–357

Current Perspectives on the Diagnosis and Treatment of Double Depression

  • David J. Hellerstein
  • Suzanne A. S. Little
Disease Management
  • 11 Downloads

Summary

In recent years, the frequency with which patients present with ‘double depression’, i.e. coexisting chronic depression (dysthymia) and acute major depression, has become increasingly evident. A growing research literature demonstrates that patients with double depression are at increased risk for poor outcome, including poor psychosocial functioning, high usage of medical services, high rates of suicide attempts, and increased recurrence of major depression. Furthermore, naturalistic studies have shown that when these patients are treated in the community, they often do not receive adequate antidepressant medication to treat their acute or chronic depressive disorders.

In this article, we introduce a typology that is designed to assist clinicians in determining useful strategies in the short and long term treatment of double depression. This differentiates between those patients with double depression who present primarily with acute depression; those presenting primarily with chronic depression (where treatment can focus on the single, more severe disorder, and may be time-limited or episodic); and those presenting with severe acute depression and severe chronic depression, in whom lifelong medication is often required. Aggressive treatment is recommended for all patients with double depression, but refined treatment strategies based on depressive typology may help to increase compliance, consolidate therapeutic gains and forestall relapse.

A growing psychopharmacology literature shows that several different classes of medication [tricyclic antidepressants, monamine oxidase inhibitors, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors and others] are effective in the treatment of double depression, although perhaps somewhat less effective than in the treatment of acute major depression.

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References

  1. 1.
    Keller MB, Shapiro RW. ‘Double depression’: superimposition of acute depressive disorders on chronic depressive disorders. Am J Psychiatry 1982; 139: 438–42PubMedCrossRefGoogle Scholar
  2. 2.
    Keller MB, Lavori PW, Endicott J, et al. ‘Double depression’: two-year follow-up. Am J Psychiatry 1983; 140: 689–94PubMedCrossRefGoogle Scholar
  3. 3.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC: American Psychiatric Association, 1980: 220–3Google Scholar
  4. 4.
    Akiskal HS, Rosenthai TL, Radwan F, et al. Characterological depressions: clinical and sleep EEG findings separating ‘subaffective’ dysthymias from ‘character-spectrum disorders.’ Arch Gen Psychiatry 1980; 37: 777–83PubMedCrossRefGoogle Scholar
  5. 5.
    Kocsis JH, Markowitz JC, Prien RF. Comorbidity of dysthymic disorder. In: Maser JD, Cloninger RC, editors. Comorbidity of mood and anxiety disorders. Washington, DC: American Psychiatric Press, 1990: 316–28Google Scholar
  6. 6.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. rev. Washington, DC: American Psychiatric Association, 1987: 230–3Google Scholar
  7. 7.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994; 623–4Google Scholar
  8. 8.
    Angst J, Stabl M. Efficacy of moclobemide in different patient groups: a meta-analysis of studies. Psychopharmacology 1992; 106Suppl.: S109–13PubMedCrossRefGoogle Scholar
  9. 9.
    Rounsaville BJ, Sholomskas D, Prosoff BA. Chronic mood disorders in depressed outpatients: diagnosis and response to pharmacotherapy. J Affect Disord 1980; 2: 73–88PubMedCrossRefGoogle Scholar
  10. 10.
    Klein DN, Taylor EB, Harding K, et al. Double depression and episodic major depression: demographic, clinical, familial, personality, and socioenvironmental characteristics and short-term outcome. Am J Psychiatry 1988; 145: 1226–31PubMedCrossRefGoogle Scholar
  11. 11.
    Levitt AJ, Joffee RT, MacDondald C. Life course of depressive illness and characteristics of current episode in patients with double depression. J Nerv Ment Dis 1991; 179: 678–82PubMedCrossRefGoogle Scholar
  12. 12.
    Howland RH. Chronic depression. Hosp Community Psychiatry 1993; 44: 633–9PubMedGoogle Scholar
  13. 13.
    Weissman MM, Leaf PJ, Bruce ML, et al. The epidemiology of dysthymia in five communities: rates, risks, comorbidity, and treatment. Am J Psychiatry 1988; 145: 815–9PubMedCrossRefGoogle Scholar
  14. 14.
    Kashani JH, Carlson GA, Beck NC, et al. Depression, depressive symptoms and depressed mood among a community sample of adolescents. Am J Psychiatry 1987; 144: 931–4PubMedCrossRefGoogle Scholar
  15. 15.
    Horwath E, Johnson J, Klerman GL, et al. Depressive symptoms as relative and attributable risk factors for first-onset major depression. Arch Gen Psychiatry 1992; 49: 817–23PubMedCrossRefGoogle Scholar
  16. 16.
    Howland RH, Thase ME. Biological studies of dysthymia. Biol Psychiatry 1991; 30: 283–304PubMedCrossRefGoogle Scholar
  17. 17.
    Howland RH. General health, health care utilization, and medical comorbidity in dysthymia. Int J Psychiatry Med 1993; 23: 211–38PubMedCrossRefGoogle Scholar
  18. 18.
    Friedman RA. Social impairment in dysthymia. Psychiatr Ann 1993; 23: 632–7CrossRefGoogle Scholar
  19. 19.
    Markowitz JC, Moran ME, Kocsis JH, et al. Prevalence and comorbidity of dysthymic disorder. J Affect Disord 1992; 24: 63–71PubMedCrossRefGoogle Scholar
  20. 20.
    Stewart JW, Quitkin FM, McGrath PJ, et al. Social functioning in chronic depression: effect of six weeks of antidepressant treatment. Psychiatry Res 1988; 25: 213–22PubMedCrossRefGoogle Scholar
  21. 21.
    Endicott J, Spitzer RL. A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 1978; 35: 837–44PubMedCrossRefGoogle Scholar
  22. 22.
    Weissman MM, Bothwell S. Assessment of social adjustment by patient self-report. Arch Gen Psychiatry 1976; 33: 1111–5PubMedCrossRefGoogle Scholar
  23. 23.
    Hays RD, Wells KB, Sherbourne CD, et al. Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Arch Gen Psychiatry 1995; 52: 11–9PubMedCrossRefGoogle Scholar
  24. 24.
    Wells KB, Burnam MA, Rogers W, et al. The course of depression in adult outpatients: results from the medical outcomes study. Arch Gen Psychiatry 1992; 49: 788–94PubMedCrossRefGoogle Scholar
  25. 25.
    Allgulander C. Suicide and mortality patterns in anxiety neurosis and depressive neurosis. Arch Gen Psychiatry 1994; 51: 708–12PubMedCrossRefGoogle Scholar
  26. 26.
    Keller MB, Hanks DL. The natural history and heterogeneity of depressive disorders: implications for rational antidepressant therapy. J Clin Psychiatry 1994; 55(9 Suppl. A): 25–31PubMedGoogle Scholar
  27. 27.
    Keller MB. Dysthymia in clinical practice: course, outcome and impact on the community. Acta Psychiatr Scand 1994; 383Suppl.: 24–34CrossRefGoogle Scholar
  28. 28.
    Froom J, Schlager DAS, Steneker S, et al. Detection of major depressive disorder in primary care patients. J Am Board Fam Pract 1993; 6: 5–11PubMedGoogle Scholar
  29. 29.
    Katon W, von Korff M, Lin E, et al. Adequacy and duration of antidepressant treatment in primary care. Med Care 1992; 30: 67–76PubMedCrossRefGoogle Scholar
  30. 30.
    Simon GE, von Korff M, Wagner EH, et al. Patterns of antidepressant use in community practice. Gen Hosp Psychiatry 1993; 15: 399–408PubMedCrossRefGoogle Scholar
  31. 31.
    Kocsis JH, Voss C, Mann JJ, et al. Chronic depression: demographic and clinical characteristics. Psychopharmacol Bull 1986; 22: 192–5PubMedGoogle Scholar
  32. 32.
    Wells KB, Katon W, Rogers B, et al. Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the Medical Outcomes Study. Am J Psychiatry 1994; 151: 694–700PubMedCrossRefGoogle Scholar
  33. 33.
    Harrison WM, Stewart JW. Pharmacotherapy of dysthymia. Psychiatr Ann 1993; 23: 638–48CrossRefGoogle Scholar
  34. 34.
    Howland RH. Pharmacotherapy of dysthymia: a review. J Clin Psychopharmacol 1991; 11: 83–92PubMedGoogle Scholar
  35. 35.
    Harrison W, Rabkin J, Stewart JW, et al. Phenelzine for chronic depressions: a study of continuation treatment. J Clin Psychiatry 1986; 47: 346–9PubMedGoogle Scholar
  36. 36.
    Kocsis JH, Frances AJ, Voss CB, et al. Imipramine for treatment of chronic depression. Arch Gen Psychiatry 1988; 45: 253–7PubMedCrossRefGoogle Scholar
  37. 37.
    Hellerstein DJ, Yanowitch P, Rosenthal J, et al. Long-term treatment of double depression: a preliminary study with serotonergic antidepressants. Prog Neuropsych Biol Psychiatry 1994; 18: 139–47CrossRefGoogle Scholar
  38. 38.
    Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 25: 56–62CrossRefGoogle Scholar
  39. 39.
    Hellerstein DJ, Yanowitch P, Rosenthal J, et al. A randomized double-blind study of fluoxetine versus placebo in treatment of dysthymia. Am J Psychiatry 1993; 150: 1169–75PubMedCrossRefGoogle Scholar
  40. 40.
    Marin DB, Kocsis JH, Frances AJ, et al. Desipramine for the treatment of ‘pure’ dysthymia versus ‘double’ depression. Am J Psychiatry 1994; 151: 1079–80PubMedCrossRefGoogle Scholar
  41. 41.
    Kocsis JH, Sutton BM, Frances AJ. Long-term follow-up of chronic depression treated with imipramine. J Clin Psychiatry 1991; 52: 56–9PubMedGoogle Scholar
  42. 42.
    Hellerstein DJ, Little SAS. SSRI medications in the treatment of dysthymia and chronic depression. J Serotonin Res 1994; 1: 181–7Google Scholar
  43. 43.
    Kocsis JH, Friedman RA, Markowitz JC, et al. Maintenance therapy for chronic depression: a controlled clinical trial of desipramine. Arch Gen Psychiatry. In pressGoogle Scholar
  44. 44.
    Frank E, Kupfer DJ, Perel JM, et al. Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 1990; 47: 1093–9PubMedCrossRefGoogle Scholar
  45. 45.
    Montgomery SA, Dufour H, Brion S, et al. The prophylactic efficacy of fluoxetine in unipolar depression. Br J Psychiatry 1992; 160: 217–22CrossRefGoogle Scholar
  46. 46.
    Doogan DP, Caillard V. Sertraline in the prevention of depression. Br J Psychiatry 1992; 160: 1082–8CrossRefGoogle Scholar
  47. 47.
    Markowitz Je. Comorbidity of dysthymia. Psychiatr Ann 1993; 23: 617–24CrossRefGoogle Scholar
  48. 48.
    Pilkonis PA, Frank E. Personality pathology in recurrent depression: nature, prevalence, and relationship to treatment response. Am J Psychiatry 1988; 145: 435–41PubMedCrossRefGoogle Scholar
  49. 49.
    Greden JE. Antidepressant maintenance medications: when to discontinue and how to stop. J Clin Psychiatry 1993; 54Suppl. 8: 39–45PubMedGoogle Scholar
  50. 50.
    Akiskal HS. Dysthymic and cyclothymic depressions: therapeutic considerations. J Clin Psychiatry 1994; 55Suppl. 4: 46–52PubMedGoogle Scholar
  51. 51.
    Johnston JA, Lineberry CG, Ascher JA, et al. A 102-center prospective study of seizures in association with bupropion. J Clin Psychiatry 1991; 52: 450–6PubMedGoogle Scholar
  52. 52.
    Quitkin FM, Stewart JW, McGrath PJ, et al. Columbia atypical depression. A subgroup of depressives with better response to MAOI than to tricyclic antidepressants or placebo. Br J Psychiatry 1993; 21Suppl.: 30–4Google Scholar
  53. 53.
    Fyer AJ, Mannuzza S, Coplan JD. Panic disorders and agoraphobia. In: Kaplan HI, Sadock BJ, editors. Comprehensive textbook of psychiatry. 6th ed. Baltimore: Williams and Wilkins, 1995: 1201–2Google Scholar
  54. 54.
    Rasmussen SA, Eisen JL, Pato MT. Current issues in the pharmacologic management of obsessive compulsive disorder. J Clin Psychiatry 1993; 54Suppl.: 4–9PubMedGoogle Scholar
  55. 55.
    Schweizer E, Weise C, Calry C, et al. Placebo-controlled trial of venlafaxine for the treatment of major depression. J Clin Psychopharmacol 1991; 11: 233–6PubMedGoogle Scholar
  56. 56.
    Schweizer E, Feighner J, Mandos L, et al. Comparison of venlafaxine and imipramine in the acute treatment of major depression in outpatients. J Clin Psychiatry 1994; 55: 104–8PubMedGoogle Scholar
  57. 57.
    Nemeroff CB. Evolutionary trends in the pharmacotherapeutic management of depression. J Clin Psychiatry 1994; 55Suppl. 12: 3–15PubMedGoogle Scholar
  58. 58.
    Deleo D, Magni G. Sexual side effects of antidepressant drugs. Psychosomatics 1983; 24: 1076–82CrossRefGoogle Scholar
  59. 59.
    McElroy SL, Keck Jr PE, Friedman LM. Minimizing and managing antidepressant side effects. J Clin Psychiatry 1995; 56Suppl. 2: 49–55PubMedGoogle Scholar
  60. 60.
    Fawcett J. Compliance: definition and key issues. J Clin Psychiatry 1995; 56Suppl.: 4–8PubMedGoogle Scholar
  61. 61.
    Nierenberg AA. Treatment-resistant depression in the age of serotonin. Psychiatr Ann 1994; 24: 217–9CrossRefGoogle Scholar
  62. 62.
    Haykal RF. Dysthymia comorbidity and predictors of response [paper session]. American Psychiatric Association Annual Meeting: 1993 May 22-27; San Francisco (CA), 182–3Google Scholar
  63. 63.
    Thase ME, Howland RH. Refractory depression: relevance of psychosocial factors and therapies. Psychiatr Ann 1994; 24: 232–40CrossRefGoogle Scholar
  64. 64.
    Markowitz JC. Psychotherapy of dysthymia. Am J Psychiatry 1994; 151: 1114–21PubMedCrossRefGoogle Scholar
  65. 65.
    Fava M, Rappe SM, Pava JA, et al. Relapse in patients on long-term fluoxetine treatment: response to increased fluoxetine dose. J Clin Psychiatry 1995: 56: 52–5PubMedGoogle Scholar
  66. 66.
    Nelsen MR, Dunner DL. Treatment resistance in unipolar depression and other disorders: diagnostic concerns and treatment responsibilities. Psychiatr Clin North Am 1993; 16: 541–66PubMedGoogle Scholar
  67. 67.
    Markowitz Je. Psychotherapy of the post-dysthymic patient. J Psychother Pract Res 1993; 2: 157–63PubMedCentralPubMedGoogle Scholar

Copyright information

© Adis International Limited 1996

Authors and Affiliations

  • David J. Hellerstein
    • 1
  • Suzanne A. S. Little
    • 2
  1. 1.Psychiatric Outpatient Services, Beth Israel Medical Center and Department of PsychiatryAlbert Einstein College of MedicineNew YorkUSA
  2. 2.Mood Disorders Research UnitBeth Israel Medical CenterNew YorkUSA

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