Chronic depression

Depression is not just an individual problem it is also a social problem. The people most likely to become depressed are poor, unemployed and undereducated.53 To some extent, this may be due to what is called social selection or economic drift. People who are chronically depressed might find it harder to perform well or even hold a job, and this might lead to a downward shift in their economic status. But there are data showing that the cause and effect can also run in the opposite direction.54 Different ethnic groups, for example, have different rates of depression. As the authors of one of the studies investigating this pointed out, ethnic status cannot be an effect of disorder because it is present at birth . Another study showed that people are more likely to become depressed if their parents were poor or less educated. These data cannot be explained by the economic-drift hypothesis. In other words, poverty and discrimination can cause depression. 

When I started to get better I realized I was chronically depressed. I felt numb. I knew that if I let it go further than that, I wouldn t want to get out of bed. I knew that wasn t a good place to be, that... 

The increased use of petrochemical derivatives in building construction will ease the demand on timber and produce a decidedly beneficial side effect that of revitalizing the chronically depressed paper industry in a land which prides itself as the inventor of paper. 

Hypomania and use with other antidepressants One case has been reported of concurrent use of hypericum with an SSRI. Gordon (1998) reported a case of a 50-year-old woman taking 600 mg/day of hypericum for chronic depression. She had discontinued taking Paxil 10 days prior to hypericum and experienced no ill effects at that time. However, she added 20 mg of paroxetine to her regimen of hypericum to improve her sleep. She presented with lethargy, nausea, and weakness, but vital signs and mental status were normal. Following discontinuation of medications, she returned to normal status the next day. 

Piazza LA, Markowitz JC, Kocsis JH, Leon AC, Portera L, Miller NL, Adler D. (1997). Sexual functioning in chronically depressed patients treated with SSRI antidepressants a pilot study. Am J Psychiatry. 154(12) 1757-59. 

A series of studies demonstrates a synergistic effect between drug therapies and psychodynamic talk therapies. The effectiveness of each form of therapy used independently is less than their combined use in the case of major depression. See A. Solomon, The Noonday Demon An Atlas of Depression (New York Scribner s, 2001) E. Good, Chronic Depression Study Backs the Pairing of Therapy and Drugs, New York Times (May 18, 2000) L. Altshuler et al., Treatment of Depression in Women A Summary of the Expert Consensus Guidelines, of Psychiatric Practice 7 (May 2001) 185-208. Kleinman, Rethinking Psychiatry p. ii. 

From our clinical experience, we have found that youth with more severe and chronic depressions and those with significant comorbid disorders or who experience parental conflict often fail to respond to either monotherapy alone (Clarke et ah, 1992 Brent et ah, 1998 Emslie et ah, 1998). Therefore, severe and chronic depressions should be treated with both antidepressants and psychotherapy, and other risk factors for poor outcome (e.g., parent depression, ADHD) should be addressed with additional psychosocial and/or pharmacological interventions. 

In depressed adults (APA, 2000), patients who have only a single, uncomplicated episode of depression, or those with mild episodes or with lengthy intervals between episodes (e.g., 5 years) should probably not start maintenance treatment. There is also consensus that adult patients with three or more episodes (especially if they occur in a short period of time or have deleterious consequences) and those with chronic depression should receive maintenance treatment. 

D. L., Gelenberg, A.J., Markowitz, J.C., Nemeroff, C.B., Russell, J.M., Thase, M.E., Trivedi, M.H., and Zajecka, J. (2000) A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. Multicenter study. Randomized controlled trial. N Engl J Med 342 1462-1470. 

Rapid-onset of retarded depression Slow-onset/chronic depression... 

A recently conducted study compared the efficacy of IMI to that of sertraline in patients with double depression and chronic depression. After... 

Keller MB, Hanks DL Course and outcome in panic disorder and depression. J Clin Psychopharmacol Biol Psychiatry 17 551-570, 1993 Keller MB, Shapiro RW Double depression superimposition of acute depressive episodes on chronic depressive disorders. Am J Psychiatry 139 438-442, 1982 Keller MB, Shapiro RW, Lavori PW, et al Recovery in major depressive disorder analysis with the life table and regression models. Arch Gen Psychiatry 39 905-910, 1982a... 

Schatzberg AF, Kornstein S, Keitner G, et al Gender and treatment response in chronic depression. Paper presented at the 34th annual meeting of the American College of Neuropsychopharmacology, San Juan, Puerto Rico, December 11-15, 1995, Scientific Abstracts, p 247... 

Keller MB Long-term treatment of recurrent and chronic depression. J Clin Psychiatry 62 (suppl 24) 3-5, 2001... 

The study by Elkin et al. (391) from the National Institute of Mental Health Treatment of Depression Collaborative Research Program suggested that antidepressants had superior efficacy in the treatment of moderate to more severe episodes of major depression (i.e., 17-item HDRS score of 20 or more). In response to that claim, DeRubeis et al. (396) performed a metaanalysis of four studies and found that CBT was as effective as several different antidepressants in such cases. More recently, Keller et al. (397) found that a variant of CBT called cognitive-behavioral analyses (CBAS) therapy was as effective as nefazodone (mean dose = 460 mg per day) in producing both response and remission in outpatients with moderate to more severe chronic depression. 

Weissman MM, Klerman GL. The chronic depressive in the community unrecognized and poorly treated. Compr Psychiatry 1977 18 523-531. 

Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engi J Med 2000 342 1462-1470. 

Zajecka J, Dunner DL, Hirschfeld R, et al. Sexual function and satisfaction in the treatment of chronic depression with nefazodone, psychotherapy and their combination. 40th Annual Meeting NCDEU, Boca Raton, Florida, 2000. 

QUALITATIVE COMMENTS (with 15 mg, orally) "I got a strong psychedelic experience that lasted about twelve hours, but an unexpected relief from my chronic depression that lasted for four days."... 

Prozac has been the center of controversy over the past few years. Hailed by psychiatrists and psychologists as a valuable tool in the treatment of chronic depression, the press has focused in on its not too infrequent side effects including suicidal depression. Philosophical questions also arise when considering the alleviation of depression viewed as a natural human condition . Those on Prozac undergo subtle yet significant changes in motivation and outlook which some believe is abnormal in the scheme of things. 

Of 20 patients with severe hypoglycemic coma and 20 with no or light coma, those with hypoglycemia had chronic depression and anxiety and performed persistently more poorly in several cognitive tests (74). 

Bauer M, Whybrow PC, Angst J, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders, part 2 Maintenance treatment of major depressive disorder and treatment of chronic depressive disorders and subthreshold depressions. World J Biol Psychiatry. 2002 3 69-86. 

Akiskal HS, Lemmi H, Dickson H, King D, Yerevanian B, Van Valkenburg C (1984) Chronic depressions. Part 2. Sleep EEG differentiation of primary dysthymic disorders from anxious depressions. J Affect Disord 6 287-295... 

Mental disorders, also called affective disorders, are multi-level, multi-scale and multiple-system diseases (Fig. 7.1). Mental disturbances generally go along with disturbances of autonomous functions. These essentially are (1) sleep disturbances, both sleep duration and sleep pattern, and (2) disturbances of the hypothalamic-pituitary-adrenal (HPA) axis, the so-called stress axis with elevated cortisol levels. It can be expected that disturbances of autonomous control systems as well as mood are caused by neuronal malfunctioning which may concern practically all neuronal levels systemic interactions, neuronal network connections, single neuron dynamics, synaptic transmitters and/or receptors, ion channels, second messengers, and gene expression (Fig. 7.1a). Nevertheless, despite a manifold of data, there are only vague ideas so far about the differences in neuronal dynamics in the brain of a chronically depressed person compared with a person with a sensitive but balanced mood. 

Mrs. Williams remains chronically depressed and refuses to go to any doctors for anything. She lives with her daughter, who supports her financially. 

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