A study of predictive factors in depressive disorders of poor outcome

The effect of sequential antidepressant treatment on geriatric depression

This study evaluated the outcome of elderly depressed patients who were refractory to, or intolerant of, an initial trial of nortriptyline and who then underwent systematic treatment with other antidepressant therapies. 101 patients entered the study and 61% responded to nortriptyline, 64% of patients who did not improve with nortriptyline eventually responded to other antidepressant treatments. Response to second-line treatment (phenelzine) was significantly slower than response to the tricyclic antidepressant. Treatment nonresponders were more likely to have a longer episode length at index assessment and higher baseline anxiety scores compared with responders. This study demonstrates the importance of persisting with systematic antidepressant therapy in elderly patients who do not respond to the first trial of treatment.

Pharmacological management of refractory depression

Managing patients with "treatment resistant depression" offers a major challenge to clinical psychiatrists, psychopharmacologists, and others. Firstly, patient heterogeneity must be recognized in terms of symptom presentation, biological variables, co-morbidity with other psychiatric and medical disorders and associated personality disorder. Secondly, a rigorous approach to the treatment resistant patient must allow for adequate individual and combination therapies including heterocyclic agents, monoamine oxidase inhibitors, electroconvulsive therapy, and augmentation with lithium carbonate or thyroid hormone. The novel antidepressant therapies have not so far altered the relapsing course of depressive illness for many patients.

Chronic depression

Defining chronic depression as persistent symptoms for 2 or more years, a prevalence of chronic depression of 12-15% is found in the literature. A four-part classification of chronic depression is proposed: Chronic Primary Major Depression; Chronic Secondary Major Depression; Characterological or Chronic Minor Depression (Dysthymic Disorder); and 'Double Depression'. The literature indicates several factors predicting chronicity in primary major depression: more at risk are female patients, particularly those with premorbid neurotic personality traits, individuals with unipolar disorders, and those with higher familial loading for such disorders. Other factors are the adequacy and appropriateness of the treatment given, and the length of illness episode prior to treatment being received. Larger studies with well-matched controls are needed.

Prediction of outcome in depression by negative symptoms

Negative symptoms have been assessed in 34 cases of major endogenous depression (RDC) using the Scale for Assessment of Negative Symptoms. Correlation coefficients between negative symptoms and improvement rated on a 5-point scale were determined. Poverty of speech, affective flattening and avolition-apathy were found to be related with poor outcome. There was also a negative relationship between improvement and certain frequently occurring negative symptoms: inability to feel emotions, feelings of emptiness in thinking and feeling of avolition. High total negative symptom scores predicted poor outcome.

Chronicity in major depression. A naturalistic prospective study

In a prospective naturalistic study many of the 120 patients treated for a current major depressive episode continued to meet the criteria for a major depressive episode as defined by DSM-III during the whole follow-up period (from 1 to 4 years). The problem of compatibility between the chronicity of a full depressive syndrome and the definition of the major depression as episodic with possible relapses or recurrences is discussed. A relationship between chronicity and lack of adequate treatment at onset was found.

Paranoid schizophrenia: an unorthodox view

Most paranoid patients have traditionally been diagnosed as schizophrenic, although considerable evidence points to the dissimilarities between paranoid and nonparanoid schizophrenic patients and to commonalities between paranoid and affective disorder groups. Based on a review of research, it is suggested that paranoid schizophrenia, at least in some of its varieties, may more fruitfully be conceptualized as a phenotypic expression of an underlying depressive mode than as a schizophrenic form. This formulation is presented within the framework of a broad examination of diagnostic issues.