Handbook of Chronic Depression: Diagnosis and Therapeutic Management PDF

Preface

Our goal as editors of this handbook was to join with respected colleagues with complementary expertise to produce a guide to chronic depression that would be accessible, clinically relevant, and empirically based. The enthusiasm with which we have pursued this project has been fueled by the steadily emerging recognition that chronic depression is not an esoteric subtype of depression, but rather a ubiquitous clinical feature associated with significant morbidity.

Although the majority of controlled depression treatment trials extend over months (1), the burden of depressive disorders is frequently measured in years. Consistent with clinical experience, major epidemiological studies (2–4) and observations from a number of large outcome studies over the past two decades, including the Zurich Follow-Up Study (5), the National Institute of Mental Health Collaborative Depression Study (6), and theMedical Outcomes Study (7), have helped refocus our understanding of major depressive disorder (MDD) from that of an episodic illness to that of a disorder with a strong tendency to persist and/or recur and a propensity to produce long-lasting and pervasive psychosocial and general medical consequences, indeed even when present in diminished intensity as subsyndromal symptoms.

There exists, as yet, no uniform definition of ‘‘chronic depression'' and there is relatively little work comparing the clinical significance, if any, of different expressions of chronicity (8,9). Hence, the subject is defined broadly in this book, incorporating, in part, the DSM-IV specifiers for chronicity (10), but more generally regarding a depression as chronic when its clinically significant burden of symptoms and/or functional impairment extends over several years. This includes a chronic major depressive episode (>2 years meeting fullMDDcriteria), a major depressive episode with incomplete interepisode recovery, dysthymic disorder, and other protracted subsyndromal depressions, and a major depressive episode superimposed upon dysthymic disorder [‘‘double depression'' (11)]. In some clinical instances, persistence of depression is related to absence of or inadequate treatment, although in others it reflects treatment refractoriness or intolerance, and these different sources of chronicity are addressed in the chapters that follow.

The first five chapters of the handbook focus on biopsychosocial factors in chronic depression. Miller, Battle, and Anthony provide an incisive introduction to the definition and assessment of psychosocial functioning in chronic depression as well as theoretical perspectives on psychosocial impairment as antecedents and consequences of depression. Rothschild and Zimmerman explore and illuminate the often hazy and clinically challenging interface between chronic depression and personality pathology. Riso and Klein provide an overview of studies concerning risk factors for chronicity and advance a preliminary model that incorporates these findings and sets the stage for further research. Although few biological studies relate to chronicity per se, Mischoulon, Dougherty, and Fava draw broadly on neuroimaging, neuroendocrine, genetic, electro-encephalographic, and immunological studies to yield current perspectives on the pathophysiology of depression, while Smoller and Perlis focus on the rapidly evolving field of family and genetic studies.

The midsection of the handbook concerns treatment. Howland provides an expert review of the growing literature on the psychopharmacology of dysthymia and double depression, while Keitner and Cardemil describe psychotherapy treatment studies for chronic depression from a variety of perspectives, including cognitive-behavior therapy (CBT), interpersonal psychotherapy (IPT), the cognitive behavioral analysis system of psychotherapy (CBASP), group treatment, and family-based treatment. Maddux and Rapaport extend the discussion of psychopharmacological and psychotherapeutic studies to the treatment of subsyndromal forms of depression. Turning to the prevention of depressive relapse and recurrence, Friedman and Thase review continuation and maintenance treatment studies involving psychotherapy alone and in combination with medications and call attention to areas that require further study, while Petersen, Nierenberg, Ryan, and Alpert reviewthe companion literature on long-term antidepressant therapy for the prevention of relapse and recurrence and address the problem of depressive re-emergence (‘‘breakthrough'') during treatment. M. Fava provides an up-to-date discussion of pharmacological treatment tactics and strategies for resistant depression and residual symptoms, while G.A. Fava and Ruini look specifically at psychotherapy of residual symptoms, including a description of a novel approach known as ‘‘well-being therapy'' (WBT).

Treatment of chronic depression among special populations and in special settings is the agenda of the subsequent four chapters, including an introduction by Nonacs and Cohen to the management of depression during pregnancy, insights about the assessment and treatment of depression in later life by Apfeldorf and Alexopoulos, and a comprehensive and thoughtful review of current knowledge about pediatric depression and its treatment by Pilowsky and Weissman. Finally, Rosenstein, Soleymani, and Cai tackle the complexities of treating chronic depression in the setting of concurrent medical illness, including the risks of drug–drug interactions.

Simon and Ludman highlight critical shortcomings and barriers in the treatment of chronic depression and describe how chronic illness management principles could be used to optimize patient care. Zajecka and Beeler focus on improving patient adherence, a major challenge in long term depression treatment, and Kinrys, Simon, Farach, and Pollack provide a detailed and practical guide to the treatment of common antidepressant side effects to enhance both treatment adherence and quality of life for those many individuals requiring long-term pharmacotherapy.

Despite the growing recognition of depression as a chronic disorder for which management rather than cure is frequently the most accurate model, perhaps nowhere has the gap been more obvious between clinical practice and research than when it comes to the long-term management of depression. Our fond hope is that this book, by providing a synthesis of current research findings and clinical strategies for addressing chronic depression, helps bridge this gap.