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.
Similar content being viewed by others
References
Keller MB, Shapiro RW. ‘Double depression’: superimposition of acute depressive disorders on chronic depressive disorders. Am J Psychiatry 1982; 139: 438–42
Keller MB, Lavori PW, Endicott J, et al. ‘Double depression’: two-year follow-up. Am J Psychiatry 1983; 140: 689–94
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC: American Psychiatric Association, 1980: 220–3
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: 777–83
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: 316–28
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. rev. Washington, DC: American Psychiatric Association, 1987: 230–3
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994; 623–4
Angst J, Stabl M. Efficacy of moclobemide in different patient groups: a meta-analysis of studies. Psychopharmacology 1992; 106Suppl.: S109–13
Rounsaville BJ, Sholomskas D, Prosoff BA. Chronic mood disorders in depressed outpatients: diagnosis and response to pharmacotherapy. J Affect Disord 1980; 2: 73–88
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: 1226–31
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: 678–82
Howland RH. Chronic depression. Hosp Community Psychiatry 1993; 44: 633–9
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: 815–9
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: 931–4
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: 817–23
Howland RH, Thase ME. Biological studies of dysthymia. Biol Psychiatry 1991; 30: 283–304
Howland RH. General health, health care utilization, and medical comorbidity in dysthymia. Int J Psychiatry Med 1993; 23: 211–38
Friedman RA. Social impairment in dysthymia. Psychiatr Ann 1993; 23: 632–7
Markowitz JC, Moran ME, Kocsis JH, et al. Prevalence and comorbidity of dysthymic disorder. J Affect Disord 1992; 24: 63–71
Stewart JW, Quitkin FM, McGrath PJ, et al. Social functioning in chronic depression: effect of six weeks of antidepressant treatment. Psychiatry Res 1988; 25: 213–22
Endicott J, Spitzer RL. A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 1978; 35: 837–44
Weissman MM, Bothwell S. Assessment of social adjustment by patient self-report. Arch Gen Psychiatry 1976; 33: 1111–5
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: 11–9
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: 788–94
Allgulander C. Suicide and mortality patterns in anxiety neurosis and depressive neurosis. Arch Gen Psychiatry 1994; 51: 708–12
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): 25–31
Keller MB. Dysthymia in clinical practice: course, outcome and impact on the community. Acta Psychiatr Scand 1994; 383Suppl.: 24–34
Froom J, Schlager DAS, Steneker S, et al. Detection of major depressive disorder in primary care patients. J Am Board Fam Pract 1993; 6: 5–11
Katon W, von Korff M, Lin E, et al. Adequacy and duration of antidepressant treatment in primary care. Med Care 1992; 30: 67–76
Simon GE, von Korff M, Wagner EH, et al. Patterns of antidepressant use in community practice. Gen Hosp Psychiatry 1993; 15: 399–408
Kocsis JH, Voss C, Mann JJ, et al. Chronic depression: demographic and clinical characteristics. Psychopharmacol Bull 1986; 22: 192–5
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: 694–700
Harrison WM, Stewart JW. Pharmacotherapy of dysthymia. Psychiatr Ann 1993; 23: 638–48
Howland RH. Pharmacotherapy of dysthymia: a review. J Clin Psychopharmacol 1991; 11: 83–92
Harrison W, Rabkin J, Stewart JW, et al. Phenelzine for chronic depressions: a study of continuation treatment. J Clin Psychiatry 1986; 47: 346–9
Kocsis JH, Frances AJ, Voss CB, et al. Imipramine for treatment of chronic depression. Arch Gen Psychiatry 1988; 45: 253–7
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: 139–47
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 25: 56–62
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: 1169–75
Marin DB, Kocsis JH, Frances AJ, et al. Desipramine for the treatment of ‘pure’ dysthymia versus ‘double’ depression. Am J Psychiatry 1994; 151: 1079–80
Kocsis JH, Sutton BM, Frances AJ. Long-term follow-up of chronic depression treated with imipramine. J Clin Psychiatry 1991; 52: 56–9
Hellerstein DJ, Little SAS. SSRI medications in the treatment of dysthymia and chronic depression. J Serotonin Res 1994; 1: 181–7
Kocsis JH, Friedman RA, Markowitz JC, et al. Maintenance therapy for chronic depression: a controlled clinical trial of desipramine. Arch Gen Psychiatry. In press
Frank E, Kupfer DJ, Perel JM, et al. Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 1990; 47: 1093–9
Montgomery SA, Dufour H, Brion S, et al. The prophylactic efficacy of fluoxetine in unipolar depression. Br J Psychiatry 1992; 160: 217–22
Doogan DP, Caillard V. Sertraline in the prevention of depression. Br J Psychiatry 1992; 160: 1082–8
Markowitz Je. Comorbidity of dysthymia. Psychiatr Ann 1993; 23: 617–24
Pilkonis PA, Frank E. Personality pathology in recurrent depression: nature, prevalence, and relationship to treatment response. Am J Psychiatry 1988; 145: 435–41
Greden JE. Antidepressant maintenance medications: when to discontinue and how to stop. J Clin Psychiatry 1993; 54Suppl. 8: 39–45
Akiskal HS. Dysthymic and cyclothymic depressions: therapeutic considerations. J Clin Psychiatry 1994; 55Suppl. 4: 46–52
Johnston JA, Lineberry CG, Ascher JA, et al. A 102-center prospective study of seizures in association with bupropion. J Clin Psychiatry 1991; 52: 450–6
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.: 30–4
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: 1201–2
Rasmussen SA, Eisen JL, Pato MT. Current issues in the pharmacologic management of obsessive compulsive disorder. J Clin Psychiatry 1993; 54Suppl.: 4–9
Schweizer E, Weise C, Calry C, et al. Placebo-controlled trial of venlafaxine for the treatment of major depression. J Clin Psychopharmacol 1991; 11: 233–6
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: 104–8
Nemeroff CB. Evolutionary trends in the pharmacotherapeutic management of depression. J Clin Psychiatry 1994; 55Suppl. 12: 3–15
Deleo D, Magni G. Sexual side effects of antidepressant drugs. Psychosomatics 1983; 24: 1076–82
McElroy SL, Keck Jr PE, Friedman LM. Minimizing and managing antidepressant side effects. J Clin Psychiatry 1995; 56Suppl. 2: 49–55
Fawcett J. Compliance: definition and key issues. J Clin Psychiatry 1995; 56Suppl.: 4–8
Nierenberg AA. Treatment-resistant depression in the age of serotonin. Psychiatr Ann 1994; 24: 217–9
Haykal RF. Dysthymia comorbidity and predictors of response [paper session]. American Psychiatric Association Annual Meeting: 1993 May 22-27; San Francisco (CA), 182–3
Thase ME, Howland RH. Refractory depression: relevance of psychosocial factors and therapies. Psychiatr Ann 1994; 24: 232–40
Markowitz JC. Psychotherapy of dysthymia. Am J Psychiatry 1994; 151: 1114–21
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: 52–5
Nelsen MR, Dunner DL. Treatment resistance in unipolar depression and other disorders: diagnostic concerns and treatment responsibilities. Psychiatr Clin North Am 1993; 16: 541–66
Markowitz Je. Psychotherapy of the post-dysthymic patient. J Psychother Pract Res 1993; 2: 157–63
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Hellerstein, D.J., Little, S.A.S. Current Perspectives on the Diagnosis and Treatment of Double Depression. CNS Drugs 5, 344–357 (1996). https://doi.org/10.2165/00023210-199605050-00004
Published:
Issue Date:
DOI: https://doi.org/10.2165/00023210-199605050-00004