Chronic Depression: Diagnosis and Classification

Author(s): Daniel N. Klein

Source: Current Directions in Psychological Science, Vol. 19, No. 2 (APRIL 2010), pp. 96-100
Published by: Sage Publications, Inc. on behalf of Association for Psychological Science
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 aps ^MHM I ASSOCIATION FOR
^MHM I ASSOCIATION FOR
PSYCHOLOGICAL SCIENCE

Current Directions in Psychological

Science

Chronic Depression: Diagnosis and 19(2) 96-100

The Author(s) 2010
Classification Reprints and permission:
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($)SAGE
Daniel N. Klein
Stony Brook University

Abstract

Traditionally, non-bipolar depression has been viewed as an episodic, remitting condition. However, with the recognition
depressions can persist for many years, the current diagnostic classification system includes various forms of chronic depre
The distinction between chronic and nonchronic depressions is useful for reducing the heterogeneity of the disorder. Indiv
with chronic depression differ from those with nonchronic depression on a variety of clinically and etiologically significant
ables, including comorbidity, impairment, suicidality, history of childhood maltreatment, familial psychopathology, and long
course. In contrast, there is little support for current distinctions between different forms of chronic depression. This su
that it may be simpler to collapse the existing forms of chronic depression in the current classification system into a si
category. However, there is growing evidence that other characteristics, such as age of onset and a childhood history of
adversity, may provide meaningful approaches to subtyping chronic depression.

Keywords
depression, chronic, mood disorders, dysthymic disorder, double depression

Traditionally, depressive disorders have been conceptualized

article, I provide a brief overview of research on the diagnosis
and pub-
as episodic, remitting conditions. However, following the classification of chronic depression.
lication of several seminal papers in the late 1970s and 1980s
(Akiskal et al., 1980; Keller & Shapiro, 1982; Kocsis &
Frances, 1987; Weissman & Klerman, 1977), it is now widely
Chronic Depression in the DSM-IV
recognized that many individuals suffer from chronic condi-
tions that can last for decades. In an attempt to cover the broad variety of trajectories that
Chronic depression is significant for several reasons. It isthe mood disorders can take, the Diagnostic and Statistical
a common problem from a public health perspective: The Manual of Mental Disorders, 4th edition (DSM-IV; American
lifetime prevalence of chronic depression is approximately Psychiatric Association, 1994) includes a number of categories,
3% to 6% in community and primary care samples (e.g., subtypes, and specifiers relevant to chronic depression (see
Satyanarayana, Enns, Cox, & Sareen, 2009); and more than a Fig. 1). Dysthymic disorder is defined as a mild condition
third of patients may suffer from chronic depression in general(depressed mood plus at least two other depressive symptoms)
outpatient mental health settings (see Klein, 2008b). Chronicthat is chronic (depressed most of the day, more days than not,
depression is also associated with considerable functionalfor at least 2 years) and persistent (no symptom-free periods of
impairment, often greater than in nonchronic major depressionlonger than 2 months) and has an insidious onset (no major
(e.g., Gilmer et al., 2005; Satyanarayana et al., 2009), and depressive
it episode within the first 2 years of the disturbance). It
can present with the full gamut of depressive symptoms, although
may also be associated with greater suicidality and more hospi-
talizations (Klein, Shankman, & Rose, 2006). From a research cognitive symptoms (e.g., low self-esteem, hopelessness), affec-
perspective, non-bipolar, nonpsychotic depressive disorders tive symptoms (dysphoric mood), and social-motivational
are a highly heterogeneous group of conditions, complicating
the search for causes and the development of efficacious inter-
Corresponding Author:
ventions. However, as I will discuss, there is evidence that
Daniel N. Klein, Department of Psychology, Stony Brook University, Stony
whether or not it is chronic (i.e., chronicity) may be useful in
Brook, NY 11794-2500
parsing the heterogeneity of non-bipolar depression. In thisE-mail: daniel.klein@stonybrook.edu

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Chronic Depression 97

episode meet crit

2005).
The DSM-IV includes several additional episode and course
specifiers relevant to chronic depression. In coding the severity
of major depressive episodes, DSM-IV includes an option for
patients who are in partial remission. This refers to patients
who have recovered to the point they no longer meet full cri-
teria for a major depressive episode but continue to experience
significant symptoms. The distinction between full and partial
remission is important because the persistence of subthreshold
symptoms is associated with significant functional impairment
and an increased risk of recurrence (Judd et al., 2000). In many
cases, these subthreshold depressive symptoms can persist for
many years. Such cases can be considered another form of
chronic depression. If these patients experience a recurrence,
Fig. I. Pictorial representation of
they qualify for the DSM-IV longitudinal course specifier,
non-bipolar depression. The horiz
vertical axis
"recurrent major depression without full interepisode
represents mood,
recov- wit
representing ery." If the total continuous duration of illness is
euthymic, or greater thannorma
downward 2 years, this can also be viewed as a(the
deflection form of chronic depression.
blue are
symptoms. Panel (a) is non-chroni
case, recurrent, as two depressiv
Distinction Between Chronic and
dysthymic disorder. Panel (c) is d
episode Nonchronic Depression
superimposed on anteced
is chronic major depressive episo
In the 1980s and early 1990s, there was vigorous debate over
episode in partial remission. Pane
without full whether chronic depressions (particularly
interepisode dysthymic disorder)
recovery
are better conceptualized as personality disorders than as mood
disorders, due to their chronic course and often early onset.
This controversy eventually subsided following evidence that
symptoms (e.g.,
most individuals social withd
with dysthymic disorder develop major
vegetative symptoms (e.g.,
depressive episodes at some point, dysthymic disorder ands
Although major depressive disorder occur
dysthymic in the same families, and both
disorder m
point, the
cumulative
dysthymic disorder and doubleburden of
depression respond to antide-
and impaired pressant medications (Klein, 2008b). However, is
functioning the evidence
su
that of more severe
for a close acute
relationship between dysthymic de
disorder and major
Berlim, Fleck, &
depressive Joiner,
disorder then raises the question of 2006).
whether existing
Most personsclassificatory
with distinctions between these two conditions, or
dysthymic
tions that meet criteria
between chronic and nonchronic depressions for
more generally,a
et al, 2006). Indeed,
are meaningful and useful. Ifthis is and
not, it would be simpler oftmore
dysthymic efficient to classify to
disorder depression as a unitary diagnostic
seek trea
category in the
construct. current classif
tion of a major A number depressive epis
of studies have reported that dysthymic disorder
referred to as "double
and double depress
depression differ in important ways from non-
receive diagnoses of Fewer
chronic major depression. both majo
studies have compared
thymic disorder. Although
chronic and nonchronic major depressive disorder, butthi the
tinct, comorbid conditions,
results have generally been similar. Thus, persons with chronic it
major depressive
depression have an episodes in
earlier onset (Angst, Gamma, Rssler, p
represent different
Aj dacie, & Klein, 2009; Klein, phases
Shankman, Lewinsohn, Rohde, of a
wanes, often & in response
Seeley, 2004; Mondimore et al, 2006); higher rates toof comor-str
Major depressive episode,
bid Axis I (e.g., anxiety chr
disorders) and Axis II (personality dis-
severe condition that
orders) conditions meets
(e.g., Angst et al., 2009; Gilmer et al., 2005;fu
(defined by Holm-Denoma et al., 2006; Mondimore
depressed mood et al, 2006); moreor
almost everyextreme
day) continuousl
personality traits, such as neuroticism, and higher levels
differs fromof atdysthymic
least some depressive cognitive biases (e.g., disor
Riso et al.,
required (a 2003); and greater suicidality (Gilmer
minimum of et al., 2005;
five) a
tent ("nearly every
Holm-Denoma day"
et al, 2006; Klein et al., 2006; Mondimore inst
Approximately
et al., 2006) than do20% of
persons with nonchronic pati
major depression.

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 98

Individu
subtypes, and specifiers for chronic depression in the
experien
DSM-IV also capture clinically and etiologically significant
enting
variability? t
(e.g., Only a handful of studies have compared different formsBrof
adversity
chronic depression. Several studies compared dysthymic disor-
is correl
der and double depression; several compared dysthymia and
of chro
chronic major depression; and several compared double
addition,
depression, chronic major depression, and, in one study, recur-
bit highe
rent major depression with incomplete recovery between
persons
episodes and a continuous duration of at least 2 years. In all
andof these studies, there werechr
virtually no differences between the
infants
different forms of chronic depression in terms of comorbidity,
Hernand
personality, functional impairment, depressive cognitions,
Not surp
coping style, childhood adversity, familial psychopathology,
more
response to pharmacotherapy and psychotherapy, and natura- ch
poorer
listic course and outcome (see Klein, 2008b, for a review). s
et al.,The lack of distinctiveness between the various forms of 2
chronic
chronic depression is also supported by within-subject longitu-
approach
dinal data. As noted above, almost all patients with dysthymic
ment
disorder experience exacerbations that meet criteriares
for major
chronic
depressive episodes, suggesting that dysthymic disorder and
require
double depression are different phases of the same condition. a
likely
In addition, in our 10-year follow-up study, we found thatto
chother
although patients with dysthymic disorder and double depres-
et al., 20
sion often experienced recurrences of chronic depression, the
Thus,
form of chronic depression varied. Of the patients who experi- c
higher
enced a recurrence of chronic depression, 28% met criteria for le
are dysthymicnonc
disorder, 24% met criteria for a chronic major
surprisin
depressive episode, and 48% had a period of chronic depression
sionthat did not meet criteria for- either category (e.g., majordy
lized, an
depression with partial remission and a continuous duration
depressio
of over 2 years; Klein et al., 2006).
sibility
Thus, there is little evidence that the existing DSM-IV dis-
heteroge
tinctions between the various forms of chronic depression are
more
stable, etiologically meaningful, or clinically useful. On the h
chronic/
other hand, as discussed above, there do appear to be important
differen
differences between chronic and nonchronic forms of depres-
ther sets
sion. This suggests that in the interest of parsimony, the various
nonchro
forms of chronic depression recognized in the DSM-IV can be
follow-u
combined into a single group of chronic depressions and con-
mic diso
trasted with nonchronic depression. Elsewhere we have argued
to exhibi
that with the addition of an axis or dimension for severity, a
major
simple two-axis or two-dimension scheme of chronicity by d
depressio
severity can account for most of the categories, subtypes, and
depressiv
specifiers included in the DSM-IV classification of depressive
disorders (Klein, 2008a).
That is,
signific
relatives
Chronic Depression Subtypes
Mondim
Although the distinction between chronic and nonchronic
Distinction Between Forms of DSM-IV depression may reduce the heterogeneity of the large group
of non-bipolar, nonpsychotic depressions, chronic depression
Chronic Depression
is still probably heterogeneous, even if this heterogeneity is not
adequately captured in the DSM-IV. Based on Akiskal's
Thus, there appear to be a number of clinically and potentially
etiologically significant differences between chronic
seminaland
work (e.g., Akiskal et al, 1980), the DSM includes
nonchronic forms of depression. Do the various categories,
early-onset (< age 21) and late-onset (> age 21) subtypes for

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Chronic Depression 99

several of the fe
these subtypes: f
tive subtype) and
character-spectr
(2004) examined m
on the maintenan
sion. They found
chronic depressio
chronic Stressor
changes in depres
of early adversity
depression, Neme
had a history of
likely to achiev
schotherapy tha
without early adv
rates with pharm
recently, in anot
found that early
response to antid
data suggest that
pathways in ch
characterized by
to pharmacothera
Fig. 2. adversity
Depression and
severity is
(measm
Rating Scale, HAM-D) as a function
better versus adverse parent-chil
Recommended Reading
those with family history (high fa
history (low Gilmer, W.S., Trivedi, M.H., Rush,
familial A.J., Wisniewski, S.R., Luther, of
loading) J., d
Howland, R.H., et al. (2005). (See References). The most compre-
hensive study in the small literature comparing chronic and non-
dysthymic disorder. Although it
chronic major depressive disorder.
optimal cutoff point (or indeed
Klein, D.N. (2008a). (See References). A paper proposing an alterna-
conceptualized dimensionally),
tive approach to classifying depressive disorders, drawing on some
for such a distinction. Early-on
of the work discussed in this article.
ciated with increased comorbid
Klein, D.N. (2008b). (See References). Provides a broader and more
greater childhood adversity, a s
detailed review of the literature on chronic depression.
disorders, and greater neuroen
Klein, D.N., Shankman, S.A., & Rose, S. (2006). (See References).
late-onset dysthymic disorder
Reports the main findings from the longest prospective follow-
In contrast, late-onset dysthym
up study of chronic depression published to date.
associated with stressful life ev
Mondimore, F.M., Zandi, P.P., MacKinnon, D.F., Mclnnis, M.G.,
sors related to general medical
Miller, E.B., Crowe, R., et al (2006). (See References). A paper,
loved ones. These data suggest
from a large collaborative study on the genetics of recurrent
thymic disorder may reflect a
depression, demonstrating that chronic depression runs in families.
pathways. Although DSM-IV li
tinction to dysthymia, the pa
Declaration of Conflicting Interests
patients with early- and late-o
disorder are The authors declared that they
very had no conflicts of interest with respect
similar, sug
to their authorship or the publication of this article.
important source of heterogen
chronic depressions, and perha
generally Funding
(Klein, 2008b).
Akiskal et Preparation
al. (1980)of this article was supported inalso
part by National Institute
sugges
of Mental Health Grant ROI MH069942.
depressions could be further di
acter spectrum subtypes, reg
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