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• W2073815020 abstract "WILLIAM SYTON, DARKNESS VISIBLE, p 84 Major depression is a chronic and recurrent disorder for many people who are afflicted by it. There is a wealth of literature addressing the course of this disorder with follow-up times varying from several months to several decades, which gives a remarkably consistent picture in treated and untreated populations. Fortunately, most people who develop major depression recover from their initial episode; unfortunately, a significant minority do not recover fully and a near majority develop additional episodes. This article of this issue of The Psychiatric Clinics of North America examines a selected group of studies that have examined the course of depression with a focus on a large naturalistic longitudinal prospective study of affective disorders—the NIMH Collaborative Depression Study (CDS). It is difficult to avoid the heterogeneity of depression. Other articles in this issue address topics of differential diagnosis, stability of diagnosis, and other aspects of the nosology. Although much of the literature on the long-term course of depression antedated systematic nosologic systems, the conclusions derived from this work remain clinically relevant. Most of the patients who serve as the focus of these studies clearly are suffering from a serious affective syndrome, and most authors provide sufficient detail to allow the reader to concur that subjects would likely meet modern criteria for major depressive disorder. More recent work clearly specifies a recognizable diagnostic system such as the Research Diagnostic Criteria (RDC), DSM-III or DSM-III-R.44 Nonetheless, a review such as this cannot avoid heterogeneity. As a consequence, it focuses on the course of major depressive episodes (“major depression”), which usually occur in the context of major depressive disorder. Studies of the course of major depression share several organizing principles: (1) the studies are generally long-term, (2) they either follow subjects naturalistically or as part of a treatment protocol, and (3) the subjects are either recruited from treatment settings or from community samples. Long-term studies are necessary because major depression is chronic and recurrent. Early studies that were short-term suggested that major depression eventually would resolve in everyone.50 This was based on the finding that over the course of 1 to 2 years the process of recovery did not level off. It appeared that with enough follow-up everyone would recover; however, this does not appear to be the case from the evidence gathered in prospective follow-up studies. Additionally, once recovered, most people are at risk to develop another episode. Naturalistic studies investigate the course of depression with no attempt to effect treatment other than to monitor it. Although periodically asking people about the treatment they receive for major depression may influence that treatment, there is no systematic effort to encourage subjects to take any particular action. Naturalistic designs have more external validity than do controlled treatment trials, but at the cost of internal validity. Naturalistic studies provide the closest estimate of the “natural” course of a disorder but are limited in their ability to address issues of treatment effects. Because treatments are not manipulated, the issue of causality always looms. Is the level of treatment received a marker of the severity of the disorder, or does the level of treatment influence the severity of the disorder? Naturalistic studies have demonstrated consistently two significant findings: few people receive consistent treatment and increasing levels of treatment improve the course of major depression. Treatment, however, is the focus of another article in this issue; for the purposes of the course of major depression this section focuses on individuals with uncontrolled treatments. The source of subjects with major depression may influence the course of the disorder by selecting people with different degrees of severity a priori. People who enter studies by virtue of seeking treatment for their disorder may represent a group who has a more severe form of the illness. Studying the course of their disorder may reveal a more malignant course by virtue of that selection bias. Conversely, subjects recruited from the community without regard to the status of their illness or treatment needs may represent a more mild form of the disorder. Surprisingly, the course of major depression in the two populations is more similar than one might expect." @default.
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• W2073815020 date "1996-03-01" @default.
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• W2073815020 title "RECOVERY, CHRONICITY, AND LEVELS OF PSYCHOPATHOLOGY IN MAJOR DEPRESSION" @default.
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• W2073815020 doi "https://doi.org/10.1016/s0193-953x(05)70275-6" @default.
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