Depression. Aaron T. Beck, M.D.

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      Chapter 3

      Course and Prognosis

Depression as a Clinical Entity

      In Chapter 2, depression was treated as a psychopathological dimension or syndrome. The clinical features of depression were examined in cross-section, that is, in terms of the cluster of pathological phenomena exhibited at a given point in time. In this chapter, depression is treated as a discrete clinical entity (such as bipolar disorder or dysthymia) that has certain specific characteristics occurring over time in terms of onset, remission, and recurrence. As a clinical entity or reaction type, depression has many salient characteristics that distinguish it from other clinical types such as schizophrenia, even though these other types may have depressive elements associated with them. The depressive constellation as a concomitant of other nosological entities will not be described in this chapter but will be considered later in terms of its association with schizophrenic symptomatology in the schizoaffective category (Chapter 8).

      Among the important characteristics of the clinical entity of depression are the following: There is generally a well-defined onset, a progression in the severity of the symptoms until the condition bottoms out, and then a steady regression (improvement) of the symptoms until the episode is over; the remissions are spontaneous; there is a tendency toward recurrence; the intervals between attacks are free of depressive symptoms.

Importance of Course and Outcome

      The longitudinal aspects of depression have been the subject of many investigations since the time of Kraepelin. Adequate information regarding the short-term and long-term course of depression is important, not only for practical management, but also for an understanding of the psychopathology and for evaluation of specific forms of treatment. Considerable data on the life histories of depressed patients were accumulated before the advent of the specific therapeutic agents—psychological treatments (such as cognitive and interpersonal therapy), electroconvulsive therapy (ECT), and drugs. These data are generally regarded as reflecting the natural history of the disorder, although it is difficult to separate out the effects of hospitalization.

      The physician charged with making a determination of the prognosis in a given case is confronted with a number of questions.

      1. In the case of a first episode of depression, what are the prospects for complete remission, and what is the likelihood of residual symptoms or of a chronic, unrecovered state?

      2. What is the probable duration of the first attack?

      3. What is the likelihood of recurrence, and what is the probable duration of any multiple attacks?

      4. How long must one wait following a patient’s remission from a given attack before ruling out the likelihood of recurrence?

      5. What is the risk of death through suicide?

      Answers to these questions can be provided by reference to research on early cases diagnosed as manic-depressive psychoses and subsequent studies that elaborated the prior findings. A number of fairly well-designed studies have been conducted to determine the fate of such patients. It should be emphasized that much of the available data applies primarily to hospitalized patients.

      A series described by Paskind as “manic depressive” in 1930 undoubtedly contained a preponderance of cases that would later be diagnosed as “neurotic-depressive reactions.” Since this study antedated the modern somatic therapies, the findings may be assumed to be relevant to the natural history of neurotic-depressive reactions.

Systematic Studies

      Kraepelin¹ studied the general course of 899 cases of manic-depressive psychosis. The period of observation varied considerably; some patients were followed for brief periods and others for as long as 40 years. Moreover, since the follow-up depended largely on readmission to the hospital, the information on patients who were not readmitted is scanty. Despite these limitations, his study is of great value in providing solid facts regarding recurrent episodes, frequency and duration of the attacks, and duration of the intervals between attacks. His sample was as follows: single depression, 263; recurrent depression, 177; biphasic single episode, 106; combined, recurrent, 214; single manic episode, 102; recurrent manic, 47. Biphasic was used for cases in which both manic and depressive episodes occurred. These have been designated by terms such as compound, mixed, combined, double-form, cyclothymic, and cyclical. Alternating and circular refer to cases in which one phase follows immediately after the opposite without any free interval. “Closed circular type” refers to uninterrupted manic and depressive cycles.

      Paskind’s study^2,3,4 of cases of depression seen in private practice provides data on the course of depressions observed outside the hospital. Although there are many serious methodological deficiencies in this study, the data presented are relevant to milder episodes of depression. Paskind reviewed the records of 633 cases of depression in the private practice of Dr. Q. T. Patrick. Although all of these cases had been placed in the all-inclusive category of manic-depressive psychosis, a review of the case histories presented in the articles leaves little doubt that these cases are actually descriptive of the bipolar mood disorders rather than psychosis. In reviewing the tabulated data presented by the author, it is apparent that his findings are based on 248 cases abstracted from the original group. The cases were collected over a period of 32 years, but there is no mention of the average period of observation or of any systematic attempt to obtain follow-up material on these patients. Paskind noted that 88 cases (32 percent) could be classified as “brief attacks of manic-depressive psychosis,” since the average duration of the episodes ranged from a few СКАЧАТЬ