Depression. Aaron T. Beck, M.D.
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Название: Depression
Автор: Aaron T. Beck, M.D.
Издательство: Ingram
Жанр: Общая психология
isbn: 9780812290882
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The earlier, less refined studies predominantly reported a period of 6–18 months as the average duration of the first attack: Kraepelin,1 6–8 months; Pollack,17 1.1 years; Strecker et al.,10 1.5 years. The clinical impression of writers of monographs on depression published in the 1950s and 1960s shows similar variation. Kraines18 stated that the average depressive episode lasts about 18 months. Ayd14 reported that prior to age 30, the attacks average 6–12 months; between ages of 30 and 50, they average 9–18 months; and after 50, they tend to persist longer, with many patients remaining ill from three to five years.
In regard to the duration of multiple episodes of depression, there was a prevalent opinion among the earliest clinicians of a trend toward prolongation of the episodes with each recurrence.1 Lundquist, however, performed a statistical analysis of the duration of multiple episodes and found no significant increase in duration with successive attacks. Paskind’s4 study of outpatient cases similarly showed that the attacks do not become longer as the disease recurs. The median duration for first attacks was four months, and for second, third, or subsequent attacks three months.
The differences in the findings between the rough clinical studies and the statistical studies may reflect a difference in samples and/or different criteria for recovery from the depression. It is probable that certain biases influenced the selection of cases in the less refined studies and, therefore, the samples cannot be considered representative.
Lundquist found a significant association between prolonged duration and the presence of delusions in younger but not older patients. The presence of confusion, however, favored a shorter duration.
Brief Attacks of Manic-Depressive Psychosis (Bipolar Disorder)
In 1929, Paskind2 described 88 cases of depression of very brief duration, from a few hours to a few days. These patients had essentially the same symptoms as those in his other extramural cases of longer duration and constituted 13.9 percent of his large series of cases diagnosed as manic-depressive disorder. The case histories he presented leave little doubt that they would later be diagnosed as neurotic-depressive (dysthymia) reaction.
TABLE 3-2. Frequency of Single and Multiple Attacks of Depression
Most of these patients with brief attacks also experienced longer episodes of depression. In 51, the brief attacks came first and were followed from months to decades later by longer attacks lasting from several weeks to several years. In 18, longer attacks occurred first, and were followed by the transient episodes. In nine, there were brief episodes only.
Recurrence
There is considerable variation in the older literature relevant to the frequency of relapses among depressed patients. Except as indicated, the statistics for manic-depressive psychosis include some manic patients in addition to the depressed patients. In the earlier studies, German authors reported a substantially higher incidence of recurrence than American investigators.6 These differences may be attributed to more stringent diagnostic criteria and to longer periods of observation by the German authors.
Of the more refined studies, Rennie’s reported relapse rate was closer to that of the German writers than to those of the other American investigators. He found that 97 of 123 patients (79 percent) initially admitted to the hospital in a depressed state subsequently had a recurrence of depression. (These figures do not include 14 patients who committed suicide after the first admission or who remained chronically ill.) When the cyclothymic cases (i.e., patients who had at least one manic attack in addition to the depression) are added to this group, the proportion of relapse is 142 patients of 170 (84 percent).
The Scandinavian investigators Lundquist6 and Stenstedt12 reported, respectively, a 49 percent and a 47 percent incidence of relapse. In comparing their studies with Rennie’s, one can reasonably conclude that the more stringent diagnostic criteria employed by Rennie and the longer period of observation of his sample may account for the higher percentage of relapses in his report.
The differences in relapse rate are reflected in a striking difference in the rate of multiple recurrences. In Rennie’s series more than half of the depressed patients had three or more recurrences (see Table 3-2). The frequency of multiple recurrences in the cyclothymic cases was particularly high in Rennie’s series. Thirty-seven of the 47 patients in the group had four or more episodes. In Kraepelin’s series, 204 out of 310 cases of this type (67 percent) had one or more recurrences, with more than half having three or more attacks.
Another important aspect of the recurrent attacks is their duration. The opinion was frequently expressed that the episodes become progressively longer with each recurrence. Rennie, however, in analyzing his data, found that the second episode had the same duration as the initial episode in 20 percent, was longer in 35 percent, and was shorter in 45 percent. Paskind found that the median duration decreased with successive attacks.
Belsher and Costello19 reviewed 12 published studies of relapse in unipolar as opposed to bipolar depression. They selected studies that included correlates of relapse, rates of relapse, and a naturalistic follow-up period with no controlled maintenance therapy. They found a number of methodological inadequacies, such as unclear and variable definitions of recovery and relapse, nebulous patient characteristics, and vague inclusion and exclusion criteria. Despite these uncertainties, they were able to conclude that the risk of relapse in unipolar depression goes down the longer a person stays well. Several factors did predict relapse: (1) a history of depressive episodes, (2) recent stress, (3) poor social support, and (4) neuroendocrine dysfunction. Other variables did not predict relapse, including marital status, gender, and socioeconomic status.
Intervals Between Attacks
In examining the older literature on the intervals between episodes of depression, one is struck by the fact that recurrences may occur after years, or even decades, of apparent good health. The systematic studies offer little encouragement for the notion of a permanent cure analogous to the 5-year cures reported for cancer treatment. Recurrences have been reported as long as 40 years after remission from an initial depression.1
The findings presented by Rennie, in particular, are noteworthy in that the highest proportion of relapses occurred 10–20 years after the initial episode of depression. His follow-up showed the following relapse rate for his 97 cases of recurrent depressions: less than 10 years after the first attack of depression, 35 percent; 10–20 years, 52 percent; more than 20 years, 13 percent. It should be emphasized that 65 percent had recurrences after remissions of 10–30 years.
In an earlier study, Kraepelin had tabulated the symptom-free intervals between 703 episodes of depression. Unlike Rennie’s study, Kraepelin’s included intervals after the second and later attacks (as well as intervals between the first and second episodes). He found that with each successive attack the intervals tended to become shorter. Since his series consisted of hospitalized patients, it is interesting to note the same trend among the extramural patients in Paskind’s study. A comparison of the distribution of intervals in ten-year categories is shown in Table СКАЧАТЬ