Depression. Aaron T. Beck, M.D.

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      Adapted from Kiloh et al. 1988.

Outcome for “Endogenous” Versus “Neurotic” Depression

      Kiloh et al.²⁰ studied the long-term outcome of 145 patients with primary depressive illness who were admitted to a university hospital between 1966 and 1970. Patients were categorized into endogenous and neurotic subtypes. The follow-up period was an average of 15 years later, and data were obtained on 92 percent of the patients. Table 3-6 shows the percentages of those who (1) recovered and remained well, (2) recovered but experienced subsequent depression, or (3) remained incapacitated or committed suicide.

Schizophrenic Outcome

      In Rennie’s 1942 sample of 208 cases of manic-depressive psychosis, four cases changed their character sufficiently to justify the conclusion of an ultimate schizophrenic development. A review of these cases suggested that there was a strong component of schizophrenic symptomatology at the time of the diagnosis of manic-depressive psychosis.

      At about the same time, Hoch and Rachlin²¹ reviewed the records of 5,799 cases of schizophrenia admitted to Manhattan State Hospital, New York City. They found that 7.1 percent of these patients had been diagnosed as manic depressive during previous admissions. Whether there was an alteration in the nature of the disorder, an initial misclassification, or a change in diagnostic criteria was not established by these writers.

      Lewis and Piotrowski²² found that 38 (54 percent) of 70 patients, originally diagnosed as manic depressives, had their diagnoses changed to schizophrenia in a 3–20-year follow-up. In reviewing the original records, the authors demonstrated that the patients whose diagnoses were changed were misclassified initially, that is, they showed clear-cut schizophrenic signs at the time of their first admission. Because of the very loose criteria used in diagnosing manic-depressive disorder in the early decades of the twentieth century, it is difficult to determine what proportion, if any, of the clear-cut manic depressives had a schizophrenic outcome.

      Lundquist reported that about 7 percent of his manic-depressive cases eventually developed a schizophrenic picture.

      Astrup et al.¹¹ isolated 70 cases of “pure” manic-depressive disorder and followed these 7–19 years after the onset of the disorder. They found that none had a schizophrenic outcome. In contrast, 13 (50 percent) of a group of 26 cases diagnosed as schizoaffective psychosis showed schizophrenic symptomatology on follow-up.

Suicide

      At the present time, the only important cause of death in depression is suicide. (The general topic of suicide is broad, and many excellent monographs are available, e.g., Farberow and Schneidman,²³ Meerloo.²⁴) Previously, inanition due to lack of food and secondary infection were occasional causes of death, but with modern hospital treatment such complications are less usual.

      The actual suicide risk among depressed patients is difficult to assess because of the incomplete follow-ups and difficulties in establishing the cause of death. Long term follow-ups by Rennie⁵ and by Lundquist⁶ indicated that approximately 5 percent of the patients initially diagnosed in a hospital as manic depressive (or as having one of the other depressive disorders) subsequently committed suicide.

      In the mid-twentieth century, several studies demonstrated comparatively higher suicide rates among depressed patients. Pokorny²⁶ investigated the suicide rate among former patients in a psychiatric service of a Texas veterans’ hospital over a 15-year period. Using a complex actuarial system, he calculated the suicide rates per 100,000 per year as follows: depression, 566; schizophrenia, 167; neurosis, 119; personality disorder, 130; alcoholism, 133; and organic, 78. He then calculated the age-adjusted suicide rate for male Texas veterans as 22.7 per 100,000. The suicide rate for depressed patients, therefore, was 25 times the expected rate and substantially higher than that of other psychiatric patients.

      Temoche et al.,²⁷ studying the suicide rates among current and former mental institution patients in Massachusetts, found a substantially higher rate of suicide among depressed patients than nondepressed patients. The computed ratio for depressives was 36 times as high as for the general population and about three times as high as for either schizophrenics or alcoholics.

      The suicide rate among patients known to be suicidal risks is apparently high. Moss and Hamilton²⁸ conducted a follow-up study for periods of two months to 20 years of 50 patients who had been considered “seriously suicidal” during their previous hospitalization (average 4 years). Eleven (22 percent) of the 50 later committed suicide. In a retrospective study of 134 suicides, Robins et al.²⁹ found that 68 percent had previously СКАЧАТЬ