We all know them. (Maybe we even recognize them in the mirror.) They are the people who move through life with the weight of the world upon them.
Morose, sullen, angry, negative; there are lots of adjectives to describe what has been typically thought of as just an unfortunate personality trait.
Now, however, mental health experts are saying that many of these people are chronically depressed. In the first major study to follow hundreds of people who have been depressed for most of their adult lives, researchers have found promising evidence that this persistent melancholy can be lifted with long-term antidepressant therapy.
The research, laid out in five lengthy journal articles that have appeared in recent weeks, should put a new imperative on treating people who seem born sad.
"The message here is very good. Even if you've been depressed for seven years, you still have an excellent chance of recovering," said Dr. Lorrin Koran, a professor of psychiatry at Stanford University.
The findings challenge the popular notion that people who have long been depressed cannot change. As recently as 1990, psychiatrists could not agree on whether a person could have an intractable "depressive personality."
"It was really thought that these individuals had a chronic lifelong down-in-the-dumps personality that was their nature," said Dr. Martin B. Keller, a Brown University professor of psychiatry who headed the research project.
And, said Dr. Michael E. Thase, another coauthor of the studies: "This used to be called 'neurotic depression.' Neurotic implies an aspect of one's character. In the public's view, these are people who are gloomy, pessimistic, the Eeyores of the world. Well, poor Eeyore probably had a treatable disorder."
Chronic depression is defined as symptoms of major depression that persist for at least two years. There are also two subsets of the disorder: dysthymia, which is defined as symptoms of a lesser severity that last for at least two years; and double depression, which is a combination of major depression and dysthymia.
An estimated 5% to 10% of the roughly 18 million Americans with depression are thought to have some type of chronic depression.
"Major depression is easier to recognize. These are people who can't get out of bed or have attempted suicide," said Lydia Lewis, executive director of the National Depressive and Manic Depressive Assn. "But chronic depression is very insidious. People tend to look at these people and say, 'Oh, he is so self-centered; he thinks about himself too much.' Or they might call these people lazy or unambitious. But what it might actually be is chronic depression."
Because of this prevailing view, people with chronic depression are not as likely to be diagnosed or seek treatment, Keller said. The new data should alert both doctors and the public that treatment is beneficial. In addition, the studies could help doctors provide evidence to insurance companies in cases in which antidepressants and other mental health benefits are limited.
"We're certainly hoping this will lead to increased recognition of chronic depression among patients and health-care providers," Keller said.
The study, published in several parts in recent issues of the Journal of the American Medical Assn. and the Journal of Clinical Psychiatry, marks an ambitious effort by top researchers in the field to gain insight into the little-explored area of chronic depression. Only a few studies have been done on the impact of an initial course of treatment, and only one other study has attempted to follow chronically depressed people after their first phase of treatment to see how they fared over a longer period of time.
Moreover, until the new study, there was no information that documented how chronically depressed people fared when treated with Prozac and other antidepressants in a class of drugs known as Selective Serotonin Reuptake Inhibitors. SSRIs are the preferred treatment for many forms of depression because they cause fewer side effects than older classes of medications.
In the study, 635 patients were treated with either the SSRI sertraline or the older antidepressant called imipramine. The patients were generally people who had struggled with depression most of their adult lives. About 25% also had coexisting conditions, such as alcoholism or drug addiction, anxiety or panic disorder. Only 43% had ever received any treatment for their depression.
The study showed that 52% of the individuals responded to either sertraline or imipramine. Patients taking the imipramine were twice as likely to stop the treatment because of side effects from the medication.
"Other smaller studies had hinted at this. But this is the largest and most carefully done study of its kind," said Thase, a professor of psychiatry at the University of Pittsburgh. "This pushes the evidence over the top."
Another part of the study explored how these patients fared in a second phase of maintenance treatment over 16 weeks. Of the 77 patients taking sertraline, only 6% relapsed after 18 months, contrasted with 23% of the 84 people who took a placebo.
While the rate of recovery was high, the study did show that patients with chronic depression need somewhat longer to recover. It's also clear that the patients need to stay on the medication for at least two years.
"We've shown that a minimum of 18 months of maintenance therapy is needed after the initial seven months of treatment," Keller said.
It's not known whether some--or all--people with chronic depression will need lifelong therapy.
But, Keller said: "In the absence of data, I would continue to treat them unless they develop difficulty taking the medication or unless they were insistent that they wouldn't stay on the drug."