Chronic depressions. Part 1. Clinical and familial characteristics in 137 probands.

Factors associated with chronicity in 137 probands with 2 or more years of low-grade intermittent depression were evaluated in a naturalistic setting. Four groups were tentatively identified and chronicity related to: (1) early onset (less than 25 years) intermittent subsyndromal or dysthymic depressions with positive family history for both unipolar and bipolar illness; (2) a spectrum of 'unstable' characterologic disorders with history for childhood object loss; (3) pre-existing non-affective psychiatric or incapacitating medical disorders, especially in combination; (4) incomplete remission from late-onset primary unipolar episode(s) with strong familial background for affective illness, multiple object losses, alcohol and sedative hypnotic dependence, superimposed incapacitating medical disorders, use of depressant antihypertensive agents, disabled spouses, and 'marital deadlock'. Beneficial effects of thymoleptic drugs and practical psychotherapy occurred in 45% of the total sample and were largely limited to groups 1 and 4. These findings argue against a common clinical stereotype that equates all chronic depressions with character disorder.

Familial and developmental factors in characterological depressions.

Patients with chronic low-grade depressions (screened to exclude primary affective illness and those secondary to rigorously defined nonaffective disorders) were divided into subaffective dysthymic versus character-spectrum groups and compared to 40 primary unipolar controls. A prior report found the 30 character-spectrums different from the 20 dysthymics (and usually from the unipolars) on pharmacological, phenomenological, REM sleep, social and outcome criteria. The present study parsed family history and developmental differences: The character-spectrum group had significantly lower incidence of familial depressions, but higher frequencies of loss of a parent in childhood, familial alcoholism, and parental assortative mating than both other groups--which did not differ. Just 10% of our 90 patients had bipolar family histories; 7 were dysthymics and 6 of these had earlier shown brief, tricyclic-induced hypomania. The results support, at the subsyndromal level, Winokur's separation of disorders with +FH for alcoholism from those with +FH for affective illness. Furthermore, data suggest the DSM-III concept of 'dysthymia' is too broad and needs further distinctions among several subaffective and nonaffective chronic depressions.

Characterological depressions. Clinical and sleep EEG findings separating 'subaffective dysthymias' from 'character spectrum disorders'.

Early-onset characterological depressions are distinguished from late-onset chronic depressions that complicate the long-term course of unipolar and nonaffective illnesses. In turn, characterological depressions are divisible into at least two subtypes: (1) "Subaffective dysthymias" have even sex distribution, are often complicated by superimposed depressive episodes, rapid eye movement latency is shortened, and they tend to respond to tricyclics of lithium carbonate. In brief, they share many features of primary affective illness. (2) "Character spectrum disorders," by contrast, represent a heterogeneous mixture of personality disorders with inconstant depressive features, are more common in women, are often complicated by alcohol and drug abuse, and outcome tends to be unfavorable.