DA 00004

DEPRESSION AND ANXIETY 13:11–17 (2001)

DIFFERENTIAL SUBTYPING OF DEPRESSION

Thomas Yang, M.D., and David L. Dunner, M.D.*

We studied a group of patients with depression divided into subtypes of non-

chronic major depression, chronic major depression, and pure dysthymia. The
purpose of this study was to determine if clinical and family history factors
separated these types of depression. We reviewed records from semi-structured
clinical interviews and abstracted data regarding factors that might differenti-
ate these three depressive subtypes. In general we found what might be pre-
dicted from the definitions of dysthymia versus major depression, that is,
ratings for severity of depression were lower for dysthymic patients as com-
pared to patients with non-chronic or chronic major depression. We also found
lower ratings for social functioning (GASF) for dysthymic patients as com-
pared to the other depressive subtypes. Our study does not provide data to suffi-
ciently separate these three subtypes. However, in the course of reviewing the
literature on this topic, very few studies have separated patients into these dis-
tinct depressive subtypes. Further studies are needed to indicate if these sub-
types can be meaningfully separated. Depression and Anxiety 13:11–17, 2001.
© 2001 Wiley-Liss, Inc.

Key words: dysthymia; chronic major depression; acute major depression

INTRODUCTION
T he purpose of this paper is to differentiate subtypes
of depression. The major subtypes of major depression
in DSM-IV [American Psychiatric Association, 1994]
are single episode, recurrent, and chronic. Among
chronic mood disorders, one might include chronic
major depression, “pure” dysthymic disorder, dysthy-
mic disorder complicated by major depressive episodes
(double depression) [Keller and Shapiro, 1982], and
major depression in incomplete remission if the de-
pressive symptoms persist for at least 2 years.
A recent family study of dysthymic disorder by Klein
et al. [1995] suggested that depression subtypes might
cluster in families such that individuals with chronic
major depression or dysthymic disorder had increased
risks for chronic depression or dysthymic disorder in
their first degree relatives as compared to individuals
who had episodic major depression, whose relatives
showed episodic depressive illnesses. These data sug-
gest that chronic depressions may be more similar to
each other than to recurrent depressions. Perhaps a
way of classifying mood disorders for the next DSM
might be to have dysthymia and the chronic major de-
pressive disorders classified as one group (“chronic de-
pression”) and recurrent major depression and perhaps
bipolar II classified as a second group (“recurrent de-
pression”) [Pages and Dunner, 1997]. In order to pro-
vide data regarding this issue, we undertook the
current study. We reviewed a large cohort of unipolar
mood disorder patients who were separated into acute
and chronic depressive disorder subtypes.
METHODS
Subjects for this study were selected from patients
who had participated in various psychopharmacologi-
cal research studies at the University of Washington,
Center for Anxiety and Depression/Pharmaco Re-
search between 1992 and 1999. These subjects were
respondents to radio and newspaper advertisements
that requested individuals with various types of de-
pression to volunteer for research protocols. Clinical
records of subjects who had participated in these phar-
macological research studies were reviewed and sub-
jects were selected for the current analysis if they met
DSM-III-R [American Psychiatric Association, 1987]
or DSM-IV [American Psychiatric Association, 1994]
criteria for major depressive disorder or dysthymic
disorder. Additionally subjects had to be between the
ages of 18 and 75. Exclusion criteria for participation
Department of Psychiatry and Behavioral Science, Center
for Anxiety and Depression, University of Washington, Se-
attle, Washington
Dr. Yang is a Resident in Psychiatry, Baylor College of Medicine.
*Correspondence to: Dr. David L. Dunner, Department of Psychia-
try and Behavioral Science, Center for Anxiety and Depression,
University of Washington, 4225 Roosevelt Way NE, Suite 306C,
Seattle, WA 98105-6099. E-mail: ddunner@u.washington.edu
Received for publication 27 March 2000; Accepted 31 August 2000

© 2001 WILEY-LISS, INC.

12 Yang and Dunner
in these pharmacological research studies included a
history of psychotic features or other history of psy-
chosis, a history of manic or hypomanic episodes, al-
cohol or substance abuse/dependence occurring in the
6 month period prior to study onset, or a principle di-
agnosis of another psychiatric disorder such as panic
disorder, generalized anxiety disorder, social phobia,
or post traumatic stress disorder. Additionally, indi-
viduals with severe personality disturbances such as
borderline personality disorder or antisocial personal-
ity disorder were excluded. General medical exclusion
criteria for participation in these studies included any
unstable medical condition, a history of central ner-
vous system disorders (seizure disorders and stroke),
active and unstable cardiovascular, liver or renal dis-
ease, or physical or laboratory evaluations that pre-
cluded study participation. Before participating in a
pharmacological research study, all subjects provided
informed consent for the studies, which had been ap-
proved by the University of Washington human sub-
jects review board.
All subjects for the current project had been inter-
viewed by DLD using a semi-structured interview
[Dunner, 1993] and subjects were additionally diag-
nosed by a structured interview such as the SCID
[Spitzer et al., 1987]. Charts of all subjects were re-
viewed by TY and selected for the current study based
on their meeting criteria for major depressive disorder
or dysthymic disorder. Subjects were then categorized
into three groups: non-chronic major depression,
chronic major depressive disorder, and dysthymic dis-
order. Chronic depression was diagnosed if the cur-
rent major depressive episode had persisted for 2 years
or longer. Individuals with double depression [Keller
and Shapiro, 1982] were not included in the current
study. In any instances where the course of illness was
unclear, diagnosis and categorization were established
by mutual agreement between the authors after review
of the appropriate clinical information.
The semi-structured interview provided informa-
tion regarding age, marital status, years of education,
age of illness onset, history of physical and sexual
abuse during childhood, and history of suicide at-
tempts. Other psychiatric disorders such as panic dis-
order, eating disorders, alcohol or other substance
abuse, obsessive compulsive disorder, or post trau-
matic stress disorder were systematically inquired
about. Psychiatric treatment was recorded and this in-
cluded use of pharmacotherapy, psychotherapy, or any
history of psychiatric hospitalizations. Subjects were
judged to have an adequate trial of an antidepressant if
they had a history of being on the equivalent of 150
mg of imipramine for at least 4 weeks. Subjects were
assumed to have an adequate exposure to psycho-
therapy if they participated in ten or more psycho-
therapy sessions for treatment of depression. Other
forms of psychotherapy such as group therapy and
therapy not related to depression were not included.
As part of the interview subjects were assessed using
the Hamilton Depression Rating Scale (HAMD)
[Hamilton, 1960] and for the current study HAMD-
17 data were selected. Additional rating scales in-
cluded the Montgomery Asberg Depression Rating
Scale (MADRS) [Montgomery and Asberg, 1979], the
Hamilton Anxiety Rating Scale (HAMA) [Hamilton,
1959], and the Global Assessment of Functioning
Scale (GASF). Additionally the Seasonal Pattern As-
sessment Questionnaire (SPAQ) [Rosenthal et al.,
1984] was assessed.
Family history of mental disorders in first degree
relatives was obtained using the family history method.
Relatives were diagnosed specifically as having bipolar
I, bipolar II, or any type of depressive disorder. Addi-
tionally any substance abuse or history of other psy-
chiatric disorders including schizophrenia and suicide
was elicited. Family members were not available for
direct interview. Morbidity risks for affective disorders
in family members were calculated using the Strom-
gen [1935] method to calculate the number of subjects
at risk using age of onset data from Dunner [1983].
Eighteen years of age was used as the age of risk for
substance abuse.
Statistical tests were performed using SPSS version
9.0 [SPSS, 1999]. We used chi-squared analysis and
analysis of variance (ANOVA) when appropriate for
continuous variables. Post-hoc Bonferroni adjust-
ments were used for multiple comparisons between
depressive groups if significance was found within the
groups [Dunn, 1961].
RESULTS
DEMOGRAPHICS
Of the 344 subjects selected for this study, 158
(46%) were classified as non-chronic major depres-
sion, 96 (28%) were classified as chronic major de-
pression, and 90 (26%) were classified as dysthymic
disorder. The subject demographics are summarized
in Table 1. The groups did not differ significantly in
age or marital status. However, subjects with dysthy-
mic disorder had more years of education when com-
pared to subjects with non-chronic depression and
chronic major depression. Also, the groups differed in
sex distribution.
CLINICAL CHARACTERISTICS
The clinical characteristics of each group are sum-
marized in Table 2. As we would expect, subjects with
dysthymic disorder had significantly lower mean
HAMD, MADRS, and HAM scores when compared
to the mean scores of both non-chronic and chronic
depressive subjects. GASF scores were lower for sub-
jects with dysthymia when compared to scores for
subjects with non-chronic and chronic depression.
There was no significant difference within the
groups regarding treatment with psychotherapy.
However, a history of adequate medication treat-
ments showed a significant difference among groups.
 Research Article: Differential Subtyping of Depression 13

TABLE 1. Subject demograhics: non-chronic depression vs. chronic depression (not including double depression) vs.
dysthymic disorder

Non-chronic major depression Chronic major depression Dysthymic disorder Statistical test
N 158 96 90
Age, Y (mean ± SD) 40.3 ± 12.5 43.8 ± 11.5 40.5± 12.3 F = 2.65, df = 2, P = .072
Sex χ2= 7.1, df = 2, P = .029
Male 69 56 52
Female 89 40 38
Marital status χ2 = 13.1, df = 8, P = .108
Single 60 30 32
Married 44 31 36
Divorced 42 33 21
Separated 9 1 1
Widowed 3 1 0
Education Y (mean ± SD) 15.0 ± 2.3 15.1 ± 2.3 16.2 ± 5.0 F = 4.39, df = 2, P = .013

In particular, only 30% of the subjects with dysthy- COMORBIDITY

mic disorder had an adequate trial of an antidepres-
sant compared to 47.9% of the subjects with chronic
depression. In spite of being ill for a short time, non-
chronic depressed patients had higher rates of pharma-
cotherapy than dysthymic patients. This difference in
treatment is also demonstrated in the number of pa-
tients hospitalized. Only 1.1% of the subjects with
dysthymic disorder had a history of psychiatric hos-
pitalization, compared to 11.5% of subjects with
chronic depression and 7.6% of non-chronic de-
pressed patients.
There was no significant difference among the three
groups regarding atypical features. We also found no
significant difference between non-chronic depressives
and chronic depressives regarding melancholic fea-
tures or seasonal pattern. No significant differences
were seen within the groups comparing history of
sexual abuse, history of physical abuse, history of sui-
cide attempts, or mean age of illness onset.
Rates of comorbid disorders are shown in Table 3.
Rates of comorbid eating disorders, panic disorder,
and alcohol and substance abuse were low and did not
differ significantly among the three depressive groups.
FAMILY HISTORY
Morbidity risks for psychiatric disorders in first-de-
gree family members are shown in Table 4. The table
is divided into female family members and male family
members. We found no significant difference among
the depressive groups for morbidity risk for major de-
pression, bipolar 1 or bipolar 2 disorder, or alcohol
and other substance abuse in first-degree relatives.
DISCUSSION
Robins and Guze [1970] proposed five criteria for
delineating syndromes. These criteria include clinical
and demographic data, rates of disorders in relatives,

TABLE 2. Subject characteristics

Non-chronic Chronic Dysthymic

major depression major depression disorder Statistical test
HAMD (17) (mean ± SD) 22.3 ± 2.8 21.9 ± 2.5 17.5 ± 3.3 F = 92.77, df = 2, P < .001
HAM-A (mean ± SD) 23.6 ± 6.8 24.5 ± 7.6 19.3 ± 7.2 F = 14.11, df = 2, P < .001
MADRS (mean ± SD) 32.6 ± 2.3 31.7 ± 2.7 29.2 ± 4.0 F = 14.48, df = 2, P < .001
GASF (mean ± SD) 54.5 ± 6.7 53.2 ± 5.7 50.6 ± 5.4 F = 4.98, df = 2, P = .008
Adequate trial of medication, % 35.4 47.9 30.0 χ2 = 6.8, df = 2, P = .032
Ten or more sessions of psychotherapy, % 34.8 45.8 36.7 χ2 = 3.2, df = 2, P = 0.2
No treatment, % 32.9 18.8 22.2 χ2 = 7.18, df = 2, P = .028
History of hospitalization, % 7.6 11.5 1.1 χ2 = 7.84, df = 2, P = .02
Atypical features, % 24.3 26.5 36.5 χ2 = 2.44, df = 2, P = .03
Melancholic features, % 31.2 29.5 – χ2 = .084, df = 1, P = .77
Seasonal pattern, % 11.4 4.5 – χ2 = 3.31, df = 1, P = .07
SPAQ (mean ± SD) 3.4 ± 4.9 2.8 ± 4.2 – F = 4.13, df = 2, P = .02
Age of illness onset, y (mean ± SD) 27.9 ± 14.2 28.4 ± 14.7 24.2 ± 14.4 F = 2.48, df = 2, P = .08
Duration of illness, months (mean ± SD) 7.8 ± 5.6 121.8 ± 119.4 182.1 ± 234.2 F = 52.48, df 2, P < .001
History of sexual abuse, % 14.7 18.1 12.5 χ2 = .99, df = 2, P = .61
History of physical abuse, % 9.5 16.9 14.9 χ2 = 1.16, df = 2, P = .56
Unemployed, % 13.9 13.5 11.1 χ2 = .42, df = 2, P = .81
History of suicide attempt, % 14 12.5 13.3 χ2 = .12, df = 2, P = .94
14 Yang and Dunner

TABLE 3. Comorbid diagnosis

Non-chronic major depression Chronic major depression Dysthymic disorder Statistical test

Panic χ = 2.76, df = 4, P = .60

2

Attack, % 5.7 4.2 6.7

Disorder, % 1.3 4.2 3.3
Eating disorder χ2 = 3.43, df = 4, P = .49
Anorexia, % 0.6 0 1.1
Bulimia, % 2.5 0 2.2
Alcohol abuse, % 15.9 16.8 15.7 χ2 = .05, df = 2, P = .98
Other substance abuse, % 38.9 42.1 40.0 χ2 = .26, df = 2, P = .88

biological and pharmacological data, longitudinal tion studied. Individuals who are screened and ac-
course, and exclusion criteria. Our approach in this cepted for participation in pharmaceutical clinical tri-
paper has been to provide as much data as possible als are likely to have less comorbidity than a general
from this particular sample regarding these criteria. clinical sample.
CLINICAL CHARACTERISTICS FAMILY HISTORY
Our main findings of lower mood-rating scores for The failure to find differences among relatives of
dysthymic patients as compared to patients with non- our depressive subtypes may reflect methodological
chronic and chronic depression is quite in line with factors. For example, we performed a family history
the definition of dysthymia, which is a less severe de- rather than a family study. Family history data are of-
pression than other mood disorders. ten less accurate than family study data. Furthermore,
The other major differences in our results are also in we were not able to identify chronic versus non-
keeping with the general characteristics of these disor- chronic depression among relatives.
ders. For example, the duration-of-illness finding of
dysthymic patients having longer illness than chronic PRIOR STUDIES: CLINICAL
major or non-chronic major depressive patients is also CHARACTERISTICS
consistent with the early age of onset of dysthymic pa-
tients. In our particular sample, the age of onset of ill- We previously reported a similar study for patients
ness was not significantly different, although there was who had been referred for private consultation to our
a trend in the appropriate direction for dysthymic pa- center [Lott and Dunner, 1996/1997]. That study re-
tients to have an earlier onset compared to patients ported data for 54 patients with chronic major depres-
with the other depressive subtypes. sive disorder, 17 patients with dysthymic disorder, and
31 patients with acute (6 months or less) major depres-
COMORBIDITY sion. There were equal gender ratios for dysthymic and
No differences in comorbidity of panic attacks/ acute major depressive patients, and a slightly higher
panic disorder, history of eating disorder, or alcohol or female-to-male ratio for chronic major depressive pa-
other substance abuse was found for this sample. tients. The mean ages of patients in those samples were
These findings may reflect the nature of the popula- not statistically different and were about 40 years of
age. A subgroup of patients were administered the
Temperament Character Inventory (TCI) [Cloninger et
TABLE 4. Morbidity risks for first degree family al., 1994]. There were no mean differences in coopera-
members tiveness (a measure of personality disorder) among the
three groups studied. Harm avoidance did show a sig-
Non-chronic Chronic
major major Dysthymic
nificant distribution with dysthymic patients lower than
depression depression disorder chronic major depressives or acute major depressives.
This finding, however, is quite in keeping with other
Depression data, suggesting that harm avoidance may reflect de-
Male, % 11.4 14.5 13.6 pression severity and is lower in patients with less se-
Female, % 20.2 20.6 18.4
verely rated depression [Nelsen and Dunner, 1995].
Bipolar I
Male, % 0.8 0 0.7
Novelty seeking and reward dependence showed no
Female, % 0 0.6 1.3 significant differences.
Bipolar II Other studies have compared depressive subtypes. For
Male, % 0.4 0 0.8 example, Klein et al. [1988] showed no difference in
Female, % 0 1.2 0.7 mean Beck Depression Inventory (BDI) scores between
Alcohol/other substance abuse early-onset dysthymics and non-chronic major de-
Male, % 22.1 27.4 22.2 pressives. However in their study, 59% of the dysthymic
Female, % 10.6 11.5 8.7 patients also had a current major depressive episode
 Research Article: Differential Subtyping of Depression
(double depression). The dysthymic subjects with cur-
rent major depression would raise the mean BDI score
closer to that found in the major depressive group.
Shores et al. [1992] reported a comparison of pa-
tients with pure dysthymic disorder and major depres-
sive disorder (although not necessarily chronic). They
found differences in age of onset (dysthymia earlier),
mean HAMD scores (dysthymia lower), and mean
HAMA scores (dysthymia lower). On sub-scales of the
HAMD, dysthymic patients scored less than major de-
pression patients on depressed mood, guilt, suicidal
thoughts, late insomnia, work impairment, psychomo-
tor retardation, and cognitive impairment.
Clark and co-workers [1994] also studied patients
with major depression (although not necessarily
chronic), and dysthymic patients. The characteristics
of their sample description included “secondary anxi-
ety disorders” in 37% of the major depressives and
29% of the dysthymic patients. They found no gen-
der differences. There were significant differences on
rating scales such that dysthymic patients had lower
mean scores on the BDI and Beck Anxiety Inventory,
HAMD 24, and HAMA as compared with major de-
pressive patients.
Symptom profiles tend to differentiate dysthymics
from other chronic depressives. The DSM-IV field
trial for mood disorders [Keller et al., 1995] revealed a
decrease in the prevalence of vegetative depressive
symptoms in dysthymics as compared with other
chronic depressives.
Regarding Axis II comorbidity, Spaletta et al. [1996]
showed an increased frequency of personality disor-
ders for dysthymic patients (43%) as compared with
major depressive patients (not necessarily chronic,
22%) using SCID2 interviews. However, Sanderson
and co-workers [1996] did not show a difference in the
prevalence of personality disorders in their dysthymic
sample (52%) as compared to a major depressive
sample, where 50% of their patients had a personality
disorder. The Sanderson study also used the SCID2,
and they further showed an increase in the frequency
of suicide attempts in major depressive patients as
compared with dysthymic patients.
Thus in summary of clinical features, there are pre-
dictable changes in rating scales found in all studies
with dysthymic patients having less severe depression
as determined by a variety of rating scales as compared
with major depressive patients, either chronic or non-
chronic. The age of onset of dysthymic patients is usu-
ally reported to be earlier than the other subtypes.
An acute major depressive episode may become
chronic. Keller et al. [1992] showed that about 19% of
individuals did not recover from an index episode of
major depression after 2 years, and these patients
would meet the definition of chronic major depres-
sion. However for the most part, acute major depres-
sion remits and recurrent episodes are likely. The
course of illness of dysthymic patients tends to show
persistent symptoms as does chronic major depression,
15
although remissions have been reported [Coryell et
al., 1990]. Thus there are differences in the course of
illness when comparing dysthymic patients, who have
chronic depression and about half of whom develop
major depressive episodes (double depression), chronic
depressives, who tend to maintain syndromal criteria
for major depressive episode, and acute major de-
pression, which tends to be a remitting/recurring
disorder. Since patients with dysthymia often develop
major depressive episodes, it is quite possible to con-
sider dysthymia as more similar to chronic depres-
sion than to acute depression based on both groups
having chronic depression.
PHARMACOLOGICAL STUDIES
In general the response to treatment for acute ma-
jor depression is about 50–70% of patients respond
in 6 weeks. Several studies have shown a decrease in
responsivity to both placebo and to active treatments
for chronically depressed patients as compared to
acutely depressed patients. For example, Khan et al.
[1991] showed a placebo response rate of about 45%
in patients whose presenting episode was less than a
year in duration, but for those whose depression was
12 months or greater, the placebo response rate was
about 23%. Kocsis et al. [1987] found a placebo re-
sponse in 13% versus an imipramine response in
59% of chronic depressives. Other studies reporting
a decrease in placebo response rate with chronicity of
depression include Klerman and Cole [1965], who
studied hospitalized patients, Downing and Rickles
[1973], Fairchild et al. [1986], Rabkin et al. [1987],
Brown et al. [1988], and Stewart et al. [1993]. Studies
showing a decrease treatment response with chronic-
ity of depression include Kiloh et al. [1961], Deyken
and DiMascio [1972], Paykel et al. [1973], and Black
et al. [1973].
Treatment studies of dysthymia are similar in out-
come to those of chronic major depression. In general,
data for treatment response show the need for high
doses over long periods of time [Thase et al., 1979,
Kocsis et al., 1987, Kocsis et al., 1996, Keller et al.,
1998, 2000]. Thus pharmacologically, patients with
chronic depression, either dysthymia or chronic major
depression, are more similar to each other than to pa-
tients with acute major depression regarding rapidity
and completeness of response to treatment as well as
he dose required for successful treatment outcome.
BIOLOGICAL STUDIES
There are very few biological studies comparing
chronic and non-chronic depression. Rush and co-
workers [1982] reviewed biological characteristics of
chronic unipolar depression and reported data for the
dexamethasone suppression test (DST) and the poly-
somnogram. Their data showed no difference in DST
non-suppression in individuals whose first episode was
less than 6 months compared to chronic depressives
(20.1 versus 20.7%). Similarly, most measures of sleep
16 Yang and Dunner
were similar comparing these two groups, although
there was a higher proportion of acute depressives
showing reduced REM latencies (less than 65 min)
compared to chronic depressives. The chronic de-
pressives tended to have lower REM density, Stage 3,
and Stage 4 sleep.
FAMILY STUDIES
The best family study comparing chronic to non-
chronic depressives reported thus far is that of Klein
et al. [1995]. Their family study of depressed patients
showed an increased rate of dysthymia and chronic
major depression among relatives of dysthymic and
chronic depressive probands as compared to relatives
of normal controls and relatives of patients with epi-
sodic depression, who showed more recurrent depres-
sion than relatives of dysthymic and chronic patients.
The replication of this study would be an important
factor in establishing the differentiation of these de-
pressive subtypes.
DOUBLE DEPRESSION
We did not include patients in our study with
“double depression.” Our rationale was that this
group, which frequently is included in treatment stud-
ies of chronic depression, represents a confound of in-
dividuals who have chronic major depression and
dysthymia since many patients with double depression
have a chronic major depressive episode. In general,
the treatment response of double depressives is similar
to that of chronic major depressives, requiring high
doses and long duration of treatment.
Kocsis et al. [1987] reported 76 dysthymic patients
of whom 96% met criteria for a current major depres-
sive disorder. This population had a female-to-male ra-
tio of 2.3:1, 33% were married, and 46% had never
married. Atypical features were present in 16%. The
mean HAMD baseline score was 22.8, the mean GASF
score was 56.8, and a measure of social adjustment, the
Social Adjustment Scale — Self Report [Weissman and
Boswell, 1976] showed a mean of 2.6. In a subsequent
study, Kocsis et al. [1996], reviewing individuals who
had responded to newspaper and phone advertisements
for treatment of chronic depression, reported a sample
of 51 pure dysthymics, 64 double depressives, and 14
chronic major depressives. The percentage of females
was lower in the dysthymic than in the double depres-
sion or the chronic major depressive group (51% ver-
sus 61% versus 64%, respectively). Mean HAMD
ratings were lower in the pure dysthymic (19.5) as
compared to the double depressives (24) or the chronic
major depressive group (23) and the mean GASF score
was similar for these three groups (55–56%), as were
ratings on the SAS-SR (2.3-–2.7). Forty-eight percent
of dysthymics, 63% of double depressives, and 33% of
chronic major depressives had an Axis II disorder. Co-
morbid anxiety disorders were found in 42% of dys-
thymics, 21% of double depressives, and 39% of
patients with chronic major depression. The small
number of chronic major depressives (14) in this study
may have affected the results.
There are several limitations to our study. Individuals
who participate in clinical trials may represent a differ-
ent population regarding comorbidity, gender ratio, and
clinical symptomatology, as compared with patients who
are seen in clinical samples. For example, exclusion cri-
teria for clinical trials frequently preclude participation
of individuals who have active substance abuse, signifi-
cant personality disorders, current medical problems
that would exclude them from participation, or depres-
sion ratings below certain thresholds. However, our
clinical referral population [Lott and Dunner, 1996/
1997] was in many ways similar to the clinical trial
population reported here. Additionally, the definition of
chronic is an arbitrary definition. DSM-IV defines
chronic as a 2-year or longer disorder. Individuals with a
depression for somewhat less than 2 years might become
chronic given a longer period of observation and are not
likely to be different than individuals who have a slightly
longer period of persistent depression than 2 years.
However, in this study the mean duration of illness for
the non-chronic major depression (7.8 months) is cer-
tainly not overlapping with the mean duration for pa-
tients with chronic major depression (121.8 months) or
dysthymia (182.1 months).
Our study does not provide sufficient evidence to
support our hypothesis that chronic major depression
and dysthymia could be classified together and sepa-
rated from acute major depressive disorder. However,
we hope that this study will encourage other investiga-
tors to consider a similar diagnostic evaluation in the
separation of their data.
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