Strategies and Tactics in the Treatment of Chronic Depression

Chronic depressions include major depressive disorder, recurrent, without full interepisoderecovery; major depressive disorder, currently in a chronic (i.e., ≥ 2 years) episode; double depression;dysthymic disorder; and those depressive disorders—not otherwise specified(NOS)—that are persistent or predictably recurrent with substantial disability. Strategic treatmentdecisions include (1) whether to treat with medication, psychotherapy, ECT, or othermethods; (2) selection among specific agents with long-term efficacy and tolerability (preferablyestablished by randomized controlled trials); (3) selection of the next treatment should theinitial treatment fail or be found intolerable; and (4) deciding whether to provide maintenancetreatment. Tactical decisions are those needed to optimally implement the strategies selected;for example, (1) how to optimally dose, (2) how long to continue an acute phase treatment trial,(3) how to measure outcome, and (4) how to identify and manage subsequent symptomaticbreakthroughs or side effects (which may also require revisions in the initial strategies). Someantidepressant medications evidence efficacy and safety in acute phase treatment of the chronicallydepressed, but continuation and maintenance phase treatments for these patients are lesswell investigated and deserve further study. The clinical implications of what is known to datefor managing these patients are discussed.