Depression. Aaron T. Beck, M.D.

for as long as 40 years. Moreover, since the follow-up depended largely on readmission to the hospital, the information on patients who were not readmitted is scanty. Despite these limitations, his study is of great value in providing solid facts regarding recurrent episodes, frequency and duration of the attacks, and duration of the intervals between attacks. His sample was as follows: single depression, 263; recurrent depression, 177; biphasic single episode, 106; combined, recurrent, 214; single manic episode, 102; recurrent manic, 47. Biphasic was used for cases in which both manic and depressive episodes occurred. These have been designated by terms such as compound, mixed, combined, double-form, cyclothymic, and cyclical. Alternating and circular refer to cases in which one phase follows immediately after the opposite without any free interval. “Closed circular type” refers to uninterrupted manic and depressive cycles.

      Paskind’s study^2,3,4 of cases of depression seen in private practice provides data on the course of depressions observed outside the hospital. Although there are many serious methodological deficiencies in this study, the data presented are relevant to milder episodes of depression. Paskind reviewed the records of 633 cases of depression in the private practice of Dr. Q. T. Patrick. Although all of these cases had been placed in the all-inclusive category of manic-depressive psychosis, a review of the case histories presented in the articles leaves little doubt that these cases are actually descriptive of the bipolar mood disorders rather than psychosis. In reviewing the tabulated data presented by the author, it is apparent that his findings are based on 248 cases abstracted from the original group. The cases were collected over a period of 32 years, but there is no mention of the average period of observation or of any systematic attempt to obtain follow-up material on these patients. Paskind noted that 88 cases (32 percent) could be classified as “brief attacks of manic-depressive psychosis,” since the average duration of the episodes ranged from a few hours to a few days.

      Paskind described the symptoms of the short attacks as exactly like those of longer attacks: profound sadness and unhappiness without obvious cause; self-reproach; self-blame; self-derogation; lack of initiative; lack of response to usual interests accompanied by keen awareness of this lack; avoidance of friends; a feeling of hopelessness; death wishes; and inclinations or desire to commit suicide. Paskind stated that the well-known antidotes for depression, such as a philosophic outlook, company of friends, amusements, diversions, rest, change of scene, and good news did not cause the attacks to disappear. “Instead one finds a person in a normal mood who without apparent cause becomes within a brief period profoundly sad and unhappy; in spite of all attempts to cheer him, the attack remains for from a few hours to a few days; when it does disappear it does so as abruptly and mysteriously as it came.”

      Rennie⁵ did a follow-up study of 208 patients with manic-depressive reactions admitted to the Henry Phipps Psychiatric Clinic between 1913 and 1916. Atypical cases were not included because the author wanted to study only clear-cut manic-depressive (bipolar) reactions. Several patients having what seemed to be manic excitements at the time of admission developed schizophrenic reactions on long-term observation. These cases were excluded, as were cases of depression that had lost the preponderant depressive affect and had, in the course of years, evolved slowly into more automatic and schizophrenic-like behavior. Also excluded were depressive patients with hypochondriasis who had lost most of their depressive affect and who had sunk into a state of chronic invalidism with little depressive content. The material, consequently, can be regarded as following reasonably stringent criteria for diagnosing the manic-depressive syndrome.

      Follow-up on these patients was obtained by letter, social service interview, physician’s interview, newspaper notices of suicide, and records from other hospitals. In only one case were no follow-up data obtained. The follow-up period evidently ranged from 35 to 39 years.

      In Rennie’s study, the following clinical groups were described in order of frequency: (1) recurrent depression: 102 patients—15 had symptom-free intervals of at least 20 years between attacks, and 52 had remissions of at least 10 years; (2) Cyclothymic (biphasic), 49 patients in whom all combinations were observed, with elation and depression sometimes following each other in closed cycles; (3) single attacks of depression, recovered—26 patients; (4) single attacks of depression, unrecovered—14 patients, of whom 9 committed suicide; (5) recurrent manic attacks, 14 cases; (6) single manic attacks—two patients (These remained well for over 20 years after the attack. A third patient became manic for the first time at age 40 and was still hospitalized at age 64.)

      A comparison of the relative frequency of depressed, biphasic, and manic patients observed in various studies is presented in Chapter 6.

      Lundquist⁶ conducted a longitudinal study of 319 manic-depressive patients whose first hospitalization for this disorder was at the Langbrö Hospital in 1912–31. The investigator reviewed the records and checked the appropriateness of the diagnoses to “satisfy all reasonable demands in regard to reliability.” His sample consisted of 123 men (38 percent) and 196 women (62 percent).

      After locating the discharged patients, follow-up was conducted by a personal examination of patients at the hospital, a home visit by a social worker if patients lived in Stockholm, a detailed questionnaire mailed to patients living outside of Stockholm, and a review of the hospital record of patients currently hospitalized elsewhere.

      The period of observation varied considerably: 20–30 years, 42 percent; 10–20 years, 38 percent; less than 10 years, 20 percent.

      The duration of an episode was defined as the time that elapsed between patients’ recognition of their symptoms and their return to their former occupation. Remission was based on a rough gauge of patients’ ability to resume their work and ordinary mode of life.

Onset of Episodes

      The relative frequency of an insidious onset, as compared with an acute onset, was studied by Hopkinson⁷ for 100 consecutive inpatients diagnosed as having an affective illness. All were more than 50 years of age on admission, and 39 had suffered previous attacks before age 50; 80 patients were examined personally by the author, and in the remaining 20 cases, the pertinent data were abstracted from the case histories.

      When the onset of the illness was studied, it was found that 26 percent of the cases exhibited a well-defined prodromal period; the remaining 74 percent of the cases were considered of acute onset. Complaints made by these patients in the prodromal period were vague and nonspecific. Tension and anxiety occurred in all to some extent. The duration of the prodromal period before the onset of a clear-cut depressive psychosis ranged from 8 months to 10 years; the mean duration was 33.5 months.

      In a later study,⁸ Hopkinson investigated the prodromal phase in 43 younger patients (ages 16–48). Thirteen (30.2 percent) showed a prodromal phase of 2 months to 7 years (mean = 23 months). The clinical features of the prodromal period were chiefly tension, anxiety, and indecision.

      In summary, 70–75 percent of the patients in both studies with an affective disorder had an acute onset.

      The relationship of acuteness of onset to prognosis has been studied by several investigators, with contradictory results. Steen⁹ found, in a study of 493 patients, that the remission rate was higher among manic depressives who showed an acute onset than among those with a protracted onset. On the other hand, Strecker et al.,¹⁰ in a comparison of 50 recovered and 50 nonrecovered manic depressives, found that an acute onset occurred no more frequently in the recovered than in the chronic group. In a study of 96 cases grossly diagnosed as manic depressive, Astrup et al.¹¹ found that an acute onset favored remission.

      Hopkinson⁸ found a significantly higher frequency of attacks per patient among his cases with an acute onset (mean = 2.8) than among those patients with a prodromal phase (mean = 1.3).

      Lundquist⁶ reported that patients over 30 with an acute onset (less than a month) had a significantly shorter duration of their episodes than those with a gradual onset. In the age group of 30–39 years, the mean duration of the acute onset cases was 5.1 months and of the gradual onset cases, 27.2 months.

      The average age of onset of depression varied so widely among