First Glance

First of all, it seems appropriate to separate primary from secondary depression. Primary depressions are those which arise in and of themselves, while secondary depressions follow in the train of some other illness or event.

Other types are :

• Endogenous-reactive, and
• Psychotic-neurotic

These continuously have failed to stand the test of time. In some ways, endogenous depression may appear synonymous with primary depression and reactive with secondary, but the endogenous-reactive dichotomy has come to connote severity, with many people equating endogenous with psychotic and reactive with neurotic depression respectively. That this is an over simplification becomes clear when one must treat a patient with what appears to be a lifelong neurotic illness for which no external precipitants in the life of the individual can be identified as endogenous depression.

Conversely, one sometimes sees actually psychotically depressed patients with a good pre-morbid personality who "come apart" as a result of severe trauma. It is probably most consistent and useful at this point in time to recognise the endogenous-reactive and psychotic-neurotic dualisms since they add more confusion than clarity to the process of classification. They do remain clinically useful in treatment selection, and we will retain them for that reason.

Over the years, the term endogenous depression has been used for a multitude of purposes.

Among them are :

• The opposite of neurotic or reactive depression
• Depression occurring in people with normal pre-morbid personalities
• Depression with no precipitating event
• Depressions that are responsive to somatic treatment
• Depression with a characteristic complex of symptoms, principally vegetative, diurnal variations ,and early morning awakening

The term neurotic depression like endogenous, carries a multitude of meanings, often with etiologic connotations. Neurotic depression, has been variously defined as being mild depression, or non-psychotic depressions (these are not always the same), depression that is less socially incapacitating, or which follows a life event, or those without endogenous symptoms, or those which arise in individuals with long-standing characterologic problems. These criteria are not identical and thus the new term for the old concept.

Neurotic depression

The common characteristics of neurotic depression can be summarised as

• It is mild,
• It is nonpsychotic, i.e .lacks psychotic symptoms,
• It is less socially incapacitating,
• It is situational or reactive, as a reaction to an event or situation
• No endogenous symptoms, like marked loss of weight, appetite, guilt, diurnal variation are prominent,
• Characterological, in terms of being long term.
• It results from unconscious conflict which usually cannot be easily identified,
• It is associated with other neuroses like anxiety, obsessions conversions or hypochondriasis.

Chronic depressive disorder

This is characterised by a chronic (at least two years) nonpsychotic disturbance involving mood or loss of interest or pleasure in all or almost all usual activities and pastime, and associated symptoms but not of sufficient severity to meet the criteria for a depressive episode. The depressed mood may be charaterised by the individual as feeling sad, blue, down in the dumps or low.

The depressed mood or loss of interest or pleasure may be either relatively persistent or intermittent and separated by periods of normal mood, interest and pleasure. These normal periods may last a few days to a few weeks.

During the depressive periods there are some of the nonpsychotic and milder features of the depressive syndrome which change from the individual's usual or former self. Other features are similar to those of a depressive episode except that there are no delusions or hallucinations.

This disorder usually begins early in adult life, and for this reasons was often referred to as depressive personality. In other cases, it may begin at a later period, in some instances following a major depressive disorder.

The impairment in social and occupational functioning is usually mild or moderate because of the chronicity, rather than the severity of the depressive syndrome. Therefore, hospitalization is rarely required unless there is a suicide attempt or a superimposed episodic affective disorder. Such depressions are called 'double depression'. There may be a greater likelihood of developing substance-abuse.

A predisposing factor is the presence of a chronic physical disorder, chronic life stresses, or another psychiatric disorder, such as a personality disorder, or an affective disorder which does not completely remit and merges imperceptibly into this condition.

The exact prevalence is not known. However, the condition probably is common among outpatients. The disorder is apparently more common in females. Often the affective features of this disorder are viewed as secondary to an underlying personality disorder.