DYSTHYMIC AND CYCLOTHYMIC DEPRESSIONS - THERAPEUTIC CONSIDERATIONS

This paper reviews recent evidence on two prevalent course patterns of major depressive illness arising from dysthymic and cyclothymic tempe ramental substrates. The first pattern, known as ''double depression,' ' typically begins insidiously in childhood or adolescence, pursues a low-grade intermittent course, and is complicated by superimposed high ly recurrent major depressions. Patients with this pattern respond to TCAs, MAOIs (classical and reversible), and SSRIs (of which the best c urrent evidence is for fluoxetine). The second pattern, that of ''cycl othymic depression,'' is represented by bipolar II and related soft bi polar disorders; it pursues a more fluctuating course from onset in ju venile or early adult years, and appears susceptible to rapid cycling upon tricyclic antidepressant administration. For patients exhibiting the latter pattern, bupropion, MAOIs, and low-dose SSRIs all seem bene ficial, but should be preferably used in conjunction with lithium or o ther mood stabilizers such as valproate; thyroid augmentation is parti cularly relevant to these cyclothymic depressions. Practical and suppo rtive psychotherapeutic approaches would be useful for double depressi ve patients, while psychoeducation and attention to rhythmopathy would be more relevant for those with cyclothymic depressions. Conjugal and other interpersonal strains should also be addressed in both affectiv e subtypes. The evidence reviewed does not support the commonly held b elief that depressions associated with ''personality'' disorders respo nd suboptimally to treatment. On the contrary, the temperamental dysre gulation underlying depressive subtypes defined by course appears resp onsive-even overresponsive-to a new spectrum of thymoleptic agents. Th ese considerations underscore the close link between innovative temper ament-based classifications of depressive illness and emerging clinica l management strategies with thymoleptic agents and psychosocial inter ventions.