They say time flies when you’re enjoying yourself. When you’re depressed, the moments creep miserably by, and to those with chronic depression, this misery is endless. Looking back, misery predominates. To those who dare to look forward, it seems certain that they will never experience any lasting relief. Chronic depression casts a very long, black shadow over the person’s life.
In this book, we will be illustrating the advances that a cognitive approach can provide in understanding and treating persistent depression by describing the stories of several patients. As will become clear, there are as many different precise presentations of persistent depression as there are patients. For example, Kate described being tossed about by extremes of every different kind of unpleasant emotion, whereas Stan was mired in an unvarying bleak flatness of mood. Elizabeth was struggling to keep up standards of performance that others would have been proud to attain, whereas Peter struggled to keep going at all. Amid all the variety, the common factor is the ongoing suffering of anyone afflicted by persistent depression.
As we describe below, persistent depression has drastic effects, not only on the mood of individuals, but also on their overall mental and physical well-being, their daily functioning, their relationships, their working life and on society around them.
The scale of the problem of persistent depression has only recently begun to emerge. The latter half of the twentieth century saw great optimism surrounding the treatment of depression, as pharmacological and psychological treatments were found to be effective (Hollon et al., 1993). The substantial minority of patients who did not benefit from treatment seemed at first to receive little notice. Gradually, the continued suffering of individual patients and its effect on society has been reflected in consideration given to the diagnosis and treatment of persistent depression. It was not until 1987 that the diagnosis of chronic depression was included in the influential Diagnostic and Statistical Manual of the American Psychiatric Association with publication of the revised third edition (DSM-III-R).
The lack of consensus over issues of definition and diagnosis has hindered the gathering of consistent information about predictors and possible causes of persistent depressive symptoms. As a result, although the potential treatment options are many, evidence that might inform decisions about the most beneficial treatments remains limited.
The majority of patients feel overwhelmed by helplessness in the face of the persistence of their depression. In view of the sketchiness of the available information on causes and treatments, clinicians too can feel helpless when faced with the prospect of treating persistent depression. In setting the scene for describing the treatment of persistent depression with cognitive therapy, we aim to present some of the information that is available. In this introduction, we first outline the nature of the problem by describing the symptoms of persistent depression and outlining some of its psychological and social consequences.
We then discuss some of the main issues in defining and diagnosing chronic and persistent depression. We draw attention to the role of the inadequacy of treatment received by many patients, and highlight the distinction between chronicity and treatment resistance. We then review some of the main research findings on predictors of persistence of depression and put forward some of the reasons for pursuing psychotherapeutic treatments in chronic depression. Existing evidence on the use of cognitive therapy with patients with persistent depression is then reviewed, and more recent developments in cognitive therapy are described.