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 temperamental 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 highly recurrent major depressions. Patients with this pattern respond to TCAs, MAOIs (classical and reversible), and SSRIs (of which the best current evidence is for fluoxetine). The second pattern, that of "cyclothymic depression," is represented by bipolar II and related soft bipolar disorders; it pursues a more fluctuating course from onset in juvenile 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 beneficial, but should be preferably used in conjunction with lithium or other mood stabilizers such as valproate; thyroid augmentation is particularly relevant to these cyclothymic depressions. Practical and supportive psychotherapeutic approaches would be useful for double depressive 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 affective subtypes. The evidence reviewed does not support the commonly held belief that depressions associated with "personality" disorders respond suboptimally to treatment. On the contrary,the temperamental dysregulation underlying depressive subtypes defined by course appears responsive--even overresponsive--to a new spectrum of thymoleptic agents. These considerations underscore the close link between innovative temperament-based classifications of depressive illness and emerging clinical management strategies with thymoleptic agents and psychosocial interventions.