sinned in an unforgivable way. Less commonly, the hallucinations or delusions have no obvious relationship to sadness (mood-incongruent); for example, there may be persecutory delusions, for which the person has no explanation. Studies to date suggest that mood-incongruent symptoms are associated with a worse prognosis; evolve into schizophreniform or schizoaffective disorders; involve a less episodic, more chronic course; and require more assiduous, longer maintenance treatment(s). (See LaliveAubert and Rush, 1992; Lalive-Aubert and Rush, in press, for reviews.)

The psychotic features of psychotic major depressive disorder usually recur in subsequent episodes, should such episodes occur. Some studies suggest that psychotic depressive episodes are familial (Schatzberg and Rothschild, in press; Weissman and Johnson, 1990).

For psychotic depressions, TCAs plus a neuroleptic or

electroconvulsive therapy (ECT) are each superior to TCAs alone in treating the illness (Depression Guideline Panel, forthcoming). Given the markedly disabling nature of psychotic depression, maintenance treatments are strongly indicated when the disorder is recurrent. However, the relative efficacy of maintenance treatment compared to placebo; the value of including both a neuroleptic and an antidepressant in maintenance treatment; and the acute and maintenance phase efficacy of non-TCA medications, lithium, or selected anticonvulsants have not been studied in randomized controlled trials (Schatzberg and Rothschild, 1992).

Melancholic Features

Guideline: The key melancholic features of major depressive disorder

are:

Psychomotor retardation or agitation.

Loss of interest or pleasure.

Lack of reactivity to usually pleasant stimuli.

Worse depression in the morning.

Early morning awakening.

(Strength of Evidence = A.)

Melancholic symptom features appear to repeat from episode to episode in individuals with recurrent, severe major depressive disorder. They are more commonly present in older depressed patients (see Rush and Weissenburger, in press, for a review). Melancholic features are not uniquely associated with a family history of depression. They are associated with reduced rapid eye movement latency and/or dexamethasone nonsuppression (Rush, Cain, Raese, et al., 1991).

Severely symptomatic patients whose depression has melancholic features are likely to respond to treatment with TCAS or to ECT.

Melancholic features do not predict which antidepressants will be effective, though their presence indicates that anxiolytics will not be effective (Depression Guideline Panel, forthcoming). The presence of melancholic

symptom features, especially in the severely ill, should sharply increase the practitioner's tendency to treat with antidepressants and should provoke a thorough questioning for the presence of psychotic symptom features. If medications fail, ECT should be strongly considered for these patients.

Atypical Features

The groups studying atypical features define the features differently. Two types, vegetative and anxious, have been proposed in the literature. Vegetative features include:

■ Overeating.

■ Oversleeping.

■ Weight gain.

■ A mood that still responds to events (reactive mood).

Extreme sensitivity to interpersonal rejection.

■ A feeling of heaviness in the arms and legs.

Anxious features include:

■ Marked anxiety.

■ Difficulty in falling asleep.

Phobic symptoms.

■Symptoms of sympathetic arousal.

Atypical features of either type are associated with a younger age at onset of illness. Whether these symptoms run in families, repeat across episodes, or are associated with an identifiable or unique biology is not known. However, rapid eye movement latency is not characteristically reduced in this type of mood disorder. The relationship between atypical and melancholic symptom features remains to be clarified. Some data suggest that atypical symptoms may be more likely earlier in the course of major depressive disorder, while melancholic features are more likely to appear later.

Several randomized controlled trials indicate that, when atypical features (those in the vegetative group above) are present, monoamine oxidase inhibitors (MAOIS) are more effective than TCAs, although the latter are still more effective than placebo. Case reports and clinical experience suggest that those depressions with atypical features may respond better to selective serotonin reuptake inhibitors (SSRIs) than to TCAS.

Seasonal Pattern

Guideline: DSM-III-R indicates that a seasonal pattern for major depressive disorder can be diagnosed only if:

■ Episodes are recurrent (at least two episodes by some criteria, three by other criteria).

■ There has been a regular temporal relationship between the onset of the major depressive episodes and a particular period of the year (such as regular onset of depression in fall and offset in spring). ■ Seasonal episodes substantially outnumber nonseasonal episodes. Most often, depressive symptoms remit fully between seasonal episodes. (Strength of Evidence = A.)

The first systematic evidence of the prevalence of seasonal affective disorder was an estimate of 6 percent from a study in the New York area. Subsequently extended to various east coast latitudes, this study showed less than 2 percent prevalence in Florida and nearly 10 percent prevalence in New Hampshire (Rosenthal, Levendosky, Skwerer, et al., 1990; Terman, 1988). There are two to three times as many people personally troubled by the winter recurrence of seasonal mood symptoms than there are those with manifestations severe enough to warrant clinical diagnosis (Kasper, Wehr, Bartko, et al., 1989; Rosen, Targum, Terman, et al., 1990; Terman, Botticelli, Link, et al., 1989).

Preliminary evidence suggests that light therapy is effective in the short-term treatment of outpatients with mild to moderate seasonal major depressive disorder. Further research is required before such a claim can be made for subsyndromal seasonal affective disorder. To date, no hazard has been encountered with short-term light therapy using standard fluorescent lighting apparatus (designed to produce 2,500 to 10,000 lux stimulation and low levels of ultraviolet emission). Exposure extending beyond 2 weeks has not been fully evaluated. Clinical reports suggest that medications may also be effective for some seasonal mood disorders.

Postpartum Onset

Postpartum mood symptoms are divided into three categories, based on severity: blues, psychosis, and depression (Kendell, 1985; for a review, see Purdy and Frank, in press). Postpartum blues are brief episodes (1 to 4 days) of labile mood/tearfulness that normally occur in 50 to 80 percent of women within 1 to 5 days of delivery. Treatment consists of reassurance and time to resolve this normal response.

Postpartum psychoses can be divided into depressed and manic types. Patients with the depressed type show more psychotic, disoriented, agitated, and emotionally labile features, as well as more psychomotor retardation, than do nonpostpartum matched depressed controls (Dean and Kendell, 1981). Most of these cases are associated with signs of organic impairment. Features of the manic type are similar to features of a classic mania. The incidence of postpartum psychosis is low (0.5 to 2.0 per 1,000 deliveries), as shown in eight studies (Grundy and Roberts, 1975;

Hemphill, 1952; Kendell, Rennie, Clarke, et al., 1981; Meltzer and Kumar, 1985; Nott, 1982; Paffenbarger, 1964; Paffenbarger and McCabe, 1966;

Paffenbarger, Steinmetz, Pooler, et al., 1961). Many early cases were mistaken for toxic/infectious states.

The symptoms of postpartum psychosis develop rapidly (over 24 to 72 hours), typically beginning 2 to 3 days after delivery. The period of risk for developing postpartum psychosis is within the first month following delivery. For acute postpartum psychosis, the prognosis is generally good. However, many patients have previously had or subsequently develop a bipolar disorder. The risk of postpartum psychosis is higher for those with episodes at prior deliveries. The recurrence rate is from 33 to 51 percent. Nonpsychotic postpartum depressions (major or minor depressive disorders) have also been identified (O'Hara, Neunaber, and Zekoski, 1984). These conditions may occur from 2 weeks to 12 months postpartum, but typically occur within 6 months. The prevalence of nonpsychotic depressions is 10 to 15 percent within the first 3 to 6 months after childbirth, which is somewhat higher than are the rates (5 to 7 percent) in nonchildbearing matched controls. However, the risk for nonpsychotic postpartum depression is higher for persons with a psychiatric history.

No randomized controlled treatment trials for any of the postpartum mood conditions are available. Logic and clinical experience suggest that prophylactic lithium be given as soon as possible after delivery to prevent a postpartum precipitation in patients with a history of bipolar disorder. Likewise, given the high likelihood of recurrence, other previously effective psychotropic medications should be considered in those with a history of psychotic postpartum mood episodes immediately after giving birth.

Dysthymic Disorder

Clinical Features and Course

Guideline: The essential feature of dysthymic disorder is a chronic mood disturbance (sadness in adults; sadness and, possibly, irritability in children and adolescents) present most of the time for at least 2 consecutive years (1 year for children and adolescents). (Strength of Evidence = A.)

Patients with dysthymic disorder exhibit at least two of the associated symptoms noted in Table 4. The associated features of dysthymic disorder are similar to those of major depressive disorder, except that, by definition, delusions or hallucinations are absent. Dysthymic disorder usually begins in childhood or adolescence without a clear onset and with a chronic

course.

Differentiation between dysthymic disorder and major depressive disorder can be difficult. Their symptoms are similar, differing only in duration and severity. Individuals who initially present with dysthymic disorder frequently go on to develop concurrent major depressive disorder.

Table 4. DSM-III-R criteria for dysthymic disorder

A. Depressed mood for most of the day, more days than not, for at least 2 years

B. While depressed, presence of at least two of the following:

(1) Poor appetite/overeating.

(2) Insomnia/hypersomnia.

(3) Low energy/fatigue.

(4) Low self-esteem.

(5) Poor concentration or difficulty making decisions.

(6) Feelings of hopelessness.

C. During a 2-year period of the disturbance, never without the symptoms

in A and B for more than 2 months at a time.

D. No evidence of a major depressive episode during the first 2 years.

E. Never had a manic or hypomanic episode.

F. Not superimposed on a chronic psychotic disorder, such as schizophrenia or delusional disorder.

G. Cannot be established that an organic factor initiated and maintained the disturbance.

Source: American Psychiatric Association, 1987.

Some develop hypomanic episodes, a situation requiring a revised diagnosis of either bipolar disorder not otherwise specified or bipolar II disorder. If the onset of an apparent dysthymic disorder directly follows a major depressive episode, the correct diagnosis is major depressive disorder in partial remission. By definition, dysthymic disorder cannot follow an episode of major depressive disorder unless the major depressive episode has been in full remission for at least 6 months before the onset of the dysthymic condition. When a major depressive episode immediately follows a preexisting dysthymic disorder that has been present for at least 2 years, the diagnosis is concurrent major depressive disorder and dysthymic disorder.

Dysthymic disorders may be primary (i.e., unrelated to other preexisting disorders), or they may accompany coexisting nonmood psychiatric disorders or other nonpsychiatric medical conditions. In the latter case, they are called secondary dysthymic disorders. The presence of dysthymic disorder with no prior episodes of major depressive disorder should cue the practitioner to search for other nonmood psychiatric disorders, such as substance or alcohol abuse. The reanalysis of the ECA Study data showed that, in patients with dysthymic disorder (with and without major depressive disorder) who were reexamined 1 year later, 7 to 26 percent still had dysthymic disorder, 4 to 10 percent had major depressive disorder, 5 to 20 percent had both, 11 to 23 percent had DNOS, and 41 to 52 percent were well (Johnson and Weissman, unpublished manuscript).