Skip to main content
    • Aa
    • Aa

The long-term course of depression: development of an empirical index and identification of early adult outcomes

  • J. W. Pettit (a1), P. M. Lewinsohn (a2), R. E. Roberts (a3), J. R. Seeley (a2) and L. Monteith (a1)...

Research on the long-term course of major depressive disorder (MDD) is hindered by the absence of established course criteria and by idiosyncratic definitions of chronicity. The aims of this study were to derive an empirical index of MDD course, to examine its predictive validity, and to identify the adulthood outcomes associated with a chronic course.


Indicators for a MDD course factor were rationally selected and subjected to principal components (PCA) and confirmatory factor analyses (CFA) among 426 subjects with a lifetime history of MDD by age 30. Scores on the index prior to age 19 were examined as predictors of course from age 19 to 30. Associations between the index and outcomes of interest at age 30 were examined.


Three indicators loaded highly on a chronic course index and displayed adequate internal consistency: early onset age, number of episodes, and duration of ill time. Predictive validity of the index was supported. A more chronic course was associated with greater symptom severity, greater likelihood of treatment utilization, and greater psychosocial impairment in multiple domains. Treatment utilization interacted with chronicity to predict relatively few outcomes and did not reduce the negative impact of a chronic course.


The course of MDD through early adulthood is best represented by a composite of early onset age, number of episodes, and duration of ill time. A chronic course through early adulthood is associated with numerous indicators of psychosocial impairment. Mental health treatment utilization in a naturalistic setting does not appear to reduce the negative impact of chronic MDD.

Corresponding author
*Address for correspondence: Dr J. W. Pettit, Department of Psychology, 126 Heyne Building, University of Houston, Houston, TX 77204-5022, USA. (Email:
Hide All
Andrews JA, Lewinsohn PM, Hops H, Roberts RE (1993). Psychometric properties of scales for the measurement of psychosocial variables associated with depression in adolescence. Psychological Reports 73, 10191046.
Berndt ER, Koran LM, Finkelstein SN, Gelenberg AJ, Kornstein SG, Miller IM, Thase ME, Trapp GA, Keller MB (2000). Lost human capital from early-onset chronic depression. American Journal of Psychiatry 157, 940947.
Birmaher B, Arbelaez C, Brent D (2002). Course and outcome of child and adolescent major depressive disorder. Child and Adolescent Psychiatric Clinics of North America 11, 619637.
Cohen J, Cohen P (1983). Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences, 2nd edn. Lawrence Erlbaum: Hillsdale, NJ.
Crown W, Finkelstein S, Brendt E, Ling D, Poret AW, Rush J, Russell JM (2002). The impact of treatment-resistant depression in health care utilization and costs. Journal of Clinical Psychiatry 63, 963971.
Dalrymple KL, Zimmerman M (2007). Does comorbid social anxiety disorder impact the clinical presentation of principal major depressive disorder? Journal of Affective Disorders 100, 241247.
Dunn V, Goodyer IM (2006). Longitudinal investigation into childhood and adolescent onset depression: psychiatric outcome in early adulthood. British Journal of Psychiatry 188, 216222.
Folkman S, Lazarus RS (1980). An analysis of coping in a middle-aged community sample. Journal of Health and Social Behavior 21, 219239.
Garyfallos G, Adamopoulou A, Karastergiou A, Voikli M, Sotiropoulou A, Donias S, Giouzepas J, Paraschos A (1999). Personality disorders in dysthymia and major depression. Acta Psychiatrica Scandinavica 99, 332340.
Gilmer WS, Trivedi MH, Rush AJ, Wisniewski SR, Luther J, Howland RH, Yohanna D, Khan A, Alpert J (2005). Factors associated with chronic depressive episodes: a preliminary report from the STAR*D project. Acta Psychiatrica Scandinavica 112, 425433.
Hamilton M (1960). A rating scale for depression. Journal of Neurology and Neurosurgery 23, 5661.
Harter S (1982). The Perceived Competence Scale for Children. Child Development 53, 8797.
Hasin DS, Tsai WY, Endicott J, Mueller TI, Coryell W, Keller M (1996). Five-year course of major depression: effects of comorbid alcoholism. Journal of Affective Disorders 41, 6370.
Hays JC, Krishnan KR, George LK, Pieper CF, Flint EP, Blazer DG (1997). Psychosocial and physical correlates of chronic depression. Psychiatry Research 72, 149159.
Holmes TH, Rahe RH (1967). The social readjustment rating scale. Journal of Psychosomatic Research 11, 213218.
Judd LL, Akiskal HS, Zeller PJ, Paulus M, Leon AC, Maser JD, Endicott J, Corvell W, Kunovac JL, Mueller TI, Rice JP, Keller MB (2000). Psychosocial disability during the long-term course of unipolar major depressive disorder. Archives of General Psychiatry 57, 375380.
Keller MB, Lavori PW, Friedman B, Nielsen E (1987). The longitudinal interval follow-up evaluation: a comprehensive method for assessing outcome in prospective longitudinal studies. Archives of General Psychiatry 44, 540548.
Keller MB, McCullough JP, Klein DN, Arnow BL, Duner DL, Gelenberg AJ, Markowitz JC, Nemeroff CB, Russell JM, Thase ME, Trivedi MH, Zajecka J (2000). A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. New England Journal of Medicine 342, 14621470.
Klein DN (in press). Classification of depressive disorders in DSM-V: proposal for a two-dimension system. Journal of Abnormal Psychology.
Klein DN, Lewinsohn PM, Rohde P, Seeley JR, Durbin CE (2002). Clinical features of major depressive disorder in adolescents and their relatives: impact on familial aggregation, implications for phenotype definition and specificity of transmission. Journal of Abnormal Psychology 111, 98106.
Klein DN, Shankman AS, Lewinsohn PM, Rohde P, Seeley JR (2004). Family study of chronic depression in a community sample of young adults. American Journal of Psychiatry 161, 646653.
Lewinsohn PM, Hops H, Roberts RE, Seeley JR, Andrews JA (1993). Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology 102, 133144.
Lewinsohn PM, Mermelstein RM, Alexander C, MacPhillamy D (1985). The Unpleasant Events Schedule: a scale for the measurement of aversive events. Journal of Clinical Psychology 41, 483498.
Lewinsohn PM, Mischel W, Chaplin W, Barton R (1980). Social competence and depression: the role of illusory self-perceptions. Journal of Abnormal Psychology 89, 203212.
Lewinsohn PM, Roberts RE, Seeley JR, Rohde P, Gotlib IH, Hops H (1994). Adolescent psychopathology: II. Psychosocial risk factors for depression. Journal of Abnormal Psychology 103, 302315.
Markowitz JC, Moran ME, Kocsis JH, Frances AJ (1992). Prevalence and comorbidity of dysthymic disorder. Journal of Affective Disorders 24, 6371.
McCullough JP, Klein DN, Borian FE, Howland RH, Riso LP, Keller MB, Banks PLC (2003). Group comparisons of DSM–IV subtypes of chronic depression: validity of the distinctions, Part 2. Journal of Abnormal Psychology 112, 614622.
Merikangas KR, Wicki W, Angst J (1994). Heterogeneity of depression. Classification of depressive subtypes by longitudinal course. British Journal of Psychiatry 164, 342348.
Mondimore FM, Zandi PP, MacKinnon DF, McInnis MG, Miller EB, Crowe RP, Scheftner WA, Marta DH, Weissman MM, Levinson DF, Murphy-Ebenez KP, DePaulo JR, Potash JB (2006). Familial aggregation of illness chronicity in recurrent, early-onset major depression pedigrees. American Journal of Psychiatry 163, 15541560.
Mondimore FM, Zandi PP, MacKinnon DF, McInnis MG, Miller EB, Schweizer B, Crowe RP, Scheftner WA, Weissman MM, Levinson DF, DePaulo JR, Potash JB (2007). A comparison of the familiality of chronic depression in recurrent early-onset depression pedigrees using different definitions of chronicity. Journal of Affective Disorders 100, 171177.
Orvaschel H, Puig-Antich J, Chambers WJ, Tabrizi MR, Johnson R (1982). Retrospective assessment of prepubertal major depression with the Kiddie-SADS-E. Journal of the American Academy of Child and Adolescent Psychiatry 21, 392397.
Parker GB, Brown LB (1979). Repertoires of response to potential precipitants of depression. Australian and New Zealand Journal of Psychiatry 13, 327333.
Pettit JW, Lewinsohn PM, Joiner TE Jr. (2006). Propagation of major depressive disorder: relationship between first episode symptoms and recurrence. Psychiatry Research 141, 271278.
Procidano ME, Heller K (1983). Measures of perceived social support from friends and from family: three validation studies. American Journal of Community Psychology 11, 124.
Radloff LS (1977). The CES-D Scale: a self-report depression scale for research in the general population. Applied Psychological Measurement 1, 385401.
Rohde P, Lewinsohn PM, Klein DN, Seeley JR (2005). Association of parental depression with psychiatric course from adolescence to young adulthood among formerly depressed individuals. Journal of Abnormal Psychology 114, 409420.
Rohde P, Lewinsohn PM, Seeley JR (1997). Comparability of telephone and face-to-face interviews assessing Axis I and II disorders. American Journal of Psychiatry 154, 15931598.
Rosenberg M (1965). Society and the Adolescent Self-Image. Princeton University Press: Princeton, NJ.
Sandler IN, Block M (1979). Life stress and maladaption of children. American Journal of Community Psychology 7, 425439.
Schatzberg AF, Rush AJ, Arnow BA, Banks PL, Blalock JA, Borian FE, Howland R, Klein DN, Kocsis JH, Kornstein SG, Manber R, Markowitz JC, Miller I, Ninan PT, Rothbaum BO, Thase ME, Trivedi MH, Keller MB (2005). Chronic depression: medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not. Archives of General Psychiatry 62, 513520.
Scheier MF, Carver CS, Bridges MW (1994). Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a re-evaluation of the Life Orientation Test. Journal of Personality and Social Psychology 67, 10631078.
Shankman S, Klein D (2002). The impact of comorbid anxiety disorders on the course of dysthymic disorder: a 5-year prospective longitudinal study. Journal of Affective Disorders 70, 211217.
Sobin E, Weissman MM, Goldstein RB, Adams P, Wickramaratne P, Warner V, Lish JD (1993). Diagnostic interviewing for family studies: comparing telephone and face-to-face methods for the diagnosis of lifetime psychiatric disorders. Psychiatric Genetics 3, 227233.
Solomon DA, Leon AC, Endicott J, Mueller TI, Coryell W, Shea MT, Keller MB (2004). Psychosocial impairment and recurrence of major depression. Comprehensive Psychiatry 45, 423430.
Spijker J, De Graaf R, Bijl RV, Beekman ATF, Ormel J, Nolen WA (2004). Determinants of persistence of major depressive episodes in the general population. Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Journal of Affective Disorders 81, 231240.
Watkins KE, Paddock SM, Zhang L, Wells KB (2006). Improving care for depression in patients with comorbid substance misuse. American Journal of Psychiatry 163, 125132.
Weissman MM, Bothwell S (1976). Assessment of social adjustment by patient self-report. Archives of General Psychiatry 33, 11111115.
Zalsman G, Brent DA, Weersing VR (2006). Depressive disorders in childhood and adolescence: an overview. Epidemiology, clinical manifestation and risk factors. Child and Adolescent Psychiatric Clinics of North America 15, 827841.
Zimmerman M, Chelminski I, Zisook S, Ginsberg DL (2006). Recognition and treatment of depression with or without comorbid anxiety disorders. Primary Psychiatry 13, 113.
Zisook S, Rush AJ, Albala A, Alpert J, Balasubramani GK, Fava M, Husain M, Sackeim H, Trivedi M, Wisniewski S (2004). Factors that differentiate early vs. later onset of major depression disorder. Psychiatry Research 129, 127140.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 1
Total number of PDF views: 33 *
Loading metrics...

Abstract views

Total abstract views: 189 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 22nd October 2017. This data will be updated every 24 hours.