Course and Chronicity of Unipolar Major Depressive Disorder: Commentary on Joiner

Joiner (this issue) outlines an organizational framework of dysfunctional psychological processes observed in unipolar major depressive disorder (MDD) patients, which he hypothesizes makes substantial contributions to the chronicity of this common and disabling disorder. Rather than concentrating on the clinical characteristics, past history, biological markers, or genetic variables as risk factors for chronicity, Joiner references the scarring effects of repeated episodes and a set of destructive interpersonal processes present in depressed patients that he feels promotes depressive chronicity. This extends observations reported in prior studies on psychosocial disability in depression, which have concentrated primarily on such issues as employment status, estimates of well-being, and so on, whereas Joiner emphasizes psychological disability and disrupted interpersonal relationships.
This commentary introduces a new dimension of chronicity of unipolar MDD that involves the long-term, chronic manifestation of depressive symptomatology, in addition to the frequent major depressive episode relapse. Further, the long-term symptomatic structure of unipolar MDD is described as a dimensional continuum of symptom severity and illness activity and then highlighted as to the relevance of both of these newer concepts to Joiner's proposals. A number of interesting research questions are outlined in by Joiner that need empirical validation but, if answered, could make a contribution to the understanding and reduction of depression chronicity.