Persistent Depressive Disorder (Dysthymia)

Persistent depressive disorder (formerly called dysthymia) is a form of depression that lasts more than two years at a time in adults and more than one year at a time in children and adolescents.

Persistent depressive disorder, as it is called in the current standard diagnostic manual, the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5), was called dysthymia in previous diagnostic manuals (for example, DSM-IV).

• This illness is a chronic form of depression that tends to be characterized by fatigue, low energy, low self-esteem, and changes in appetite or sleep.
• This mood (affective) disorder tends to be less severe than major depression, which can also be characterized by a lack of interest in usually enjoyable activities (anhedonia), feeling sped up or slowed down, as well as thoughts of death or wanting to die.
• However, persistent depressive disorder is characterized by chronic depression, in that despite potential brief periods of normal mood, symptoms last at least two years at a time in adults and more than one year at a time in children and adolescents.
• The impact of persistent depressive disorder to people with the disorder, their families, and society is significant.
• For example, people with this depressive disorder can be twice as likely to develop dementia and therefore be unproductive and otherwise unable to care for themselves or others compared to those without persistent depressive disorder.
• Given these significant negative outcomes, this illness should be seriously addressed rather than being seen as merely a low-grade version of major depression.
• The potential consequences of persistent depressive disorder also further debunk the now-outdated way of classifying less severe forms of depression as neurotic depression and more severe depressive episodes as psychotic depression.
• Statistics on persistent depressive disorder include its affecting 3%-6% of the population and up to one-third of those people receiving outpatient mental health services in the United States.
• It tends to afflict women more often than men, those who are unmarried more than those who are married, and has been assessed more often in high-income countries.
• While elderly individuals seem to be less likely to experience a major depressive episode compared to younger people, senior citizens are more at risk for developing the less severe but more chronic persistent depressive disorder. In contrast to the prevalence of major depression in ethnic groups in the United States, persistent depressive disorder tends to be more common in African-Americans than in Caucasians and some Hispanic-Americans in most age groups.
• In the elderly, older, non-Hispanic Caucasians are thought to experience persistent depressive disorder and other depressive disorders more often than African-American and Asian people but of equal frequency as older Latino individuals.
• Persistent depressive disorder usually co-occurs (is comorbid) with other disorders, most commonly with major depression, anxiety, personality, or somatic symptom and related disorders, as well as with alcohol or other drug abuse.

• As with most mental health disorders, persistent depressive disorder does not have a single definitive cause. Rather, people with this illness tend to have a number of biological, psychological, and environmental contributing factors that contribute to its occurrence.
• Different parts of the brain of people with persistent depressive disorder tend to respond differently to negative emotions like fear and sadness, as well as to some physical sensations compared to the brains of people without the disorder.
• Genetic risk factors for developing persistent depressive disorder include the tendency for those who suffer from this illness to have a family member who also suffers from either persistent depressive disorder, major depressive disorder, or a personality disorder.
• Significant stress during childhood or adulthood (like exposure to neglect, abuse, or community violence) and having negative social supports are some psychosocial risk factors for persistent depressive disorder.

In order to meet criteria for the diagnosis of persistent depressive disorder, a person must experience depressed mood, which can look like (present as) a loss of interest or general discontent (may be irritability or excessive anger in children and adolescents) most of every day, more days than not for at least two years in a row in adults, and one year for children and teens. The persistent depressive disorder sufferer will not have more than a two-month symptom-free period during the course of the illness and must experience at least two of the following signs and symptoms of this type of depression:

• Poor appetite or overeating
• Insomnia or excessive sleeping (hypersomnia)
• Fatigue or other physical symptoms; slowness in thought and completing daily activities
• Low self-esteem/excessive self-criticism
• Poor concentration or making decisions
• Hopelessness

A person with persistent depressive disorder can also have major depression but does not suffer from cyclothymia, never has the mania or hypomania of bipolar disorder, and does not have symptoms that are better explained by another mental health problem, the effects of a medication, drug of abuse, or medical condition.

• Many health care providers may help make the diagnosis of persistent depressive disorder and treat the condition, including licensed mental health therapists, pediatricians, or other primary care providers, specialists whom one sees for a medical condition, emergency physicians, physician assistants, psychiatrists, clinical psychologists, psychiatric nurses and nurse practitioners, and social workers.
• One of these professionals will likely perform or refer for an extensive medical interview and physical examination as part of determining the diagnosis.
• Persistent depressive disorder may be associated with a number of other medical conditions, the result of exposure to alcohol or other drugs of abuse or as part of a general medical condition, so routine laboratory tests are often performed during the initial evaluation to rule out other medical causes of symptoms. Occasionally, an X-ray, scan, or another imaging study may be needed.
• As part of the evaluation, the sufferer may be asked a series of questions from a standardized questionnaire or self-test to help assess the presence of depression.
• Thorough exploration for any history or presence of mental health symptoms will be conducted such that persistent depressive disorder can be distinguished from other types of depression like major depression, depressive symptoms in reaction to stress (adjustment disorder), or depressed mood as part of the mood swings of bipolar disorder or cyclothymic disorder.
• The mental health practitioner will also explore whether or not other forms of mental illness are present.

For people with mild persistent depressive disorder who want to try treatment without medication, there are a number of lifestyle changes and home/natural remedies that may be useful for coping with the condition.

Healthy lifestyle changes that may help alleviate persistent depressive disorder include getting enough sleep, establishing a healthy diet, getting regular physical exercise, setting small goals for oneself, limiting alcohol intake and abstaining from abusing any other drug.

Specific support in the workplace has been found to positively affect outcomes for people with persistent depressive disorder. Some natural remedies that have found some success in treating mild depression include St. John's wort and SAM-e. However, these treatments have variable results and may result in side effects so should only be taken in cooperation with a physician.

The treatment of moderate to severe persistent depressive disorder is found to be most effective when it includes both medication treatment and at least 18 sessions of talk therapy (psychotherapy), but medications tend to be more effective compared to therapy alone.

• Medications that increase the amount of the neurochemical serotonin in the brain are the most common group of medical treatments used to address persistent depressive disorder since brain serotonin levels are often thought to be low in depression.
• The selective serotonin reuptake inhibitor drugs (SSRIs) work by maintaining high serotonin levels in the synapses (spaces between nerve cells across which nerve signals are transmitted). These drugs do this by preventing the reuptake of serotonin back into the sending nerve cell. The reuptake of serotonin is responsible for turning off the production of new serotonin.
• Therefore, the message to continue making serotonin keeps on being sent. It is thought that this, in turn, helps stimulate (activate) cells that have been deactivated by persistent depressive disorder, thereby relieving the person's symptoms.
• SSRIs tend to have fewer side effects than the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), two other classes of antidepressant drugs.
• SSRIs do not interact with the chemical tyramine in foods, as do the MAOIs, and therefore do not require the dietary restrictions of the MAOIs.
• SSRIs are unlikely to cause orthostatic hypotension (sudden, significant drop in blood pressure when sitting up or standing) and heart-rhythm disturbances, like the TCAs do.
• Therefore, SSRIs are often the first-line treatment for persistent depressive disorder.
• Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), escitalopram (Lexapro), vortioxetine (Trintellix), and vilazodone (Viibryd). SSRIs are generally well tolerated, and side effects are usually mild.
• The most common side effects are nausea, diarrhea, agitation, insomnia, and headache. However, these side effects generally go away within the first month of SSRI use.
• Some patients experience sexual side effects, such as decreased sexual desire (decreased libido), delayed orgasm, or an inability to have an orgasm. Some patients experience tremors with SSRIs. The so-called serotonergic (meaning caused by serotonin) syndrome is a serious neurologic condition associated with the use of SSRIs. It is characterized by high fevers, seizures, and heart-rhythm disturbances.
• This condition is very rare and tends to occur only in very ill psychiatric patients taking multiple psychiatric medications.

All patients are unique biochemically. Therefore, the occurrence of side effects or the lack of adequate results with one SSRI does not mean that another medication in this group will not be beneficial. However, if someone in the patient's family has had a positive response to a particular drug, that medication may be the preferable one to try first.

Dual-action antidepressants (SNRIs) are thought to affect both serotonin and norepinephrine in the brain. Examples of that class of medications include venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq), and levomilnacipran (Fetzima). While generally well tolerated, side effects of these medications can include flu-like symptoms (body aches, tiredness, dizziness), especially when doses are missed.

Atypical antidepressants are not TCAs, SSRIs, MAOIs, or SNRIs, but they are effective in treating depression for many people nonetheless. More specifically, they increase the level of certain neurochemicals in the brain synapses. Examples of atypical antidepressants include trazodone (Desyrel or Oleptro) and bupropion (Wellbutrin).

Cognitive behavioral therapy (CBT): This has been found to be effective as part of treatment for depression. This approach helps to alleviate depression and reduce the likelihood it will come back by helping the dysthymia sufferer change his or her way of thinking about certain issues. In CBT, the therapist uses three techniques to accomplish these goals:

• Didactic component: This phase helps to set up positive expectations for therapy and promote the person's engagement in the treatment process.
• Cognitive component: This helps to identify the thoughts and assumptions that influence the dysthymic individual's behaviors, particularly those that may predispose the sufferer to being depressed.
• Behavioral component: This employs behavior-modification techniques to teach the person more effective ways for dealing with problems.

• Attempts at prevention of persistent depressive disorder tend to address both specific and nonspecific risk factors and strengthen protective factors.
• Such programs often use cognitive behavioral and/or interpersonal approaches, as well as family based prevention strategies because research indicates that these interventions are the most helpful.
• The inverse of most risk factors, protective factors for depression include preventing exposure to neglect, abuse, community violence or other trauma, having the involvement of supportive family, strengthening family and peer relationships, promoting well-being in general, and developing healthy coping and emotional regulation skills that are used regularly, on a day-to-day basis.
• Children of a dysthymic parent tend to be more resilient when the child is more able to focus on age-appropriate tasks in their lives and on their relationships, as well as being able to understand their parent's illness.
• For depressed adults, their children seem to be more protected from developing the illness when the parent is able to demonstrate a commitment to parenting and to relationships.

Around half of the people who have persistent depressive disorder have a suboptimal response to the first antidepressant drug they receive and therefore are considered treatment resistant.

• Furthermore, about two-thirds of people with persistent depressive disorder are thought to continue having some symptoms of the disorder 10 years later.
• These individuals are at risk for long-term complications like having marital problems, generally having low social support, and an overall compromised life adjustment.
• It is thought that these risks are greater for persistent depressive disorder sufferers than even people with major depression because of the chronic nature of the illness and the greater influence of life stressors in the development of persistent depressive disorder.
• Having another mental health condition, a history of trauma, or history of poor family relationships during childhood further negatively impacts the prognosis of people with dysthymic disorder.
• The age that someone first develops this condition is also important to his or her prognosis.
• Those who experience their first episode of a compromised life adjustment prior to 21 years of age tend to have a worse prognosis than people who first have persistent depressive disorder at 21 years of age or older.
• Medically, the presence of depressive symptoms can increase the mortality (death) risk in older people generally, as well as in those who have had a heart attack or who have even mild dementia, specifically.
• Persistent depressive disorder sufferers are at higher risk of suffering a number of medical problems, including stroke.

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