Persistent Depressive Disorder

Symptoms

This disorder is more than just having a bad day or feeling sad from time to time. It is consistently struggling with depressive symptoms, though symptoms may be less acute or severe than those of major depressive disorder.³ While the symptoms may ebb and flow, they are never gone for longer than 2 months.¹

Persistent depressive disorder tends to begin early (in childhood, adolescence, or early adulthood) and subtly, so it often is not recognized as a mental illness and may feel “normal” to the person. They may simply describe their day-to-day mood as “sad” or “down”. As such, they may not realize they have a diagnosable disorder that can be treated.^{1 ,2}

For a diagnosis of dysthymia to be made, the person must suffer from a depressed mood most of the day, more days than not, for at least 2 years* AND have 2 or more of the following symptoms while depressed:¹

• Sleep problems (sleeping too much or too little).
• Fatigue and/or low energy.
• Change in appetite, such as eating less or overeating.
• Having a hard time concentrating or making decisions.
• Poor self-esteem.
• Feeling hopeless.

*Children and adolescents have more flexible diagnostic criteria. They can have an irritable mood or a depressed mood, and their symptoms only need to be present for one year or longer.¹

For a diagnosis of PDD, the symptoms cannot be better explained by another mental illness (with the exception that criteria can also be met for major depression for some or all of the duration of dysthymia) and cannot be due to any substance or underlying medical illness.¹

Finally, for a diagnosis to be made, the symptoms must cause significant distress or impairment of a person’s functioning in major areas of their life, such as at work or in relationships, and the symptoms never disappear entirely for any period of time longer than 2 months during the disturbance.¹

Prevalence and Severity

Using results from the National Comorbidity Survey Replication (NCS-R), a 2005 study found that 2.5% of those who were surveyed suffered from dysthymia at some point during their lifetime.⁵

Of those who responded to the survey who had dysthymia, nearly 50% were categorized by researchers as “serious”, based on certain indicators. Approximately 32% were classified as “moderate,” while only about 18% were deemed “mild.”⁶

Short- and Long-Term Effects

Individuals suffering from PDD may exhibit problems in school or at work due to an inability to concentrate or get enough sleep. They may not eat enough or eat too much and, as a result, gain or lose a significant amount of weight. They may also be too lethargic to perform necessary daily activities.¹

People who develop PDD early on, when they are a child or adolescent, may also confuse their mood symptoms for characteristics of their personality, which may keep them from getting the help they need.³

One possible complication that may be associated with PDD is substance abuse. People with PDD may have thoughts of harming themselves and may attempt suicide.⁷

Dysthymia may also be associated with:^3,7

• Low quality of life.
• Major depressive disorder, other mood disorders, anxiety disorders, and other mental illnesses.
• Medical illnesses and chronic pain.
• Disability.
• Inadequate social support.
• Problems with school, work, and/or relationships.
• Poor marital adjustment.
• Greater responsiveness to stress.

According to the DSM-5, the effects of PDD on an individual’s functioning may vary among individuals but may be as severe or even more severe than those of major depressive disorder.

Treatment

For those who have dealt with depressive symptoms for many years, a sense of hopelessness about treatment may set in.

If you have tried a certain type of treatment or a specific therapist and have not noticed an improvement, it doesn’t mean treatment won’t work for you.

The National Alliance on Mental Illness states you may need to try out different therapists and/or other mental health providers until you find one (or more) that meets your needs.²  If you have not yet tried medication, that may also be an approach to look into. The best treatment may be a combination of therapy and medication, as they are thought to be more effective together than either alone.⁸

Therapy

Cognitive behavioral therapy (CBT) is one form of therapy that research has shown to be effective for people struggling with PDD.9 CBT helps individuals identify their self-defeating thoughts and behavior patterns and change them to healthier ones.1⁰ In CBT, the individual will work with their therapist to identify problems, as well as to anticipate problems that are likely to arise, and learn skills to address those problems.1¹

Insight-oriented therapy can help people with PDD understand what may be influencing their depressive symptoms.¹² A greater understanding of what leads to distressing thoughts and feelings may help the individual begin to work through them.

Medications

Medications that may be effective for the mitigation of PDD symptoms include:¹³

• Selective serotonin reuptake inhibitors (SSRIs), such as.¹⁴
  • Prozac (fluoxetine).
  • Paxil (paroxetine).
  • Zoloft (sertraline).
  • Celexa (citalopram).
  • Lexapro (escitalopram).
• Some serotonin and norepinephrine reuptake inhibitors (SNRIs), including:
  • Effexor (venlafaxine).
  • Cymbalta (duloxetine).
• Tricyclic antidepressants (TCAs), such as:
  • Elavil (amitriptyline).
  • Pamelor (nortriptyline).
  • Vivactil (protriptyline).
  • Tofranil (imipramine).
• Monoamine oxidase inhibitors (MAOIs), such as:
  • Emsam (selegiline).
  • Marplan (isocarboxazid).
  • Nardil (phenelzine).
• Other medications, including:
  • Remeron (mirtazapine).
  • Wellbutrin (bupropion).

One review study found that about 55% of individuals with dysthymia who took any antidepressant had a response. In contrast, only 31% of those who took a placebo had a response. Another review indicated that SSRIs, TCAs, and MAOIs were all equally effective for treating dysthymia, but that SSRIs may be more tolerable. SSRIs are the most common medication used for dysthymia, probably because they are safer than MAOIs and TCAs and have less significant side effects.¹³

Some studies have shown that individuals younger than 25 years old who take antidepressants, such as SSRIs or SNRIs, have an increased risk of suicidal thoughts and actions.1⁵ Young people on an antidepressant regimen should have close monitoring by their health care provider, and their loved ones should also watch them closely for any concerning changes. If needed, the medication may be discontinued and a new approach planned. However, for many youths, antidepressants effectively treat depression and other mental illnesses, and untreated depression can be dangerous. Therefore, the health care provider should discuss the pros and cons of using an antidepressant with the patient and, if appropriate, the patient’s guardian(s), so that they can together decide if that patient should be started on an antidepressant.¹⁶

Complementary Approaches

The two primary treatments for PDD are medication and psychotherapy, and anyone who thinks they may have persistent depressive disorder should seek professional treatment. In addition, there are a number of complementary approaches that can help to alleviate symptoms.⁷ The U.S. National Library of Medicine suggests:¹²

• Exercising regularly.
• Eating a healthy and well-balanced diet.
• Getting sufficient sleep.
• Finding hobbies/activities you enjoy.
• Connecting with family and friends who are positive and who will support you.
• Talking openly with people you can trust.
• Avoiding alcohol and other substances of abuse.

Co-Occurring Disorders

The National Institute on Drug Abuse states that those who suffer from a mood disorder or an anxiety disorder are approximately two times as likely to also have a co-occurring drug use disorder.1⁷ Up to half of all individuals with dysthymic disorder suffer from comorbid substance abuse.³

Individuals who suffer from dysthymia may try to self-medicate with alcohol and other substances to attempt to alleviate their feelings of sadness, hopelessness, or lethargy. However, while this may provide some relief initially, it can worsen their moods over time and it can impair judgment.¹² Self-medicating may also lead to the development of a substance use disorder.¹⁸

While depression raises the risk of substance use disorders, the opposite is also true. Abusing substances may “unmask” or worsen depressive symptoms. In vulnerable individuals who already have abnormalities in their neurotransmitter systems or signaling pathways in their brains, drugs may worsen these and bring about an increase in the severity of mood-related symptoms.¹⁹

Because either disorder can worsen the other, treatment should address both conditions.²⁰

Treatment for Co-Occurring Disorders

Professional assessment and treatment is recommended for individuals who think they may have co-occurring disorders. Treatment for co-occurring disorders may include behavioral therapies and/or medications.

Cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), assertive community treatment (ACT), and contingency management (CM) can be effective for co-occurring disorders. Medications may be used to treat the mental illness(es) and/or medications may be used to treat the substance use disorder(s).²⁰ Integrated treatment that addresses both mental illnesses and substance use disorders provides better results for individuals with co-occurring disorders.²¹

According to the National Institute on Drug Abuse, there are numerous types of treatment programs for substance use disorders, including outpatient programs, short-term residential treatment, and long-term residential treatment. Individuals who are looking for a program for themselves or loved ones should pursue options that provide evidence-based care.

Those seeking treatment for drug or alcohol addiction who also suffer from a mood disorder or another mental illness should consider programs that offer integrated treatment for co-occurring disorders, sometimes referred to as dual diagnosis treatment. Only focusing on the substance addiction and not treating the mood disorder, for example, may result in relapse if substance use was a coping mechanism used by that individual for their depressive symptoms.²⁰

Residential treatment typically provides 24-hour care in a supportive environment. Those with significant needs may require a medically monitored intensive inpatient program, where there is 24-hour nursing care and physicians are available if needed.2² Since clients have 24-hour care, the chances of relapse are reduced.

If a person is physically dependent on their substance of use, an initial detoxification program can manage their withdrawal. Supervised detox can prevent potentially dangerous complications. It may also involve interventions to increase patient comfort.²³ Withdrawal from some substances of abuse, such as alcohol and benzodiazepines, can potentially be life-threatening.^24,25 Inpatient medical detox offers 24/7 supervision and support during the withdrawal process.²³

A common course of treatment involves a stay in a short-term residential treatment program, such as a 30- to 90-day stay, and then a step down to outpatient treatment. Outpatient programs allow patients to live at home while they receive treatment. They may be utilized as step-down treatments after the completion of inpatient/residential programs, or they may be used for some individuals instead of residential or inpatient programs.²⁶ People may continue participating in therapy in an outpatient setting for many years.

Long-term residential treatment is also available. One type is a therapeutic community (TC), which focuses on improving the individual’s social skills, using the program’s community as treatment components. Therapeutic communities may recommend a stay of 6 months to one year.²⁶

Your specific treatment plan may look different and should incorporate your unique needs.

How to Help a Loved One

Speaking to a loved one about mental health can be difficult. Remember that the person may be scared or ashamed and may not know how to ask for help.

If you think a loved one is suffering from persistent depressive disorder, a substance use disorder, or both, you can learn more about these disorders and ways to help via the resources outlined below. If you think your loved one may be a danger to him-/herself or someone else, call 911.

• Substance Abuse and Mental Health Services Administration (SAMHSA): SAMHSA’s Behavioral Health Treatment Services Locator can help you find resources in your area to address mental health and/or substance abuse issues.
• Anxiety and Depression Association of America: Users can search for local support groups for those suffering from mood and/or anxiety disorders. In addition, they offer online support groups and advice for those looking to start their own support group.
• Depression and Bipolar Support Alliance: This organization offers information on depression and some other mental illnesses, including a screening center where users can complete questionnaires regarding their mental health. Users can also search for local support groups.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. National Alliance on Mental Illness. (2018). Understanding Dysthymia.
3. Sansone, R. A., & Sansone, L. A. (2009). Dysthymic disorder: forlorn and overlooked? Psychiatry (Edgmont (Pa. : Township)),  6(5), 46-51.
4. Halverson, J. L. (2015). Dysthymic Disorder.
5. Kessler, R.C., Berglund, P.A., Demler, O., Jin, R., Merikangas, K.R., Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602.
6. Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of general psychiatry, 62(6), 617-27.
7. Mayo Clinic. (2018). Persistent depressive disorder (dysthymia).
8. Ishizaki, J., & Mimura, M. (2011). Dysthymia and apathy: diagnosis and treatment. Depression research and treatment, 2011.
9. Halverson, J.L. (2015). Dysthymic Disorder Treatment & Management.
10. American Psychiatric Association. (2017). What Is Depression?
11. National Institute on Drug Abuse. (2018). Cognitive-Behavioral Therapy (Alcohol, Marijuana, Cocaine, Methamphetamine, Nicotine).
12. S. National Library of Medicine. (2019). Persistent depressive disorder.
13. Halverson, J.L. (2015). Dysthymic Disorder Medication.
14. Mayo Clinic. (2018). Selective serotonin reuptake inhibitors (SSRIs).
15. Stone, M., Laughren, T., Jones, M. L., Levenson, M., Holland, P. C., Hughes, A., Hammad, T. A., Temple, R., … Rochester, G. (2009). Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ (Clinical research ed.), 339, b2880.
16. Mayo Clinic. (2016). Antidepressants for children and teens.
17. National Institute on Drug Abuse. (2010). Comorbidity: Addiction and Other Mental Illnesses.
18. Lazareck, S., Robinson, J. A., Crum, R. M., Mojtabai, R., Sareen, J., & Bolton, J. M. (2012). A longitudinal investigation of the role of self-medication in the development of comorbid mood and drug use disorders: findings from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The Journal of clinical psychiatry, 73(5), e588-93.
19. Quello, S. B., Brady, K. T., & Sonne, S. C. (2005). Mood disorders and substance use disorder: a complex comorbidity. Science & practice perspectives, 3(1), 13-21.
20. National Institute on Drug Abuse. (2018). Comorbidity: Substance Use Disorders and Other Mental Illnesses.
21. Kelly, T. M., & Daley, D. C. (2013). Integrated treatment of substance use and psychiatric disorders. Social work in public health, 28(3-4), 388-406.
22. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
23. Substance Abuse and Mental Health Services Administration. (2006). Detoxification and Substance Abuse Treatment.
24. S. National Library of Medicine. (2017). Alcohol withdrawal.
25. Lann, M. A. & Molina, D. K. (2009). A fatal case of benzodiazepine withdrawal. The American journal of forensic medicine and pathology, 30(2), 177-179.
26. National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition): Types of Treatment Programs.