Persistent Depressive Disorder (Dysthymia)

Persistent Depressive Disorder (Dysthymia)

Persistent Depressive Disorder (Dysthymia)

The condition discussed here goes by several names—dysthymic disorder, dysthymia, chronic depression, and now persistent depressive disorder. Whatever you call it (I’ll generally stick with dysthymia), these patients are indeed chronically depressed. For years at a time, they have many of the same symptoms found in major depressive episodes, including low mood, fatigue, hopelessness, trouble concentrating, and problems with appetite and sleep. But notice what’s absent from this list of symptoms (and from the criteria): inappropriate guilt feelings and thoughts of death or suicidal ideas. In short, most of these patients have an illness that’s enduring, but also relatively mild.

In the course of a lifetime, perhaps 6% of adults have dysthymia, with women about twice as often affected as men. Although it can begin at any age, late onset is uncommon, and the classic case starts so quietly and so early in life that some patients regard their habitual low mood as, well, normal. In the distant past, clinicians regarded these patients as having depressive personality or depressive neurosis.

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Dysthymic patients suffer quietly, and their disability can be subtle: they tend to put much of their energy into work, with less left over for social aspects of life. Because they don’t appear severely disabled, such individuals may go without treatment until their symptoms worsen into a more readily diagnosed major depressive episode. This is the fate of many, probably most, dysthymic patients. In 1993 this phenomenon was recounted in a book that made The New York Times best-seller list: Listening to Prozac. However, the astonishing response to medication that book reported is by no means limited to one drug.

DSM-IV differentiated between dysthymic disorder and chronic major depressive disorder, but research has not borne out the distinction. So what DSM-5 now calls persistent depressive disorder is a combination of the two separate DSM-IV conditions. The current criteria supply some specifiers to indicate the difference. Here’s what’s clear: Patients who have depression that goes on and on (whatever we choose to call it) tend to respond poorly to treatment, are highly likely to have relatives with either bipolar disorders or some form of depression, and continue to be ill at follow-up.

There’s one other feature that results from the lumping together of dysthymia and chronic major depression. Because some major depression symptoms do not occur in the dysthymia criteria set, it is possible (as DSM-5 notes) that a few patients with chronic major depression won’t meet criteria for dysthymia: The combination of psychomotor slowing, suicidal ideas, and low mood/energy/interest would fit that picture (of those symptoms, only low energy appears among the B criteria for dysthymia). Improbable, I know, but there you are. We are advised that such patients should be given a diagnosis of major depressive disorder if their symptoms meet criteria during the current episode; if not, we’ll have to retreat to other specified (or unspecified) depressive disorder.

Essential Features of Persistent Depressive Disorder (Dysthymia)

“Low-grade depression” is how these symptoms are often described, and they occur most of the time for 2 years (they are never absent for longer than 2 months running). Some patients aren’t even aware that they are depressed, though others can see it. They will acknowledge such symptoms as fatigue, problems with concentration or decision making, poor self-image, and feeling hopeless. Sleep and appetite can be either increased or decreased. They may meet full requirements for a major depressive episode, but the concept of mania is foreign to them.

The Fine Print

For children, mood may be irritable rather than depressed, and the time requirement is 1 year rather than 2.

The D’s: • Duration (more days than not, 2+ years) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, ordinary grief and sadness, adjustment to a long-standing stressor, bipolar disorders, major depressive disorder)

Coding Notes

Specify severity.

Specify onset:

Early onset, if it begins by age 20.

Late onset, if it begins at age 21 or later.

Specify if:

With pure dysthymic syndrome. Hasn’t met full criteria for major depressive episode for the past 2 years.

With persistent major depressive episode. Does meet criteria throughout preceding 2 years.

With intermittent major depressive episodes, with current episode. Meets major depressive criteria now, but at times hasn’t.

With intermittent major depressive episodes, without current episode. Has met major depressive criteria in the past, though doesn’t currently.