Persistent depressive disorder (dysthymia)

Date Updated: 12/08/2018

Overview

Persistent depressive disorder, also called dysthymia (dis-THIE-me-uh), is a continuous long-term (chronic) form of depression. You may lose interest in normal daily activities, feel hopeless, lack productivity, and have low self-esteem and an overall feeling of inadequacy. These feelings last for years and may significantly interfere with your relationships, school, work and daily activities.

If you have persistent depressive disorder, you may find it hard to be upbeat even on happy occasions — you may be described as having a gloomy personality, constantly complaining or incapable of having fun. Though persistent depressive disorder is not as severe as major depression, your current depressed mood may be mild, moderate or severe.

Because of the chronic nature of persistent depressive disorder, coping with depression symptoms can be challenging, but a combination of talk therapy (psychotherapy) and medication can be effective in treating this condition.

Symptoms

Persistent depressive disorder symptoms usually come and go over a period of years, and their intensity can change over time. But typically symptoms don't disappear for more than two months at a time. In addition, major depression episodes may occur before or during persistent depressive disorder — this is sometimes called double depression.

Symptoms of persistent depressive disorder can cause significant impairment and may include:

Loss of interest in daily activities
Sadness, emptiness or feeling down
Hopelessness
Tiredness and lack of energy
Low self-esteem, self-criticism or feeling incapable
Trouble concentrating and trouble making decisions
Irritability or excessive anger
Decreased activity, effectiveness and productivity
Avoidance of social activities
Feelings of guilt and worries over the past
Poor appetite or overeating
Sleep problems

In children, symptoms of persistent depressive disorder may include depressed mood and irritability.

When to see a doctor

Because these feelings have gone on for such a long time, you may think they'll always be part of your life. But if you have any symptoms of persistent depressive disorder, seek medical help.

Talk to your primary care doctor about your symptoms. Or seek help directly from a mental health professional. If you're reluctant to see a mental health professional, reach out to someone else who may be able to help guide you to treatment, whether it's a friend or loved one, a teacher, a faith leader, or someone else you trust.

If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.

Causes

The exact cause of persistent depressive disorder isn't known. As with major depression, it may involve more than one cause, such as:

Biological differences. People with persistent depressive disorder may have physical changes in their brains. The significance of these changes is still uncertain, but they may eventually help pinpoint causes.
Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. Recent research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.
Inherited traits. Persistent depressive disorder appears to be more common in people whose blood relatives also have the condition. Researchers are trying to find genes that may be involved in causing depression.
Life events. As with major depression, traumatic events such as the loss of a loved one, financial problems or a high level of stress can trigger persistent depressive disorder in some people

Risk factors

Persistent depressive disorder often begins early — in childhood, the teen years or young adult life — and is chronic. Certain factors appear to increase the risk of developing or triggering persistent depressive disorder, including:

Having a first-degree relative with major depressive disorder or other depressive disorders
Traumatic or stressful life events, such as the loss of a loved one or financial problems
Personality traits that include negativity, such as low self-esteem and being too dependent, self-critical or pessimistic
History of other mental health disorders, such as a personality disorder

Complications

Conditions that may be linked with persistent depressive disorder include:

Reduced quality of life
Major depression, anxiety disorders and other mood disorders
Substance abuse
Relationship difficulties and family conflicts
School and work problems and decreased productivity
Chronic pain and general medical illnesses
Suicidal thoughts or behavior
Personality disorders or other mental health disorders

Prevention

There's no sure way to prevent persistent depressive disorder. Because it often starts in childhood or during the teenage years, identifying children at risk of the condition may help them get early treatment.

Strategies that may help ward off symptoms include the following:

Take steps to control stress, to increase your resilience and to boost your self-esteem.
Reach out to family and friends, especially in times of crisis, to help you weather rough spells.
Get treatment at the earliest sign of a problem to help prevent symptoms from worsening.
Consider getting long-term maintenance treatment to help prevent a relapse of symptoms.

Diagnosis

If your doctor suspects you have persistent depressive disorder, exams and tests may include:

Physical exam. The doctor may do a physical exam and ask in-depth questions about your health to determine what may be causing your depression. In some cases, it may be linked to an underlying physical health problem.
Lab tests. Your doctor may order lab tests to rule out other medical conditions that may cause depressive symptoms. For example, your doctor may order a blood test to find out if your thyroid is underactive (hypothyroidism).
Psychological evaluation. This includes discussing your thoughts, feelings and behavior and it may include a questionnaire to help pinpoint a diagnosis. This evaluation can help determine if you have persistent depressive disorder or another condition that can affect mood, such as major depression, bipolar disorder or seasonal affective disorder.

For a diagnosis of persistent depressive disorder, the main indication for an adult differs somewhat from that of a child:

For an adult, depressed mood occurs most of the day for two or more years
For a child, depressed mood or irritability occurs most of the day for at least one year

Symptoms caused by persistent depressive disorder can vary from person to person. When persistent depressive disorder starts before age 21, it's called early onset; if it starts at age 21 or older, it's called late onset.

Treatment

The two main treatments for persistent depressive disorder are medications and talk therapy (psychotherapy). The treatment approach your doctor recommends depends on factors such as:

Severity of your symptoms
Your desire to address emotional or situational issues affecting your life
Your personal preferences
Previous treatment methods
Your ability to tolerate medications
Other emotional problems you may have

Psychotherapy may be the first recommendation for children and adolescents with persistent depressive disorder, but that depends on the individual. Sometimes antidepressants are also needed.

Medications

The types of antidepressants most commonly used to treat persistent depressive disorder include:

Selective serotonin reuptake inhibitors (SSRIs)
Tricyclic antidepressants (TCAs)
Serotonin and norepinephrine reuptake inhibitors (SNRIs)

Talk with your doctor or pharmacist about possible side effects.

Finding the right medication

You may need to try several medications or a combination before you find one that works. This requires patience, as some medications take several weeks or longer for full effect and for side effects to ease as your body adjusts.

Don't stop taking an antidepressant without talking to your doctor — your doctor can help you gradually and safely decrease your dose. Stopping treatment abruptly or missing several doses may cause withdrawal-like symptoms, and quitting suddenly may cause a sudden worsening of depression.

When you have persistent depressive disorder, you may need to take antidepressants long term to keep symptoms under control

Antidepressants and pregnancy

If you're pregnant or breast-feeding, some antidepressants may pose an increased health risk to your unborn baby or nursing child. Talk to your doctor if you become pregnant or are planning on becoming pregnant.

FDA alert on antidepressants

Although antidepressants are generally safe when taken as directed, the FDA requires all antidepressants to carry a black box warning, the strictest warning for prescriptions. In some cases, children, teens and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed.

Anyone taking an antidepressant should be watched closely for worsening depression or unusual behavior, especially when first beginning a new medication or with a change in dosage. If your teen has suicidal thoughts while taking an antidepressant, immediately contact your doctor or get emergency help.

Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood.

Psychotherapy

Psychotherapy is a general term for treating depression by talking about your condition and related issues with a mental health professional. Psychotherapy is also known as talk therapy or psychological counseling.

Different types of psychotherapy, such as cognitive behavioral therapy, can be effective for persistent depressive disorder. You and your therapist can discuss which type of therapy is right for you, your goals for therapy and other issues, such as the length of treatment.

Psychotherapy can help you:

Adjust to a crisis or other current difficulty
Identify issues that contribute to your depression and change behaviors that make it worse
Identify negative beliefs and behaviors and replace them with healthy, positive ones
Find better ways to cope and solve problems
Explore relationships and experiences, and develop positive interactions with others
Regain a sense of satisfaction and control in your life and help ease depression symptoms, such as hopelessness and anger
Learn to set realistic goals for your life

Lifestyle and home remedies

Persistent depressive disorder generally isn't a condition that you can treat on your own. But, in addition to professional treatment, these self-care steps can help:

Stick to your treatment plan. Don't skip psychotherapy sessions or appointments, and even if you're feeling well, don't skip your medications. Give yourself time to improve gradually.
Learn about persistent depressive disorder. Education about your condition can empower you and motivate you to stick to your treatment plan. Encourage your family to learn about the disorder to help them understand and support you.
Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your symptoms. Make a plan so that you know what to do if symptoms get worse or return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Consider involving family members or friends to watch for warning signs.
Take care of yourself. Eat healthy, be physically active and get plenty of sleep. Consider walking, jogging, swimming, gardening or another activity that you enjoy. Sleeping well is important for both your physical and mental well-being. If you're having trouble sleeping, talk to your doctor about what you can do.
Avoid alcohol and recreational drugs. It may seem like alcohol or drugs lessen depression-related symptoms, but in the long run they generally worsen depression and make it harder to treat. Talk with your doctor or therapist if you need help dealing with alcohol or drug use.

Alternative medicine

Make sure you understand the risks as well as possible benefits if you pursue alternative or complementary therapy. Avoid replacing conventional medical treatment or psychotherapy with alternative medicine. When it comes to depression, alternative treatments aren't a substitute for medical care.

For example, the herbal supplement called St. John's wort is not approved by the Food and Drug Administration (FDA) to treat depression in the U.S., though it's available. It may help improve mild or moderate depression, but the overall evidence is not conclusive.

St. John's wort can interfere with a number of medications, including blood-thinning drugs, birth control pills, chemotherapy, HIV/AIDS medications and drugs to prevent organ rejection after a transplant. Also, avoid taking St. John's wort while taking antidepressants because the combination can cause serious side effects.

FDA doesn't monitor supplements

Dietary supplements aren't approved and monitored by the FDA the same way medications are. You can't always be certain of what you're getting and whether it's safe. Also, because some herbal and other dietary supplements can interfere with prescription medications or cause dangerous interactions, talk to your healthcare provider before taking any supplements.

Coping and support

Persistent depressive disorder makes it hard to engage in behavior and activities that can help you feel better. In addition to the treatments recommended by your doctor or therapist, consider these tips:

Focus on your goals. Dealing with persistent depressive disorder is an ongoing process. Set reasonable goals for yourself. Stay motivated by keeping your goals in mind. But give yourself permission to do less when you feel down.
Simplify your life. Cut back on obligations when possible. Structure your time by planning your day. You may find it helps to make a list of daily tasks, use sticky notes as reminders or use a planner to stay organized.
Write in a journal. Journaling as part of your treatment may improve mood by allowing you to express pain, anger, fear or other emotions.
Read reputable self-help books and websites. Ask your doctor or therapist to recommend books or websites to read.
Stay connected. Don't become isolated. Try to participate in social activities, and get together with family or friends regularly. Support groups for people with depression can help you connect with others facing similar challenges and share experiences.
Learn ways to relax and manage your stress. Examples include meditation, progressive muscle relaxation, yoga and tai chi.
Don't make important decisions when you're down. Avoid decision-making when you're feeling depressed, since you may not be thinking clearly.

Preparing for an appointment

You may decide to schedule an appointment with your primary care doctor to talk about your concerns or you may decide to see a mental health specialist, such as a psychiatrist or psychologist, for evaluation.

What you can do

Prepare for your appointment by making a list of:

Any symptoms you've had, including any that may seem unrelated to the reason for which you scheduled the appointment
Key personal information, including any major stresses or recent life changes
All medications, vitamins, supplements or herbal preparations that you're taking, and the doses
Questions to ask your doctor

Taking a family member or friend along can help you remember something that you missed or forgot.

Basic questions to ask your doctor may include:

Why can't I get over this depression on my own?
How do you treat this type of depression?
Will talk therapy (psychotherapy) help?
Are there medications that might help?
How long will I need to take medication?
What are some of the side effects of the medication you're recommending?
How often will we meet?
How long will treatment take?
What can I do to help myself?
Are there any brochures or other printed materials that I can have?
What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor may ask you several questions, such as:

When did you first notice symptoms?
How is your daily life affected by your symptoms?
What other treatment have you had?
What have you tried on your own to feel better?
What things make you feel worse?
Have any relatives had any type of depression or another mental illness?
What do you hope to gain from treatment?