A Current Look at Chronic Depression
A chronic form of depression, dysthymia is characterized by depressed mood on most days for at least two years. On some days individuals may feel relatively fine or even have moments of joy. But the good mood usually lasts no longer than a few weeks to a few months. Other signs include low self-esteem, plummeting energy, poor concentration, hopelessness, irritability and insomnia.
Dysthymia — also known as dysthymic disorder — is typically described as a mild depression. But the data show a different story: Dysthymia is often a serious and severe disorder, said David J. Hellerstein, M.D., professor of clinical psychiatry at Columbia University and a research psychiatrist at New York State Psychiatric Institute. Experts refer to dysthymia as a paradoxical condition because it appears mild day to day but becomes brutal long-term, he said.
Epidemiological studies reveal that dysthymia frequently has a devastating impact on people’s lives. Individuals with dysthymia are more likely to receive government assistance, have high healthcare costs and have elevated rates of unemployment. If they do work, they typically work part-time or report under-achieving because of emotional problems. They also tend to be single because depression can make relationships more challenging.
People with dysthymia also are at increased risk for more severe episodes of depression. In fact, as many as 80 to 90 percent will get major depression, according to Dr. Hellerstein, who’s also author of the book Heal Your Brain: How the New Neuropsychiatry Can Help You Go from Better to Well. “It’s like if you have asthma, you are more likely to get bronchitis and pneumonia because you have this baseline condition all the time,” he said.
There’s evidence that dysthymia boosts the risk for suicidal behavior. One seven-year study found that the rates of suicidal behavior in dysthymia were similar to the rates in major depression.
Comorbidity with anxiety disorders also is common. And dysthymia tends to co-occur with alcohol problems and attention deficit hyperactivity disorder, Hellerstein said.
Dysthymia still largely goes undiagnosed and untreated. As many as three percent of Americans struggle with dysthymia, while less than half ever seek treatment. Part of the problem is that many people mistake the symptoms for their personality, Hellerstein said. They may assume that they’re just pessimistic or self-conscious or moody. After struggling for so many years, people come to view the fog of depression as their normal functioning. If people do seek treatment, it’s usually for other concerns, such as vague physical aliments or relationship problems, he said. As a result, these individuals rarely get evaluated for a mood disorder.
There’s a common myth that a look on the bright side cures depression. That if you think positively enough, you’ll simply snap out of it. But individuals can’t snap out of depression any more than they can will themselves out of chronic asthma.
Another misconception is that dysthymia doesn’t require treatment. Lifestyle changes, exercise, and social support are usually enough to improve short-term mild depression, Hellerstein said. But this doesn’t work for dysthymia. Most people with dysthymia have typically tried modifying their lifestyle; yet their depression doesn’t disappear, he said.
Fortunately, people greatly improve with treatment. Unfortunately, the data on dysthymia are still limited, Hellerstein said. Only about 20 pharmacological studies have compared medication to placebo. Most studies show that antidepressants are effective in minimizing symptoms. The response to placebo tends to be low — lower than in major depression research — which speaks to the stubbornness of the condition, Hellerstein said.
As with major depression, the first line of pharmacological treatment is selective serotonin reuptake inhibitors or SSRIs. Wellbutrin and serotonin-norepinephrine reuptake inhibitors (SNRIs) also show improvements. Other classes of antidepressants such as tricyclics and MAO inhibitors also work, but have more side effects. The deciding factor is usually tolerability, Hellerstein said.
He recommends dysthymia patients take medication for two years and taper off very gradually (with monitoring from a psychiatrist). Once depressive symptoms have responded to treatment, there is an opportunity to make lifestyle changes, whether that means looking for a good job, finishing a degree, starting a romantic relationship or establishing healthy routines, Hellerstein said.
If individuals are hesitant to take medication, Hellerstein suggested trying psychotherapy first. But if there’s little improvement after several months, medication might be necessary.
The literature on psychotherapy also is scant. Still, it appears that cognitive-behavioral therapy, interpersonal therapy and behavior activation therapy are helpful for treating dysthymia. These therapies work on challenging maladaptive thoughts and adopting healthier behaviors.
People with chronic depression frequently develop avoidance behaviors, such as procrastinating and ruminating, which only perpetuate symptoms and stress, Hellerstein said. The above therapies help patients take an active approach for solving their problems and achieving their goals, he said. Patients not only feel better but also have the psychological tools to improve their lives and cope effectively with stress.
If you think you might have dysthymia, it’s important to get an accurate assessment, he said. Teaching hospitals or facilities affiliated with a medical school are the best places to find practitioners, because they tend to be especially up-to-date on the latest research.
As Hellerstein underscored, dysthymia is not a hopeless condition. “[With treatment] I see a lot of people who go through an accelerated process of psychological development,” he said. They’re able to return to work, pursue their education, enjoy healthy relationships and lead fulfilling lives.
Tartakovsky, M. (2013). A Current Look at Chronic Depression. Psych Central. Retrieved on April 21, 2015, from http://psychcentral.com/lib/a-current-look-at-chronic-depression/00011267