Persistent depressive disorder (PDD), previously known as dysthymia, is typically under-diagnosed and under-treated. Part of the problem is that most people don’t even realize they have it. They’ve been struggling with PDD symptoms for so long that they assume this is just how they are, this is just part of their personality. Maybe they’re simply a true-blue pessimist, or maybe they’re moody, or maybe they’re really self-conscious.
PDD is a serious, stubborn condition. And because you’ve struggled with it for a long time (the criterion is 2 years), you likely feel hopeless and helpless. Because you think this is how you are, you assume that this is how it’ll always be.
Thankfully, PDD is treatable. Research suggests that the first line treatment is a combination of medication and psychotherapy.
PDD tends to start in childhood, adolescence, or early adulthood. This underscores the importance of, and provides the opportunity to intervene early. In order to meet criteria for PDD, kids and teens must have symptoms for a minimum of 1 year. Chronic depression in kids and teens also can be effectively treated. The first-line treatment is psychotherapy (followed by medication, if necessary).
The only treatment that’s specifically designed for adults with chronic depression is the cognitive behavioral analysis system of psychotherapy (CBASP). This highly structured, empirically validated psychotherapy combines components of cognitive, behavioral, interpersonal, and psychodynamic psychotherapies. CBASP helps individuals with chronic depression learn to recognize the consequences of their behavior on others, gain social problem-solving skills, examine and heal past traumatic experiences, develop authentic empathy, and change unhelpful behavior. For instance, individuals receive training in assertiveness, and learn that they’re absolutely not helpless in what happens in their lives.
Interpersonal therapy (IPT) also is a structured treatment that’s been found to be helpful. IPT focuses on improving conflict and problems in current relationships that may be perpetuating depressive symptoms. IPT consists of three phases: In phase 1 both the therapist and client identify one target area to work one (there are four areas: grief, role transition, role dispute, and interpersonal deficits). For instance, maybe you feel isolated because you lack good communication skills, or you’re grieving the loss of an important relationship. In phase 2, you learn about depression, examine your relationships, and sharpen your interpersonal skills. In phase 3, you review what you’ve learned, and cultivate healthy relationships outside of therapy.
Cognitive behavioral therapy (CBT) may help with chronic depression, as well. CBT also is an effective treatment for other disorders, which often co-occur with chronic depression, such as anxiety disorders. For depression, CBT focuses on identifying and changing maladaptive thoughts and behaviors that perpetuate and exacerbate symptoms. For instance, you’ll learn to challenge and reframe thoughts such as “I am worthless,” “I’ll never find a job I like,” and “I’ll never be happy.” You’ll also engage in behaviors that help to boost your mood.
For teens, it appears that CBT and IPT are effective in treating depressive symptoms. (Many studies in younger populations lump dysthymia with major depressive disorder and other depressive disorders.)
Similar to CBT for adults, teens learn to identify and challenge automatic negative thoughts (about themselves and their environment), problem solve, participate in enjoyable activities, and use healthy coping strategies. Together, therapists and teens create goals for treatment, while also working closely with parents.
CBT appears to be less effective for children. A 2017 review found that CBT was no more beneficial than a wait-list group and placebo group. This might be because kids aren’t developmentally ready to explore CBT concepts.
IPT has been specifically adapted for adolescents. This is important because teens who struggle with depression have more conflict with their parents and their peers than teens who don’t suffer from depressive symptoms. Which is why IPT-A focuses on challenges such as developing autonomy from one’s parents, and building stronger connections with peers.
Recently, researchers have explored the efficacy of an adapted version of IPT for preadolescents (ages 7 to 12 years old) involving parents, which is called family-based IPT or FB-IPT. Like traditional and adolescent IPT, it features three phases: In phase 1, which is four sessions, the therapist meets individually with the preadolescent, helping them link their symptoms to negative experiences in their relationships. One or both parents, who meet individually with the therapist, learn about depression, and the best ways to support their pre-teen, including helping them to maintain a healthy routine. In phase 2, sessions six through 10, preadolescents learn communication skills and role-play first with the therapist and then with their parents. They also work on initiating positive interactions with their peers. Phase 3, sessions 11 to 14, focuses on sharpening skills, learning maintenance strategies, and creating a plan for recurrence.
Another treatment that’s recently been developed and studied for kids ages 7 to 14 is family-focused treatment for childhood depression (FFT-CD). This is also a structured therapy with up to 15 sessions. FFT-CD consists of five modules: psychoeducation teaches parents and children about their depression (which will be different and specific to every child); communication skills increases positive feedback, promotes active listening, and improves assertiveness; behavioral activation focuses on increasing enjoyable activities and positive family interactions; problem solving focuses on taking an “emotional temperature,” preventing problems when temperatures are cool to moderate, and learning conflict-resolution skills; and relapse prevention includes identifying and planning for potential stressors, identifying symptoms to watch for, and establishing family meetings.
Depression often runs in families. Some research has suggested that when parents get their depression successfully treated, kids’ symptoms also improve.
Medication is an effective, evidence-based option for treating persistent depressive disorder (PDD). According to a 2014 meta-analysis, the medications that have been found to be helpful are: fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), moclobemide (Amira), imipramine (Tofranil), and amisulpride (Solian).
However, moclobemide (Rima), a monoamine oxidase inhibitor (MAOI), is not currently approved in the U.S. It is approved in other Western countries, including Canada, Australia, and the U.K. Amisulpride, an antipsychotic, isn’t approved in the U.S. or Canada, but is used in Europe and Australia.
Fluoxetine, paroxetine, and sertraline are part of a class of medications called selective serotonin reuptake inhibitors (SSRIs). A 2016 met-analysis that specifically looked at adverse events in individuals with chronic depression taking antidepressants found that sertraline and fluoxetine were primarily associated with greater gastrointestinal side effects, such as nausea, vomiting, diarrhea, and loss of appetite, when compared to other antidepressants and placebo. Both medications also were associated with more activating adverse events, such as insomnia and agitation. Sertraline was associated with (anti)-cholinergic (e.g., dry mouth), extrapyramidal (e.g., tremor), and endocrine (e.g., galactorrhea and decreased libido) side effects more often than placebo.
Imipramine is a tricyclic antidepressant (TCA). In the same meta-analysis, it was associated with sleepiness, fatigue, dry mouth, excessive thirst, bitter taste, blurred vision, sweating, hot flashes, and dizziness. It also was associated with rash, flushing, constipation, tremor, and palpitations.
Your doctor will likely choose your medication based on past history, tolerability, specific symptoms, and the side effect profiles of each medication. For instance, according to researchers of the 2016 meta-analysis, fluoxetine and sertraline’s activating side effects might be inappropriate for individuals with PDD who also have insomnia and agitation. However, either medication might be a good choice for individuals with PDD who lack motivation.
On the other hand, imipramine’s sedating side effects might be helpful for individuals with PDD who struggle with insomnia and agitation.
Whatever medication you start, it’s important to keep track of your symptoms and side effects. (You can download a mood chart here or use Psych Central’s online mood tracker.) It can take about 4 to 8 weeks to experience the full benefits of an antidepressant (it varies depending on which medication you take). Many side effects can be minimized, so it’s also important to bring your concerns to your doctor. This way you can collaborate on the best treatment for you.
When kids and teens need medication, the typical approach is to start with SSRIs. According to a 2016 review, the best available evidence is for fluoxetine (Prozac). Fluoxetine is the only medication approved by the U.S. Food and Drug Administration (FDA) for kids age 8 and older. Other medications, such as escitalopram (Lexapro) are approved for use in kids age 12 and older. Sometimes, your child’s doctor might prescribe a medication “off-label.”
This Canadian website has helpful information sheets on specific antidepressant classes and medications for kids and teens, and includes a monitoring chart.
The authors of the 2016 review concluded that: “We strongly suggest that medications should not be prescribed outside of a comprehensive treatment approach that includes supportive, problem-focused psychotherapeutic interventions, assessment and monitoring of suicide risk and education about these disorders and their treatment.”
- Consider support groups. Building a strong support system is vital for effectively navigating any kind of depression. One option is in-person support groups. For instance, Alcoholics Anonymous (A.A.) and Narcotics Anonymous (N.A.) can help individuals who struggle with substance abuse, which often co-occurs with persistent depressive disorder (PDD). You also might consider online support groups, such as Project Hope & Beyond, and Psych Central’s forums.
- Participate in physical activities. Exercise is a well-known mood booster and anxiety reducer. It also can help to combine exercise with connection. That is, you might join a running club, softball league, cycling group, or yoga studio. You might take group fitness classes at your local gym. If your child has chronic depression, help them identify what physical activities are fun for them, and encourage them to try them.
- Participate in enjoyable activities. Identify your values, and what you like to do. Try to include those activities in your day. This might be anything from writing to gardening to sewing to volunteering to walking your dog. If your child has chronic depression, similar to exercise, help them identify their hobbies, and encourage them to add them to their everyday.
- Brush up on your interpersonal skills. If you’re currently not seeing a therapist, seek out articles and books that teach communication and assertiveness skills, and try to practice them regularly.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Cognitive Behavioral Analysis System of Psychotherapy for Depression. Society of Clinical Psychology, Division 12, American Psychological Association. Retrieved from https://www.div12.org/treatment/cognitive-behavioral-analysis-system-of-psychotherapy-for-depression.
Cognitive Behavioral Therapy. (2017, August 5). Effective Child Therapy. Society of Clinical Child & Adolescent Psychology. Retrieved from https://effectivechildtherapy.org/therapies/cognitive-behavioral-therapy/.
Dietz, L.J., Weinberg, R.J., Brent, D.A., Mufson, L. (2015). Family-based interpersonal psychotherapy for depressed preadolescents: Examining efficacy and potential treatment mechanisms. Journal of the American Academy of Child & Adolescent Psychiatry, 54, 3, 191-199.
Garland, E.J., Kutcher, S., Virani, A., Elbe, D. (2016). Update on the Use of SSRIs and SNRIs with Children and Adolescents in Clinical Practice. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25, 1, 4-10.
Greenstein, Laura. (2018, January 17). Understanding dysthymia. National Alliance on Mental Health. Retrieved from https://www.nami.org/Blogs/NAMI-Blog/January-2018/Understanding-Dysthymia.
Meister R, von Wolff A, Mohr H, Härter M,Nestoriuc Y, Hölzel L, et al. (2016) Comparative Safety of Pharmacologic Treatments for Persistent Depressive Disorder: A Systematic Review and Network Meta-Analysis. PLoS ONE 11(5), 1-16.
Melrose, S. (2017). Persistent Depressive Disorder or Dysthymia: An Overview of Assessment and Treatment Approaches. Open Journal of Depression, 6, 1-13.
Mychailyszyn, M.P., Elson, D.M. (2018). Working through the blues: A meta-analysis on interpersonal psychotherapy for depressed adolescents (IPT-A). Children and Youth Services Review, 87, 123-129.
Negt, P., Brakemeier, E., Michalak, J., Winter, L., Bleich, S., Kahl, K.G. (2016). The treatment of chronic depression with cognitive behavioral analysis system of psychotherapy: a systematic review and meta-analysis of randomized-controlled clinical trials. Brain and Behavior, 6, 8, 1-15.
Persistent Depressive Disorder Basics. Child Mind Institute. Retrieved from https://childmind.org/guide/persistent-depressive-disorder-dysthymia/.
Tompson, M.C., Langer, D.A. (2017). Family-focused treatment for childhood depression: Model and case illustrations. Cognitive and Behavioral Practice, 24, 269-287.
Uher, R. (2014, July 31). Persistent Depressive Disorder, Dysthymia, and Chronic Depression: Update on Diagnosis, Treatment. Psychiatric Times, 31, 8, 1-3. Retrieved from https://www.psychiatrictimes.com/special-reports/persistent-depressive-disorder-dysthymia-and-chronic-depression-update-diagnosis-treatment.
Yang, L., Zhou, X., Zhou, C., Zhous, C., Zhang Y, Pu, J., Liu, L., Gong, X., Xie, P. (2017). Efficacy and acceptability of cognitive behavioral therapy for depression in children: A systematic review and meta-analysis. Academic Pediatrics, 17, 9 to 16.