More Than the Blues: Understanding Dysthymia
You have everything you've ever wanted—a loving spouse, two bright-eyed kids, a terrific job, and a shiny new car parked in the driveway of your suburban dream house. Then why do you still awaken many mornings with a sort of numb, "oh, God, not another day" feeling? If the glass always seems half-empty instead of half-full and your pessimistic outlook and dreary mood lingers for weeks or months or even longer, you may be suffering from dysthymia.
Dysthymia, an often undiagnosed depression of mild to moderate severity, affects 3%-6% of the population (between 10 and 15 million Americans). According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), people with dysthymia have a "chronically depressed mood that lasts for most of the day, more days than not, for two years or longer, with symptoms never disappearing completely for a period of more than two months."
For many years, dysthymia, previously known as "depressive neurosis," was believed to be a character disorder. It is now classified as a mood disorder characterized by the presence of a sad, depressed mood for the greater part of most days, for at least two years (one year in children), as well as at least two of the following symptoms:
- Poor appetite or overeating
- sleep disorder (insomnia or sleeping too much)
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness and despair
Despite the subtlety of the symptoms—which may also include irritability, impaired ability to experience pleasure, and decreased productivity—untreated dysthymia can have significant effects on relationships, work life, and overall health and well-being.
Effects on Daily Life
According to the Clarke Institute of Psychiatry in Toronto, up to 80% of people with dysthymia report severe, long-term symptoms that lead to difficulties in social and/or occupational functioning, as well as high rates of anxiety and substance abuse. Estimates of the incidence of suicide among dysthymics range from 3%-12%.
Joel Yager, MD, a professor in the Department of Psychiatry at the University of New Mexico School of Medicine, notes that about 40% of people with dysthymia eventually have a major depressive episode, which is known as double depression. Major depression, which profoundly affects daily functioning, is marked by:
- Significant changes in sleeping patterns and appetite
- Intense feelings of sadness
- Guilt (which at times may reach delusional proportions)
This is often accompanied by recurrent thoughts about death and/or suicide. If you are having these symptoms, seek medical help.
Causes: Genetic, Biochemical, or Environmental?
Depression is now believed to result from a combination of biochemical, genetic, and environmental factors. According to Daniel N. Klein of the Psychology Department at the State University of New York at Stony Brook, "Knowledge of the causes and origins of dysthymia remains incomplete. We do know that it runs in families, although it is unclear whether this linkage is due to genetic or environmental factors, or both."
Dysthymia is more common among females and can begin at any age, although onset in childhood and adolescence is particularly common. People with dysthymia have a high rate of major depression in other family members, particularly their parents.
Life Experiences and Dysthymia
Robert Hirschfield, MD, chairman of the Department of Psychology and Behavior Sciences at the University of Texas in Galveston, is the author of When The Blues Won't Go Away, a comprehensive, readable and useful guide to dysthymic disorder. He says that there are five life experiences that can set you on a downhill course to long-lasting, low-grade depression. Although these situations do not directly cause dysthymia, they may increase the likelihood of developing the disorder in someone who has a genetic predisposition or vulnerability to depression.
These life situations include:
- Adjustment problems during adolescence
- Troublesome life transitions (moving, job changes, children leaving home)
- Losses and life crises (death of loved ones, divorce)
- Chronic, unresolved life problems (poverty, unemployment)
- Stress (difficult relationships, illness/disability)
Unfortunately, many people with dysthymia, who often describe their mood as sad or "down in the dumps," don't recognize that they have an illness for which help is available. Instead, they believe that "this is just the way I am."
Traditionally, long-term psychotherapy has been the treatment of choice for dysthymia. Recent studies suggest that dysthymia responds particularly well to focused, short-term psychotherapies, such as cognitive therapy and interpersonal therapy. These forms of therapy teach ways to modify dysfunctional beliefs and behaviors while addressing relationship problems associated with or exacerbated by the depressive mood.
There is also considerable evidence showing that dysthymia is highly responsive to treatment with antidepressant drugs. A study reported in the American Journal of Psychiatry found significant improvement or complete remission in a sizable percentage of patients with dysthymia who were treated with Zoloft or Tofranil, two commonly used antidepressant drugs. Patients taking these medications also reported improved family relationships, social and work functioning, and overall quality of life. A review of the literature found that, in general, antidepressant drugs are about equally effective as each other.
Because their side effects are relatively mild, selective serotonin reuptake inhibitors (SSRIs), such as Celexa (citalopram), Prozac (fluoxetine), Paxil, (paroxetine) and Zoloft (sertraline), are the most commonly prescribed medications for patients with dysthymia. Side effects of the SSRIs include sexual disorders, mild nausea, headache, insomnia, and restlessness.
An older class of antidepressant drugs, referred to as tricyclics, are equally as effective as the SSRIs, but have more side effects on average, including weight gain, dry mouth, constipation, and blurry vision.
***Please note: In March, 2004, the Food and Drug Administration (FDA) issued a Public Health Advisory that cautions physicians, patients, families, and caregivers of patients with depression to closely monitor both adults and children receiving certain antidepressant medications. The FDA is concerned about the possibility of worsening depression and/or the emergence of suicidal thoughts, especially among children and adolescents at the beginning of treatment, or when there’s an increase or decrease in the dose. The medications of concern—mostly SSRIs (Selective Serotonin Re-uptake Inhibitors)—are: Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), Lexapro (escitalopram), Wellbutrin (bupropion), Effexor (venlafaxine), Serzone (nefazodone), and Remeron (mirtazapine). For more information, please visit http://www.fda.gov/cder/drug/antidepressants .
Joanna Landau, PhD, NPP, CS, a psychiatric nurse practitioner at Four Winds Hospital in New York, says that some people are reluctant to take antidepressants because they feel it will "alter their personality" or "make them into a different person." These drugs affect moods, not personality, explains Dr. Landau, who believes that medication in conjunction with psychotherapy is usually the most effective treatment for dysthymia. And, she emphasizes, "There is no reason to resign yourself to living with chronic feelings of unhappiness, no matter how mild. Dysthymia is a treatable disorder."
Depression and Bipolar Support Alliance
National Institutes of Mental Health
Canadian Mental Health Association
Mental Health Canada
Ask the experts: medicine (dysthymia). Scientific American website. Available at: http://www.sciam.com.
Silva de Lima M, Hotopf M. A comparison of active drugs for the treatment of dysthymia [review]. Cochrane Database Syst. 2003;CD004047.
Last reviewed March 2008 by Theodor B. Rais, MD
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