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Dysthymia: - More than the blues

More than the blues

A chronic depression of mood which does not currently fulfil the criteria for recurrent depressive disorder, mild or moderate severity, in terms of either severity or duration of individual episodes, although the criteria for mild depressive episode may have been fulfilled in the past, particularly at the onset of the disorder. The balance between individual phases of mild depression and intervening periods of comparative normality is very variable. Sufferers usually have periods of days or weeks when they describe themselves as well, but most of the time (often for months at a time) they feel tired and depressed; everything is an effort and nothing is enjoyed. They brood and complain, sleep badly and feel inadequate, but are usually able to cope with the basic demands of everyday life. Dysthymia therefore has much in common with the concepts of depressive neurosis and neurotic depression. If required, age of onset may be specified as early (in late teenage or the twenties) or late.

Diagnostic Guidelines

The essential feature is a very long-standing depression of mood which is never, or only very rarely, severe enough to fulfil the criteria for recurrent depressive disorder, mild or moderate severity. It usually begins early in adult life and lasts for at least several years, sometimes indefinitely. When the onset is later in life, the disorder is often the aftermath of a discrete depressive episode and associated with bereavement or other obvious stress.

Includes:

  • depressive neurosis
  • depressive personality disorder
  • neurotic depression (with more than 2 years' duration)
  • persistent anxiety depression

Excludes:

  • anxiety depression (mild or not persistent)
  • bereavement reaction, lasting less than 2 years (prolonged depressive reaction)
  • residual schizophrenia

More than the blues: understanding dysthymia
by Barbara Williams Cosentino, C.S.W., R.N.

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. " There is no reason to resign yourself to living with chronic feelings of unhappiness, no matter how mild. Dysthymia is a treatable disorder. "
Joanna Landau, psychiatric nurse practitioner

Dysthymia, an often undiagnosed depression of mild to moderate severity, affects 3% to 6% of the population (between 10 and 15 million Americans). According to the American psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , 4th edition (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. "

The symptoms

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 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, anhedonia (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% to 12%.

Joel Yager, M.D., 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, hopelessness, and guilt which at times may reach delusional proportions; and is often accompanied by recurrent thoughts about death and/or suicide.)

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.

Heading for dysthymia

Robert M.A. Hirschfield, M.D., 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 (see Resources below), 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. "

psychotherapy treatment

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, which teaches ways to modify dysfunctional beliefs and behaviors while addressing relationship problems associated with or exacerbated by the depressive mood.

Antidepressant drugs

There is also considerable evidence showing that dysthymia is highly responsive to treatment with antidepressant drugs. A 1997 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.

Because their side effects are relatively mild, selective serotonin reuptake inhibitors (SSRIs) such as prozac (fluoxetine), paxil, (paroxetine) and Zoloft (sertraline) are now the most commonly prescribed medications for patients with dysthymia. Side effects of the SSRIs include decreased sexual sensation, mild nausea, headache, and, infrequently, anxiety and insomnia. An older class of antidepressant drugs, referred to as tricyclics, are equally as or more effective than the SSRIs, but have many uncomfortable side effects, including weight gain, dry mouth, constipation, and blurry vision.

Newer antidepressants such as Effexor, Remeron, Serzone and Celexa have been found to be extremely effective and are tolerated well by most people. Joanna Landau, ph.D., N.p.p., C.S., a psychiatric nurse practitioner at Four Winds Hospital in Katonah, 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. "

Resources

American psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders , 4th edition . Washington, DC: American psychiatric Association, 1994.

Hirschfield, R. When the Blues Won't Go Away . New York: Macmillian publishing Company, 1991.

" What is Dysthymia "
The Clarke Institute of psychiatry
www.clarke-inst.on.ca/about_illnesses/dysthymia.html
Information on diagnosis and treatment, including interpersonal therapy and advice for the family and friends of people with dysthymia.

" Dysthymia "
Scientific American: Ask the Experts: Medicine
www.sciam.com/askexpert/medicine/medicine1.html
Several prominent clinicians give an overview of the disorder with particular focus on the connection between dysthymia and major depression.

Mental Health Net
http://mhnet.org/
Features over 6300 resources for disorders such as depression, anxiety and substance abuse, with an annotated list of top-rated sites. Includes access to professional resources in psychology and psychiatry.

Dr. Ivan's Depression Central
www.psycom.net/depression.central.dysthymia.html
A clearinghouse for information on dysthymia, with recent journal articles, DSM-IV criteria for diagnosis, and information on etiology, treatment options and antidepressant medications.

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