In another article on this website, I argued that we should not diagnose patients as having “depression” or “anxiety”. Instead, we should ask ourselves: What KIND of depression (or anxiety)?
For more on this, please see the following article on this website:
Let’s not say that the diagnosis is “Depression” or “Anxiety”
One of the patterns of depressive disorders that we see is patients who have been clinically depressed for many years. Maybe not every day, but much of the time. This chronic depressive disorder is long been believed to be qualitatively different from other depressive disorders.
When the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5®) was published in 2013, a new diagnosis of Persistent Depressive Disorder was added that combined two DSM-IV-TR® diagnoses:
- Major depressive disorder, chronic
- Dysthymic disorder
There are some important misunderstandings about how to treat persistent depressive disorder that I want to discuss. But first, let’s take a closer look at what it is. We don’t need to go over all the DSM-5® diagnostic criteria for persistent depressive disorder, but let’s highlight some key points.
Note: The description below is my own way of organizing and conceptualizing the clinical features of persistent depressive disorder.
The x-axis: How much time?
Obviously, depressed mood is the central feature of persistent depressive disorder.
Over the day: For most of the day (as in major depressive disorder)
Over the weeks/ months: For “more days than not,” that is, the depressed mood may not be
present every day.
Over the years: For at least 2 years—not necessarily continuously but without periods of
more than two months free of depression and associated symptoms.
(Note: In children and adolescents, there are two differences: The mood may be irritable instead of depressed, and the minimum duration must be at least 1 year instead of at least 2 years in adults.)
The y-axis: How severe?
In persistent depressive disorder, the severity of depression can present in different ways:
1. With pure dysthymic syndrome—In the last two years, the criteria for a major depressive
episode were not met
2. With persistent major depressive episode—In the last two years, the criteria for a major
depressive episode were met continuously.
And, between the above two extremes:
3. With intermittent major depressive episodes
A common misunderstanding about dysthymia
There has always been a subgroup of colleagues who believe that dysthymia or dysthymic disorder, now subsumed under the diagnosis of persistent depressive disorder, is a form of personality disorder rather than a mood disorder.
And it is true that patients with dysthymia often have comorbid personality disorders and/or high scores on neuroticism.
But patients with dysthymia:
– Have a higher incidence of major depressive disorder in first-degree relatives
– Are extremely likely to later develop one or more major depressive episodes
Why does this make a big difference?
We should NOT think that antidepressant medications don’t work for patients with “dysthymia”. A meta-analysis of 17 randomized, placebo-controlled studies of antidepressant medications for the treatment of dysthymia found them to be efficacious (Levkovitz et al., 20111). Are you surprised to read this?
In fact, that meta-analysis found that the drug-placebo difference was statistically significantly greater in dysthymia than for major depressive disorder (Levkovitz et al., 2011).
Also, psychotherapy may be less effective than medications in pure dysthymia (Schramm et al., 2020).
Clinical Recommendations
We should not deprive patients with persistent depressive disorder—whether with pure dysthymic syndrome, persistent major depressive episodes, or intermittent major depressive episodes—of the option of being treated with an antidepressant medication.
Related Pages
Depressive Disorders–Diagnosis and Assessment
Let’s not say that the diagnosis is “Depression” or “Anxiety”
A Deeper Understanding of the DSM-5-TR® Criteria for Major Depressive Disorder
Grief versus Major Depression
Tips on differentiating unipolar from bipolar depression
Understanding the diagnosis of Persistent Depressive Disorder (DSM-5-TR®)
“Specifiers” for mood disorders
How to diagnose atypical features in depressive and bipolar disorders
What to assess for if atypical features are present in a depressive episode
Understanding “mixed features” in episodes of mood disorders
Anxious distress (in depressive episodes)
Cognitive dysfunction in major depressive disorder
Excessive daytime sleepiness after remission of major depression
Can beta-blockers cause depression or is this a myth?
Seasonal Affective Disorder
Can oral contraceptives cause or worsen depression?
How to diagnose premenstrual dysphoric disorder (PMDD)
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2022.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
Levkovitz Y, Tedeschini E, Papakostas GI. Efficacy of antidepressants for dysthymia: a meta-analysis of placebo-controlled randomized trials. J Clin Psychiatry. 2011 Apr;72(4):509-14. doi: 10.4088/JCP.09m05949blu. PMID: 21527126.
von Wolff A, Hölzel LP, Westphal A, Härter M, Kriston L. Selective serotonin reuptake inhibitors and tricyclic antidepressants in the acute treatment of chronic depression and dysthymia: a systematic review and meta-analysis. J Affect Disord. 2013 Jan 10;144(1-2):7-15. doi: 10.1016/j.jad.2012.06.007. Epub 2012 Sep 7. PMID: 22963896.
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