Introduction
Background
Dysthymia is a depressive mood disorder characterized by a chronic course and an insidious onset. Many people with dysthymia describe life-long depression.
By definition, dysthymia is a chronic mood disorder with a duration of at least 2 years (1 year in adolescents and children). It is manifested as depressed mood for most of the day, occurring more days than not, and accompanied by at least 2 of the following symptoms:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration
- Difficulty making decisions
- Feelings of hopelessness
To diagnose dysthymia, any major depressive episodes must not have occurred in the first 2 years of the illness (the first 1 year in children) and history of mania should not exist. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR)1 allows transient euthymic episodes (periods of normal mood) of up to 2 months during the course of dysthymia.
The DSM-IV-TR categorizes dysthymia according to course specifiers. These include (1) early onset if symptoms began before age 21 years, (2) late onset if symptoms began at age 21 years or later, and (3) dysthymia with atypical features if symptoms include increased appetite or weight gain, hypersomnia, a feeling of leaden paralysis, and extreme sensitivity to rejection.
Dysthymia should be differentiated from major depression. In contrast to dysthymia, a diagnosis of major depression requires that at least 5 or more of the following symptoms have been present most of the day, every day, for the past 2 weeks:
- Depressed mood
- Loss of interest or pleasure in usual activities
- Significant weight loss or gain
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive or inappropriate guilt
- Diminished ability to think or concentrate
- Recurrent thoughts of death or suicide
Major depressive disorder, dysthymia, double depression, and some apparently transient dysphorias may all be manifestations of the same disease process. These varieties of depressive mood states, while distinct diagnostic entities, share similar symptoms and respond to similar pharmacologic and psychotherapeutic approaches.2,3
Although dysthymia was traditionally considered less severe than major depression, the consequences of dysthymia are increasingly recognized as grave and include severe functional impairment, increased morbidity from physical disease, and increased risk of suicide.
The various outcomes of dysthymia.
Of note, an estimated 75% of people with dysthymia meet criteria for at least 1 major depressive episode, referred to as double depression.4 Those with dysthymia who have depressive episodes tend to have longer periods of depression and spend less time fully recovered.5 In a 10-year follow-up study of people with dysthymia, 75% experienced some (at least 2 m) period of recovery from major depression; the mean time to recovery was 52 months from study entry. In this study, most (70%) of those who recovered experienced a relapse into another episode of depression, most commonly in the 3 years following recovery.6
The DSM IV-TR also includes research criteria for depressive personality disorder, which may also be considered in the differential diagnosis of chronic low mood. Depressive personality disorder is characterized by a depressive disposition, introversion, a tendency toward self-criticism, and pessimistic cognitive processes, with fewer of the mood and neurovegetative symptoms seen in dysthymia. Dysthymia or depression may be comorbid with depressive personality disorder.7,8 See also, eMedicine's article Personality Disorders.
Pathophysiology
The pathophysiology of dysthymia has not been clearly established.
Involvement of serotonin and noradrenergic systems is suggested by positive clinical responses to serotonergic and noradrenergic medications, such as selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants.
Abnormalities in neuroendocrine systems, especially thyroid and hypothalamo-pituitary-adrenocortical (HPA) systems, have been linked to depressive disorders in general; the HPA axis has not been adequately studied in dysthymic disorder. Cytokines and inflammation have also been implicated in major depression; however, a link to dysthymia has not been clearly established.
EEG and polysomnogram data demonstrate that about 25% of people who have dysthymia have sleep changes similar to those who have major depression, including shortened rapid eye movement (REM) latency, increased REM density, and poor sleep continuity.
Frequency
United States
Best estimates are that the lifetime risk of significant depression exceeds 25%, with a point prevalence of about 5%. The lifetime community prevalence of dysthymia is 6%. Dysthymia affects an estimated 36% of patients in outpatient mental health treatment.
Mortality/Morbidity
Mortality is reflected not only in the death rate from suicide but also increased morbidity and mortality from a variety of physical illnesses among patients with dysthymia.
Race
Minimal research has been performed to define differences in frequency and symptoms between races. One study, the National Health and Nutrition Examination Survey III (NHANES III), found that dysthymia is more common among African Americans and Mexican Americans than among Caucasians.9
Sex
For major depressive disorders, females outnumber males, with a female-to-male ratio of 2:1 during their childbearing years. Before puberty and after menopause, the 2 sexes appear to be affected about equally. In elderly people, dysthymia is relatively more frequent in females, but dysthymia adversely affects survival in males more than in females.
Age
Most often, patients with dysthymia recall unexplained unhappiness in preadolescent childhood. Whether DSM-IV-TR adequately addresses dysthymia in children and adolescents is a matter of some controversy.10
Clinical
History
Patients with dysthymia often have a gloomy or negative outlook on life with an underlying sense of personal inadequacy. Compared with major depression, patients' histories tend to include more subjective symptoms with fewer dramatic psychomotor disturbances or neurovegetative symptoms including abnormal sleep, appetite, and libido. Some note a diurnal variation, with low energy, inertia, and anhedonia worst in the morning. People with dysthymia may exhibit decreased mental flexibility on neuropsychological testing.
The most common symptoms include the following:
- A negative, pessimistic, or gloomy outlook
- Depressed mood
- Restlessness
- Anxiety
- Neurovegetative symptoms (eg, disturbed sleeping and feeding behaviors, lethargy), usually less marked than those seen in a major depressive episode
- Loss of pleasurable feelings (anhedonia)
- Tend to spend little time engaged in leisure activities
- Alternative research criteria for dysthymic disorder also include irritability, excessive anger, and guilty brooding about the past.
- A family history of a mood disorder is supporting evidence for the diagnosis. Of note, patients with dysthymia are more likely than patients with episodic major depression to have relatives with dysthymia or major depression.
- Although people with dysthymia often have social relationships, some research suggests that this population tends to invest most of their expendable energy into work, leaving little for social life or family and placing a strain on those relationships.
- A tendency to anticipate that future events and future affective experiences will be negative.11
- As many as 15% of those with dysthymia may have comorbid substance dependence. Since substance dependence can lead to symptoms similar to those caused by dysthymia, a detailed substance abuse history should always be obtained.
- Niculescu and Akisal proposed that dysthymia be divided into 2 subtypes: anxious dysthymia and anergic dysthymia. They describe a subset of patients with anxious dysthymia with pronounced symptoms of low self-esteem, undirected restlessness, and interpersonal rejection sensitivity. They propose that these patients are help-seeking and may be more likely to make lower-lethality suicide attempts and have a better response to SSRIs. Substances of choice for these patients include benzodiazepines, alcohol, marijuana, opiates, and possibly food. This group is compared with those with anergic dysthymia with low energy, hypersomnia, and anhedonia. This group, the authors suggest, may have a better response to treatment with agents that increase norepinephrine or dopamine.12
- A mental status examination is needed to confirm the diagnosis and to determine if comorbid diagnoses are present.
- Use of depression rating scales is recommended. Many rating scales, both self-administered and clinician rated, are available. The clinician-administered 17-item Hamilton Rating Scale of Depression (HAM-D) and the self-report scales, the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16), PHQ-9, and Beck Depression Inventory (BDI), are all commonly used. These are simple enough to use on a routine basis, offer diagnostic confirmation, and provide a baseline against which change can be evaluated. Recent studies have emphasized the importance of these rating scales in detecting small changes that may indicate the initial phases of a treatment response.13
- Although psychological tests, such as the Minnesota Multiphasic Inventory or the Rorschach, are not administered routinely in current clinical practice, these tests can be quite helpful for diagnostic purposes.
Physical
The mental status examination findings of a person with dysthymic disorder are similar to those seen in major depressive episodes.
- Some depressed people are less attentive to their appearance, with decline in attention to dress or grooming.
- Speech may be slowed or show diminished emotional prosody.
- Mood is likely to be low with a congruent affect.
- Some observable signs of depressed affect include decreased eye contact, slumped posture, and diminished range of facial expression.
- With dysthymia alone, one would expect the person to retain the ability to convey their thoughts in a linear and logical manner and would not expect disorganization in speech or behavior.
- Hallucinations or delusions would not be explained by dysthymia and should prompt consideration of other diagnoses.
- A safety evaluation is an essential part of any mental status examination; the clinician should inquire about suicidal and homicidal thoughts and plans in those with dysthymia as they would during any psychiatric examination.
- Other thought content could be consistent with sad, hopeless, or guilty themes. One would not expect disruption of intellect, orientation, memory, or abstraction from dysthymia alone.
A sample mental status examination for a person with dysthymia might include the following:
Patient is alert, attentive, and fully oriented. She appears her stated age and is appropriately and casually dressed, although slightly unkempt, with wrinkled clothing. Her mood is stated as depressed and her affect is mood congruent with avoidant eye contact, less spontaneous movement and gesture, and occasional tearfulness. Her thoughts are linear and logical with themes reflecting low self-esteem. She expresses guilt that does not rise to a delusional level; she denies paranoid, religious, grandiose, and bizarre delusions and none are apparent.
She denies hallucinations and does not appear to respond to internal stimuli. She denies current suicidal and homicidal ideation, intent, and plan and demonstrates good judgment, as evidenced by her seeking treatment for her depressed mood. She is in good impulse control. Her intellect is estimated to be average. No deficits are detected in her immediate, short-term, and long-term memory and she is able to interpret proverbs appropriately.
No physical findings are pathognomonic for dysthymia; however, examination may reveal the following:
- Evidence of weight gain or loss
- Low body temperature, brittle nails and hair, slow reflexes, and other symptoms suggestive of thyroid dysfunction
Causes
The cause of dysthymia is not clear and is likely multifactorial. A biopsychosocial formulation, considering the interplay of family history and other genetic factors, medical problems, psychological make-up and coping strategies, and social stressors, is helpful when considering the cause of dysthymia. Some examples of common contributing factors include the following:
- Genetic predisposition
- Biological factors, such as alterations in neurotransmitters, endocrine, or inflammatorymediators
- Chronic stress (eg, particularly with feelings of hopelessness and/or helplessness)
- Chronic medical illness
- Psychosocial factors, such as social isolation, losses
- Ruminative coping strategies, as opposed to problem solving or cognitive restructuring strategies, are common among people with dysthymia and may predispose to or sustain dysthymia.14
- Persons diagnosed with antisocial, borderline, dependent, depressive, histionic, or schizotypal personality traits are at an increased risk for developing dysthymic disorder.
More on Dysthymic Disorder |
 Overview: Dysthymic Disorder |
| Differential Diagnoses & Workup: Dysthymic Disorder |
| Treatment & Medication: Dysthymic Disorder |
| Follow-up: Dysthymic Disorder |
| Multimedia: Dysthymic Disorder |
| References |
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References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. 2000.
McCullough JP Jr, Klein DN, Borian FE, Howland RH, Riso LP, Keller MB, et al. Group comparisons of DSM-IV subtypes of chronic depression: validity of the distinctions, part 2. J Abnorm Psychol. Nov 2003;112(4):614-22. [Medline].
Kessing LV. Epidemiology of Subtypes of Depression. Acta Psychiatr Scand. 2007;115 (Suppl 433):85-89.
Keller MB, Harrison W, Fawcett JA, Gelenberg A, Hirschfeld RM, Klein D, et al. Treatment of chronic depression with sertraline or imipramine: preliminary blinded response rates and high rates of undertreatment in the community. Psychopharmacol Bull. 1995;31(2):205-12. [Medline].
Klein DN, Schwartz JE, Rose S, Leader JB. Five-year course and outcome of dysthymic disorder: A prospective, naturalistic follow-up study. Am J Psychiatry. Jun 2000;157(6):931-9. [Medline].
Klein DN, Shankman SA, Rose S. Ten-year prospective follow-up study of the naturalistic course of dysthymic disorder and double depression. Am J Psychiatry. May 2006;163(5):872-80. [Medline].
Laptook RS, Klein DN, Dougherty LR. Ten-year stability of depressive personality disorder in depressed outpatients. Am J Psychiatry. May 2006;163(5):865-71. [Medline].
Ryder AG, Schuller DR, Bagby RM. Depressive personality and dysthymia: evaluating symptom and syndrome overlap. J Affect Disord. Apr 2006;91(2-3):217-27. [Medline].
Riolo SA, Nguyen TA, Greden JF, King CA. Prevalence of depression by race/ethnicity: findings from the National Health and Nutrition Examination Survey III. Am J Public Health. Jun 2005;95(6):998-1000. [Medline].
Masi G, Millepiedi S, Mucci M, Pascale RR, Perugi G, Akiskal HS. Phenomenology and comorbidity of dysthymic disorder in 100 consecutively referred children and adolescents: beyond DSM-IV. Can J Psychiatry. Mar 2003;48(2):99-105. [Medline].
Casement MD, Shestyuk AY, Best JL, Casas BR, Glezer A, Segundo MA, et al. Anticipation of affect in dysthymia: behavioral and neurophysiological indicators. Biol Psychol. Feb 2008;77(2):197-204. [Medline].
Niculescu AB 3rd, Akiskal HS. Proposed endophenotypes of dysthymia: evolutionary, clinical and pharmacogenomic considerations. Mol Psychiatry. Jul 2001;6(4):363-6. [Medline].
Keitner GI, Ryan CE, Solomon DA. Realistic expectations and a disease management model for depressed patients with persistent symptoms. J Clin Psychiatry. Sep 2006;67(9):1412-21. [Medline].
Kelly O, Matheson K, Ravindran A, Merali Z, Anisman H. Ruminative coping among patients with dysthymia before and after pharmacotherapy. Depress Anxiety. 2007;24(4):233-43. [Medline].
Leichsenring F, Hiller W, Weissberg M, Leibing E. Cognitive-behavioral therapy and psychodynamic psychotherapy: techniques, efficacy, and indications. Am J Psychother. 2006;60(3):233-59. [Medline].
Leichsenring F, Leibing E. Psychodynamic psychotherapy: a systematic review of techniques, indications and empirical evidence. Psychol Psychother. Jun 2007;80:217-28. [Medline].
Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty KF, Wickramaratne P. Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. JAMA. Jun 18 2003;289(23):3117-24. [Medline].
Johnson JE, Zlotnick C. A pilot study of group interpersonal psychotherapy for depression in substance-abusing female prisoners. J Subst Abuse Treat. Jun 2008;34(4):371-7. [Medline].
Agency for Healthcare Research and Quality. Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression. AHRQ: Agency for Healthcare Research and Quality. Available at Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression. Accessed May 19, 2009.
Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. Nov 2006;163(11):1905-17. [Medline].
Carvalho AF, Cavalcante JL, Castelo MS, Lima MC. Augmentation strategies for treatment-resistant depression: a literature review. J Clin Pharm Ther. Oct 2007;32(5):415-28. [Medline].
Lifschytz T, Segman R, Shalom G, Lerer B, Gur E, Golzer T, et al. Basic mechanisms of augmentation of antidepressant effects with thyroid hormone. Curr Drug Targets. Feb 2006;7(2):203-10. [Medline].
Tuunainen A, Kripke DF, Endo T. Light therapy for non-seasonal depression. Cochrane Database Syst Rev. 2004;CD004050. [Medline].
Bernal M, Haro JM, Bernert S, Brugha T, de Graaf R, Bruffaerts R, et al. Risk factors for suicidality in Europe: results from the ESEMED study. J Affect Disord. Aug 2007;101(1-3):27-34. [Medline].
Bakken K, Vaglum P. Predictors of suicide attempters in substance-dependent patients: a six-year prospective follow-up. Clin Pract Epidemol Ment Health. 2007;3:20. [Medline].
Lerner D, Adler DA, Chang H, Lapitsky L, Hood MY, Perissinotto C. Unemployment, job retention, and productivity loss among employees with depression. Psychiatr Serv. Dec 2004;55(12):1371-8. [Medline].
Shankman SA, Klein DN. The impact of comorbid anxiety disorders on the course of dysthymic disorder: a 5-year prospective longitudinal study. J Affect Disord. Jul 2002;70(2):211-7. [Medline].
Hayden EP, Klein DN. Outcome of dysthymic disorder at 5-year follow-up: the effect of familial psychopathology, early adversity, personality, comorbidity, and chronic stress. Am J Psychiatry. Nov 2001;158(11):1864-70. [Medline].
Barbui C, Motterlini N, Garattini L. Health status, resource consumption, and costs of dysthymia. A multi-center two-year longitudinal study. J Affect Disord. Feb 2006;90(2-3):181-6. [Medline].
Adler DA, Irish J, McLaughlin TJ, Perissinotto C, Chang H, Hood M, et al. The work impact of dysthymia in a primary care population. Gen Hosp Psychiatry. Jul-Aug 2004;26(4):269-76. [Medline].
Airaksinen E, Larsson M, Lundberg I, Forsell Y. Cognitive functions in depressive disorders: evidence from a population-based study. Psychol Med. Jan 2004;34(1):83-91. [Medline].
Angst J, Merikangas K. The depressive spectrum: diagnostic classification and course. J Affect Disord. Aug 1997;45(1-2):31-9; discussion 39-40. [Medline].
Askinazi C, Weintraub RJ, Karamouz N. Elderly depressed females as a possible subgroup of patients responsive to methylphenidate. J Clin Psychiatry. Sep 1986;47(9):467-9. [Medline].
Beauregard M, Leroux JM, Bergman S, Arzoumanian Y, Beaudoin G, Bourgouin P, et al. The functional neuroanatomy of major depression: an fMRI study using an emotional activation paradigm. Neuroreport. Oct 5 1998;9(14):3253-8. [Medline].
Bunevicius R, Kazanavicius G, Zalinkevicius R, Prange AJ Jr. Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients with hypothyroidism. N Engl J Med. Feb 11 1999;340(6):424-9. [Medline].
Cassidy F, Murry E, Forest K, Carroll BJ. Signs and symptoms of mania in pure and mixed episodes. J Affect Disord. Sep 1998;50(2-3):187-201. [Medline].
Chen LS, Eaton WW, Gallo JJ, Nestadt G, Crum RM. Empirical examination of current depression categories in a population-based study: symptoms, course, and risk factors. Am J Psychiatry. Apr 2000;157(4):573-80. [Medline].
Claes SJ. Corticotropin-releasing hormone (CRH) in psychiatry: from stress to psychopathology. Ann Med. 2004;36(1):50-61. [Medline].
Cohen-Kettenis PT, Gooren LJ. Transsexualism: a review of etiology, diagnosis and treatment. J Psychosom Res. Apr 1999;46(4):315-33. [Medline].
Cyranowski JM, Frank E, Young E, Shear MK. Adolescent onset of the gender difference in lifetime rates of major depression: a theoretical model. Arch Gen Psychiatry. Jan 2000;57(1):21-7. [Medline].
Dantzer R, Bluthe RM, Layé S, Bret-Dibat JL, Parnet P, Kelley KW. Cytokines and sickness behavior. Ann N Y Acad Sci. May 1 1998;840:586-90. [Medline].
De Lima MS, Hotopf M. Benefits and risks of pharmacotherapy for dysthymia: a systematic appraisal of the evidence. Drug Saf. 2003;26(1):55-64. [Medline].
de Lima MS, Hotoph M, Wessely S. The efficacy of drug treatments for dysthymia: a systematic review and meta-analysis. Psychol Med. Nov 1999;29(6):1273-89. [Medline].
Dierker LC, Avenevoli S, Stolar M, Merikangas KR. Smoking and depression: an examination of mechanisms of comorbidity. Am J Psychiatry. Jun 2002;159(6):947-53. [Medline].
Dunner DL. Duration of periods of euthymia in patients with dysthymic disorder. Am J Psychiatry. Dec 1999;156(12):1992-3. [Medline].
Frances A, Kocsis J, Marin D, Manning D, Markowitz J, Mason B, et al. Diagnostic criteria for dysthymic disorder. Psychopharmacol Bull. 1989;25(3):325-9. [Medline].
Greenlee BA, Ferrell RB, Kauffman CI, McAllister TW. Complex partial seizures and depression. Curr Psychiatry Rep. Oct 2003;5(5):410-6. [Medline].
Halbreich U, Tworek H. Altered serotonergic activity in women with dysphoric premenstrual syndromes. Int J Psychiatry Med. 1993;23(1):1-27. [Medline].
Hellerstein DJ, Batchelder S, Miozzo R, Kreditor D, Hyler S, Gangure D. Citalopram in the treatment of dysthymic disorder. Int Clin Psychopharmacol. May 2004;19(3):143-8. [Medline].
Hermens ML, van Hout HP, Terluin B, van der Windt DA, Beekman AT, et al. The prognosis of minor depression in the general population: a systematic review. Gen Hosp Psychiatry. Nov-Dec 2004;26(6):453-62. [Medline].
Hibbeln JR. Fish consumption and major depression. Lancet. Apr 18 1998;351(9110):1213. [Medline].
Jimerson DC, Lesem MD, Kaye WH, Hegg AP, Brewerton TD. Eating disorders and depression: is there a serotonin connection?. Biol Psychiatry. Sep 1 1990;28(5):443-54. [Medline].
Johnson JG, Cohen P, Kasen S, Brook JS. Personality disorder traits associated with risk for unipolar depression during middle adulthood. Psychiatry Res. Sep 15 2005;136(2-3):113-21. [Medline].
Judd LL, Akiskal HS. Delineating the longitudinal structure of depressive illness: beyond clinical subtypes and duration thresholds. Pharmacopsychiatry. Jan 2000;33(1):3-7. [Medline].
Klein DN, Schwartz JE. The relation between depressive symptoms and borderline personality disorder features over time in dysthymic disorder. J Personal Disord. Dec 2002;16(6):523-35. [Medline].
Klein DN, Shankman SA, Lewinsohn PM, Rohde P, Seeley JR. Family study of chronic depression in a community sample of young adults. Am J Psychiatry. Apr 2004;161(4):646-53. [Medline].
Kovacs M, Akiskal HS, Gatsonis C, Parrone PL. Childhood-onset dysthymic disorder. Clinical features and prospective naturalistic outcome. Arch Gen Psychiatry. May 1994;51(5):365-74. [Medline].
Markowitz JC, Bleiberg KL, Christos P, Levitan E. Solving interpersonal problems correlates with symptom improvement in interpersonal psychotherapy: preliminary findings. J Nerv Ment Dis. Jan 2006;194(1):15-20. [Medline].
Markowitz JC, Kocsis JH, Bleiberg KL, Christos PJ, Sacks M. A comparative trial of psychotherapy and pharmacotherapy for "pure" dysthymic patients. J Affect Disord. Dec 2005;89(1-3):167-75. [Medline].
Markowitz JC, Skodol AE, Petkova E, Xie H, Cheng J, Hellerstein DJ, et al. Longitudinal comparison of depressive personality disorder and dysthymic disorder. Compr Psychiatry. Jul-Aug 2005;46(4):239-45. [Medline].
Mischoulon D, Burger JK, Spillmann MK, Worthington JJ, Fava M, Alpert JE. Anemia and macrocytosis in the prediction of serum folate and vitamin B12 status, and treatment outcome in major depression. J Psychosom Res. Sep 2000;49(3):183-7. [Medline].
Moore E, Wisniewski A, Dobs A. Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab. Aug 2003;88(8):3467-73. [Medline].
Murphy JM, Laird NM, Monson RR, Sobol AM, Leighton AH. A 40-year perspective on the prevalence of depression: the Stirling County Study. Arch Gen Psychiatry. Mar 2000;57(3):209-15. [Medline].
Ordway GA. Searching for the chicken's egg in transporter gene polymorphisms. Arch Gen Psychiatry. Aug 2000;57(8):739-40. [Medline].
Penninx BW, Geerlings SW, Deeg DJ, van Eijk JT, van Tilburg W, Beekman AT. Minor and major depression and the risk of death in older persons. Arch Gen Psychiatry. Oct 1999;56(10):889-95. [Medline].
Ravindran AV, Guelfi JD, Lane RM, Cassano GB. Treatment of dysthymia with sertraline: a double-blind, placebo-controlled trial in dysthymic patients without major depression. J Clin Psychiatry. Nov 2000;61(11):821-7. [Medline].
Rudas S, Schmitz M, Pichler P, Baumgartner A. Treatment of refractory chronic depression and dysthymia with high-dose thyroxine. Biol Psychiatry. Jan 15 1999;45(2):229-33. [Medline].
Stahl SM. Essential Psychopharmacology. In: Neuroscientific Basis and Practical Applications. 2nd ed. Cambridge, UK: Cambridge University Press; 2000.
West M, George C. Attachment and dysthymia: the contributions of preoccupied attachment and agency of self to depression in women. Attach Hum Dev. Dec 2002;4(3):278-93. [Medline].
Williams JW Jr, Barrett J, Oxman T, Frank E, Katon W, Sullivan M, et al. Treatment of dysthymia and minor depression in primary care: A randomized controlled trial in older adults. JAMA. Sep 27 2000;284(12):1519-26. [Medline].
Wolkowitz OM, Reus VI. Treatment of depression with antiglucocorticoid drugs. Psychosom Med. Sep-Oct 1999;61(5):698-711. [Medline].
Further Reading
Keywords
dysthymic disorder, chronic depression, chronic depressive personality disorder, neurotic depression, minor depressive reaction, major depressive disorder, double depression, transient dysphorias, TCAs, SSRIs, dysthymia, depressive mood disorder, depression, chronic mood disorder
