eMedicine Specialties > Psychiatry > Adult
Dysthymic Disorder: Treatment & Medication
Updated: May 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Psychotherapy and medication management are both effective treatment modalities for dysthymia and combination treatment is common. Minimal data are available; however, a randomized trial that compared interpersonal psychotherapy, brief supportive psychotherapy, sertraline treatment alone, and sertraline plus interpersonal psychotherapy found the greatest effect when sertraline and interpersonal therapy were combined.
Therapy
The effectiveness of several types of therapy, including psychodynamic, cognitive behavioral, and interpersonal therapy, has been demonstrated in controlled studies to be effective in the treatment of depression and dysthymia.
Short- and long-term psychodynamic psychotherapy are both effective for depressive disorders and, in particular, help in developing an individual’s understanding of their relationships and decreases maladaptive interpersonal interactions.15,16
Cognitive behavioral therapy (CBT) is a structured time-limited treatment that involves recognizing and restructuring cognitive processes leading to depression and noting the relationship between depressive cognitions, mood state, and the individual’s behavior. Cognitive strategies, such as reformulating distorted thinking, and behavioral strategies, such as daily activity scheduling, are effective for depressive symptoms.
Interpersonal therapy (IPT) is also a structured, time-limited treatment. This therapy focuses on current problems and the interpersonal context in which they occur. Success in solving interpersonal conflicts in interpersonal therapy is associated with improved symptoms of dysthymia.
Although research in this area is limited, group therapy, including CBT and IPT groups, may be helpful for people with dysthymia.17,18
Consultations
Close collaboration among all providers and treatment of any underlying or comorbid medical conditions are essential.
Activity
Studies suggest that individuals with depressed mood are helped by aerobic exercise 4-6 times a week and that any exercise is more helpful than none at all.
Medication
Antidepressants are effective in treating dysthymia; the mean response for any antidepressant in a review study was 55% among dysthymic patients (compared with 31% response for placebo). Doses are the same as those used for major depression. A systematic review of antidepressant treatment in dysthymia suggests that SSRIs, tricyclic antidepressants, and monoamine oxidase inhibitors (MAOIs) are all equally effective, but SSRIs may be slightly better tolerated. Success has also been reported with more noradrenergic agents such as mirtazapine (Remeron), nefazodone (Serzone), venlafaxine (Effexor), duloxetine (Cymbalta), and bupropion (Wellbutrin).
Comparisons of agents within or between classes have not been reported for dysthymia. A 2007 research summary by the Agency for Healthcare Research and Quality (AHRQ) identified no head-to-head trial comparing different second-generation antidepressants for treatment of dysthymia; comparison between placebo-controlled trials was stymied by significant differences in population characteristics. The AHRQ noted that in a fair-quality placebo-controlled study of paroxetine, a subgroup of patients older than 60 years showed a significantly greater improvement than those on placebo, whereas paroxetine was no more effective than placebo in a subgroup of patients younger than 60 years.19
While the older antidepressants such as tricyclics and MAOIs are effective, the SSRIs are the medications most commonly used for dysthymia, likely because of their relative safety and milder side effect profile. Given that dysthymia is a chronic condition, tolerability is important to facilitate compliance over the long-term.
Little data exist for choosing one antidepressant over another unless (1) the risk of a particular adverse effect is to be avoided, (2) the patient has a history of prior response to a particular drug, or (3) if a drug is known to have been effective for a member of the patient's family.
Of note, antidepressants may cause a temporary worsening of anxiety symptoms; lower doses, slower titration, or temporary use of benzodiazepines (if not contraindicated, for example, because of a substance use disorder) may mitigate anxiety and improve tolerability.
Physicians should be aware of the FDA black box warning regarding antidepressant treatment in children and younger adults and use appropriate caution when considering the risks and benefits of antidepressant treatment in these populations.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality was noted in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
Augmentation
Treatment resistance is common is depression and dysthymia. Patients should be closely tracked for residual symptoms and if symptoms have not remitted, a medication change or an augmentation should be considered to target full remission.20 Data guiding antidepressant augmentation are drawn from studies in treatment-resistant major depression. The strongest data exists for lithium and thyroid hormone augmentation. While thyroid dysfunction is common among people with depression and must be treated, thyroid hormone supplementation is an effective augmentation strategy even for those with normal thyroid function.21,22 Buspirone, bupropion, stimulants, and mirtazapine are commonly used in clinical practice.
Bright light therapy may be considered as an adjunct treatment, especially for those who experience exacerbation of symptoms in the winter time. Bright light therapy is best studied in patients with seasonal affective disorder, but limited evidence supports its use in other depressive disordersl.23
Selective serotonin reuptake inhibitors
Potentiate the pharmacological effects of serotonin (5-HT) in the CNS.
Citalopram (Celexa)
SSRI used to treat depression. Similar to fluoxetine, sertraline, and paroxetine. Highly selective reuptake inhibitor of serotonin and has little effect on other neurotransmitters.
Adult
10-60 mg PO qd
Pediatric
Consult child psychiatrist if SSRI treatment of pediatric patient considered
Increased risk of serotonin syndrome with MAOIs; increases serum levels/toxicity of metoprolol; increased toxicity with antiretroviral protease inhibitors, calcium channel blockers, corticosteroids, H2 inhibitors, macrolides, azole antifungals, fluvastatin, isoniazid, INH, metronidazole, modafinil, nefazodone, norfloxacin, quinine, and topiramate
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use with caution if history of mania or hypomania; should not be given within 2 wk of MAOI; reduce risk of withdrawal symptoms by gradual tapering; may induce sexual adverse effects (eg, decreased libido, ejaculation dysfunction, impotence, orgasm dysfunction)
Fluvoxamine (Luvox)
Potent selective inhibitor of neuronal serotonin reuptake. Does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than tricyclic antidepressants. Approved initially for OCD, but effective in dysthymia. Expensive.
Adult
50 mg PO initially as a single hs dose, increase dose in 50-mg increments q4-7d as tolerated until maximum therapeutic benefit achieved, divide total daily dose into 2 doses; if doses are unequal, administer larger dose hs; not to exceed 300 mg/d
Pediatric
Consult child psychiatrist if SSRI treatment of pediatric patient considered
Fluvoxamine has important interactions with tricyclic antidepressants and may increase tricyclic levels into the toxic range
Fluvoxamine potentiates effect of triazolam and alprazolam and thus, when taking them concurrently, reduce dose by at least 50%; reduce theophylline dose by one third; monitor plasma levels if taking concurrently with fluvoxamine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of fluvoxamine
Documented hypersensitivity; administration within 14 d of receiving MAOI
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use with caution if history of mania or hypomania; should not be given within 2 wk of MAOI; common adverse effects include insomnia, sexual dysfunction, nausea, diarrhea, sweating, fatigue, and somnolence or agitation; caution in liver dysfunction or cardiovascular disease and history of seizures or suicide attempts
Paroxetine (Paxil)
Potent selective inhibitor of neuronal serotonin reuptake. Also has a weak effect on norepinephrine and dopamine neuronal reuptake. For maintenance therapy, adjust dosage to maintain patient on lowest effective dosage, and reassess patient periodically to determine need for continued treatment.
Adult
10 mg/d PO initial therapy; increase in 10-mg/d increments, if necessary; dose changes should occur at intervals of at least 1 wk; 10-60 mg/d usual dose range; not to exceed 60 mg/d
Pediatric
Consult child psychiatrist if SSRI treatment of pediatric patient considered
Phenobarbital and phenytoin decrease effects of paroxetine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of paroxetine
Documented hypersensitivity; administration within 14 d of receiving MAOI
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Use with caution if history of mania or hypomania; should not be given within 2 wk of MAOI; common adverse effects include insomnia, sexual dysfunction, nausea, diarrhea, sweating, fatigue, and somnolence or agitation; caution in history of seizures, renal disease, and cardiac disease
Fluoxetine (Prozac)
Best-studied drug. Has a long half-life. Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in reuptake of norepinephrine or dopamine.
Adult
20 mg/d PO in am, increase after several wk by 20 mg/d; not to exceed 80 mg/d
Pediatric
Consult child psychiatrist if SSRI treatment of pediatric patient considered
Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs
Documented hypersensitivity; concurrently taking MAOIs or receiving MAOIs in the last 2 wk
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use with caution if history of mania or hypomania; should not be given within 2 wk of MAOI; common adverse effects include insomnia, sexual dysfunction, nausea, diarrhea, sweating, fatigue, and somnolence or agitation; caution in hepatic impairment and history of seizures
Sertraline (Zoloft)
Selectively inhibits presynaptic serotonin reuptake.
Adult
50 mg/d PO in am with 50-mg/d increments q2-3d to 100 mg/d, if tolerated; not to exceed 200 mg/d
Pediatric
Consult child psychiatrist if SSRI treatment of pediatric patient considered
Increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use with caution if history of mania or hypomania; should not be given within 2 wk of MAOI; common adverse effects include insomnia, sexual dysfunction, nausea, diarrhea, sweating, fatigue, and somnolence or agitation; caution in preexisting seizure disorders and in those who have experienced a recent myocardial infarction, have unstable heart disease, and hepatic or renal impairment
Escitalopram (Lexapro)
SSRI and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in CNS resulting from inhibition of CNS neuronal reuptake of serotonin.
Adult
10 mg PO qd initially; if needed, may increase to 20 mg/d after 1 wk
Pediatric
Consult child psychiatrist if SSRI treatment of pediatric patient considered
Primarily metabolized by CYP450 3A4 and 2C19; coadministration with alcohol or other centrally acting drugs increases CNS depression; cimetidine increases AUC and maximum serum concentration; coadministration with sumatriptan and SSRIs has caused weakness and hyperreflexia
Documented hypersensitivity; administration within 14 d of receiving MAOI
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use with caution if history of mania or hypomania; should not be given within 2 wk of MAOI; common adverse effects include insomnia, sexual dysfunction, nausea, diarrhea, sweating, fatigue, and somnolence or agitation; caution with history of seizures, suicide
Tricyclic antidepressants
The tricyclics are the prototypical antidepressants. Their anticholinergic (dry mouth) and antihistaminic (sedating) effects make noncompliance more of a problem than with the newer drugs. This is particularly a problem when the depressive symptoms are relatively mild. However, their very broad-based actions on a variety of neurotransmitters make them effective on occasions when SSRIs fail. Adverse effects with the so-called second-generation drugs generally are less of a problem.
Nortriptyline (Aventyl HCl, Pamelor)
Has demonstrated effectiveness in the treatment of chronic pain. By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane this drug increases the synaptic concentration of these neurotransmitters in the CNS. Pharmacodynamic effects such as the desensitization of adenyl cyclase and down-regulation of beta-adrenergic receptors and serotonin receptors also appear to play a role in its mechanisms of action.
Adult
25 mg PO tid/qid; not to exceed 150 mg/d
Pediatric
Consult child psychiatrist if antidepressant treatment of pediatric patient considered
Cimetidine may increase nortriptyline levels when used concurrently
Documented hypersensitivity; narrow-angle glaucoma; receiving MAOIs within 14 d of initiating treatment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause drowsiness; discontinue use if patient develops sore throat, fever, or other signs of infection; suicide ideation is inherent in depression and may persist until significant remission occurs; severe neutropenia reported in clinical trials
Desipramine HCl (Norpramin)
May increase synaptic concentration of norepinephrine in CNS by inhibiting reuptake by presynaptic neuronal membrane. May have effects in the desensitization of adenyl cyclase, down-regulation of beta-adrenergic receptors, and down-regulation of serotonin receptors.
Adult
75 mg/d PO initially in equally divided doses, increase gradually prn; not to exceed 300 mg/d
For elderly patients, 25-100 mg/d PO; not to exceed 150 mg/d
Pediatric
Consult child psychiatrist if antidepressant treatment of pediatric patient considered
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects of desipramine increase with phenytoin and carbamazepine
Documented hypersensitivity; narrow-angle glaucoma; recent postmyocardial infarction; patients currently receiving MAOIs, SSRIs, or who took them in the previous 2 wk
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, and patients receiving thyroid replacement
Miscellaneous mixed serotonergic and noradrenergic drugs
Because norepinephrine is involved in depression as well as serotonin, arguments exist. These drugs have effects on serotonin and norepinephrine and, in some cases, on dopamine and even nicotinic acetylcholine systems. Because of the empirical nature of psychopharmacology, they may be used as first-line agents or as follow-up agents when SSRIs fail.
Duloxetine (Cymbalta)
Potent inhibitor of neuronal serotonin and norepinephrine reuptake. Antidepressive action is theorized to be due to serotonergic and noradrenergic potentiation in CNS.
Adult
20 mg PO bid; may increase to 60 mg/d administered qd or divided as 30 mg bid
Pediatric
Not established
Metabolized by CYP1A2 and CYP2D6; coadministration with drugs that inhibit CYP1A2 (eg, fluvoxamine, cimetidine, ciprofloxacin, enoxacin) may increase duloxetine blood levels and toxicity; coadministration with drugs that inhibit CYP2D6 (eg, paroxetine, fluoxetine, quinidine) may increase duloxetine blood levels and toxicity; duloxetine moderately inhibits CYP2D6 and may decrease elimination of CYP2D6 substrates (eg, tricyclic antidepressants, phenothiazines {eg, thioridazine], type 1C antiarrhythmics [eg, propafenone, flecainide]); coadministration with MAOIs or triptans serotonin syndrome consisting of serious, sometimes fatal reactions that include hyperthermia, rigidity, myoclonus, autonomic instability, mental status changes including extreme agitation, delirium, and coma (see contraindications)
Documented hypersensitivity; uncontrolled narrow-angle glaucoma; within 14 d of stopping MAOI use (do not initiate MAOIs within 5 d of stopping duloxetine)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Observe closely for clinical worsening and suicidality when initiating treatment or following dosage change; gradually decrease dose when discontinuing, do not abruptly discontinue; caution with hepatic impairment or end-stage renal disease; recommended not to prescribe to patients with substantial alcohol use or evidence of chronic liver disease; may cause slight blood pressure increase; may activate mania or hypomania; common adverse effects include nausea, dry mouth, constipation, decreased appetite, fatigue, somnolence and increased sweating; may cause serotonin syndrome (ie, changes in mental status [agitation, hallucinations, coma], autonomic instability [tachycardia, labile blood pressure, hyperthermia], neuromuscular abnormalities [hyperreflexia, incoordination], and/or gastrointestinal tract symptoms
Bupropion (Wellbutrin)
Inhibits neuronal dopamine reuptake in addition to being a weak blocker of serotonin and norepinephrine reuptake. Low incidence of sexual dysfunctions. Binds to nicotinic receptor and helps with smoking cessation.
Adult
75-200 mg PO bid (sustained release)
Pediatric
Consult child psychiatrist if antidepressant treatment of pediatric patient considered
Carbamazepine, cimetidine, phenytoin, and phenobarbital may decrease effects; toxicity increases with concurrent administration of levodopa and MAOIs; alcohol increases risk of seizures
Documented hypersensitivity; seizure disorder; anorexia nervosa; concurrent use with MAOIs
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal or hepatic insufficiency; doses >450 mg/d significantly decrease seizure threshold; use with caution if history of mania or hypomania; should not be given within 2 wk of MAOI
Mirtazapine (Remeron, Remeron SolTab)
Antidepressant that is not chemically related to tricyclic or any other class of antidepressants. Primary mechanism of action of mirtazapine is antagonism at central presynaptic alpha-2 receptors. Actions of drug change as dose is raised. Exhibits both noradrenergic and serotonergic activity.
Adult
15-45 mg PO qd
Pediatric
Consult child psychiatrist if antidepressant treatment of pediatric patient considered
May increase effect of CNS depressants; taken within 14 d of MAOIs may trigger hypertensive crisis
Documented hypersensitivity; agranulocytosis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue therapy if sore throat, fever, stomatitis, or other signs of infection and neutropenia develop; use with caution if history of mania or hypomania; should not be given within 2 wk of MAOI
Venlafaxine (Effexor, Effexor XR)
Structurally unrelated to other available antidepressants. Inhibits serotonin reuptake at select receptors and reuptake of norepinephrine.
Adult
IR: 75 mg/d PO divided bid, may increase by 75 mg/d PO at 4-d intervals prn; not to exceed 375 mg/d administered in 3 divided doses
ER: 75 mg PO qd
Alternatively: 37.5 mg PO qd for 4-7 d initial, then increase to 75 mg/d, may increase by 75 mg/d PO at 4-d intervals prn; not to exceed 225 mg PO qd
Pediatric
Consult child psychiatrist if antidepressant treatment of pediatric patient considered
Increased risk of serotonin syndrome with coadministration of SSRI or MAOI
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for hypertension
Thyroid products
Used as augmentation strategy. May convert nonresponders (to antidepressants) to responders by increasing receptor sensitivity and enhancing effects of antidepressants, particularly, tricyclic antidepressants.
T3, liothyronine (Cytomel)
Synthetic form of natural thyroid hormone T3 converted from T4. Duration of activity is short and allows for quick dosage adjustments in event of overdosage. May need to be administered as often as qid. In active form, influences growth and maturation of tissues.
Dose should be one quarter of T4 dose, according to some; others recommend administering it alone.
Adult
12.5-100 mcg/d PO single or in divided doses
Pediatric
Consult child psychiatrist
Cholestyramine may decrease liothyronine absorption; estrogens may decrease response to thyroid hormone therapy in patients with nonfunctioning thyroid glands; effect of anticoagulants is potentiated by liothyronine; activity of some beta-blockers may decrease when patient with hypothyroidism is converted to a euthyroid state
Documented hypersensitivity; uncorrected adrenal insufficiency; hyperthyroidism
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution when administering to patients with angina pectoris or cardiovascular disease; monitor thyroid status periodically
T3/T4 combinations (Armour Thyroid, Thyrolar)
Mixtures of 1 part T3 to 4 parts T4 and carry the same advice and warnings as the 2 hormones when administered separately. For desiccated thyroid, 1 grain (60 mg) contains 38 mcg T4 and 9 mcg T3. Thyrolar 1 contains 50 mcg T4 and 12.5 mcg T3.
Adult
Base dosing on corresponding dosing regimens for liothyronine or levothyroxine
Pediatric
Consult child psychiatrist
Cholestyramine may decrease liothyronine absorption; estrogens may decrease the response to thyroid hormone therapy in patients with nonfunctioning thyroid glands; effect of anticoagulants is potentiated by liothyronine; activity of some beta-blockers may decrease when the hypothyroid patient is converted to a euthyroid state
Documented hypersensitivity; uncorrected adrenal insufficiency; hyperthyroid conditions
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution when administering to patients with angina pectoris or cardiovascular disease; monitor thyroid status periodically
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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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
