eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Dysthymic Disorder: Follow-up

Author: Edwin S Rogers, PhD, ABPP, Assistant Director Behavioral Medicine Fellowship, Associate Professor, Department of Family Medicine, University of Tennessee Medical Center at Knoxville
Coauthor(s): Steven L Spalding, MD, Behavioral Medicine Fellowship Director, Assistant Professor, Department of Family Practice, University of Tennessee Medical Center
Contributor Information and Disclosures

Updated: Dec 5, 2008

Follow-up

Further Inpatient Care

  • Inpatient care generally is not necessary for the treatment of dysthymic disorder. If major depression develops with suicidal ideation, then inpatient care may be urgently needed.

Further Outpatient Care

  • Given the chronic nature of dysthymic disorder, ongoing psychotherapeutic and/or psychopharmacologic care may be necessary to foster sustained remission and modification of maladaptive coping. Termination of cognitive behavioral therapy and interpersonal therapy, when studied in the treatment of major depression in the pediatric population, has resulted in a significant relapse rate on follow-up care, suggesting the need for maintenance therapy.

Inpatient & Outpatient Medications

  • Dysthymic disorder rarely is treated by itself on an inpatient basis. Outpatient treatment is mainly via psychotherapy, with occasional use of medications as noted above.

Transfer

  • Psychotherapeutic treatment for children with mood disorders is best done by a clinician who is trained in the area of psychotherapy in pediatric populations. Transfer of care to a child and adolescent psychiatrist, behavioral-developmental pediatrician, clinical pediatric psychologist, social worker, or family therapist is recommended. When medication is considered, consultation with a psychiatrist or behavioral pediatrician is required.

Deterrence/Prevention

  • Very few studies have been published on the prevention of depressive disorders in general in children and adolescents. Given the lengthy course of dysthymic disorder, prevention and early intervention are key to minimizing suffering and functional impairment.
  • Dysthymic disorder is often followed by recurrent major depression; prevention and early treatment of dysthymic disorder could help to prevent this more serious condition, as well as other potential future comorbidities such as substance abuse and school failure.
  • The few studies that have been conducted show that group cognitive behavioral therapy, together with relaxation training and group problem-solving therapy, may prevent recurrences of subclinical depression for many months posttreatment.
  • Although long-term data are unavailable, brief family-based educational interventions have also helped prevent mood disorders in children at risk because of parental depression.

Complications

  • Comorbid conditions frequently accompany dysthymic disorder. Such conditions need treatment as well, because they may influence the maintenance and recurrence of depression. Anxiety symptoms often coexist with depressive disorders. Early onset dysthymic disorder is associated with an increased risk of subsequent major depressive disorder and substance abuse.
  • The presence of a comorbid externalizing psychiatric disorder (eg, conduct disorder, oppositional disorder, attention deficit hyperactivity disorder [ADHD]) delays recovery from dysthymia, suggesting that these conditions should be addressed first.
  • Substance abuse sometimes is a complication or coexisting disorder in depressed adolescents and should be treated if it occurs.
  • Cognitive and psychodynamic psychotherapies have been shown to be effective for both depressive symptoms and anxiety symptoms, as have selective serotonin reuptake inhibitors (SSRIs).

Prognosis

  • Children who experience dysthymic disorder have a mean episode length of 3-4 years (1 y duration is required for the diagnosis).
  • Presence of a comorbid externalizing disorder appears to add almost 2.5 years to the episode length.
  • Within 5 years of diagnosis, 69% of children with dysthymic disorder had a major depressive episode.
  • The spontaneous remission rate for all patients with dysthymic disorder (adult and child) may be as low as 10% per year, but the outcome is significantly better with active treatment.

Patient Education

  • Education about the long-term risks of dysthymic disorder, the role of behavioral and cognitive-behavioral interventions, and teaching of social and interpersonal skills can be helpful as adjuncts to treatment.
  • For excellent patient education resources, visit eMedicine's Depression Center. Also, see eMedicine's patient education article, Depression.

Miscellaneous

Medicolegal Pitfalls

  • The major medical/legal pitfall to be aware of in depressive disorders is failure to assess the intensity of depression or a lack of thorough exploration of impending suicidal plans of the patient. Failure to comprehensively assess suicidal thoughts or plans may potentially result in a patient's suicide. Although dysthymic disorder typically does not involve suicidal ideation or attempts, these patients are at increased risk for development of more severe types of affective disorders, such as major depression or bipolar disorder, which could result in severe impairment or death. Unfortunately, many patients who attempt or complete suicide have seen a health care practitioner relatively recently before their suicide attempt. Frequent and thorough assessment of depressive symptoms can potentially detect an overlooked presentation of more serious disorders.
  • Adolescent patients with dysthymic disorder may develop a superimposed major depressive episode and deteriorate quickly into a more severely ill state. Such a change may be overlooked by the patient, who sometimes becomes accustomed to the chronically depressed state and may not differentiate development of an acute major depressive episode from the baseline. The emotional lability of adolescents and the intensity of their developmental state and relationships may provide sufficient stress to potentiate an impulsive suicidal act. Frequent assessment of suicidal ideation and other depressive symptoms can assist the clinician in intervening appropriately. Suicide attempts are a psychiatric emergency and should be treated as such, with intensive assessment and intervention, including hospitalization if safety of the patient cannot be ensured as an outpatient.
 


More on Dysthymic Disorder

Overview: Dysthymic Disorder
Differential Diagnoses & Workup: Dysthymic Disorder
Treatment & Medication: Dysthymic Disorder
Follow-up: Dysthymic Disorder
References
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Further Reading

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Keywords

dysthymic disorder, mood disorder, dysthymia, depressive neurosis, neurotic depression, depressive personality, depression, irritable mood, diminished appetite, increased appetite, insomnia, hypersomnia, low energy, fatigue, poor self-esteem, concentration difficulties, decision-making difficulties, feelings of hopelessness, suicide, suicidal thoughts, suicidality, bipolar disorder, anxiety disorder, conduct disorder, enuresis, encopresis, sexual abuse, hyperactivity, learning disabilities, attention deficit hyperactivity disorder, ADHD, schizophrenia, social withdrawal, hypersomnia, major depressive disorder

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Contributor Information and Disclosures

Author

Edwin S Rogers, PhD, ABPP, Assistant Director Behavioral Medicine Fellowship, Associate Professor, Department of Family Medicine, University of Tennessee Medical Center at Knoxville
Edwin S Rogers, PhD, ABPP is a member of the following medical societies: Association for Behavioral Science and Medical Education and Society of Teachers of Family Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Steven L Spalding, MD, Behavioral Medicine Fellowship Director, Assistant Professor, Department of Family Practice, University of Tennessee Medical Center
Steven L Spalding, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center
Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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