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Dysthymic Disorder: Treatment & Medication
Updated: Dec 5, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Various types of psychotherapy (psychodynamic, cognitive-behavioral, interpersonal, family therapy) have been the mainstay of treatment of dysthymic disorder in children and adolescents. Increasing emphasis has been placed on psychopharmacology in depressed pediatric patients.2 However, most of the recommendations for treatment with either psychotherapy or drugs are based on the adult literature. At the time of writing, controlled studies of different treatment strategies for major depressive disorder in the pediatric population have only begun to be conducted. Given the experience with adult patients that effective treatments for major depression also work for dysthymic disorder, the results from these current studies can probably inform treatment planning for children with dysthymic disorder.
Integration of psychotherapeutic treatment and psychopharmacologic treatment is typical in the adult population suffering from dysthymic disorder. In adults, studies have shown that tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs) are helpful when administered at the same dosages used in the treatment of major depressive disorder. However, most of the studies of treatment in the pediatric population have used psychotherapy as the primary treatment. Very few studies on the use of pharmacotherapy alone or on combined pharmacotherapy and psychotherapy with pediatric dysthymic patients are available.
The American Academy of Child and Adolescent Psychiatry recommends that interventions that have been effective in treating major depressive disorder should be used in children and adolescents with dysthymic disease because no controlled trials and few clinical studies have been performed assessing treatment of pediatric dysthymia.3 Because of the chronicity of dysthymic disorder (mean episode duration 3-4 y for community samples, duration at least 1 y to make the diagnosis), intense and long-term treatment may be necessary. This is particularly challenging given the arbitrary limits on insurance coverage for mental health diagnoses.
- Psychotherapy is used to teach patients and their families to cope with stress (both current and historical), improve social skills and self-concept, understand themselves and their family, and deal with interpersonal and social conflict. In addition, it can help patients deal with the familial, academic, and occupational problems associated with depression. Psychodynamic psychotherapy, interpersonal therapy, cognitive behavioral therapy, behavior therapy, family therapy, supportive psychotherapy, and group psychotherapy have been used with depressed pediatric patients. Several factors appear to be related to the effectiveness of psychotherapy, including the following:
- Age at onset of depression
- Severity of depression
- Presence of comorbid psychiatric disorders
- Presence of or lack of support
- Parental psychopathology
- Significant family conflict
- Exposure to stressful life events
- Socioeconomic status
- Quality of treatment
- Therapist's expertise
- Motivation of both patient and therapist
- Psychodynamic psychotherapy, informed by psychoanalytic thinking, has as its goals helping patients understand themselves, identify feelings, improve self-esteem, change dysfunctional patterns of behavior, interact more appropriately with others, and manage past and ongoing conflicted relationships.
- Interpersonal therapy focuses on interpersonal roles and difficulties. Grief, disputes, and role transitions are among issues that may be dealt with in individuals with dysthymic disorder. Improved interpersonal relationships may help lessen the possibility of relapse after treatment.
- Cognitive behavioral therapy deals with the cognitive distortions present in the patients' views of themselves, others, and the world. Cognitive behavioral therapy systematically examines and counteracts these distortions, which contribute to the maintenance of depression. In the pediatric population, of course, intellectual and conceptual development may limit the usefulness of this technique.
- Supportive psychotherapy offers a nurturing environment for the expression of affect. However, in one study of adolescents, it has been shown to be less effective than cognitive-behavior therapy.
- Group psychotherapy, using various techniques, can be effective and efficient.
Consultations
Psychotherapeutic treatment generally requires the pediatrician to make a referral to a trained mental health clinician. Child clinical psychologists, child and adolescent psychiatrists, behavioral-developmental pediatricians, child- trained clinical social workers, and professional counselors are resources for the pediatrician who encounters dysthymic patients. Given the paucity of data in children showing clear safety and efficacy of pharmacologic intervention in children with dysthymic disorder psychosocial interventions are often tried before psychopharmacological treatment is considered.
Activity
Encouragement of developmentally appropriate play, physical exercise, and pleasurable activities are appropriate for children with anhedonia. Physical exercise has been shown to improve mood. Active play or sports (if psychologically supportive, rather than an opportunity for criticism) can accomplish these aims.
Medication
According to the AACAP Practice Parameters, few studies are available to inform the use of antidepressant medication in children with dysthymic disorder. Studies of adult patients with dysthymic disorder have shown that tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs) are effective in treating dysthymic disorder at the same doses effective for major depressive disorder.
"...based on the limited adult literature, efficacious treatment for [major depressive disorder] may also be useful for the management of [dysthymic disorder]," states the AACAP.3 However, the US Food and Drug Administration (FDA) has approved only a handful of the multiple drugs in the first 2 of the above 3 classes for use in depression (or for other indications) in children and adolescents. Because most medications administrated to children have not been extensively studied in the pediatric population, information below is given with the understanding that this use reflects current practice among child and adolescent psychiatrists. As a patient's age approaches adolescence, the physician can be more confident that the treatment is likely to be as effective as it is for the disorder in adulthood.
Current consensus is that SSRIs are greatly preferred over the other classes of antidepressants. The adverse effect profile is less prominent, promoting compliance. SSRIs are also much safer from a medical standpoint, without the risk of cardiac arrhythmia observed in TCAs. Such a risk is especially pertinent in overdose, and suicide risk always must be considered in the treatment of a child or adolescent with a mood disorder.
Selective serotonin reuptake inhibitors (SSRIs)
Antidepressant agents chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. They inhibit CNS neuronal uptake of serotonin (5HT). They may also have a weak effect on norepinephrine and dopamine neuronal reuptake.
Increasing controversy surrounds the use of SSRIs in the pediatric population. 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 treated with antidepressant medications for major depressive disorder (not dysthymic disorder). This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. Nonetheless, the FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and, thus, could not be linked to drug treatment (see Complications, Medical/Legal Pitfalls).
In March 2004, the FDA issued a public health advisory regarding several antidepressant medications, partly in response to their use in the pediatric population. For more information, see the FDA advisory statement on worsening depression and risk of suicidality with antidepressant drugs. After the initiation of medical treatment, physicians are advised to closely monitor for worsening depression or suicidality and for signs of mania or hypomania development. Furthermore, the FDA advisory specifically states that health care providers should instruct patients, families, and caregivers to be alert for the emergence of suicidality, worsening depression, agitation, irritability, and other symptoms (eg, anxiety, panic attacks, insomnia, hostility, impulsivity, akathisia, hypomania, mania) and to immediately report such symptoms to the health care provider.
In October 2004, the FDA issued a Public Health Advisory intended to warn the public about the risks of increasing suicidality among adolescents and children treated with antidepressants. These efforts included requiring a "black box" warning on medication labeling directed to prescribers and development of patient information materials to inform consumers of the potential risks of suicidal behavior in depressed pediatric patients. For more information, see the FDA statement on safeguards for children treated with antidepressants and information specific to certain antidepressants from the FDA.
However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the used of antidepressants.4 This is the largest study to date to address this issue.
Currently, evidence does not exist to associate obsessive compulsive disorder (OCD) and other anxiety disorders treated with SSRIs with an increased risk of suicide.
Note that fluoxetine (Prozac) is the only medication approved by the FDA to treat depression in children aged 7 years and older. Other medications are used off-label.
The FDA's recommendations are sound in the treatment and monitoring of all patients with mood disorders, whether or not medication is used, as noted elsewhere in this article. Because treatment response and the course of the illness vary, ongoing monitoring for increasing severity of the illness and development of more intense symptoms is wise.
Physicians are advised to be aware of the above information and use appropriate caution when considering treatment with antidepressant medications in the pediatric population.
Prescribing of antidepressants by pediatricians (psychiatrists were not part of this study) has decreased since the FDA issued the "black box" requirement.5
Fluoxetine (Prozac)
FDA-approved for depression in children 7-17 years; half-life is 7-9 d. Selectively inhibits presynaptic serotonin reuptake.
Adult
20 mg PO qd am initially; increase after several wk to usual effective dose of 20-40 mg/d; not to exceed 80 mg/d
Pediatric
5-10 mg PO qd; or 10 mg 3 times/wk; not to exceed 20 mg/d
Inhibits CYP3A4; increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and warfarin
Serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan); discontinue other serotonergic agents at least 2 wk prior to SSRIs
Documented hypersensitivity; concurrent use of MAOIs or use within previous 2 wk
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before initiating fluoxetine therapy
Sertraline (Zoloft)
FDA-approved for OCD in children aged 6 years and older; off-label use in depression in children. Selectively inhibits presynaptic serotonin reuptake.
Adult
50 mg PO qd, may increase after 1 wk; usual effective dose is 50-200 mg/d; not to exceed 200 mg/d
Pediatric
<6 years: Not established
6-12 years: 25 mg PO qd initially, may slowly titrate upward as needed; not to exceed 200 mg/d
>13 years: Administer as in adults
Inhibits CYP450 isoenzymes 3A3/4, 2C9, 2C19, and 2D6, resulting in possible decreased clearance of isoenzyme substrates (eg, metoprolol, thioridazine, imipramine, haloperidol, phenytoin, barbiturates, glyburide, warfarin)
Increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan); discontinue other serotonergic agents at least 2 wk prior to SSRIs
Documented hypersensitivity; do not use concurrently or within 2 wk of MAOIs
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 preexisting seizure disorders and with recent myocardial infarction, unstable heart disease, and hepatic or renal impairment; libido dampening and sexual dysfunction; volume depletion or diuretic use may cause hyponatremia
Fluvoxamine (Luvox)
FDA-approved for OCD in children >8 years. Used off-label in children for depression. Selectively inhibits presynaptic serotonin reuptake.
Adult
50 mg PO hs; increase by 50 mg/d q4-7d to usual effective dose of 100-300 mg/d divided bid; not to exceed 300 mg/d
Pediatric
>8 years: 25 mg PO hs; may be increased by 25 mg/d q4-7d to usual effective dose of 50-200 mg/d; doses >50 mg/d should be divided bid
Inhibits CYP1A2, 2C9, 2C19, 2D6, and 3A4; risk of a hypertensive crisis increases in coadministration with MAOIs; fluvoxamine potentiates effect of triazolam and alprazolam, and thus, when taking them concurrently, dose should be reduced by at least 50%; also reduce the dose of theophylline by a third, and monitor plasma levels if taking it concurrently with fluvoxamine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of fluvoxamine
Documented hypersensitivity; concurrent use of MAOIs or use within 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 liver dysfunction or cardiovascular disease and history of seizures or suicidal tendencies
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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References
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Further Reading
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
