Approach Considerations

Psychotherapy and medication management are 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 treatment plus interpersonal psychotherapy found the greatest effect when sertraline and interpersonal therapy were combined.

Psychotherapy

Several types of therapy, including psychodynamic, cognitive behavioral, and interpersonal therapy, have been demonstrated in controlled studies to be effective in the treatment of depression and dysthymia.

Short- and long-term psychodynamic psychotherapy are effective for depressive disorders; in particular, they help in developing an individual’s understanding of their relationships and decrease maladaptive interpersonal interactions.^{[26, 27]}

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 IPT is associated with improved symptoms of dysthymia.^{[28, 29]}

Although research in this area is limited, group therapy, including CBT and IPT groups, may be helpful for people with dysthymia.^{[30, 31]}

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 per week and that any exercise is more helpful than none at all.

Prevention

No studies have focused on prevention, but social supports, adequate exercise, a rewarding occupation, and a generally healthy lifestyle may either be protective or else be evidence of a low propensity toward dysthymia.

Inpatient care

Patients should be hospitalized when their psychiatric illness puts them at risk of harming themselves or another person or when it dangerously impairs their ability to care for themselves.

Follow-up and outpatient care

Because of the high rate of relapses from depression and from dysthymia, follow-up is important.

The patient who has recovered with pharmacotherapy should be encouraged to continue follow-up for at least 6 months before considering any medication taper.

Because of the chronic nature of dysthymia, long-term treatment with medications is often advisable. In cases where a medication loses its effectiveness, a new regimen should be considered.

Medication

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.
Niculescu AB 3rd, Akiskal HS. Proposed endophenotypes of dysthymia: evolutionary, clinical and pharmacogenomic considerations. Mol Psychiatry. 2001 Jul. 6(4):363-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. 2000 Jun. 157(6):931-9. [QxMD MEDLINE Link].
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. 2006 May. 163(5):872-80. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. 2004 Nov-Dec. 26(6):453-62. [QxMD MEDLINE Link].
Johnson JG, Cohen P, Kasen S, Brook JS. Personality disorder traits associated with risk for unipolar depression during middle adulthood. Psychiatry Res. 2005 Sep 15. 136(2-3):113-21. [QxMD MEDLINE Link].
Ho PS, Yen CH, Chen CY, Huang SY, Liang CS. Changes in cytokine and chemokine expression distinguish dysthymic disorder from major depression and healthy controls. Psychiatry Res. 2017 Feb. 248:20-27. [QxMD MEDLINE Link].
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. 2005 Jun. 95(6):998-1000. [QxMD MEDLINE Link].
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. 2002 Jul. 70(2):211-7. [QxMD MEDLINE Link].
Laptook RS, Klein DN, Dougherty LR. Ten-year stability of depressive personality disorder in depressed outpatients. Am J Psychiatry. 2006 May. 163(5):865-71. [QxMD MEDLINE Link].
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. 2001 Nov. 158(11):1864-70. [QxMD MEDLINE Link].
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. 2005 Jul-Aug. 46(4):239-45. [QxMD MEDLINE Link].
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. 2006 Nov. 163(11):1905-17. [QxMD MEDLINE Link].
Rush AJ, Kraemer HC, Sackeim HA, et al. Report by the ACNP Task Force on response and remission in major depressive disorder. Neuropsychopharmacology. 2006 Sep. 31(9):1841-53. [QxMD MEDLINE Link].
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. 2004 Jul-Aug. 26(4):269-76. [QxMD MEDLINE Link].
Lerner D, Adler DA, Chang H, Lapitsky L, Hood MY, Perissinotto C. Unemployment, job retention, and productivity loss among employees with depression. Psychiatr Serv. 2004 Dec. 55(12):1371-8. [QxMD MEDLINE Link].
Barbui C, Motterlini N, Garattini L. Health status, resource consumption, and costs of dysthymia. A multi-center two-year longitudinal study. J Affect Disord. 2006 Feb. 90(2-3):181-6. [QxMD MEDLINE Link].
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. 2007 Aug. 101(1-3):27-34. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. 2008 Feb. 77(2):197-204. [QxMD MEDLINE Link].
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. 2004 Apr. 161(4):646-53. [QxMD MEDLINE Link].
Keitner GI, Ryan CE, Solomon DA. Realistic expectations and a disease management model for depressed patients with persistent symptoms. J Clin Psychiatry. 2006 Sep. 67(9):1412-21. [QxMD MEDLINE Link].
Airaksinen E, Larsson M, Lundberg I, Forsell Y. Cognitive functions in depressive disorders: evidence from a population-based study. Psychol Med. 2004 Jan. 34(1):83-91. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Leichsenring F, Leibing E. Psychodynamic psychotherapy: a systematic review of techniques, indications and empirical evidence. Psychol Psychother. 2007 Jun. 80:217-28. [QxMD MEDLINE Link].
Markowitz JC, Bleiberg KL, Christos P, Levitan E. Solving interpersonal problems correlates with symptom improvement in interpersonal psychotherapy: preliminary findings. J Nerv Ment Dis. 2006 Jan. 194(1):15-20. [QxMD MEDLINE Link].
Markowitz JC, Kocsis JH, Bleiberg KL, Christos PJ, Sacks M. A comparative trial of psychotherapy and pharmacotherapy for "pure" dysthymic patients. J Affect Disord. 2005 Dec. 89(1-3):167-75. [QxMD MEDLINE Link].
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. 2003 Jun 18. 289(23):3117-24. [QxMD MEDLINE Link].
Johnson JE, Zlotnick C. A pilot study of group interpersonal psychotherapy for depression in substance-abusing female prisoners. J Subst Abuse Treat. 2008 Jun. 34(4):371-7. [QxMD MEDLINE Link].
Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression. Accessed: May 19, 2009. AHRQ: Agency for Healthcare Research and Quality. Jan. 24, 2007. Available at http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=61.
Carvalho AF, Cavalcante JL, Castelo MS, Lima MC. Augmentation strategies for treatment-resistant depression: a literature review. J Clin Pharm Ther. 2007 Oct. 32(5):415-28. [QxMD MEDLINE Link].
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. 2006 Feb. 7(2):203-10. [QxMD MEDLINE Link].
Tuunainen A, Kripke DF, Endo T. Light therapy for non-seasonal depression. Cochrane Database Syst Rev. 2004. CD004050. [QxMD MEDLINE Link].
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. 2003 Nov. 112(4):614-22. [QxMD MEDLINE Link].
Kessing LV. Epidemiology of Subtypes of Depression. Acta Psychiatr Scand. 2007. 115 (Suppl 433):85-89.
Murphy JA, Byrne GJ. Prevalence and correlates of the proposed DSM-5 diagnosis of Chronic Depressive Disorder. J Affect Disord. 2012 Feb 29. [QxMD MEDLINE Link].
Olfson M, Liu SM, Grant BF, Blanco C. Influence of comorbid mental disorders on time to seeking treatment for major depressive disorder. Med Care. 2012 Mar. 50(3):227-32. [QxMD MEDLINE Link]. [Full Text].
Ryder AG, Schuller DR, Bagby RM. Depressive personality and dysthymia: evaluating symptom and syndrome overlap. J Affect Disord. 2006 Apr. 91(2-3):217-27. [QxMD MEDLINE Link].
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. 2003 Mar. 48(2):99-105. [QxMD MEDLINE Link].
Hellerstein DJ, Batchelder S, Miozzo R, Kreditor D, Hyler S, Gangure D. Citalopram in the treatment of dysthymic disorder. Int Clin Psychopharmacol. 2004 May. 19(3):143-8. [QxMD MEDLINE Link].

Media Gallery

The various outcomes of dysthymia.

of 1

Author

Jerry L Halverson, MD Medical Director of Rogers Memorial Hospital at Oconomowoc; Voluntary Clinical Assistant Professor, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health; Clinical Assistant Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, Medical College of Wisconsin

Jerry L Halverson, MD is a member of the following medical societies: American College of Psychiatrists, American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Acknowledgements

Sarah C Langenfeld, MD Assistant Professor, Department of Psychiatry, University of Massachusetts Medical School; Attending Psychiatrist, Community HealthLink

Sarah C Langenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Massachusetts Medical Society

Disclosure: Nothing to disclose. Rebecca S Lundquist, MD Consulting Staff, Department of Psychiatry, UMass Memorial Medical Center

Rebecca S Lundquist, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Pfizer Salary Employment; Biogen Salary Employment

Alan D Schmetzer, MD Professor Emeritus, Interim Chairman, Vice-Chair for Education, Associate Residency Training Director in General Psychiatry, Fellowship Training Director in Addiction Psychiatry, Department of Psychiatry, Indiana University School of Medicine; Addiction Psychiatrist, Midtown Mental Health Cener at Wishard Health Services

Alan D Schmetzer, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Clinical Psychiatrists, American Academy of Psychiatry and the Law, American College of Physician Executives, American Medical Association, American Neuropsychiatric Association, American Psychiatric Association, and Association for Convulsive Therapy

Disclosure: Eli Lilly & Co. Grant/research funds Other

Brian R Szetela, MD Assistant Professor, Department of Psychiatry, University of Massachusetts Medical School; Consulting Psychiatrist, Psychiatric Consultation - Liaison Service, University of Massachusetts Memorial Medical Center

Brian R Szetela, MD is a member of the following medical societies: American Psychiatric Association, American Society of Addiction Medicine, and Association for Convulsive Therapy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment