Psychotherapists and patients confront
the high cost of “low-grade” depression.
(This article was first printed in the February
2005 issue of the Harvard Mental Health
Letter. For more information or to order,
please go to http://www.health.harvard.edu/mental.)
Depression is a word with many meanings — anything
from a passing mood of sadness or discouragement
to a condition of inconsolable misery, suicidal
thoughts, and even delusions as well as severe
physical symptoms. It’s regarded as a clinical
disorder when depressed mood and related symptoms
are serious enough or last long enough to interfere
with work, social life, family life, or physical
The Greek word dysthymia means “bad state
of mind” or “ill humor.” As
one of the two chief forms of clinical depression,
it usually has fewer or less serious symptoms
than major depression but lasts longer. The American
Psychiatric Association defines dysthymia as
depressed mood most of the time for at least
two years, along with at least two of the following
symptoms: poor appetite or overeating; insomnia
or excessive sleep; low energy or fatigue; low
self-esteem; poor concentration or indecisiveness;
Dysthymia and major depression naturally have
many symptoms in common, including depressed
mood, disturbed sleep, low energy, and poor concentration.
There are also parallel symptoms: poor appetite,
low self-esteem, and hopelessness in dysthymia,
corresponding to the more severe symptoms of
weight change, excessive guilt, and thoughts
of death or suicide in major depression. Major
depression may also include two symptoms not
found in the standard definition of dysthymia:
anhedonia (inability to feel pleasure) and psychomotor
symptoms (chiefly lethargy or agitation). An
episode of major depression requires at least
five symptoms instead of three, but it need last
only two weeks rather than two years.
Dysthymia is a serious disorder. It is not “minor” depression,
and it is not a condition intermediate between
severe clinical depression and depression in
the casual colloquial sense. In some cases it
is more disabling than major depression. Still,
dysthymia is so similar to major depression that
the American Psychiatric Association’s
diagnostic manual also suggests, as a possibility
for further investigation, an alternative definition
with symptoms including anhedonia, social withdrawal,
guilt, and irritability but not appetite or sleep
disturbance. The purpose is to distinguish dysthymia
more clearly from major depression by emphasizing
mood and personal relations over physical symptoms.
Dysthymia is about as common as major depression.
Given its chronic nature, that makes it one of
the disorders most often seen by psychotherapists.
About 6% of the population of the United States
has had an episode of dysthymia at some time,
3% in the last year. As many as a third of patients
in psychotherapy may be suffering from dysthymia.
Like major depression, it is more common in women
than in men, but it tends to arise earlier in
life. The American Psychiatric Association distinguishes
between this early-onset form and a form that
occurs later in life and often comes on less
More than half of people with dysthymia eventually
have an episode of major depression, and about
half of patients treated for major depression
are suffering from this double depression. Many
patients who recover partially from major depression
also have milder symptoms that persist for years.
This type of chronic depression is difficult
to distinguish from dysthymia.
Is there a depressive personality?
In principle, personality is usually lifelong,
while moods come and go. But dysthymia has to
last longer than any other psychiatric disorder
in the manual. That can make it difficult to
distinguish from a personality disorder — especially
the group that includes avoidant, dependent,
and obsessive-compulsive personality, with their
symptoms of timidity, excessive worry, helplessness,
and social withdrawal.
Some would prefer to speak of a depressive personality
disorder instead. That diagnosis was removed
from the official manual in 1980 but has been
re-introduced as a possible topic of investigation.
The proposed symptoms include a strong tendency
to be critical of oneself and others, pessimism,
guilt, brooding, and gloominess. Anhedonia and
physical symptoms are not part of the definition,
but this personality disorder otherwise has a
great deal in common with dysthymia.
Mood and personality are the emotional weather
and emotional climate of individuals, so the
symptoms of mood and personality disorders naturally
overlap. The thought schemas that cognitive therapists
find at the roots of major depression and dysthymia — certain
beliefs about the self, the world, and the future — are
also the basis of depressive personality. Disturbances
in mood can have effects on a person’s
emotional state and social life that resemble
a personality disorder. And people are more easily
demoralized and recover more slowly from any
stress or misfortune if they are pessimistic
and self-critical by nature — or emotionally
unstable, impulsive, and hypersensitive to loss.
Looking for causes
Like major depression, dysthymia has roots in
genetic susceptibility, neurochemical imbalances,
childhood and adult stress and trauma, and social
circumstances, especially isolation and the unavailability
of help. Depression that begins as a mood fluctuation
may deepen and persist when equilibrium cannot
be restored because of poor internal regulation
or external stress.
Dysthymia runs in families and probably has
a hereditary component. The rate of depression
in the families of people with dysthymia is as
high as 50% for the early-onset form of the disorder.
There are few twin or adoption studies, so it’s
uncertain how much of this family connection
is genetic. Nearly half of people with dysthymia
have a symptom that also occurs in major depression,
shortened REM latency — that is, they start
rapid eye movement (vivid dreaming) sleep unusually
early in the night.
The stress that provokes dysthymia, at least
the early-onset form, is usually chronic rather
than acute. Studies show that it usually has
a gradual onset and does not follow distinct
upsetting events. In old age, dysthymia is more
likely to be the result of physical disability,
medical illness, cognitive decline, or bereavement.
In some older men, low testosterone may also
be a factor. Physical brain trauma — concussions
and the like — can also have surprising
long-term effects on mood that often take the
form of dysthymia.
At least three-quarters of patients with dysthymia
also have a chronic physical illness or another
psychiatric disorder such as one of the anxiety
disorders, drug addiction, or alcoholism. In
these cases, it is difficult to distinguish the
original cause, especially when there is a vicious
cycle in which, say, depression exacerbates alcoholism
or heart disease exacerbates depression.
The same vicious cycle exists in many other
situations. For a person who is vulnerable to
depression, every problem seems more difficult
to solve and every misfortune causes more suffering.
Depressed people give discouraging interpretations
to every event in their lives, and these interpretations
make them still more depressed. Depression often
alienates others, and the resulting isolation
and low social support make the symptoms worse.
The experience of chronic depression may sensitize
the brain to stress, heightening its vulnerability
to further depression.
Most people with dysthymia are undertreated.
They usually see only their family doctors, who
often fail to diagnose the problem. They may
only complain about physical symptoms, or fail
to complain at all because the disorder has become
so much a part of them that they believe that
is simply how life is. In older people, dysthymia
may be disguised as dementia, apathy, or irritability.
A physician might ask an open question like, “How
are things at home?” — follow with, “Have
you been feeling down, depressed, or sad?” — then
go on to ask whether the symptoms have affected
a patient’s home life, work, or personal
relations. There are also several brief screening
questionnaires, including the Hamilton Rating
Scale for Depression and the Patient Health Questionnaire.
If the answers suggest dysthymia, a standard
clinical interview can be used to confirm the
Like major depression, dysthymia is treated
with psychotherapy and medications — usually
the same medications and the same kinds of psychotherapy.
The most common drug treatments are selective
serotonin reuptake inhibitors like fluoxetine
(Prozac) and sertraline (Zoloft), or one of the
dual action antidepressants such as venlafaxine
(Effexor). Some patients may do better with a
tricyclic antidepressant like imipramine (Tofranil).
Supportive therapy provides advice, reassurance,
sympathy, and education about the disorder. Cognitive
therapy identifies and corrects thought patterns
that promote self-defeating attitudes. Behavioral
treatment improves social skills and teaches
ways to manage stress and unlearn learned helplessness.
Psychodynamic therapy helps patients resolve
emotional conflicts, especially those derived
from childhood experience. Interpersonal therapy
helps patients cope with personal disputes, loss
and separation, and transitions between social
Drugs or psychotherapy?
A 2003 review of controlled research found that
medication is slightly superior to psychotherapy
in the treatment of dysthymia. But a statistical
difference among a large number of patients in
many different situations is not necessarily
a guide for any individual case. Some patients — especially
older people — will not or cannot take
drugs, sometimes because of side effects or drug
interactions. For many others, a combination
of long-term psychotherapy and medication may
be most effective. A solid relationship with
a psychotherapist or other professional can be
important in maintaining a willingness to continue
Recovery from dysthymia often takes a long time,
and the symptoms often return. One study found
that 70% recovered in an average of about four
years, and 50% had a recurrence. Another study
found an average time to recurrence of nearly
six years. After recovery, many patients find
it helpful to continue doing whatever made them
well — whether it was a drug or psychotherapy.
While the search continues for better drugs
and better forms of psychotherapy, the problem
remains that, despite much improvement, most
people with dysthymia are not receiving even
the imperfect available treatments. Even when
they do see professionals, they may not fill
their prescriptions or take their drugs consistently,
and they may abandon psychotherapy too soon.
A study based on a telephone survey of more
than 800 adults with dysthymia found that only
20% had seen a mental health professional; only
one-quarter had received any medication and only
one-third some kind of counseling, usually brief.
And a survey commissioned by the National Depressive
and Manic Depressive Association (now the Depression
and Bipolar Support Alliance) found that doctors
and patients often communicate poorly about the
symptoms and treatment. Patients may stop taking
drugs because they do not receive enough information
about side effects or routine follow-up visits.
For both the public and professionals, what is
most important may be recognizing that dysthymia
is a treatable disorder, identifying it, and
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