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CLINICAL SYNTHESIS   |    
Dysthymic Disorder and Other Chronic Depressions
Mario A. Cristancho, M.D.; James H. Kocsis, M.D.; Michael E. Thase, M.D.
FOCUS 2012;10:422-427. doi:10.1176/appi.focus.10.4.422
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Author Information and CME Disclosure

Mario A. Cristancho, M.D., Department of Psychiatry, University of Pennsylvania, Philadelphia, PA.

James H. Kocsis, M.D., Department of Psychiatry, Weill Medical College, New York, NY.

Michael E. Thase, M.D., Department of Psychiatry, University of Pennsylvania, Philadelphia, PA.

All authors report no competing interests.

Dr. Cristancho is supported through the NIMH-funded Clinical Research Scholars Program of the Department of Psychiatry, University of Pennsylvania.

Address correspondence to: Mario A. Cristancho, M.D., 3535 Market St.–4th floor, Philadelphia, PA 19104; e-mail: mario.cristancho@uphs.upenn.edu

Chronic forms of depression have been closely studied over the last three decades, and it is now widely recognized that these conditions are better classified under the umbrella of affective disorders rather than characterological or personality disorders. Chronic depressive disorders include dysthymic disorder, chronic major depressive episode, major depressive episode superimposed on dysthymic disorder (double depression), as well as recurrent major depressive disorder without full interepisode recovery. Chronic forms of depression are prevalent in the general population, and even those with low grade severity can lead to significant functional impairment, occupational dysfunction, suicide attempts, and worse prognosis. Given the obvious potential for deleterious effects, chronic forms of depression should be promptly recognized and aggressively treated. Clinical benefit from using psychopharmacologic agents alone or in combination with psychotherapy for the treatment of chronic depression has been demonstrated. In this article the authors review pertinent clinical and diagnostic aspects in chronic depressive disorders as well as their treatment.

Abstract Teaser
Figures in this Article

Chronic forms of depression were once understood as mainly a characterological or personality disorder (1). However, as these depressive states have been more closely studied over the last three decades, it has been more widely recognized that these conditions are better classified along with the other affective disorders. Chronic depressive disorders include dysthymic disorder, chronic major depressive episode, major depressive episode superimposed on dysthymic disorder (double depression), as well as recurrent major depressive disorder without full interepisode recovery. These subforms of chronic depression are included in DSM-IV either as specifiers or as independent diagnostic category (e.g., dysthymic disorder). However, a broader category called “chronic depression” is being proposed for DSM-5, with the intent to encompass all forms of longstanding depression other than a chronic major depressive episode (2).

The majority of the available information on this subject derives from studies on dysthymic disorder, which is the most frequently studied entity among the various forms of chronic depression. However, when possible, specific clinical and epidemiologic characteristic for each subform of chronic depression will be highlights throughout the manuscript.

An individual with a longstanding, low-grade depression (i.e., dysthymia) has been classically portrayed as habitually gloomy, introverted, brooding, overly conscientious, incapable of fun, and preoccupied with personal inadequacy and failure (3). The concept of dysthymia has gone through different stages of development and was officially included as an axis I condition in DSM-III, essentially replacing the DSM-II diagnosis of neurotic depression (4, 5). As an “independent” condition, dysthymic disorder was defined as a subsyndromal state (i.e., too few symptoms to meet criteria for a major depressive episode), with a protracted duration of at least 2 years in adults. It was characterized by an insidious onset, often in childhood or adolescence, and a persistent, intermittent, or fluctuating course (6). As seen in Table 1, the diagnosis of dysthymic disorder requires the presence of predominantly depressed mood for at least 2 years (criterion A; irritability and 1-year duration will satisfy criteria in children and adolescents) and at least two or more criterion B features (i.e., change in appetite, change in sleep, decreased energy, low self-esteem, difficulties concentrating or making decisions, or hopelessness). The presence of either a symptom-free period lasting longer than 2 months or the presence of a major depressive episode during the first 2 years of the onset of the condition (1 year for children and adolescents) rule out the diagnosis (criterion C and D). Although some people with bipolar disorder also experience longstanding mild depressions, the diagnosis of dysthymic disorder cannot be made when an individual has a history of mania, hypomania, mixed affective episodes, or cyclothymia (criterion E). A history of psychotic symptoms does not rule out a diagnosis of dysthymic disorder as long as mood symptoms are not exclusively present during psychotic episodes (criterion F). As is true of other DSM-IV affective disorders diagnoses, the symptoms should not be a direct consequence of substance abuse or a medical condition, and a significant functional impairment should be present as a consequence of the symptoms (criterion G and H) (7). In the current classification, several specifiers can be used to further describe the disorder, including early versus late onset (21 years being the cutoff point) and presence of atypical features (7). The distinction between early- and late-onset dysthymia is thought to have particularly important prognostic implications (7).

 
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Table 1. DSM-IV Criteria for Dysthymic Disordera
Table Footer Note

a Adapted from Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994 (7).

Clinical similarities and frequent coexistence with the various forms of major depressive disorder (MDD) can lead to diagnostic difficulties. In this regard, adults who meet criteria for MDD can be diagnosed with dysthymic disorder as long as the dysthymic disorder has been evident for at least 2 years before the onset of the major depressive episode or the major depressive episode has been in full remission for 2 months before onset of dysthymia. In fact, across a lifetime, most people with dysthymic disorder will experience superimposed major depressive episodes and, conversely, at least 20% of people with MDD will have a history of antecedent dysthymic disorder (8). Whether such “double depressions” are a truly unique entity or more simply reflect the waxing and waning of single condition has been a topic of some interest to mood disorders nosologists for the past 30 years.

As illustrated above, to diagnose dysthymic disorder one should consider not only the chronicity of the symptoms but also the characteristic number and intensity of the symptoms. By convention, a hallmark of dysthymic disorder is that the symptom burden across any and all 2-week intervals is below the threshold for diagnosis of MDD. This convention, in turn, is why the specifier “chronic” is used to describe major depressive episodes that last 2 years or longer (i.e., chronic major depressive episode) in people with MDD or bipolar affective disorder (7). Patients with MDD can also have a chronic course of illness because of failure to achieve full remission of symptoms. As such, they would not meet criteria for dysthymia or chronic major depressive episode, but instead they would be diagnosed as recurrent major depression without full interepisode recovery (7).

Although the presence of chronic depressive symptoms is no longer thought of as a form of personality disorder, axis II conditions are not uncommon among people with early onset chronic forms of depression, with cluster C or “internalizing” personality disorders being the most common. In one study of patients with chronic forms of MDD, nearly one-half of the patients had at least one co-occurring personality disorder, even though patients with borderline and more severe antisocial personality disorders were excluded from this study (9).

Not all conditions associated with chronic depressive symptoms are classifiable as mood disorders. For example, entities such as prolonged grief disorder and chronic adjustment disorder with depressed mood can also present with protracted depressive symptoms but at this juncture are not formally considered forms of chronic depression.

The presence of medical conditions as perpetuating or etiologic factors should always be explored when evaluating a patient with chronic depression. Such conditions include endocrine disturbances (e.g., hypothyroidism, low testosterone, or protracted perimenopausal changes), anemia, hyponatremia, autoimmune disturbances, tumors (e.g., pancreatic, brain, and lung cancer), infections (including human immunodeficiency virus infection), and neurological conditions like epilepsy, Parkinson’s disease, and multiple sclerosis. Chronic mood symptoms can be caused or perpetuated by the abuse of drugs or alcohol and can be induced iatrogenically by antihypertensives, oral contraceptives, steroids, analgesics, antimicrobials, retinoic acid, benzodiazepines, and other medications (10, 11).

The diagnostic validity of chronic forms of depression has been an area of controversy, with most of the work done in patients with dysthymia. Biological research initially was used to help establish the validity of dysthymia as a subtype of depressive disorder. Findings that support a biological basis for this condition included sleep cycle abnormalities that are characteristic of MDD (reduced rapid eye movement [REM] latency, increased REM sleep, and abnormal theta bursts) and abnormalities in central nervous system electrophysiological functions (electroencephalogram during waking state, electrodermal activity, and evoked potentials) (12). Other markers suggesting its biological independence from major depressive disorder include differences in growth hormone secretion and in hypothalamic pituitary axis function (12). However, little has been found when exploring for differences in demographic variables, symptom patterns, treatment response or family history between the different forms of chronic depression (13). In light of that, the depressive disorders work group for DSM-5 has proposed the substitution of dysthymia for a broader category named “chronic depression” (2). The proposed criteria for DSM-V chronic depression are the same as the DSM-IV criteria for dysthymic disorder except for minor modifications to criteria D and E, which are intended to decrease the impact of the chronically depressed patient’s recall bias. The proposed DSM-5 criteria focuses in the last 2 years of symptoms (instead of the first 2) when exploring the presence of chronic major depressive episode or cyclothymia (2).

It is estimated that chronic forms of depression affect 3%–6% of adults in the United States (14, 15). Chronic courses are expected in up to 20% of patients with major depressive disorder (14, 15). Prevalence of dysthymic disorder is relatively high in primary care settings (7%) (16) and even higher in psychiatric outpatient clinics (36%) (17). Chronic courses of depressive symptoms are associated with a higher degree of occupational and psychosocial maladjustment and more frequent suicide attempts than the more episodic forms of depression (18). For example, although by definition dysthymia is a condition of low-grade severity, it is associated with significant functional impairment. In fact, patients with dysthymia are more likely to have supplemental social security income and Medicaid status and less likely to work full time than individuals with nonchronic forms of MDD (19). Patients with dysthymic disorder are more likely to have coexisting axis I conditions with a comorbidity rate of up to 75% in which major depressive disorder, anxiety disorders, and substance abuse are more frequently present (20). By itself, dysthymia is a risk factor for the development of a major depressive episode and (21) its presence is associated with poorer prognosis and more treatment resistance in patients with major depressive disorder (22).

The presence of chronic depressive symptoms, even when subthreshold for major depressive episode, is associated with worse prognosis in patients with coronary heart disease (23) and pregnancy. Newborns of mothers with dysthymia are more likely to have shorter gestational age, a lower birth weight, shorter birth length, and less optimal obstetric outcomes (24).

Given the significant potential for deleterious effects, chronic forms of depression should be promptly recognized by healthcare and mental health providers and aggressively treated.

As part of the zeitgeist to validate dysthymic disorder and other forms of chronic depression as mood disorders, a number of randomized clinical trials of antidepressants were conducted in the 1980s and 1990s. The first large-scale, randomized, placebo-controlled trial of an antidepressant for chronic forms of depression was published in the late 1980s by Kocsis et al. and reported an encouraging 59% response rate with imipramine (as compared with a 13% response rate with placebo) in a sample of 76 subjects in which 84% had courses greater than 5 years (25). Significant benefits were subsequently reported in a large scale, placebo-controlled multicenter study contrasting imipramine and the selective serotonin reuptake inhibitor (SSRI) sertraline (26). In that study, both types of antidepressants were effective, with the SSRI showing better tolerability. The advantage of active pharmacotherapy over placebo in the treatment of chronic forms of depression has been replicated by other investigators and most recently confirmed by meta-analyses. In one recent meta-analysis, for example, Levkovitz et al. reported response rates of up to 52.4% and a number needed to treat of 4.4 was calculated in a sample of 1,454 dysthymic patients receiving monotherapy with a broad range of antidepressants agents including imipramine, fluoxetine, sertraline, and moclobemide (a reversible inhibitor of monoamine oxidase A that, although available in many countries, is not approved for use in the United States), as well as the experimental compounds ritanserin and amisulpride (27). Antidepressant response rates in dysthymia are comparable to those of patients with major depressive disorder even in the presence of negative prognostic indicators such as axis II comorbidities (9). Although the available evidence does not identify a single best type of antidepressant for the treatment of chronic depression, the evidence is strongest for tricyclic antidepressants and selective serotonin reuptake inhibitors (28). These classes of antidepressants may benefit different patients and those who do not respond to one type may still benefit from an adequate trial of the other class of medication. For example, in one study of chronic forms of depression (average duration >6 years), patients showed similar response rates to an initial, 12-week course of double-blind treatment with either sertraline or imipramine monotherapy (52% with sertraline and 51% with imipramine) (29). Nonresponders were then switched to the alternate medications and over one-half responded and about one-quarter remitted (29). As expected, given its more favorable safety and tolerability profile, selective serotonin reuptake inhibitors are more frequently used.

When antidepressants are effective, continuation of treatment beyond acute response and remission is necessary to lower the risk of relapse in patients with chronic depression (3032). It is not known whether treatment should be continued indefinitely or can be tapered after an extended period of recovery without great hazard of recurrence. In practice, such decisions should be made on a case-by-case basis, considering both the costs and side effects of ongoing pharmacotherapy and the potential risks of a recurrence following withdrawal of the antidepressant.

Frequent comorbid personality disorders as well as possible changes in personality resulting from years or even decades of depression have long made psychotherapy an important consideration for individuals with chronic forms of depression. The general range of response rates in small studies of patients with double depression and dysthymia receiving cognitive behavioral therapy has been reported to be above 30% (33), and there is ample clinical experience that many patients with longstanding depressions can benefit from cognitive, behavioral, interpersonal, and psychodynamic psychotherapies. However, meta-analyses of randomized clinical trials suggest that antidepressant medications (including sertraline, fluoxetine, and nortriptyline) may—on average—convey greater symptomatic benefits over psychotherapies across the first 3-4 months of treatment (3436).

Although widely practiced and often recommended, combination therapy (i.e., medication plus psychotherapy) has not always been shown in randomized controlled trials to convey a significant advantage compared with medications alone in randomized controlled trials. For example, in two large trials of dysthymic disorder conducted in Canada, no advantages for combining interpersonal psychotherapy (IPT) (37) or group cognitive behavioral (38) therapies with sertraline were found in comparison to pharmacotherapy with sertraline alone. An advantage was found in a large study of patients with chronic forms of MDD (681 subjects). In this trial, patients were randomly assigned to 12 weeks of treatment with the antidepressant nefazodone, a form of psychotherapy developed specifically for chronic depression known as CBASP (cognitive behavioral analysis system of psychotherapy), or their combination. Patients receiving the monotherapies had a 48% response rate (i.e., drug and psychotherapy were almost identically effective at week 12), whereas there was a 73% response rate in combination treatment group (18). A similarly large advantage was shown for chronically depressed inpatients in a German study that contrasted the combination of interpersonal psychotherapy (IPT) and treatment as usual (i.e., pharmacotherapy and milieu therapies) as compared with treatment as usual alone (39). However, no advantage for combined treatment was observed in a third trial known by the acronym REVAMP (Research Evaluating the Value of Augmenting Medication With Psychotherapy). This outpatient study, which randomly assigned 491 patients with chronic forms of major depression who had not remitted with an initial prospective course of algorithm-guided course of pharmacotherapy, found that the addition of psychotherapy (either brief supportive psychotherapy or CBASP) to medications did not result in significantly better outcomes as compared with pharmacotherapy alone (40). Nonetheless, psychotherapy remains and important element when treating chronic depression, and combination therapy continues to be an appropriate option for many patients with persistent and disabling depressive disorders that have not responded to pharmacotherapy alone (41).

As illustrated by this brief review and based on the available evidence and our clinical experience, chronic forms of depression are prevalent and even those with low grade severity can lead to significant functional impairment if untreated. Therefore chronic depression should be considered when evaluating patients with dysphoria even in the presence of significant characterological traits. Clinical benefit from using psychopharmacologic agents alone or in combination with psychotherapy for the treatment of chronic depression is supported in the literature and should be pursued when taking care of patients with chronic depressive symptoms.

Akiskal  HS:  Dysthymia and cyclothymia in psychiatric practice a century after Kraepelin.  J Affect Disord 2001; 62:17–31
[CrossRef] | [PubMed]
 
Akiskal  HS:  Dysthymic disorder: psychopathology of proposed chronic depressive subtypes.  Am J Psychiatry 1983; 140:11–20
[PubMed]
 
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC, APA, 1980.
 
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. Washington, DC, APA, 1968.
 
Akiskal H: Mood disorders: clinical features, in Kaplan and Sadock's Comprehensive Textbook of Psychiatry. Edited by Sadock BJ, Sadock VA, Ruiz P. Baltimore, Lippincott Williams & Wilkins, 2009.
 
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, APA, 1994.
 
Keller  MB;  Klein  DN;  Hirschfeld  RM;  Kocsis  JH;  McCullough  JP;  Miller  I;  First  MB;  Holzer  CP  3rd;  Keitner  GI;  Marin  DB  et al:  Results of the DSM-IV mood disorders field trial.  Am J Psychiatry 1995; 152:843–849
[PubMed]
 
Russell  JM;  Kornstein  SG;  Shea  MT;  McCullough  JP;  Harrison  WM;  Hirschfeld  RM;  Keller  MB:  Chronic depression and comorbid personality disorders: response to sertraline versus imipramine.  J Clin Psychiatry 2003; 64:554–561
[CrossRef] | [PubMed]
 
Williams  ER;  Shepherd  SM:  Medical clearance of psychiatric patients.  Emerg Med Clin North Am 2000; 18:185–198, vii
[CrossRef] | [PubMed]
 
Orlando  M;  Burnam  MA;  Beckman  R;  Morton  SC;  London  AS;  Bing  EG;  Fleishman  JA:  Re-estimating the prevalence of psychiatric disorders in a nationally representative sample of persons receiving care for HIV: results from the HIV Cost and Services Utilization Study.  Int J Methods Psychiatr Res 2002; 11:75–82
[CrossRef] | [PubMed]
 
Howland  RH;  Thase  ME:  Biological studies of dysthymia.  Biol Psychiatry 1991; 30:283–304
[CrossRef] | [PubMed]
 
McCullough  JP  Jr;  Klein  DN;  Borian  FE;  Howland  RH;  Riso  LP;  Keller  MB;  Banks  PL:  Group comparisons of DSM-IV subtypes of chronic depression: validity of the distinctions, part 2.  J Abnorm Psychol 2003; 112:614–622
[CrossRef] | [PubMed]
 
Weissman  MM;  Leaf  PJ;  Tischler  GL;  Blazer  DG;  Karno  M;  Bruce  ML;  Florio  LP:  Affective disorders in five United States communities.  Psychol Med 1988; 18:141–153
[CrossRef] | [PubMed]
 
Kessler  RC;  McGonagle  KA;  Zhao  S;  Nelson  CB;  Hughes  M;  Eshleman  S;  Wittchen  HU;  Kendler  KS:  Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey.  Arch Gen Psychiatry 1994; 51:8–19
[CrossRef] | [PubMed]
 
Howland  RH:  General health, health care utilization, and medical comorbidity in dysthymia.  Int J Psychiatry Med 1993; 23:211–238
[CrossRef] | [PubMed]
 
Markowitz  JC;  Moran  ME;  Kocsis  JH;  Frances  AJ:  Prevalence and comorbidity of dysthymic disorder among psychiatric outpatients.  J Affect Disord 1992; 24:63–71
[CrossRef] | [PubMed]
 
Keller  MB;  McCullough  JP;  Klein  DN;  Arnow  B;  Dunner  DL;  Gelenberg  AJ;  Markowitz  JC;  Nemeroff  CB;  Russell  JM;  Thase  ME;  Trivedi  MH;  Zajecka  J:  A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression.  N Engl J Med 2000; 342:1462–1470
[CrossRef] | [PubMed]
 
Hellerstein  DJ;  Agosti  V;  Bosi  M;  Black  SR:  Impairment in psychosocial functioning associated with dysthymic disorder in the NESARC study.  J Affect Disord 2010; 127:84–88
[CrossRef] | [PubMed]
 
Weissman  MM;  Leaf  PJ;  Bruce  ML;  Florio  L:  The epidemiology of dysthymia in five communities: rates, risks, comorbidity, and treatment.  Am J Psychiatry 1988; 145:815–819
[PubMed]
 
Shelton  RC;  Davidson  J;  Yonkers  KA;  Koran  L;  Thase  ME;  Pearlstein  T;  Halbreich  U:  The undertreatment of dysthymia.  J Clin Psychiatry 1997; 58:59–65
[CrossRef] | [PubMed]
 
Emslie  GJ;  Mayes  T;  Porta  G;  Vitiello  B;  Clarke  G;  Wagner  KD;  Asarnow  JR;  Spirito  A;  Birmaher  B;  Ryan  N;  Kennard  B;  DeBar  L;  McCracken  J;  Strober  M;  Onorato  M;  Zelazny  J;  Keller  M;  Iyengar  S;  Brent  D:  Treatment of Resistant Depression in Adolescents (TORDIA): week 24 outcomes.  Am J Psychiatry 2010; 167:782–791
[CrossRef] | [PubMed]
 
Rafanelli  C;  Milaneschi  Y;  Roncuzzi  R;  Pancaldi  LG:  Dysthymia before myocardial infarction as a cardiac risk factor at 2.5-year follow-up.  Psychosomatics 2010; 51:8–13
[PubMed]
 
Field  T;  Diego  M;  Hernandez-Reif  M:  Prenatal dysthymia versus major depression effects on the neonate.  Infant Behav Dev 2008; 31:190–193
[CrossRef] | [PubMed]
 
Kocsis  JH;  Frances  AJ;  Voss  C;  Mann  JJ;  Mason  BJ;  Sweeney  J:  Imipramine treatment for chronic depression.  Arch Gen Psychiatry 1988; 45:253–257
[CrossRef] | [PubMed]
 
Thase  ME;  Fava  M;  Halbreich  U;  Kocsis  JH;  Koran  L;  Davidson  J;  Rosenbaum  J;  Harrison  W:  A placebo-controlled, randomized clinical trial comparing sertraline and imipramine for the treatment of dysthymia.  Arch Gen Psychiatry 1996; 53:777–784
[CrossRef] | [PubMed]
 
Levkovitz  Y;  Tedeschini  E;  Papakostas  GI:  Efficacy of antidepressants for dysthymia: a meta-analysis of placebo-controlled randomized trials.  J Clin Psychiatry 2011; 72:509–514
[CrossRef] | [PubMed]
 
Silva de Lima  M;  Hotopf  M: A comparison of active drugs for the treatment of dysthymia. Cochrane Database Syst Rev 2003; 3:CD004047
 
Thase  ME;  Rush  AJ;  Howland  RH;  Kornstein  SG;  Kocsis  JH;  Gelenberg  AJ;  Schatzberg  AF;  Koran  LM;  Keller  MB;  Russell  JM;  Hirschfeld  RM;  LaVange  LM;  Klein  DN;  Fawcett  J;  Harrison  W:  Double-blind switch study of imipramine or sertraline treatment of antidepressant-resistant chronic depression.  Arch Gen Psychiatry 2002; 59:233–239
[CrossRef] | [PubMed]
 
Keller  MB;  Kocsis  JH;  Thase  ME;  Gelenberg  AJ;  Rush  AJ;  Koran  L;  Schatzberg  A;  Russell  J;  Hirschfeld  R;  Klein  D;  McCullough  JP;  Fawcett  JA;  Kornstein  S;  LaVange  L;  Harrison  W:  Maintenance phase efficacy of sertraline for chronic depression: a randomized controlled trial.  JAMA 1998; 280:1665–1672
[CrossRef] | [PubMed]
 
Kocsis  JH;  Friedman  RA;  Markowitz  JC;  Leon  AC;  Miller  NL;  Gniwesch  L;  Parides  M:  Maintenance therapy for chronic depression: a controlled clinical trial of desipramine.  Arch Gen Psychiatry 1996; 53:769–774, discussion 775–776
[CrossRef] | [PubMed]
 
Gelenberg  AJ;  Trivedi  MH;  Rush  AJ;  Thase  ME;  Howland  R;  Klein  DN;  Kornstein  SG;  Dunner  DL;  Markowitz  JC;  Hirschfeld  RM;  Keitner  GI;  Zajecka  J;  Kocsis  JH;  Russell  JM;  Miller  I;  Manber  R;  Arnow  B;  Rothbaum  B;  Munsaka  M;  Banks  P;  Borian  FE;  Keller  MB:  Randomized, placebo-controlled trial of nefazodone maintenance treatment in preventing recurrence in chronic depression.  Biol Psychiatry 2003; 54:806–817
[CrossRef] | [PubMed]
 
Markowitz  JC:  Psychotherapy of dysthymia.  Am J Psychiatry 1994; 151:1114–1121
[PubMed]
 
Cuijpers  P;  van Straten  A;  Schuurmans  J;  van Oppen  P;  Hollon  SD;  Andersson  G:  Psychotherapy for chronic major depression and dysthymia: a meta-analysis.  Clin Psychol Rev 2010; 30:51–62
[CrossRef] | [PubMed]
 
Cuijpers  P;  van Straten  A;  van Oppen  P;  Andersson  G: Are psychological and pharmacologic interventions equally effective in the treatment of adult depressive disorders? A meta-analysis of comparative studies. J Clin Psychiatry 2008; 69:1675–1685; quiz 1839–1841
 
Imel  ZE;  Malterer  MB;  McKay  KM;  Wampold  BE:  A meta-analysis of psychotherapy and medication in unipolar depression and dysthymia.  J Affect Disord 2008; 110:197–206
[CrossRef] | [PubMed]
 
Browne  G;  Steiner  M;  Roberts  J;  Gafni  A;  Byrne  C;  Dunn  E;  Bell  B;  Mills  M;  Chalklin  L;  Wallik  D;  Kraemer  J:  Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs.  J Affect Disord 2002; 68:317–330
[CrossRef] | [PubMed]
 
Ravindran  AV;  Anisman  H;  Merali  Z;  Charbonneau  Y;  Telner  J;  Bialik  RJ;  Wiens  A;  Ellis  J;  Griffiths  J:  Treatment of primary dysthymia with group cognitive therapy and pharmacotherapy: clinical symptoms and functional impairments.  Am J Psychiatry 1999; 156:1608–1617
[PubMed]
 
Schramm  E;  Schneider  D;  Zobel  I;  van Calker  D;  Dykierek  P;  Kech  S;  Härter  M;  Berger  M:  Efficacy of interpersonal psychotherapy plus pharmacotherapy in chronically depressed inpatients.  J Affect Disord 2008; 109:65–73
[CrossRef] | [PubMed]
 
Kocsis  JH;  Gelenberg  AJ;  Rothbaum  BO;  Klein  DN;  Trivedi  MH;  Manber  R;  Keller  MB;  Leon  AC;  Wisniewski  SR;  Arnow  BA;  Markowitz  JC;  Thase  ME;  REVAMP Investigators:  Cognitive behavioral analysis system of psychotherapy and brief supportive psychotherapy for augmentation of antidepressant nonresponse in chronic depression: the REVAMP Trial.  Arch Gen Psychiatry 2009; 66:1178–1188
[CrossRef] | [PubMed]
 
American Psychiatric Association: Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 3rd ed. Arlington, VA, APA, 2010.
 
References Container
Anchor for Jump
Table 1. DSM-IV Criteria for Dysthymic Disordera
Table Footer Note

a Adapted from Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994 (7).

+

References

Akiskal  HS:  Dysthymia and cyclothymia in psychiatric practice a century after Kraepelin.  J Affect Disord 2001; 62:17–31
[CrossRef] | [PubMed]
 
Akiskal  HS:  Dysthymic disorder: psychopathology of proposed chronic depressive subtypes.  Am J Psychiatry 1983; 140:11–20
[PubMed]
 
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC, APA, 1980.
 
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. Washington, DC, APA, 1968.
 
Akiskal H: Mood disorders: clinical features, in Kaplan and Sadock's Comprehensive Textbook of Psychiatry. Edited by Sadock BJ, Sadock VA, Ruiz P. Baltimore, Lippincott Williams & Wilkins, 2009.
 
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, APA, 1994.
 
Keller  MB;  Klein  DN;  Hirschfeld  RM;  Kocsis  JH;  McCullough  JP;  Miller  I;  First  MB;  Holzer  CP  3rd;  Keitner  GI;  Marin  DB  et al:  Results of the DSM-IV mood disorders field trial.  Am J Psychiatry 1995; 152:843–849
[PubMed]
 
Russell  JM;  Kornstein  SG;  Shea  MT;  McCullough  JP;  Harrison  WM;  Hirschfeld  RM;  Keller  MB:  Chronic depression and comorbid personality disorders: response to sertraline versus imipramine.  J Clin Psychiatry 2003; 64:554–561
[CrossRef] | [PubMed]
 
Williams  ER;  Shepherd  SM:  Medical clearance of psychiatric patients.  Emerg Med Clin North Am 2000; 18:185–198, vii
[CrossRef] | [PubMed]
 
Orlando  M;  Burnam  MA;  Beckman  R;  Morton  SC;  London  AS;  Bing  EG;  Fleishman  JA:  Re-estimating the prevalence of psychiatric disorders in a nationally representative sample of persons receiving care for HIV: results from the HIV Cost and Services Utilization Study.  Int J Methods Psychiatr Res 2002; 11:75–82
[CrossRef] | [PubMed]
 
Howland  RH;  Thase  ME:  Biological studies of dysthymia.  Biol Psychiatry 1991; 30:283–304
[CrossRef] | [PubMed]
 
McCullough  JP  Jr;  Klein  DN;  Borian  FE;  Howland  RH;  Riso  LP;  Keller  MB;  Banks  PL:  Group comparisons of DSM-IV subtypes of chronic depression: validity of the distinctions, part 2.  J Abnorm Psychol 2003; 112:614–622
[CrossRef] | [PubMed]
 
Weissman  MM;  Leaf  PJ;  Tischler  GL;  Blazer  DG;  Karno  M;  Bruce  ML;  Florio  LP:  Affective disorders in five United States communities.  Psychol Med 1988; 18:141–153
[CrossRef] | [PubMed]
 
Kessler  RC;  McGonagle  KA;  Zhao  S;  Nelson  CB;  Hughes  M;  Eshleman  S;  Wittchen  HU;  Kendler  KS:  Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey.  Arch Gen Psychiatry 1994; 51:8–19
[CrossRef] | [PubMed]
 
Howland  RH:  General health, health care utilization, and medical comorbidity in dysthymia.  Int J Psychiatry Med 1993; 23:211–238
[CrossRef] | [PubMed]
 
Markowitz  JC;  Moran  ME;  Kocsis  JH;  Frances  AJ:  Prevalence and comorbidity of dysthymic disorder among psychiatric outpatients.  J Affect Disord 1992; 24:63–71
[CrossRef] | [PubMed]
 
Keller  MB;  McCullough  JP;  Klein  DN;  Arnow  B;  Dunner  DL;  Gelenberg  AJ;  Markowitz  JC;  Nemeroff  CB;  Russell  JM;  Thase  ME;  Trivedi  MH;  Zajecka  J:  A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression.  N Engl J Med 2000; 342:1462–1470
[CrossRef] | [PubMed]
 
Hellerstein  DJ;  Agosti  V;  Bosi  M;  Black  SR:  Impairment in psychosocial functioning associated with dysthymic disorder in the NESARC study.  J Affect Disord 2010; 127:84–88
[CrossRef] | [PubMed]
 
Weissman  MM;  Leaf  PJ;  Bruce  ML;  Florio  L:  The epidemiology of dysthymia in five communities: rates, risks, comorbidity, and treatment.  Am J Psychiatry 1988; 145:815–819
[PubMed]
 
Shelton  RC;  Davidson  J;  Yonkers  KA;  Koran  L;  Thase  ME;  Pearlstein  T;  Halbreich  U:  The undertreatment of dysthymia.  J Clin Psychiatry 1997; 58:59–65
[CrossRef] | [PubMed]
 
Emslie  GJ;  Mayes  T;  Porta  G;  Vitiello  B;  Clarke  G;  Wagner  KD;  Asarnow  JR;  Spirito  A;  Birmaher  B;  Ryan  N;  Kennard  B;  DeBar  L;  McCracken  J;  Strober  M;  Onorato  M;  Zelazny  J;  Keller  M;  Iyengar  S;  Brent  D:  Treatment of Resistant Depression in Adolescents (TORDIA): week 24 outcomes.  Am J Psychiatry 2010; 167:782–791
[CrossRef] | [PubMed]
 
Rafanelli  C;  Milaneschi  Y;  Roncuzzi  R;  Pancaldi  LG:  Dysthymia before myocardial infarction as a cardiac risk factor at 2.5-year follow-up.  Psychosomatics 2010; 51:8–13
[PubMed]
 
Field  T;  Diego  M;  Hernandez-Reif  M:  Prenatal dysthymia versus major depression effects on the neonate.  Infant Behav Dev 2008; 31:190–193
[CrossRef] | [PubMed]
 
Kocsis  JH;  Frances  AJ;  Voss  C;  Mann  JJ;  Mason  BJ;  Sweeney  J:  Imipramine treatment for chronic depression.  Arch Gen Psychiatry 1988; 45:253–257
[CrossRef] | [PubMed]
 
Thase  ME;  Fava  M;  Halbreich  U;  Kocsis  JH;  Koran  L;  Davidson  J;  Rosenbaum  J;  Harrison  W:  A placebo-controlled, randomized clinical trial comparing sertraline and imipramine for the treatment of dysthymia.  Arch Gen Psychiatry 1996; 53:777–784
[CrossRef] | [PubMed]
 
Levkovitz  Y;  Tedeschini  E;  Papakostas  GI:  Efficacy of antidepressants for dysthymia: a meta-analysis of placebo-controlled randomized trials.  J Clin Psychiatry 2011; 72:509–514
[CrossRef] | [PubMed]
 
Silva de Lima  M;  Hotopf  M: A comparison of active drugs for the treatment of dysthymia. Cochrane Database Syst Rev 2003; 3:CD004047
 
Thase  ME;  Rush  AJ;  Howland  RH;  Kornstein  SG;  Kocsis  JH;  Gelenberg  AJ;  Schatzberg  AF;  Koran  LM;  Keller  MB;  Russell  JM;  Hirschfeld  RM;  LaVange  LM;  Klein  DN;  Fawcett  J;  Harrison  W:  Double-blind switch study of imipramine or sertraline treatment of antidepressant-resistant chronic depression.  Arch Gen Psychiatry 2002; 59:233–239
[CrossRef] | [PubMed]
 
Keller  MB;  Kocsis  JH;  Thase  ME;  Gelenberg  AJ;  Rush  AJ;  Koran  L;  Schatzberg  A;  Russell  J;  Hirschfeld  R;  Klein  D;  McCullough  JP;  Fawcett  JA;  Kornstein  S;  LaVange  L;  Harrison  W:  Maintenance phase efficacy of sertraline for chronic depression: a randomized controlled trial.  JAMA 1998; 280:1665–1672
[CrossRef] | [PubMed]
 
Kocsis  JH;  Friedman  RA;  Markowitz  JC;  Leon  AC;  Miller  NL;  Gniwesch  L;  Parides  M:  Maintenance therapy for chronic depression: a controlled clinical trial of desipramine.  Arch Gen Psychiatry 1996; 53:769–774, discussion 775–776
[CrossRef] | [PubMed]
 
Gelenberg  AJ;  Trivedi  MH;  Rush  AJ;  Thase  ME;  Howland  R;  Klein  DN;  Kornstein  SG;  Dunner  DL;  Markowitz  JC;  Hirschfeld  RM;  Keitner  GI;  Zajecka  J;  Kocsis  JH;  Russell  JM;  Miller  I;  Manber  R;  Arnow  B;  Rothbaum  B;  Munsaka  M;  Banks  P;  Borian  FE;  Keller  MB:  Randomized, placebo-controlled trial of nefazodone maintenance treatment in preventing recurrence in chronic depression.  Biol Psychiatry 2003; 54:806–817
[CrossRef] | [PubMed]
 
Markowitz  JC:  Psychotherapy of dysthymia.  Am J Psychiatry 1994; 151:1114–1121
[PubMed]
 
Cuijpers  P;  van Straten  A;  Schuurmans  J;  van Oppen  P;  Hollon  SD;  Andersson  G:  Psychotherapy for chronic major depression and dysthymia: a meta-analysis.  Clin Psychol Rev 2010; 30:51–62
[CrossRef] | [PubMed]
 
Cuijpers  P;  van Straten  A;  van Oppen  P;  Andersson  G: Are psychological and pharmacologic interventions equally effective in the treatment of adult depressive disorders? A meta-analysis of comparative studies. J Clin Psychiatry 2008; 69:1675–1685; quiz 1839–1841
 
Imel  ZE;  Malterer  MB;  McKay  KM;  Wampold  BE:  A meta-analysis of psychotherapy and medication in unipolar depression and dysthymia.  J Affect Disord 2008; 110:197–206
[CrossRef] | [PubMed]
 
Browne  G;  Steiner  M;  Roberts  J;  Gafni  A;  Byrne  C;  Dunn  E;  Bell  B;  Mills  M;  Chalklin  L;  Wallik  D;  Kraemer  J:  Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs.  J Affect Disord 2002; 68:317–330
[CrossRef] | [PubMed]
 
Ravindran  AV;  Anisman  H;  Merali  Z;  Charbonneau  Y;  Telner  J;  Bialik  RJ;  Wiens  A;  Ellis  J;  Griffiths  J:  Treatment of primary dysthymia with group cognitive therapy and pharmacotherapy: clinical symptoms and functional impairments.  Am J Psychiatry 1999; 156:1608–1617
[PubMed]
 
Schramm  E;  Schneider  D;  Zobel  I;  van Calker  D;  Dykierek  P;  Kech  S;  Härter  M;  Berger  M:  Efficacy of interpersonal psychotherapy plus pharmacotherapy in chronically depressed inpatients.  J Affect Disord 2008; 109:65–73
[CrossRef] | [PubMed]
 
Kocsis  JH;  Gelenberg  AJ;  Rothbaum  BO;  Klein  DN;  Trivedi  MH;  Manber  R;  Keller  MB;  Leon  AC;  Wisniewski  SR;  Arnow  BA;  Markowitz  JC;  Thase  ME;  REVAMP Investigators:  Cognitive behavioral analysis system of psychotherapy and brief supportive psychotherapy for augmentation of antidepressant nonresponse in chronic depression: the REVAMP Trial.  Arch Gen Psychiatry 2009; 66:1178–1188
[CrossRef] | [PubMed]
 
American Psychiatric Association: Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 3rd ed. Arlington, VA, APA, 2010.
 
References Container
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CME Activity

Add a subscription to complete this activity and earn CME credit.
Sample questions:
1.
It appears that peripheral cytokines enter or communicate with the CNS through which of the following mechanisms:

See Soskin and Fava: Peripheral cytokine signals can access the brain, p 145
2.
Pre-treatment with the antidepressant paroxetine, in patients receiving the pro-inflammatory cytokine, interferon-alpha, for hepatitis C or malignant melanoma has been shown to dramatically reduce rates of depression during cytokine therapy?

See Soskin and Fava: Interferon model, p 414
3.
Following a first episode of major depression lasting less than two years, the estimated likelihood of another episode across the lifespan is approximately which of the following:

See Shelton and Hollon, Introduction, p 434
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