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Dysthymia in Clinical Practice

Published online by Cambridge University Press:  02 January 2018

Hagop S. Akiskal
Affiliation:
Department of Psychiatry, University of California at San Diego, 9500 Gilman Dr., BSB-2072, La Jolla, California 92093-0603
Jorge Alberto Costa e Silva
Affiliation:
Division of Mental Health, WHO, Geneva
Allen Frances
Affiliation:
Department of Psychiatry, Duke University Medical Center, North Carolina 27710
Hugh L. Freeman*
Affiliation:
21 Montagu Square, London
Martin B. Keller
Affiliation:
Department of Psychiatry and Human Behaviour, Brown University, and Brown Affiliated Hospitals, 345 Blackstone Boulevard, Providence RI 029906
Yvon D. Lapierre
Affiliation:
Department of Psychiatry, Royal Ottawa Hospital, 1145 Carling, Ottawa, Ontario K1Z 7K4
Juan José Lopez Ibor Jr
Affiliation:
Psychiatric Unit, Hospital Clínico San Carlos, Martin Lagos s/n, 28040 Madrid
Eugene S. Paykel
Affiliation:
Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 2QQ
Max Stabl
Affiliation:
F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, CH-4002 Basel, Switzerland
*
Professor H. L. Freeman, 21 Montagu Square, London W1H 1RE

Abstract

Background

Dysthymia has been reconceptualised in recent years from a personality disorder to a chronic affective disorder. It is incorporated into both the DSM and ICD diagnostic systems. Method. The members of the WPA Dysthymia Working Group combined the results of their manual literature searches with a search using Medline.

Results

Available data are summarised under the headings of classification, epidemiology, validity, comorbidity, course and outcome, pharmacotherapy and psychotherapy. The coexistence of major depressive disorder, constituting ‘double depression’ is of particular importance.

Conclusions

Improved knowledge of this disorder has led to a more positive approach to treatment, in which antidepressants can usefully be complemented by psychosocial measures. A high proportion of cases remain unrecognised in most populations, leading to prolonged morbidity and distress, much of which is now treatable.

Type
Review Article
Copyright
Copyright © 1995 The Royal College of Psychiatrists 

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Footnotes

1.

Members of the WPA Dysthymia Working Group: Hagop S. Akiskal (USA), Jorge A. Costa e Silva (Chair) (Brazil), Allen Frances (USA), Hugh L. Freeman (UK), Martin B. Keller (USA), Yvon D. Lapierre (Canada), Juan José Lopez Ibor Jr (Spain), Eugene S. Paykel (UK), Max Stabl (Switzerland).

References

Akiskal, H. S. (1981) Subaffective disorders: dysthymic, cyclothymic and bipolar II disorders in the ‘borderline’ realm. Psychiatric Clinics of North America, 4, 2546.CrossRefGoogle ScholarPubMed
Akiskal, H. S. (1982) Factors associated with incomplete recovery in primary depressive illness. Journal of Clinical Psychiatry, 43, 266271.Google Scholar
Akiskal, H. S. (1983) Dysthymic disorder: psychopathology of proposed chronic depressive subtypes. American Journal of Psychiatry, 140, 1120.Google Scholar
Akiskal, H. S. (1993) La dysthymie et son traitement. Encéphale, 19, 375378.Google Scholar
Akiskal, H. S., Bitar, A. H., Puzantian, V. R., et al (1978) The nosological status of neurotic depression. Archives of General Psychiatry, 35, 757766.CrossRefGoogle ScholarPubMed
Akiskal, H. S., Rosenthal, T. L., Haykal, R. F., et al (1980) Characterological depressions; clinical and sleep EEG findings separating ‘subaffective dysthymias’ from ‘character spectrum disorders’. Archives of General Psychiatry, 37, 777783.CrossRefGoogle ScholarPubMed
Akiskal, H. S., King, D., Rosenthal, T. L., et al (1981) Chronic depressions, part I: Clinical and familial characteristics in 137 probands. Journal of Affective Disorders, 3, 297315.Google Scholar
Akiskal, H. S., Downs, J., Jordan, P., et al (1985) Affective disorders in referred children and younger siblings of manic-depressives: Mode of onset and prospective course. Archives of General Psychiatry, 42, 9961003.Google Scholar
Akiskal, H. S. & Weise, R. E. (1992) The clinical spectrum of so-called ‘minor’ depression. American Journal of Psychotherapy, 46, 922.CrossRefGoogle Scholar
Akiskal, H. S. & Akiskal, K. (1992) Cyclothymic, hyperthymic and depressive temperaments as subaffective variants of mood disorders. In American Psychiatric Association Review (eds Tasman, A. & Riba, M. B.), pp. 4362. Washington, DC: APA.Google Scholar
American Psychiatric Association (1968) Diagnostic and Statistical Manual of Mental Disorders (2nd edn) (DSM–II). Washington, DC: APA.Google Scholar
American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders (3rd edn) (DSM–III). Washington, DC: APA.Google Scholar
American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders (3rd edn, revised) (DSM–III–R). Washington, DC: APA.Google Scholar
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV). Washington, DC: APA.Google Scholar
Arriaga, F., Ruiz, I., Lara, E., et al (1986) Ritanserin, an original thymostenic for the treatment of dysthymia: a double-blind, placebo-controlled study. Collegium Internationale Neuropsychopharmacologicum, 15th Congress, p 186 (abstract).Google Scholar
Asnis, G. M., Friedman, T. A., Sanderson, W. C., et al (1993) Suicidal behaviors in adult psychiatric outpatients, I: Description and prevalence. American Journal of Psychiatry, 150, 108112.Google Scholar
Bakish, D., Lapierre, Y. D., Weinstein, R., et al (in press) Ritanserin, imipramine and placebo in the treatment of dysthymic disorder. Journal of Clinical Psychopharmacology. Google Scholar
Bech, P., Mellergard, M. & Ottoson, J. O. (1991) Secondary depression in panic disorder: an indicator of severity with a weak effect on outcome in alprazolam and imipramine treatment. Acta Psychiatrica Scandinavica, 365 (suppl.), 3945.Google Scholar
Bersani, G., Pozzi, F., Marini, S., et al (1991) 5HT2 receptor antagonism in dysthymic disorder: a double-blind placebo control with ritanserin. Acta Psychiatrica Scandinavica, 83, 244248.Google Scholar
Black, D., Winokur, G. & Nasrallah, A. (1987) Treatment and outcome in secondary depression: A naturalistic study of 1087 patients. Journal of Clinical Psychiatry, 48, 11.Google ScholarPubMed
Burton, S. W. & Akiskal, H. S. (1990) Dysthymic Disorder. London: Gaskell.Google Scholar
Chen, C., Wong, J., Lee, N., et al (1993) The Shatin community mental health survey in Hong Kong – II. Major findings. Archives of General Psychiatry, 50, 125133.Google Scholar
Conte, H. R. & Karasu, T. B. (1992) A review of treatment studies of minor depression 1980–1991. American Journal of Psychotherapy, 46, 5874.CrossRefGoogle ScholarPubMed
Corney, R. H. (1987) Marital problems and treatment outcome in depressed women: a clinical trial of social work intervention. British Journal of Psychiatry, 151, 652659.Google Scholar
Cross-National Collaborative Group (1992) The changing rate of major depression. Cross national comparisons. Journal of the American Medical Association, 268, 30983105.CrossRefGoogle Scholar
Cummins, J. L. (1992) Depression and Parkinson's disease: a review. American Journal of Psychiatry, 149, 443454.Google Scholar
De Jong, R., Treiber, R. & Heinrich, G. (1986) Effectiveness of two psychological treatments for in-patients with severe and chronic depressions. Cognitive Therapy & Research, 10, 645663.Google Scholar
De Lisio, G., Maremmani, I., Perugi, G., et al (1986) Impairment of work and leisure in depressed out-patients: a preliminary communication. Journal of Affective Disorders, 10, 7984.CrossRefGoogle ScholarPubMed
Eaton, W. W. & Kessler, L. G. (1985) Epidemiological Field Methods in Psychiatry: The Epidemiological Catchment Area Program. New York: Academic Press.Google Scholar
Finlayson, R. (1989) Recognition and management of dysthymic disorder. American Family Psychiatry, 40, 229238.Google Scholar
Frances, A., et al (1993) Recurrent brief depression, dysthymia and melancholia. International Clinical Psychopharmacology, 7, 197200.Google Scholar
Garrison, C. Z., Addy, C. L., Jackson, K. L., et al (1992) Major depressive disorder and dysthymia in young adolescents. American Journal of Epidemiology, 135, 792802.Google Scholar
Hammen, C., Burge, D., Burney, E. & Adrian, C. (1990) Longitudinal study of diagnoses in children of women with unipolar and bipolar affective disorder. Archives of General Psychiatry, 47, 11121117.Google Scholar
Harrington, R., Fudge, H., Rutter, M., et al (1990) Adult outcomes of childhood and adolescent depression I. Psychiatric status. Archives of General Psychiatry, 47, 465473.CrossRefGoogle ScholarPubMed
Hellerstein, D. J., Yanowitch, P., Rosenthal, J., et al (1993) A randomised double-blind study of fluoxetine versus placebo in the treatment of dysthymia. American Journal of Psychiatry, 150, 11691175.Google Scholar
Hirschfeld, R. M. A., Klerman, G. L., Lavori, P. W., et al (1989) Premorbid personality assessments of first onset of major depression. Archives of General Psychiatry, 46, 345350.Google Scholar
Howland, R. H. & Thase, M. E. (1991) Biological status of dysthymia. Biological Psychiatry, 30, 283304.Google Scholar
Kashani, J. H., Keller, M. B., Solomon, N., et al (1985) Double depression in adolescent substance users. Journal of Affective Disorders, 8, 153157.Google Scholar
Keller, M. B. (1985) Chronic and recurrent affective disorders: Incidence, course, and influencing factors. In Chronic Treatments in Neuropsychiatry (eds Kemali, D. & Racagni, G.). New York: Raven Press.Google Scholar
Keller, M. B. & Shapiro, R. W. (1982) ‘Double depression’: Superimposition of acute depressive episodes on chronic depressive disorders. American Journal of Psychiatry, 139, 438442.Google ScholarPubMed
Keller, M. B. & Shapiro, R. W., Lavori, P. W., et al (1982) Recovery in major depressive disorder. Archives of General Psychiatry, 39, 905910.Google Scholar
Keller, M. B., Lavori, P. W., Endicott, J., et al (1983) ‘Double depression’: A two-year follow-up. American Journal of Psychiatry, 140, 689694.Google ScholarPubMed
Keller, M. B. & Lavori, P. W. (1984) Double depression, major depression and dysthymia: Distinct entities or different phases of a single disorder? Psychopharmacology Bulletin, 20, 399402.Google Scholar
Keller, M. B. & Sessa, F. M. (1990) Dysthymia: development and clinical course. In Dysthymic Disorder (eds Akiskal, H. S. & Burton, S. W.), pp. 1323. London: Gaskell.Google Scholar
Keller, M. B. & Lavori, P. W., Endicott, J., et al (1992) Time-to-recovery chronicity in levels of psychopathology in major depression, a five year prospective follow-up of 431 subjects. Archives of General Psychiatry, 49, 809816.Google Scholar
Keller, M. B. & Russell, C. W. (in press) Dysthymia: Toward DSM–IV. In DSM–IV Sourcebook (eds Widiger, T., Frances, A. F. & Pincus, H.). Washington, DC: American Psychiatric Association Press.Google Scholar
King, C. A., Naylor, M. W., Hill, E. M., et al (1993a) Dysthymia characteristic of heavy alcohol use in depressed adolescents. Biological Psychiatry, 33, 210212.Google Scholar
Keller, M. B., Hill, E. M., Naylor, M. W., et al (1993b) Alcohol consumption in relation to other predictors of suicidality among adolescent inpatient girls. Journal of American Academy of Child and Adolescent Psychiatry, 32, 8288.Google Scholar
Kivela, S. L. & Pahkala, K. (1989) Dysthymic disorder in the aged in the community. Social Psychiatry and Psychiatric Epidemiology, 24, 7783.Google Scholar
Klein, D. N. (1990) Depressive personality: reliability, validity, and the relation to dysthymia. Journal of Abnormal Psychology, 99, 412421.Google Scholar
Klein, D. N., Taylor, E. B., Dickstein, S., et al (1988a) The early-late onset distinction in DSM–III–R dysthymia. Journal of Affective Disorders, 14, 2533.Google Scholar
Klein, D. N., Taylor, E. B., Harding, K., et al (1988b) Double depression and episodic major depression: demographic, clinical, familial, personality and socioenvironmental characteristics and short-term outcome. American Journal of Psychiatry, 145, 12261231.Google ScholarPubMed
Klein, D. N., Clark, D. C., Dansky, L., et al (1988c) Dysthymia in the offspring of parents with primary unipolar affective disorder. Journal of Abnormal Psychology, 97, 265274.CrossRefGoogle ScholarPubMed
Kocsis, J. H. (1993) Treatment of dysthymia – Overview of therapy options. Focus on Depression 4, 3, 5961.Google Scholar
Kocsis, J. H., Francis, H. A., Nann, J. J., et al (1985) Imipramine for the treatment of chronic depression. Psychopharmacology Bulletin, 21, 698700.Google ScholarPubMed
Kocsis, J. H., Francis, H. A. (1987) A critical discussion of DSM–III dysthymic disorder. American Journal of Psychiatry, 144, 15341542.Google Scholar
Kocsis, J. H., Francis, H. A., Voss, C., et al (1988) Imipramine treatment for chronic depression. Archives of General Psychiatry, 45, 253257.Google Scholar
Kovacs, M., Feinberg, T. L., Crouse-Novak, M., et al (1984) Depressive disorders in childhood: I and II. Archives of General Psychiatry, 41, 229237 (I) & 643–649 (II).Google Scholar
Kovacs, & Gatsonis, C. (1989) Stability and change in childhood – onset of depressive disorder. Longitudinal course as a diagnostic validator. In The Validity of Psychiatric Diagnosis (eds Robins, L. N. & Barrett, J. E.), pp. 5773. New York: Raven Press.Google Scholar
Kraepelin, E. (1921) Manic Depressive Insanity. Edinburgh: E. & S. Livingstone.Google Scholar
Lewinsohn, P. M., Rohde, P., Seeley, J. R., et al (1991) Comorbidity of unipolar depression: I. Major depression with dysthymia. Journal of Abnormal Psychology, 100, 205213.Google Scholar
Linehan, M. M., Armstrono, H. E., Suarez, A., et al (1991) Cognitive-behavioural treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 10601064.Google Scholar
Markowitz, J. C. (1993) Psychotherapy of the post-dysthymic patient. Journal of Psychotherapy Practice and Research, 2, 157163.Google Scholar
Markowitz, J. C., Moran, J. H., Kocsis, J. H., et al (1992) Prevalence and comorbidity of dysthymic disorder among psychiatric out-patients. Journal of Affective Disorders, 24, 6371.Google Scholar
Mason, B. J., Markowitz, J. & Klerman, G. L. (in press) IPT for dysthymic disorder. In New Applications of Interpersonal Therapy (eds Klerman, G. L. & Weissman, M. M.). Washington, DC: American Psychiatric Press.Google Scholar
Mathew, R. J., Wilson, W. H., Blazer, D. G., et al (1993) Psychiatric disorders in adult children of alcoholics: Data from the epidemiologic catchment area project. American Journal of Psychiatry, 150, 793800.Google Scholar
McCullough, J. P. (1991) Psychotherapy of dysthymia: a naturalistic study of ten patients. Journal of Nervous and Mental Diseases, 179, 734740.CrossRefGoogle ScholarPubMed
McCullough, J. P., Kasnetz, M. D., Braith, J. A., et al (1988) A longitudinal study of an untreated sample of predominantly late-onset characterological dysthymia. Journal of Nervous and Mental Disease, 176, 658667.Google Scholar
Mercier, M. A., Stewart, J. W. & Quitkin, F. M. (1992) A pilot sequential study of cognitive therapy and pharmacotherapy of atypical depression. Journal of Clinical Psychiatry, 53, 166170.Google Scholar
Narrow, W., Regier, D., Rae, D., et al (1993) Use of services by persons with mental and addictive disorders. Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry, 50, 95107.Google Scholar
Paykel, E. S. & Wiessman, M. M. (1973) Social adjustment and depression: a longitudinal study. Archives of General Psychiatry, 28, 659663.CrossRefGoogle ScholarPubMed
Paykel, E. S., Rowan, P. R., Parker, R. R., et al (1982) Response to phenelzine and amitriptyline in some types of depressed outpatients. Archives of General Psychiatry, 39, 10411049.Google Scholar
Peron-Magnan, P. (1992) Trouble dysthymique et personalité depressive. Encéphale, 18, 5154.Google Scholar
Perry, J. P. (1985) Depression in borderline personality disorder: Lifetime prevalence at interview and longitudinal course of symptoms. American Journal of Psychiatry, 142, 1521.Google Scholar
Pfeffer, C. R., Newcorn, J., Kaplan, G., et al (1988) Suicidal behavior in adolescent psychiatric in-patients. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 357361.Google Scholar
Ravindran, A. V., Bialik, R. J. & Lapierre, Y. D. (1993) Therapeutic efficacy of serotonin re-uptake inhibitors (SSRIs) in dysthymia. Canadian Journal of Psychiatry, 38, 10.Google Scholar
Reyntjens, A., Gelders, Y. G., Hoppenbrouwers, M. J. A., et al (1986) Thymostenic effects of ritanserin (R5667), a centrally acting serotonin S2 receptor blocker. Drug Development Research, 8, 205211.Google Scholar
Rihmer, Z. (1990) Dysthymia: a clinician's perspective. In Dysthymic Disorder (eds Burton, S. W. & Akiskal, H. S.), pp. 112125. London: Gaskell.Google Scholar
Robins, L. N., Helzer, J. E., Croughan, J. L., et al (1981) The NIMH Diagnostic Interview Schedule: Its history, characteristics, and validity. Archives of General Psychiatry, 38, 381389.Google Scholar
Rosenthal, T. L., Akiskal, H. S., Scott-Strauss, A., et al (1981) Familial and developmental factors in characterological depressions. Journal of Affective Disorders, 3, 183192.Google Scholar
Salkovskis, P. M., Atha, C. & Storer, D. (1990) Cognitive-behavioural problem solving in the treatment of patients who repeatedly attempt suicide: a controlled trial. British Journal of Psychiatry, 157, 871876.Google Scholar
Sanderson, W. C., Wetzler, S., Beck, A. T., et al (1992) Prevalence of personality disorders in patients with major depression and dysthymia. Psychiatry Research, 42, 9399.Google Scholar
Shores, M. M., Glubin, T., Cowley, D. S., et al (1992) The relationship between anxiety and depression: a clinical comparison of generalized anxiety disorder, dysthymic disorder, panic disorder, and major depressive disorder. Comprehensive Psychiatry, 33, 237244.CrossRefGoogle Scholar
Smith, A. L. & Weissman, M. M. (1992) Epidemiology. In Handbook of Affective Disorders (ed. Paykel, E. S.). London: Churchill Livingstone.Google Scholar
Spitzer, R. L., Endicott, J. & Robins, J. E. (1978) Research Diagnostic Criteria: rationale and reliability. Archives of General Psychiatry, 35, 773782.Google Scholar
Stabl, M., Biziere, K., Schmid-Burgk, W., et al (1989) Review of comparative clinical trials of moclobemide versus tricyclic antidepressants and versus placebo in depressive states. Journal of Neurotransmission, 28 (suppl.), 7789.Google Scholar
Stewart, J. W., Quitkin, F. M., McGrath, P. J., et al (1988) Social functioning in chronic depression: 6 weeks of antidepressant treatment. Psychiatry Research, 25, 213222.Google Scholar
Stravynski, A., Shahar, A. & Verreault, R. (1991) A pilot study of the cognitive treatment of dysthymic disorder. Behavioural Psychotherapy, 19, 369372.CrossRefGoogle Scholar
Versiani, M. (1992) RIMAs in the treatment of dysthymia. 5th Congress of the European College of Neuropsychopharmacology. (Abstract).Google Scholar
Versiani, M. & Nardi, E. (in press) Dysthymia: Comorbidity with anxiety and outcome. In Chronic Depressions and their Treatment (eds Akiskal, H. S. & Cassano, G. B.). New York: Guilford Press.Google Scholar
Waring, E. M., Chamberlaine, C. H., McCrank, E. W., et al (1988) Dysthymia: a randomised study of cognitive marital therapy and antidepressants. Canadian Journal of Psychiatry, 33, 9699.CrossRefGoogle Scholar
Weissman, M. M., Klerman, G. L. & Paykel, E. S. (1971) Clinical evaluation of hostility in depression. American Journal of Psychiatry, 128, 261266.Google Scholar
Weissman, M. M., Leaf, P. J., Bruce, M. L., et al (1988) The epidemiology of dysthymia in five communities: Rates, risks, comorbidity and treatment. American Journal of Psychiatry, 145, 815819.Google Scholar
Wells, K., Burnham, A., Rogers, W., et al (1992) The course of depression in adult out-patients – Results from the Medical Outcomes Study. Archives of General Psychiatry, 49, 788794.Google Scholar
World Health Organization (1978) The Ninth Revision of the International Classification of Diseases and Related Health Problems (ICD–9). Geneva: WHO.Google Scholar
World Health Organization (1992) The Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD–10). Geneva: WHO.Google Scholar
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