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Dysthymia: more than “minor”

Moch S, MSc(Med), MEd
Department of Pharmacy and Pharmacology, University of the Witwatersrand

Dysthymia is an under-diagnosed mood spectrum disorder that is almost as common as major depression and, if left untreated,
has a chronic course which can impact negatively on a patient’s quality of life. Whilst symptoms are not as numerous or severe
as in major depressive disorder (MDD), morbidity associated with dysthymia can be serious owing to the long duration of the
distressing syndrome. Consistently depressed mood can lead to impairment in workplace functioning, as well as compromised
management of interpersonal, marital and familial relationships. Optimal management involves a combination of pharmacological
treatment with antidepressant medications (e.g. selective serotonin reuptake inhibitors) and various forms of psychotherapy.
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What is dysthymia? In addition, approximately 75% of patients suffering from

dysthymia have a co-morbid physical or psychiatric condition,
Dysthymia is defined as a chronic mood disorder which persists
e.g. anxiety disorder, substance addiction or personality
for at least two years in adults, and one year in adolescents
disorder.6 The clinical significance of this statistic is profound,
and children. Along with depressed mood most days for the
since both dysthymia and the co-morbid conditions become
majority of the day, two or more of the following symptoms are
more resistant to treatment as each exacerbates the severity
essential for the diagnosis:
of the other. 7 For example, substance addiction can worsen
• Poor appetite or, alternatively, overeating (hyperphagia); dysthymia, which stimulates further substance use.
• Insomnia or, alternatively, excessive sleep (hypersomnia);
• Low energy, or fatigue; What causes dysthymia?
• Low self-esteem; Dysthymia has been attributed to a melange of physical,
• Poor concentration; emotional and social causes.8 Although there seems to be a
• Difficulty making decisions; and genetic component (especially with the acute onset form), there
• Hopelessness. is scant published evidence which probes this susceptibility. For
the full spectrum of mood disorders, aetiological theories focus
For a diagnosis of dysthymia, there should be no history of further downstream, documenting aberrant neurotransmitter
mania and no major depressive episode in the initial two years signalling and hormone abnormalities. Factors which
of the illness.1 perpetuate these neurochemical imbalances include chronic
Clinicians distinguish between two forms of the syndrome. stress, adult or childhood trauma and social isolation. 9 This
Acute onset applies when symptoms begin before the age of 21 poses a classical “chicken and egg” conundrum, since the more
years even though, in this form, the development of symptoms pessimistic and hypersensitive to rejection the dysthymic
can be gradual. In late onset, symptoms arise later in life, any patient becomes, the greater the negative impact on his or her
time after the age of 21, and commonly in response to an event mood by the “trigger” circumstances. Thus, the longer a patient
(e.g. bereavement or diagnosis of a major illness), in which case suffers from untreated dysthymia, the more impaired his or her
the commencement is less insidious.2 social, psychological and emotional functioning becomes.10
In addition, patients with dysthymia exhibit loss of physical
wellbeing, they utilise more health care resources, and they are
How common is dysthymia? hospitalised more frequently than non-depressed controls or
Dysthymia is approximately twice as prevalent in women than even patients with MDD. 11
in men, which is a similar ratio to the occurrence of episodic (or
non-chronic) major depressive disorder (MDD).3 Kessler et al4
How do we distinguish dysthymia from
determined that dysthymia affects about 6% of the population
in the USA and, although there are no local statistics specific major depressive disorder?
to dysthymia, the lifetime prevalence of any mood disorder in Since both MDD and dysthymia are part of the spectrum
South Africa has been reported as 9.8%.5 of mood disorders, the American Psychiatric Association

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distinguishes between them on the basis of symptomatology Symptoms common to both MDD and dysthymia include
and chronicity.1 The cardinal symptom of both illnesses is depressed mood, disturbed sleep (either insomnia or
depressed or low mood. However, this has to have been hypersomnia), low energy, poor concentration and
present for only two weeks for a diagnosis of MDD, compared indecisiveness. In addition, there are several “parallel symptoms”
with two years for dysthymia. For MDD, the low mood has to be which are expressed in a more overt form in MDD, but can be
accompanied by at least five other symptoms on the DSM-IV equated with a corresponding symptom in dysthymic patients.
checklist, whereas a diagnosis of dysthymia requires only two These include poor appetite or, conversely, overeating in
other symptoms (as listed in Table I). dysthymia, compared with frank weight changes in depressed
patients; low self-esteem in dysthymia, which is expressed as
When comparing these straightforward diagnostic criteria, it excessive guilt in depressed patients; and hopelessness in
may seem that MDD is the more serious diagnosis in terms of dysthymia, which can become suicidal ideation in depressed
morbidity. However, if treatment is initiated promptly, patients patients. From these common and parallel symptoms, it is
can be reassured that the debilitating symptoms of the disease apparent that dysthymia and MDD are not two separate
will abate. In contrast, although fewer symptoms are necessary entities, but rather different points along a spectrum of
for a diagnosis of dysthymia, the long period before diagnosis depressed mood.13 It is, therefore, not surprising that such a
contributes to great suffering and also perpetuates a pessimistic high number of patients initially diagnosed with dysthymia
go on to experience episodes of major depression. When the
and hopeless world view. Such negative thinking can impact
two disorders occur concurrently, such patients are classified as
adversely on the success of treatment and eventual recovery.12
suffering from “double depression”.14

A possible differentiating feature between MDD and dysthymia

Double depression is that, whilst dysthymic patients may exhibit flattened affect
During the course of their dysthymic illness, more than (mood), patients with MDD can suffer anhedonia (inability to
60% of patients will eventually develop a full-blown experience pleasure from normally enjoyable experiences).
major depressive disorder. When the two syndromes are In addition, patients with MDD can experience psychomotor
superimposed in this fashion, the patient is said to suffer agitation or retardation (restless, purposeless movements
from “double depression”. In reality, however, the two attributed to mental tension, or slowed movements and
conditions are not so easy to separate (see the symptoms sluggish speech, also characteristic in some forms of MDD).
which are common to both in Table 1 below) and are more These symptoms are infrequently observed in dysthymic
likely to represent fluctuating stages along a continuum patients.12
of low mood. Double depression is more resistant to
treatment and requires specialist care. Lastly, rating scales, such as the clinician-administered Hamilton
Rating Scale of Depression or the self-administered Beck
Depression Inventory, have been used to screen for depressive
symptoms, and some of these are sensitive enough
Table I: Differences and similarities between dysthymia and major to indicate either dysthymia or MDD. Confirmation of
depressive disorder the diagnosis following a clinical interview is required.
However, the rating scales are also useful in providing
Major depressive Dysthymia
disorder a baseline measurement against which treatment
response or exacerbation of symptoms can be plotted.14
Symptoms common Depressed mood
to both disorders Disturbed sleep
Low energy/fatigue Treatment options for dysthymia
Poor concentration
Indecisiveness Most patients are only driven to seek treatment for
depressive disorders when their misery impacts so
Parallel symptoms, Weight change Poor appetite/overeating negatively on their normal functioning that they feel
on a spectrum of Excessive guilt Low self-esteem
severity, between the Suicide ideation Hopelessness unable to continue as they are. For many patients with
disorders dysthymia, their sadness and negative world view
become so entrenched in their lives that they feel that
Symptoms and Anhedonia No history of mania
dysphoria is normal. This lack of insight into their illness
conditions specific to Psychomotor No major depressive
each disorder symptoms disorder in the first hinders successful treatment and ultimate recovery.15
two years
Treatment of dysthymia involves both pharmacological
Duration of Two weeks Two years and non-pharmacological approaches. When directly
symptoms required (One year for comparing these two modalities, psychotherapy was
for diagnosis adolescents and
found to be less effective than pharmacotherapy.16
However, combined treatment (medicines
Number of checklist Five or more At least two and psychotherapy) was more effective than
symptoms required
pharmacotherapy alone.17
for diagnosis

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Table II: Antidepressants used in the treatment of dysthymia and their major adverse effects

Selective serotonin Dual reuptake Noradrenergic Tri- and Monoamine Mixed action
reuptake inhibitors inhibitors drugs tetracyclic oxidase
antidepressants inhibitors
Fluoxetine Venlafaxine Reboxetine Amitriptyline Tranylcypromine Mianserin
Paroxetine Duloxetine Mirtazapine Dothiepin Moclobemide Trazodone
Sertraline Bupropion Clomipramine
Fluvoxamine Imipramine
Citalopram Lofepramine
Escitalopram Trimipramine

Insomnia, agitation, Insomnia, Increased heart Sedation, anticho- Insomnia, dietary Sedation, priapism
nausea, diarrhoea, gastrointestinal rate and blood linergic effects, restrictions (trazodone)
sexual dysfunction effects, seizures pressure, weight weight gain, with irreversible
gain cardiotoxicity in inhibitor

Pharmacological management dysthymia.22 The authors conclude that low-dose amisulpiride

The pharmacological management of dysthymia is similar to may lead to symptom reduction in dysthymia. However, the
the treatment of MDD. Selective serotonin reuptake inhibitors possible benefits of the use of other SGAs in combination
(SSRIs), tricyclic antidepressants (TCAs) and monoamine oxidase with antidepressants for resistant dysthymia do not outweigh
inhibitors (MAOIs) are all effective, but SSRIs seem better the adverse effects, like weight gain and prolactin increase.
tolerated than other antidepressants and are, consequently, The consequences of raised prolactin include amenorrhoea,
usually the drugs of choice.18 Other factors which contribute to galactorrhoea, nausea, weight gain, akathisia and sexual
drug choice include a history of response of either the patient dysfunction. Thus, the use of SGAs for the augmentation of
or a first-degree relative, the ease of adherence to the dosing antidepressant therapy is limited.
schedule, cost of the medicine and the possibility of interactions
with other medications (since there is a high incidence of co- Non-pharmacological management
morbid illness in dysthymia).19 Since dysthymia affects aspects of emotional functioning,
therapies which address these issues specifically are helpful. A
Some clinicians recommend agents which increase
range of psychotherapeutic modalities have proved efficacious
noradrenergic transmission (such as the dual noradrenaline
in the management of dysthymia (Table III). Psychotherapy,
and serotonin reuptake inhibitors, like venlafaxine or
duloxetine, or the dopamine-noradrenaline reuptake inhibitor however, requires time (usually in excess of six months) and
bupropion, or the presynaptic alpha-2 receptor antagonist dedication (weekly appointments), which can prove costly in
mirtazapine) for patients with the hypersomnic/hyperphagic economic terms as well as with respect to the patient’s already
type of dysthymia.20 Fluoxetine is the drug of choice for limited motivation and energy.23
treating dysthymia in children or adolescents, since there has
been concern that other antidepressants may increase the risk Table III: Psychotherapeutic modalities for the management of
of suicide in this age group (Table II).21 dysthymia

Unfortunately, antidepressants ameliorate dysthymia in only Type of Description

50-70% of patients, and many patients thus require several psychotherapy
trials of medication before an effective agent is identified.18 In Cognitive therapy Identifies, interrupts and corrects
addition, it is an extended process to determine the efficacy of negative thought patterns which
a particular agent, since antidepressant drugs take weeks or promote a self-reinforced critical mindset
sometimes months to effect clinical remission of illness, so non- Behavioural Introduces alternate, positive actions in
response is difficult to determine. In cases where dysthymia therapy order to circumvent learned helplessness,
has proved resistant to antidepressants alone, lithium or effects of stress and deficient social skills
thyroid hormone (thyroxine) can be added. 19 Combinations of
Interpersonal Develops sensitivity to social roles and
different classes of antidepressants prescribed together have therapy provides techniques for dealing with
also proved of some value, although the greater the number of separation, losses and disputes.
drugs, the greater the severity of adverse effects, which often
Psychodynamic Examines emotional conflicts in relation
leads to a reduction in patient adherence to the recommended therapy to childhood experiences and seeks to
drug regimen. improve insight through retrospective
Finally, a recent Cochrane review has examined the evidence
concerning the efficacy of second-generation antipsychotic Supportive Education, advice, reassurance,
drugs (SGAs), such as amisulpride, aripiprazole, olanzapine, therapy encouragement and compassion all
contribute to patient support
quetiapine and risperidone, in the treatment of depression and

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Cognitive therapy targets the symptoms of low self-esteem and days.27 It has an insidious onset in childhood and progresses
hopelessness in dysthymia. The therapist sensitises the patient into adulthood, such that a patient develops a pessimistic
to recognise that negative thought patterns provoke negative world view and may have little insight into normal mood and
emotions and feelings. Such negative “self-talk” can perpetuate functioning. The high incidence of psychiatric and physical co-
the patient’s pessimistic view of the world, which can impede morbidities complicates treatment. Whilst dysthymic patients
recovery. Learning to identify and interrupt negative thoughts may have fewer symptoms that those with MDD, the long-
is the first step in developing a more realistic outlook.24 term consequences of continuous negative thinking and low
self-esteem can be severe. Treatment with antidepressant
Behavioural therapy is often used in tandem with cognitive medications and various forms of psychotherapy is currently the
therapy and is then termed “cognitive–behavioural therapy”. regimen of choice. However, more research into the genetics,
Once the dysthymic patient learns how to recognise and disrupt aetiology and management of the condition is warranted.
negative thinking, behavioural therapy introduces alternate,
positive actions and scripts in order to circumvent learned
helplessness, manage stress better and improve deficient social 1. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. Text revision (DSMIV-TR). 4th ed. Arlington: American Psychiatric
skills.16 Association; 2000.
2. Langenfeld SC, Lundquist RS, Szetela BR. Dysthymic disorder [homepage on the
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nature of dysthymia can cause patients to view themselves depressive disorder and dysthymic disorder: results from the National
Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry.
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This causes a pathological passive-aggressive approach to 4. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of
DSM-III-R psychiatric disorders in the United States: results from the National
dealing with others, which exacerbates poor interpersonal Comorbidity Survey. Arch Gen Psychiatry. 1994;51:8–19.
relationships. Interpersonal therapy encourages dysthymic 5. Stein DJ, Seedat S, Herman A, et al. Lifetime prevalence of psychiatric disorders in
South Africa. Br J Psychiatry. 2008;192(2):112–117
patients to identify social roles and provides techniques for 6. Klein DN, Santiago NJ. Dysthymia and chronic depression: introduction,
dealing with separation, loss and disputes from a neutral rather classification, risk factors and course. J Clin Psychol. 2003;59(8):807-816
7. Gureje O. Dysthymia in a cross-cultural perspective. Curr Opin Psychiatry.
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8. Niculescu AB 3rd, Akiskal HS. Proposed endophenotypes of dysthymia:
Psychodynamic therapy seeks to expose learned emotional evolutionary, clinical and pharmacogenomic considerations. Mol Psychiatry.
defence mechanisms that arise from unresolved issues in 9. Griffiths J, Ravindran AV, Merali Z, Anisman H. Dysthymia: a review of
childhood. The therapist helps the dysthymic patient to examine pharmacological and behavioral factors. Mol Psychiatry. 2000;5(3):242-261.
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past events which could have provoked unconscious conflicts of familial psychopathology, early adversity, personality, comorbidity, and chronic
leading to maladaptive behaviours. Through retrospective stress. Am J Psychiatry. 2001;158(11):1864-1870.
11. Barbui C, Motterlini N, Garattini L; DYSCO Study Group. Health status, resource
introspection, the patient is encouraged to deal with past consumption, and costs of dysthymia. A multi-center two-year longitudinal study.
issues, let go of negative emotional defences and move on with J Affect Disord. 2006;90(2-3):181-186.
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RL, Yee GC, et al, editors. Pharmacotherapy: a pathophysiologic approach. 7th ed.
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be instructed to take their medicines as prescribed, since 17. Kriston L, Von Wolff A, Hölzel L. Effectiveness of psychotherapeutic,
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Trade names of drugs indicated for dysthymia

Generic Name Trade Name

Selective serotonin reuptake inhibitors

Fluoxetine Prozac®, A-Lennon Fluoxetine®, Deprozan, Flutinol®, Lilly-Fluoxetine®, Lorien®, Nuzak®, Prohexal®,
Ranflocs®, Rezak®, Sandoz-Fluoxetine®, Trizac®, Zydus-Fluoxetine®

Paroxetine Aropax®, Adco-Paroxetine®, Austell-Paroxetine®, Deparoc®, Hexal-Paroxetine®, Parax®, Paxil®, Sandoz-

Paroxetine®, Sedarin®, Serrapress®, Xet®

Sertraline Zoloft®, Adco-Zertra®, Aspen-Sertraline®, Austell-Sertraline®, Merck-Sertraline®, Serdep®, Serlife®,

Sertraline-Winthrop®, Sertzol®

Fluvoxamine Luvox®, Faverin®, Fluvoxamine-Hexal®

Citalopram Cipramil®, Adco-Talomil®, Austell-Citalopram®, Cilate®, Cilift®, Citalohexal®, Citalopram-Winthrop®,

Depramil®, DRL-Citalopram®, Merck-Citalopram®, Ran-Citalopram®, Sandoz-Citalopram®,

Escitalopram Cipralex®, Lexamil®, Aspen Escitalopram®, Citraz®, Mylan-Escitalopram®

Noradrenaline reuptake inhibitor

Reboxetine Edronax®

Dual reuptake inhibitors

Venlafaxine Efexor®, Venlor®, Illovex®, Odiven®, Sandoz-Venlafaxine®

Bupropion Wellbutrin® (Zyban®)

Duloxetine Cymbalta®, Cymgen®

Monoamine oxidase inhibitors

Moclobemide Aurorix®, Clorix®, Depnil®

Tranylcypromine Parnate®

Tricyclic and tetracyclic antidepressants

Amitriptyline Trepiline®, Tryptanol®, Sandoz Amitriptyline®

Dothiepin Prothiaden®, Sandoz Dothiepin®, Thaden®

Clomipramine Anafranil®, Clomidep®, Equinorm®

Imipramine Tofranil®, Ethipramine®

Lofepramine Emdalen®

Trimipramine Surmontil®, Tydamine®

Maprotiline Ludiomil®

Mixed action agents

Mirtazapine Remeron®, Adco-Mirteron®, Aspen Mirtazapine®, Sandoz-Mirtazapine®

Mianserin Lantanon®

Trazodone Molipaxin®

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