Chronic depression has long been understood as a psychological constellation and a personality disorder. In the past, recommended treatment focused on long-term psychotherapy,1 although it was acknowledged that the “depressive personality” rarely responded well.2
Psychiatrists today commonly offer antidepressant drug trials to patients with dysthymia. Yet while tricyclic antidepressants have been shown to have some value in the treatment of chronically depressed patients,3 investigations of selective serotonin reuptake inhibitors in this population have produced inconsistent results.4
This article presents two case studies that illustrate how I use the cognitive approach to dysthymia in my psychiatric practice. Both patients were treated successfully with a short-term approach to therapy. While the final verdict on brief psychotherapy as an approach to dysthymia is not in, I believe there are reasons for optimism.
What is dysthymia?
Chronic depression (dysthymia) is thought to be a heterogeneous condition in which comorbid psychiatric and medical conditions frequently occur.5 According to DSM-IV diagnostic criteria (Table 1), dysthymia differs from major depression in the number of changes necessary for diagnosis (only two of six) and in the longer duration of symptoms (at least 2 years).
DSM-IV DIAGNOSTIC CRITERIA FOR DYSTHYMIA
|*Adapted from: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text revision. Washington, DC: American Psychiatric Association, 2000.|
The lifetime prevalence of dysthymia is 6%. The chronically depressed face a 10% risk each year of developing major depression. Women are two to three times more likely to suffer dysthymia than men.6
Thase and Howland, in a classic 1995 article, described three clinical routes that lead to dysthymia:
- incompletely resolved major depression;
- chronic depressed mood with associated symptoms below the threshold for a diagnosis of major depression;
- dysthymia secondary to medical illness, medications, or substance abuse.7
The clinical term dysthymia has its roots in three older constructs: neurotic depression, depressive personality, and chronic depression.8 Use of the term “neurotic depression” is now discouraged as it has numerous meanings, some of which are contradictory. “Chronic depression” also obscures more than it illuminates. The term “depressive personality” has survived, with a new set of criteria for diagnosis outlined in DSM-IV. Its separation from “dysthymia” is not clear.
Although the subsyndromic nature of dysthymia might suggest a condition milder than major depression, its lifetime comorbidity with a range of serious emotional problems (Table 2) suggests otherwise.
Cognitive therapy for dysthymia
Cognitive therapy targets depressive thinking as the major culprit in depression.9 Researchers have found that a brief course of psychotherapy is sometimes as effective as pharmacotherapy in treating major depression.10 While it may seem counterintuitive that a short-term approach would solve a long-term problem such as dysthymia, I have found that cognitive therapy can offer a cost-effective, life-sustaining contribution of lasting value.
There is an urgent need to educate primary care clinicians about the value of a brief psychotherapy approach to chronic depression. They are the first clinicians to see 75% of patients with depression. In the medical setting, patients with dysthymia most often present with physical complaints, such as fatigue and insomnia.11 When the internist or family physician does recognize dysthymia and treat it appropriately, pharmacologic approaches predominate.
Medical training guiding whom or which disorders to refer for psychotherapy is woefully lacking. Studies documenting the value of psychotherapy as a treatment for dysthymia are needed to broaden referring physicians’ options. While long-term, psychodynamic therapy for depression may sound obscure to the medical referrer, short-term cognitive therapy typically makes sense. Moreover, both consumers and managed care organizations are demanding quicker results from providers of mental health services.
LIFETIME COMORBIDITY ASSOCIATED WITH DYSTHYMIA
|Any psychiatric disorder||77.1|
|*Adapted from: Markowitz JC. Co-morbidity of dysthymia. Psychiatr Ann 1993;23(11):617-24.|
Cognitive therapy is most clearly distinguished from traditional psychodynamic psychotherapy by its focus on the present. While a cognitive therapist may believe that current thinking in the patient with dysthymia has its roots in the past, reworking the past is not seen as necessary for change to occur.