Psych · General adult psychiatry — mood disorders
Persistent depressive disorder (dysthymia)
Also known as Dysthymia · Dysthymic disorder · Chronic depression · Double depression · PDD · Persistent depressive disorder · Chronic major depression
Exam-exhaustive fellowship reference on persistent depressive disorder (dysthymia) — DSM-5-TR consolidation of dysthymia and chronic major depression, double depression, 2-year duration rules, Klein longitudinal course, antidepressant and CBASP evidence (Keller, Levkovitz, Cuijpers), stepped care with RANZCP/NICE/APA/CANMAT deltas. FRANZCP-primary, globally tagged.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- Active suicidal ideation, plan or attempt on a chronic dysthymic background — treat acuity with full intensity; chronic baseline is not reassurance
- Double depression (superimposed major depressive episode) with food/fluid refusal, psychosis or catatonia — urgent escalation; consider ECT pathway
- New or worsening suicidality after starting or increasing an antidepressant — same-day review for activation, akathisia and care intensity
- Prior hypomania/mania or mixed features — do not manage as uncomplicated unipolar PDD with antidepressant monotherapy
- Calling years of syndromal depression 'personality' and withholding evidence-based treatment
- Elderly patient with confusion or falls on SSRI — check sodium; hyponatraemia is a classic trap
Meet the patient
A 41-year-old accountant sits down and says the sentence you will hear a thousand times: "I've always been like this." No crisis. No admission. He has worked every day for nineteen years and enjoyed almost none of them.[3][9]
His GP letter says "low mood, likely personality." His PHQ-9 today is 11 — the same as it was two years ago, and four years before that. He has taken sertraline 25 mg twice: once for three weeks, once for nine days.[4][13]
Two questions decide this consultation. How long, and were there any real gaps? Get those right and the rest of the topic writes itself.[3][9]
References16ShowHide
- [1]Keller MB, McCullough JP, Klein DN, Arnow B, et al. 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.PMID 10816183
- [2]Schatzberg AF, Rush AJ, Arnow BA, Banks PL, et al. Chronic depression: medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not Arch Gen Psychiatry, 2005.PMID 15867104
- [3]Klein DN, Shankman SA, Rose S Ten-year prospective follow-up study of the naturalistic course of dysthymic disorder and double depression Am J Psychiatry, 2006.PMID 16648329
- [4]Thase ME, Fava M, Halbreich U, Kocsis JH, et al. A placebo-controlled, randomized clinical trial comparing sertraline and imipramine for the treatment of dysthymia Arch Gen Psychiatry, 1996.PMID 8792754
- [5]Keller MB, Gelenberg AJ, Hirschfeld RM, Rush AJ, et al. The treatment of chronic depression, part 2: a double-blind, randomized trial of sertraline and imipramine J Clin Psychiatry, 1998.PMID 9862606
- [6]Levkovitz Y, Tedeschini E, Papakostas GI Efficacy of antidepressants for dysthymia: a meta-analysis of placebo-controlled randomized trials J Clin Psychiatry, 2011.PMID 21527126
- [7]Imel ZE, Malterer MB, McKay KM, Wampold BE A meta-analysis of psychotherapy and medication in unipolar depression and dysthymia J Affect Disord, 2008.PMID 18456340
- [8]Cuijpers P, van Straten A, Schuurmans J, van Oppen P, et al. Psychotherapy for chronic major depression and dysthymia: a meta-analysis Clin Psychol Rev, 2010.PMID 19781837
- [9]Schramm E, Klein DN, Elsaesser M, Furukawa TA, et al. Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications Lancet Psychiatry, 2020.PMID 32828168
- [10]Malhi GS, Bell E, Bassett D, Boyce P, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391
- [11]Kennedy SH, Lam RW, McIntyre RS, Tourjman SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments Can J Psychiatry, 2016.PMID 27486148
- [12]Parikh SV, Quilty LC, Ravitz P, Rosenbluth M, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 2. Psychological Treatments Can J Psychiatry, 2016.PMID 27486150
- [13]Kroenke K, Spitzer RL, Williams JB The PHQ-9: validity of a brief depression severity measure J Gen Intern Med, 2001.PMID 11556941
- [14]Geddes JR, Carney SM, Davies C, Furukawa TA, et al. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review Lancet, 2003.PMID 12606176
- [15]Cipriani A, Furukawa TA, Salanti G, Chaimani A, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis Lancet, 2018.PMID 29477251
- [16]Cuijpers P, Quero S, Noma H, Ciharova M, et al. Psychotherapies for depression: a network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types World Psychiatry, 2021.PMID 34002502