Persistent Depressive Disorder (PDD), also known as dysthymia, produces low mood and limited energy levels that negatively influence a person’s thoughts, feelings, and behaviors. According to the National Institute of Mental Health (NIMH), only about 1.3% of people in the U.S. will ever have persistent depressive disorder, but those who do will endure chronic depression.1
Because of its long-term nature, persistent depressive disorder is challenging to treat, but positive outcomes are possible with an individualized treatment plan, which may include both therapy and medication. Due to the nature of this disorder, the effectiveness and timeline of treatment is also highly individualized.
Persistent Depressive Disorder Types
The cornerstone of persistent depressive disorder is a long-term feeling of depression that continues for at least two years. Persistent depressive disorder is one condition, but it has several different types depending on the presence of symptoms linked to major depressive disorder (MDD).
Based on their level of depression, a person could have these types of persistent depressive disorder:
- With pure dysthymic syndrome. In this type of persistent depression, the mood symptoms will be significant, but they will never meet the criteria for a major depressive episode.
- With persistent major depressive episode. In this form, the person will report many significant major depressive episodes over the two-year period. Rather than improving or worsening with time, the symptoms will stay mostly constant.
- With intermittent major depressive episodes. A person with this type of persistent depressive disorder will have some major depressive episodes paired with their chronic depressive symptoms. To qualify for this type, the person needs eight weeks or more of major depression during the last two-year period.2
People with major depressive episodes connected to persistent depressive disorder will report chronic mood issues as well as major depressive disorder symptoms, such as:
- Irritability
- Problems sleeping or getting too much sleep
- Change in appetite or weight
- Lower energy
- Lower motivation
- Poor attention and ability to make decisions
- Feelings of guilt and worthlessness
- Appearing sped up or slowed down
- Intense thoughts of death and suicide2
Since a person cannot have both major depressive disorder and persistent depressive disorder at the same time, these types help to communicate the symptom levels.
PDD Specifiers
In addition to the types of persistent depression, people may experience other symptoms associated with the condition. These specifiers better describe the full range of symptoms a person experiences and include:
- Anxious distress – higher levels of anxiety and physical tension during periods of depression
- Mixed features – some periods of elevated mood, high self-esteem, and high energy that are similar to manic episodes of a bipolar disorder
- Melancholic features – extreme loss of pleasure, even when something good happens
- Atypical features – marked by high sensitivity to relationship rejection and moods that shift dramatically depending on recent events (may improve sharply with compliments and worsen with criticisms)
- Psychotic features – hearing, seeing, feeling, tasting, or smelling things that are not present or having odd, bizarre, or magical thinking patterns connected to delusions
- Peripartum features – symptoms of depression that first appear during pregnancy or within a few weeks after the baby’s birth. Peripartum onset may create high anxiety, panic, or violent behavior linked to hallucinations and delusional thinking.2
Persistent Depression Disorder in Different Populations
Persistent depressive disorder affects all types of people regardless of age and sex, but this condition affects specific groups of people differently than other depressive disorders. With a condition like MDD, for example, adolescents and young adults have the highest rates.3
In persistent depressive disorder, though, rates increase throughout adulthood. People from 45 to 59-years-old have the highest incidence of persistent depression. Then, people 60 and over report a very low rate of this condition.1
Persistent depression is similar to other depressive disorders because it tends to affect more women than men. By a rate of three to one, women note more persistent depressive disorder symptoms than men.1
What Persistent Depressive Disorder Looks Like
With persistent depressive disorder, the main feature is a low mood that does not alleviate over time.2 Many people with persistent depressive disorder will appear very sad and complain of low energy, little motivation, and limited interest in engaging in healthy or social behavior. To friends and loved ones, they will appear very negative and always “down in the dumps”.2
Because the unwanted symptoms last for two years or more with this disorder, the person may think that feeling depressed is normal. They may struggle to remember a time when they were not depressed and could find it impossible to imagine a time in the future when the depression lifts.
This level of hopelessness may be especially true for people with early onset persistent depressive disorder. With early onset, symptoms present before age 21, so a smaller proportion of the person’s life was free from depression.2
The absence or presence of major depressive episodes will also dictate that person’s presentation. Someone with persistent depressive episodes may experience severe depression that results in suicidal thoughts while someone with pure dysthymic syndrome could report milder symptoms that never relent.2
Symptoms of Persistent Depressive Disorder
The primary symptom of persistent depressive disorder is a low mood in place for most days over a two-year period for adults and a one-year period for children and adolescents.
The depressed person may also have:
- Poor appetite or strong hunger
- Getting too much or too little sleep
- Low energy and feeling fatigued
- Poor self-esteem and self-worth
- Limited concentration and decision-making
- Feeling hopeless or pessimistic about the future2
Like with other conditions, these symptoms cannot be explained by another mental or medical condition and must have an adverse impact on functioning.
Treatment of Persistent Depressive Disorder
Professional treatment can drastically improve persistent depressive disorder symptoms. Many treatment plans consist of a psychotherapy and medication management combination to reduce symptoms, improve happiness, and increase the person’s overall well-being.
Therapy
For depressive disorders, therapy involves meeting with a therapist to identify and resolve problematic symptoms. Therapists can help to accomplish many goals, including:
- Adjusting to the current symptoms or the risk of future symptom changes
- Pinpointing the triggers that increase the frequency or severity of symptoms
- Exploring negative thoughts and behaviors before working to replace them with healthier options
- Identifying positive coping skills
- Recognizing the influence of healthy and unhealthy relationships
- Establishing a sense of control and power in life to rebuild hope
- Working on establishing and completing short-term and long-term plans4
Therapists have varied backgrounds based on their education and experience. Psychotherapist is a general term and may include:
- Psychiatrists
- Psychologists
- Professional counselors
- Social workers
- Marriage and family therapists
- Addiction counselors
When a person with persistent depressive disorder begins therapy, the professional will assess the individual to determine the best course of action. Factors affecting treatment include:
- The severity and duration of symptoms
- The person’s desire to improve their well-being
- Successes and limitations of previous treatments
- The interaction of other psychological and physical health issues4
The intensity of psychotherapy can vary greatly. Depending on the treatment plan, therapy could involve multiple hours of therapy each day or only one hour of therapy per month.
The person’s symptoms will determine the appropriate modality of treatment as well. Many people will attend one-on-one therapy while others will participate in group or family therapy sessions. Appointments may transpire in an office, a school, the person’s home, virtually, or other locations in the community.
Common Type of Therapies for PDD
Therapists commonly utilize various therapeutic styles to meet the needs of their clients. The therapeutic orientations that provide good outcomes for depression include:
- Cognitive-behavioral therapy (CBT) – a therapy used for a variety of mental health conditions that aims to adjust flawed thinking and counterproductive behaviors to create feelings of happiness. By recognizing the connection between thoughts, feelings, and behaviors, CBT helps people confront their depression.
- Interpersonal therapy (IPT) – an approach that recognizes that unhealthy relationships can cause or fuel depression. IPT helps people shift their communication styles and relationships to produce more desirable results.
- Problem-solving therapy (PST) – a great therapy style for older adults. PST helps people cope with stressful events by looking for practical solutions to resolve the stress and prevent it from happening again.5
People with persistent depressive disorder may also benefit from other forms of insight-oriented therapy that help them better understand and manage their depression.6 Not all therapy types will work well for all people, so those with persistent depression should explore therapy options until they find an appropriate match.
Intended Treatment Outcome & Timeline
The ideal treatment outcome for persistent depressive disorder is complete remission of all depressive symptoms over a short amount of time. Unfortunately, by its nature, the condition is notoriously long-lasting and resistant to treatment.
A series of studies on persistent depressive disorder found that rates of remission vary greatly. One study found that less than half of people achieved symptom remission, while another study found just over 70% were symptom-free. These studies lasted anywhere between one and six years, so people with dysthymia should not expect rapidly improving symptoms.7
Although symptoms may not resolve as quickly as other conditions like major depressive disorder, persistent depressive disorder is treatable and responds well to therapy. Like other forms of depression, getting early treatment can help improve recovery.
Medication for PDD
Medication, alone or in addition to psychotherapy, can prove useful. Many medication options are available to treat persistent depressive disorder including:
- Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that help the brain access more serotonin, which limits symptoms of depression. Brand names of medications in this group include Celexa, Lexapro, Prozac, and Paxil.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) are another group of medications that interact with serotonin, but these have the added benefit of increasing norepinephrine in the brain as well. Brand names of medications in this group are Cymbalta, Effexor, Pristiq, and Fetzima.
- Atypical antidepressants are a group of drugs that do not operate in the body like SSRIs or SNRIs but still produce fewer depressive symptoms. Some examples are bupropion (Wellbutrin), mirtazapine (Remeron), and trazodone (Desyrel, Oleptro).
- Tricyclic antidepressants are an older group of antidepressants with generic names like nortriptyline, amitriptyline, and doxepin. This group requires extra attention to monitor and avoid unwanted side effects.8
- Monoamine oxidase inhibitors, known as MAOIs, are another group of older medications that may be used when newer medications are ineffective. Generic medications like tranylcypromine, phenelzine, isocarboxazid, and others from this group may trigger dangerous interactions with foods, so caution is essential.8
These medicines may not work as well as they do for other conditions like MDD, and they may also take longer to produce positive effects. Because of these issues, the person seeking treatment must practice patience and allow the medication enough time to work.6
Additional Depression Treatments
Since persistent depressive disorder is challenging to treat, even with therapy and medication, some people will explore additional depression treatments with their treatment team. Especially if someone experiences major depressive episodes with their persistent depression, they could benefit from ECT or brain stimulation therapies.
ECT (Electroconvulsive Therapy)
ECT is a procedure that involves passing electrical pulses through the brain. ECT is safe and effective for people with severe or treatment-resistant depression. To ensure comfort, the person is under anesthesia and a muscle relaxer. The side effects of ECT include temporary confusion and memory loss.
rTMS (Repetitive Transcranial Magnetic Stimulation)
rTMS uses magnets instead of electricity to improve depressive symptoms. The FDA approved this treatment in 2008 when medication treatments proved ineffective.5
VNS (Vagus Nerve Stimulation)
VNS is a seizure treatment that may be effective for people with depression as well. VNS involves implanting a medical device under the skin to send electrical signals (VN9). The FDA approved VNS for people whose depression lasts more than two years.5
Someone wanting to pursue these options for depression should consult their treatment team to better explore the risks and benefits for their unique situation. VNS and rTMS are still being studied to confirm efficacy.
Lifestyle Changes
Professional mental health treatments, including therapy and medication, are the best ways to address persistent depressive disorder, but efforts to limit the condition should not end there.
A person can also engage in healthy lifestyle changes, such as:
- Making enough time for sleep
- Setting a healthy diet by limiting sugar and increasing vegetables
- Adding regular exercise like walking, swimming, or weight training
- Finding activities that increase happiness and energy levels
- Spending time with people who are trustworthy and supportive
- Limiting alcohol and other drugs as these will only increase symptoms of depression in the long-term
- Taking medications as directed to ensure the proper amount is in the system 6
Perhaps the most important lifestyle change is maintaining hope. Without hope, the person may feel discouraged and fail to follow through on the professional and lifestyle changes needed. Talking to others about depression in a support group is a great way to build a support network to keep hope alive.6
How to Get Help for Persistent Depressive Disorder
If you regularly feel depressed or you notice depression increasing, it is time to get help. Fortunately, there are many ways to access effective, professional treatment for persistent depressive disorder.
These include:
- Talking to a friend or family member who has experience with therapy or medication
- Consulting with your primary care physician or another doctor for advice, referrals, or recommendations
- Calling a hotline that specializes in depression and suicide prevention
- Contacting your insurance company for available treatment providers in the area
- Going to the nearest mental health agency to seek an evaluation
Waiting will not make symptoms better. Seek help soon.
How to Get Help for a Loved One
Assisting a loved one in getting help for depression can be confusing and scary, but it does not have to be. When working to aid a loved one, it is valuable to always focus on your concern for the other person. At times, seeing someone you care for struggle with a mental health condition can trigger anger, hostility, and frustration, but these feelings only stand in the way of your loved one accessing treatment.
To speed the treatment process along, consider:
- Talking to your loved one about your concerns
- Giving support and encouragement for their healthy choices
- Letting them know that treatment can work
- Offering to drive them or sit in on their appointments
- Helping them put their thoughts and feelings into words
- Listening to their issues without judgment5
How to Get Help for a Child with PDD
If your child seems to show signs and symptoms of any depressive disorder, get help immediately. Do not wait for symptoms to worsen.
Call your child’s pediatrician for a depression screening or schedule an appointment with a trusted or reputable mental health professional to begin the treatment process.
Whether your loved one is an adult or child, always practice caution when it comes to suicide. If someone makes suicidal statements or actions, call 9-1-1 immediately to get them the professional help they need.
Persistent Depressive Disorder & Depressed Episode Statistics
Persistent depressive disorder is not studied as much as MDD, but experts found:
- Between 1.3% and 1.5% of adults in the U.S. experience persistent depressive disorder
- About 1% of males and 3% of females will have persistent depression
- 2.3% of people ages 45 to 59 have dysthymia, which is the highest level for any age range
- Nearly 50% of people with persistent depressive disorder feel the condition “seriously impairs” their life
- About 75% of people with dysthymia also experienced a major depressive episode, a combination called “double depression”
- People with dysthymia have an increased risk of losing their job based on a study that found 14% of people with the condition were newly unemployed5
Persistent Depressive Disorder Diagnosis History
Compared to other depressive conditions, persistent depressive disorder is a relatively new mental health diagnosis. In 2013, the American Psychiatric Association (APA) released its current diagnosing guidelines in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). In it, they combined two separate conditions into persistent depressive disorder.2
In previous versions of the DSM, the APA listed a condition called dysthymic disorder and another called chronic major depression. Persistent depressive disorder replaces both conditions, so if someone previously had dysthymic disorder or chronic major depression, they now have persistent depressive disorder.2
Living with Persistent Depressive Disorder: Coping & Managing Symptoms
Learning to live with persistent depression is essential since the likelihood of total recovery is low. Though they are not replacements for professional treatments, coping skills can help lessen the influence of depression.
Some of the best healthy coping skills are:
- Remaining focused on your goals without letting setbacks deter you
- Streamlining your life by creating a schedule and routine to organize your day
- Starting a journal to express your thoughts and track your symptoms and triggers
- Reducing stress with help from loved ones and mental health professionals
- Connecting yourself to the people and activities you love4
People should be careful to seek out positive coping skills and avoid negative ones. Positive coping skills may result in short-term discomfort but long-term benefits, while the opposite is true with negative coping skills. Using alcohol and other drugs to cope with depression is an example of a negative coping skill because they only make symptoms worse with time.
Persistent Depressive Disorder vs. Other Conditions
Persistent depressive disorder may masquerade as other mental health disorders due to the overlap of several symptoms.
PDD vs. Other Depressive Disorders
Persistent depressive disorder may present as major depressive disorder or other depressive disorders. The most important determining factor is the duration of symptoms. If the depression consistently lasts for two years or more, the condition is likely persistent depression.2
PDD vs. Psychotic Disorders
Some psychotic disorders like schizophrenia, schizoaffective disorder, and delusional disorder can be confused with persistent depression because of the long-term nature of symptoms. Professionals will inspect the intensity and duration of psychotic symptoms to determine the current diagnosis.2
PDD vs. Substance Use Disorders
The interaction of depression and substance use is complicated since people may self-medicate their mental health with drugs. Additionally, substance abuse and withdrawal may produce the signs and symptoms of persistent depression. Because drugs and alcohol can confuse the clinical presentation of symptoms, the real cause of the depression can best be determined once substance use concludes.2
PDD vs. Personality Disorders
Like persistent depressive disorders, personality disorders are long-term mental health conditions that significantly impact a person’s life. Separating the depression from the personality disorder can be challenging, especially since symptoms from both conditions tend to emerge in early adulthood.2
PDD and Co-Occurring Disorders
At times, persistent depression will occur with another mental health condition simultaneously. Conditions like anxiety and substance use disorders commonly co-occur with persistent depressive disorder.
A number of personality disorders are linked to dysthymia, including:
- Antisocial personality disorder
- Borderline personality disorder
- Histrionic personality disorder
- Narcissistic personality disorder
- Avoidant personality disorder
- Dependent personality disorder2
The risk of a personality disorder co-occurring with persistent depressive disorder increases for those with an early onset of depression. 2
Depression Tests, Quizzes, and Self-Diagnosis Tools
Many people explore information online to find a diagnosis that explains their condition. In the case of persistent depressive disorder, people should avoid this practice because the symptoms overlap with many other conditions. Only a trained mental health expert can make the appropriate diagnosis.
Mental Health Evaluation
To determine a person’s diagnosis, a mental health professional completes a thorough evaluation by gathering information about current and past symptoms, triggers, trauma, substance use, and family medical history. They will compare the information with diagnostic criteria listed in the DSM to draw a conclusion2.
Currently, there are no blood tests, brain scans, or other measures to otherwise diagnose this mental health condition.5
Online Quizzes and Self-Diagnosis
Though people have good intentions by trying to diagnose themselves or their loved ones using online quizzes, the practice should be avoided. These “tools” may needlessly create fear or a false sense of security. Even with mental health experience, people struggle to objectively view their symptoms, so the practice is best left to professionals.
Additional Resources for Depressive Disorders
For more information about depression, please refer to these organizations:
