Persistent Depressive Disorder (PDD), also known as dysthymia, is characterized by low mood and limited energy levels that negatively influence a person’s thoughts, feelings, and behaviors. 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, likely including both therapy and medication.
What Is Persistent Depressive Disorder?
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 and specifiers depending on the presence of symptoms linked to major depressive disorder (MDD).
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
How Is Persistent Depressive Disorder Diagnosed?
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 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to draw a conclusion.2
Symptoms of Persistent Depressive Disorder
The primary symptom of persistent depressive disorder is a low mood for most days over a two-year period for adults and a one-year period for children and adolescents.
Other symptoms of dysthymia may include:2
- 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 future
Like with other conditions, these symptoms cannot be explained by another mental or medical condition and must have an adverse impact on functioning.
Types of Persistent Depressive Disorder
Based on their level of depression, a person could have these types of persistent depressive disorder:
- With pure dysthymic syndrome, the mood symptoms will be substantial, but they will never meet the criteria for a major depressive episode.
- With persistent major depressive episodes, the person will report many severe 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 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
About 75% of people with dysthymia also experienced a major depressive episode, a combination called “double depression.”
What Persistent Depressive Disorder Looks Like
The main feature of PDD 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.
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 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.3
Persistent Depressive Disorder in Children & Teens
The condition is rarer in children and teens. In fact, anyone with persistent depressive symptoms before age 21 is considered to have “early onset.” This group presents with more irritability and intense levels of hopelessness as a smaller proportion of their life is free from depression.2 Children and teens with this condition are more likely to note symptoms of personality disorders and substance use disorders as well.
Persistent Depressive Disorder in Men
As with other depressive disorders, men are more likely than women to present with anger and irritability. They may push people away, socially isolate, and dedicate more energy towards work. Rather than seeking assistance and aid from support or professionals, they will blame others and turn towards substance use as a method of coping. 7
Persistent Depressive Disorder in Women
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 do men. Women with the condition will likely show many typical depressive symptoms including low mood, tearfulness, hopelessness, poor self-worth, and fatigue.1
Persistent Depressive Disorder in Older Adults
In persistent depressive disorder, rates increase throughout adulthood. People aged 45 to 59 have the highest incidence of persistent depression.1 Their symptoms may be challenging to identify because they could mirror the expected experiences of aging. They will have low energy, low motivation, and poor concentration.
Treatment of Persistent Depressive Disorder
Professional treatment can drastically improve symptoms of persistent depressive disorder. Many treatment plans consist of a combination of psychotherapy and medication 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 by pinpointing the triggers, exploring negative thoughts, identifying positive coping skills, and working on completing short- and long-term plans.4
Therapists commonly utilize various therapeutic styles to meet the needs of their clients. The therapeutic orientations that provide good outcomes for depression include:5
- Cognitive-behavioral therapy (CBT) is used for a variety of mental health conditions that aims to adjust flawed thinking and counterproductive behaviors to create feelings of happiness.
- Interpersonal therapy (IPT) helps people shift their communication styles and relationships to produce more desirable results.
- Problem-solving therapy (PST) is 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 occurring.
Although symptoms may not resolve as quickly as other conditions, persistent depressive disorder is treatable and typically responds well to therapy. One study found that fewer than half of people achieved remission of symptoms, while a different study found just over 70% were symptom-free. These studies lasted between one and six years, so people with dysthymia should not expect rapid improvement.7
Medication for PDD
Medication, alone or in addition to psychotherapy, can prove useful. Many medication options are available to treat persistent depressive disorder, including:8
- Selective serotonin reuptake inhibitors (SSRIs) 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) have the added benefit of increasing norepinephrine in the brain as well as serotonin. Brand names of medications in this group are Cymbalta, Effexor, Pristiq, and Fetzima.
- Atypical antidepressants produce fewer depressive symptoms, and include 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.
- Monoamine oxidase inhibitors (MAOIs) may be used when newer medications are ineffective. Generic options include tranylcypromine, phenelzine, and isocarboxazid.
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. Someone 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 electroconvulsive therapy (ECT) or brain stimulation therapies.
ECT
ECT is a procedure that involves passing electrical pulses through the brain. It is safe and effective for people with severe or treatment-resistant depression. To ensure comfort, the person is under anesthesia and given a muscle relaxant. The adverse effects of ECT may 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. It 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 specific 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.
To improve symptoms of dysthymia, these lifestyle changes could also help:6
- 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
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.
To find the right treatment for Persistent Depressive Disorder, try:
- Talking to a friend or family member who has experience with therapy or medication
- Using an online directory to choose the right therapist for you
- 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 challenging 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 vs. Other Conditions
Persistent depressive disorder may present similarly to other mental health disorders due to the overlap of several symptoms.
PDD vs. Psychotic Disorders
Some psychotic disorders like schizophrenia, schizoaffective disorder, brief psychotic 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 misuse 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 misuse is ruled out.2
PDD vs. Personality Disorders
Like persistent depressive disorders, personality disorders are long-term mental health conditions that 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 & 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:2
- Antisocial personality disorder
- Borderline personality disorder
- Histrionic personality disorder
- Narcissistic personality disorder
- Avoidant personality disorder
- Dependent personality disorder
The risk of a personality disorder co-occurring with persistent depressive disorder increases for those with an early onset of depression.2
Final Thoughts on Dysthymia
Dysthymia, or persistent depressive disorder, is a problematic mental health condition due to its intensity and duration. Although the condition may be more complicated to treat than other depressive disorders, people with the condition can progress to a state of hope and happiness with a treatment plan aimed at the entire person, not just their diagnosis.
