Anxiety & Mood
Dysthymia: what it is, symptoms and treatment
Dysthymia, or persistent depressive disorder, explained: the symptoms, “double depression”, how it develops over time and what treatment studies show.
Dysthymia is a chronic form of depression: low mood on most days for at least two years, with symptoms that are usually milder than in major depression but persistent. Today DSM-5 includes it in “persistent depressive disorder”. Because it lasts for years, it often goes unnoticed until it gets worse. It can be treated, and the combination of psychotherapy and medication has shown the best results.
What the word means
The word is Greek: “dys-”, meaning bad or difficult, and “thymos”, in its old sense of soul and mood. In DSM-5, dysthymia and chronic major depression were merged into one diagnosis, persistent depressive disorder. The term covers [1]:
dysthymia, with or without episodes of major depression on top of it,
chronic major depression,
recurrent depression without full recovery between episodes.
Symptoms
A diagnosis of persistent depressive disorder requires [1][2]:
low mood for most of the day, on most days, for at least 2 years (1 year in children and teenagers),
at least two of the following: poor appetite or overeating, insomnia or sleeping too much, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, hopelessness,
during these two years, no period without symptoms longer than 2 months.
Because the symptoms are usually milder, dysthymia does not always look like deep sadness. It can look like a grey background: tiredness, self-criticism, pessimism, little joy.
Dysthymia rarely sounds dramatic. Some people describe it simply: “my life is monotonous”. And the thought “I have always been like this, I will always be like this” feels true, because the mood has been low for years. But it is a negative filter: “because it happened in the past, it will happen in the future”. This filter is something we work on in therapy.
Dysthymia or depression? “Double depression”
Duration: dysthymia, at least 2 years; an episode of major depression, at least 2 weeks.
Symptoms: dysthymia, low mood and at least 2 more; major depression, at least 5, including low mood or loss of interest [2][3].
Intensity: dysthymia, usually milder but persistent; major depression, more intense.
When an episode of major depression comes on top of dysthymia, we speak of “double depression”. Often only then is the dysthymia recognised, because on its own it is hard to spot, even in the doctor’s office.
How common it is
In a national survey in Australia, with interviews in 8,841 households, 4.6% had at some point experienced depression lasting at least two years. That was almost 3 in 10 (29.4%) of those who had ever had a depressive disorder [5].
According to DSM-5-TR, as quoted by the medical database StatPearls, within a year about 0.5% of the population have dysthymia and about 1.5% chronic major depression [1].
What causes it
The causes are not fully known. A 2020 review notes that the evidence is limited and that many factors probably contribute together [4]. In the Australian survey, chronic depression was linked with earlier onset, more frequent episodes and other co-occurring mental disorders. The first episode had often followed the death of someone close [5].
How it develops over time
One study followed 97 adult patients with early-onset dysthymia for 10 years [6]:
an estimated 73.9% recovered at some point, with a median time to recovery of 52 months, that is, more than four years,
among those who recovered, the risk of chronic depression returning was estimated at 71.4%,
compared with people with non-chronic depression, they improved more slowly and had more symptoms at 10 years.
In plain words: dysthymia usually eases, but slowly, and it often comes back. That is why treatment needs time, and a plan for after the improvement as well.
What helps
Psychotherapy. In an analysis of 16 randomised trials on chronic depression and dysthymia, psychotherapy had a small but clear benefit compared with control groups. The best results were seen with at least 18 sessions. In patients with dysthymia, psychotherapy on its own was less effective than antidepressants [7].
Medication. In an analysis of 20 studies, most of them in patients with dysthymia, both selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants were effective compared with placebo, with similar results. With SSRIs, fewer patients stopped treatment [8].
Combination. In the same analysis of 16 trials, combining psychotherapy and medication was more effective than medication alone, and even more so than psychotherapy alone [7].
Medication is changed or stopped only with the doctor who follows your care, never on your own.
I present the options, that is psychotherapy, medication or a combination, and we decide together, with specific next steps and a set time to review. In psychotherapy we do not wait for the motivation to come first: we start with small, planned activities, because action comes before mood.
“I have tried everything”
Because dysthymia lasts for years, many people have already tried some treatment before they come.
When someone tells me they have “tried everything”, we first check whether previous attempts lasted long enough and used an adequate dose, before calling them failures. Sometimes not everything needs to change, just one targeted addition.
When to ask for help
Your mood has been low on most days for a long time, even if you are “functioning”.
You feel constantly tired, with low self-esteem or pessimism.
On top of this background, a period of heavier depression has come.
You have had treatment without seeing a change.
Safety: If you have thoughts that life is not worth living or thoughts of harming yourself, ask for help immediately: 166 (ambulance, EKAV), 112, or the Suicide Prevention Line 1018.
How I can help
Book a psychiatric assessment, at the practice in Trikala or online. See the page on depression treatment and the article on depression symptoms in adults. Treatment can also take place by video call, including for patients outside Greece where the applicable requirements allow: see how working with an online psychiatrist works, or book an appointment.
This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.
Sources
Patel RK, Aslam SP, Rose GM. Persistent Depressive Disorder. StatPearls, NCBI Bookshelf. Last updated 11 August 2024. https://www.ncbi.nlm.nih.gov/books/NBK541052/
National Institute of Mental Health. Depression. Revised 2024. https://www.nimh.nih.gov/health/publications/depression
Chand SP, Arif H. Depression. StatPearls, NCBI Bookshelf. Last updated 17 July 2023. https://www.ncbi.nlm.nih.gov/books/NBK430847/
Schramm E, et al. Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications. Lancet Psychiatry. 2020. https://doi.org/10.1016/S2215-0366%2820%2930099-7
Murphy JA, Byrne GJ. Prevalence and correlates of the proposed DSM-5 diagnosis of Chronic Depressive Disorder. J Affect Disord. 2012. https://doi.org/10.1016/j.jad.2012.01.033
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. https://doi.org/10.1176/ajp.2006.163.5.872
Cuijpers P, et al. Psychotherapy for chronic major depression and dysthymia: a meta-analysis. Clin Psychol Rev. 2010. https://doi.org/10.1016/j.cpr.2009.09.003
von Wolff A, et al. Selective serotonin reuptake inhibitors and tricyclic antidepressants in the acute treatment of chronic depression and dysthymia: a systematic review and meta-analysis. J Affect Disord. 2013. https://doi.org/10.1016/j.jad.2012.06.007
