What is Low-Grade Depression or Dysthymia?

by Yoho | Nov 27, 2019 | Depression, Dysthymia, Major Depression | 0 comments

Home » What is Low-Grade Depression or Dysthymia?

Dysthymia, or persistent depressive disorder, is a mental health condition that is often undetected
and untreated. Dysthymia is a continuous long-term (chronic) or low-grade type of depression.
Because of the nature of this mental health condition, people may not even realize that they have it.
Sometimes called high-functioning depression, it is estimated the approximately 1.5% of the U.S.
adult population are affected by dysthymia. Roughly 50 percent of the cases are
considered severe with 31 years old being the average age of onset.
A condition like dysthymia is difficult to identify due to the fact the people with this type of
depression may not realize that they are depressed. The “low-grade” nature of this illness makes
many people feel like this is normal everyday behavior. People think this is normal, when in reality
their feelings and emotions may not be normal. Instead, they pretend that everything is okay or fine.
What are the Causes and Symptoms of Dysthymia?
Precisely what causes this type of depression to develop is still a mystery. Most likely, much like
major depressive disorder, there are likely many contributing factors. Some of the most likely
factors include:
 People’s genetic predisposition:  individuals are at an elevated risk for depression if they
have relatives who have been diagnosed with a depressive disorder.
 Environmental Influences:  traumatic events, financial issues and overall high levels of
everyday stress.
 Personality traits:  People with low self-esteem, pessimistic attitude and self-critical view of
themselves.
 People with persistent depressive disorder (dysthymia), may lose interest in everyday activities and
feel hopeless and unproductive. These feelings of inadequacy can last for many years and could
significantly interfere with a person’s relationships, school and work activities. Persistent depressive
disorder is not as severe as major depression, people’s depressed moods can range from mild,
moderate or even severe.
This type of depression can wax and wane over the years with the intensity changing over time.
Amazingly, major depression episodes can even occur before or during persistent depressive
disorder. An occurrence that is sometimes called double depression.
Dysthymia can occur in short episodes as well as be separated by considerable spans of time. A fact
to keep in mind when attempting to identify symptoms. There is a chance that dysthymia could exist
if people are in a depressed mood on most days, with these feelings lingering for more than two
years without at least two months of interruption. Often, dysthymia is accompanied by some of the
following symptoms:
 Overeating or loss of appetite with changes in weight.
 Insomnia or sleeping too much.
 Fatigue, trouble concentrating and difficulty making decisions.
 Low self-esteem accompanied by feelings of hopelessness.
 Loss of enjoyment in doing favorite activities.
Sometimes older adults, especially men, may experience issues the can trigger dysthymia, such as
medical problems, social isolation, or new medications. Sometimes even a severe cold or injury can
create an episode of depression. Whether young or old, if conditions like dysthymia are left
untreated, it can have a negative impact on a person’s life.
For example, people may not form lasting friendships, romantic relationships or perform well at work.
Low-grade, persistent depression is also linked to a higher risk of cardiovascular disease. Conditions
like dysthymia can even make pre-existing conditions worse, like diabetes and high blood pressure.
Even a person’s chances of developing a major depressive disorder and increased. Researchers
have found that roughly 75 percent of people who are diagnosed with dysthymia will also have an
episode of major depression.
Professional Psychiatric Help:
Individuals should seek help from trained and experienced mental health professionals. Just going it
alone and faking it until they feel better, is not the best option. In fact, people suffering from
dysthymia may attempt to self-medicate with drugs or other substances. They may think that they
feel better, but this is a dangerous approach. They may make things worse by creating a cycle
of addiction. This occurs due to the fact that overtime, self-medicating behavior can easily spiral into
drug or substance abuse type behavior.
Because of the chronic nature of persistent depressive disorder, coping with depression symptoms
is sometimes challenging. However, a combination of talk therapy (psychotherapy) and medication is
usually effective in treating this condition.
Proper medication management is a critical aspect of many mental health treatment programs.
These programs include medical monitoring, reconciling medications as well as ensuring that
patients achieve beneficial outcomes from their treatments. Patients need to understand any
possible side effects and have a mental health professional monitor the program’s safety and
efficacy.
For More Information:
For more information about dysthymia or other behavioral health conditions, contact the staff at
Emerald Psychiatry & TMS Center. Their psychiatry practice is focused on providing experienced
and professional treatment options.
Emerald Psychiatry & TMS Center understand that they are here to serve the needs and concerns of
their patients. By forming a trusting partnership with their patients, Emerald Psychiatry generates a
comprehensive treatment plan that is customized to an individual’s needs. Their direct phone
number is (614) 580-6917.

Dysthymia (Mild, Chronic Depression)

Dysthymia, sometimes referred to as mild, chronic depression, is less severe and has
fewer symptoms than major depression. With dysthymia, the depression symptoms can
linger for a long period of time, often two years or longer. Those who suffer from dysthymia
can also experience periods of major depression--sometimes called "double depression."
In modern diagnostic classification systems, dysthymia and chronic depression are now
both referred to as persistent depressive disorder.

What Causes Dysthymia?

Experts are not sure what causes dysthymia or depression. Genes may play a role, but
many affected people will not have a family history of depression, and others with family
history will not have depression problems. Abnormal functioning in brain circuits or nerve
cell pathways that connect different brain regions regulating mood are also thought to be
involved. Major life stressors, chronic illness, medications, and relationship or work
problems may also increase the chances of dysthymia in people biologically predisposed
to developing depression.

What Are the Signs and Symptoms of Dysthymia?

The symptoms of dysthymia are the same as those of major depression but fewer in
number and not as intense. They include the following:

 Sadness or depressed mood most of the day or almost every day

 Loss of enjoyment in things that were once pleasurable
 Major change in weight (gain or loss of more than 5% of weight within a month) or appetite
 Insomnia or excessive sleep almost every day
 Being physically restless or rundown in a way that is noticeable by others
 Fatigue or loss of energy almost every day
 Feelings of hopelessness or worthlessness or excessive guilt almost every day
 Problems with concentration or making decisions almost every day
 Recurring thoughts of death or suicide, suicide plan, or suicide attempt

Is Dysthymia Common in the U.S.?

According to the National Institute of Mental Health, approximately1.5% of adult
Americans are affected by dysthymia. While not as disabling as major depression,
dysthymia can keep you from feeling your best and functioning optimally. Dysthymia can
begin in childhood or in adulthood and seems to be more common in women.
How Is Dysthymia Diagnosed?
A mental health specialist generally makes the diagnosis based on the person's
symptoms. In the case of dysthymia, these symptoms will have lasted for a longer period
of time and be less severe than in patients with major depression.
With dysthymia, your doctor will want to make sure that the symptoms are not a result of a
physical condition, such as hypothyroidism.
If you are depressed and have had depressive symptoms for more than two weeks, see
your doctor or a psychiatrist. Your provider will perform a thorough medical evaluation,
paying particular attention to your personal and family psychiatric history.
There is no blood, X-ray or other laboratory test that can be used to diagnose dysthymia.

How Is Dysthymia Treated?

While dysthymia is a serious illness, it’s also very treatable. As with any chronic illness,
early diagnosis and medical treatment may reduce the intensity and duration of symptoms
and also reduce the likelihood of developing an episode of major depression.
To treat dysthymia, doctors may use psychotherapy (talk therapy), medications such
as antidepressants, or a combination of these therapies. Often, dysthymia can be treated
by a primary care physician.

What Is Psychotherapy?
Psychotherapy (or talk therapy) is used in dysthymia and other mood disorders to help the
person develop appropriate coping skills for dealing with everyday life and challenging
erroneous negative beliefs about oneself. Psychotherapy can also help increase
adherence with medication and healthy lifestyle habits, as well as help the patient and
family understand the mood disorder. You may benefit from one-on-one therapy, family
therapy, group therapy, or a support group with others who live with chronic depression.

How Do Antidepressants Help Ease Dysthymia?

There are different classes of antidepressants available to treat dysthymia. Your doctor will
assess your physical and mental health, including any other medical condition, and then
find the antidepressant that is most effective with the least side effects.
Antidepressants may take several weeks to work fully. They should be taken for at least
six to nine months after an episode of depression. In addition, it sometimes may take
several weeks to safely discontinue an antidepressant, so let your doctor guide you if you
choose to stop the drug.
Sometimes antidepressants have uncomfortable side effects. That’s why you have to work
closely with your doctor to find the antidepressant that gives you the most benefit with the
least side effects.
 What Else Can I Do to Feel Better?
Getting an accurate diagnosis and effective treatment is a major step in feeling better with
chronic depression. In addition, ask your doctor about the benefits of healthy lifestyle
habits such as eating a well-balanced diet, getting regular exercise, avoiding alcohol
and smoking, and being with close friends and family members for strong social support.
These positive habits are also important in improving mood and well-being.

Can Dysthymia Worsen?

It’s not uncommon for a person with dysthymia to also experience an episode ofmajor
depression at the same time. This is called double depression. That’s why it’s so important
to seek an early and accurate medical diagnosis. Your doctor can then recommend the
most effective treatment to help you feel yourself again.
WebMD Medical Reference Reviewed by Jennifer Casarella on September 27, 2020

Persistent depressive disorder (dysthymia)

 Symptoms & causes
 Diagnosis & treatment

Print
Diagnosis

If your doctor suspects you have persistent depressive disorder, exams and tests may
include:

 Physical exam. The doctor may do a physical exam and ask in-depth questions about
your health to determine what may be causing your depression. In some cases, it may be
linked to an underlying physical health problem.

 Lab tests. Your doctor may order lab tests to rule out other medical conditions that may
cause depressive symptoms. For example, your doctor may order a blood test to find out if
your thyroid is underactive (hypothyroidism).

 Psychological evaluation. This includes discussing your thoughts, feelings and

behavior and it may include a questionnaire to help pinpoint a diagnosis. This evaluation
can help determine if you have persistent depressive disorder or another condition that
can affect mood, such as major depression, bipolar disorder or seasonal affective
disorder.

For a diagnosis of persistent depressive disorder, the main indication for an adult differs
somewhat from that of a child:
  For an adult, depressed mood occurs most of the day for two or more years

 For a child, depressed mood or irritability occurs most of the day for at least one year

Symptoms caused by persistent depressive disorder can vary from person to person.
When persistent depressive disorder starts before age 21, it's called early onset; if it
starts at age 21 or older, it's called late onset.

Treatment

The two main treatments for persistent depressive disorder are medications and talk
therapy (psychotherapy). The treatment approach your doctor recommends depends on
factors such as:

 Severity of your symptoms

 Your desire to address emotional or situational issues affecting your life

 Your personal preferences

 Previous treatment methods

 Your ability to tolerate medications

 Other emotional problems you may have

Psychotherapy may be the first recommendation for children and adolescents with
persistent depressive disorder, but that depends on the individual. Sometimes
antidepressants are also needed.

Medications

The types of antidepressants most commonly used to treat persistent depressive

disorder include:

 Selective serotonin reuptake inhibitors (SSRIs)

 Tricyclic antidepressants (TCAs)

 Serotonin and norepinephrine reuptake inhibitors (SNRIs)

Talk with your doctor or pharmacist about possible side effects.

Finding the right medication

You may need to try several medications or a combination before you find one that
works. This requires patience, as some medications take several weeks or longer for full
effect and for side effects to ease as your body adjusts.

Don't stop taking an antidepressant without talking to your doctor — your doctor can
help you gradually and safely decrease your dose. Stopping treatment abruptly or
missing several doses may cause withdrawal-like symptoms, and quitting suddenly may
cause a sudden worsening of depression.

When you have persistent depressive disorder, you may need to take antidepressants
long term to keep symptoms under control

Antidepressants and pregnancy

If you're pregnant or breast-feeding, some antidepressants may pose an increased

health risk to your unborn baby or nursing child. Talk to your doctor if you become
pregnant or are planning on becoming pregnant.

FDA alert on antidepressants

Although antidepressants are generally safe when taken as directed, the FDA requires
all antidepressants to carry a black box warning, the strictest warning for prescriptions.
In some cases, children, teens and young adults under 25 may have an increase in
suicidal thoughts or behavior when taking antidepressants, especially in the first few
weeks after starting or when the dose is changed.

Anyone taking an antidepressant should be watched closely for worsening depression

or unusual behavior, especially when first beginning a new medication or with a change
in dosage. If your teen has suicidal thoughts while taking an antidepressant,
immediately contact your doctor or get emergency help.

Keep in mind that antidepressants are more likely to reduce suicide risk in the long run
by improving mood.
 Psychotherapy

Psychotherapy is a general term for treating depression by talking about your condition
and related issues with a mental health professional. Psychotherapy is also known as
talk therapy or psychological counseling.

Different types of psychotherapy, such as cognitive behavioral therapy, can be effective

for persistent depressive disorder. You and your therapist can discuss which type of
therapy is right for you, your goals for therapy and other issues, such as the length of
treatment.

Psychotherapy can help you:

 Adjust to a crisis or other current difficulty

 Identify issues that contribute to your depression and change behaviors that make it
worse

 Identify negative beliefs and behaviors and replace them with healthy, positive ones

 Find better ways to cope and solve problems

 Explore relationships and experiences, and develop positive interactions with others

 Regain a sense of satisfaction and control in your life and help ease depression
symptoms, such as hopelessness and anger

 Learn to set realistic goals for your life

More Information

 Cognitive behavioral therapy

 Psychotherapy
Request an Appointment at Mayo Clinic

Lifestyle and home remedies

Persistent depressive disorder generally isn't a condition that you can treat on your own.
But, in addition to professional treatment, these self-care steps can help:
  Stick to your treatment plan. Don't skip psychotherapy sessions or appointments, and
even if you're feeling well, don't skip your medications. Give yourself time to improve
gradually.

 Learn about persistent depressive disorder. Education about your condition can

empower you and motivate you to stick to your treatment plan. Encourage your family to
learn about the disorder to help them understand and support you.

 Pay attention to warning signs. Work with your doctor or therapist to learn what might
trigger your symptoms. Make a plan so that you know what to do if symptoms get worse or
return. Contact your doctor or therapist if you notice any changes in symptoms or how you
feel. Consider involving family members or friends to watch for warning signs.

 Take care of yourself. Eat healthy, be physically active and get plenty of sleep.
Consider walking, jogging, swimming, gardening or another activity that you enjoy.
Sleeping well is important for both your physical and mental well-being. If you're having
trouble sleeping, talk to your doctor about what you can do.

 Avoid alcohol and recreational drugs. It may seem like alcohol or drugs lessen
depression-related symptoms, but in the long run they generally worsen depression and
make it harder to treat. Talk with your doctor or therapist if you need help dealing with
alcohol or drug use.

Alternative medicine

Make sure you understand the risks as well as possible benefits if you pursue
alternative or complementary therapy. Avoid replacing conventional medical treatment
or psychotherapy with alternative medicine. When it comes to depression, alternative
treatments aren't a substitute for medical care.

For example, the herbal supplement called St. John's wort is not approved by the Food
and Drug Administration (FDA) to treat depression in the U.S., though it's available. It
may help improve mild or moderate depression, but the overall evidence is not
conclusive.

St. John's wort can interfere with a number of medications, including blood-thinning
drugs, birth control pills, chemotherapy, HIV/AIDS medications and drugs to prevent
organ rejection after a transplant. Also, avoid taking St. John's wort while taking
antidepressants because the combination can cause serious side effects.
FDA doesn't monitor supplements

Dietary supplements aren't approved and monitored by the FDA the same way
medications are. You can't always be certain of what you're getting and whether it's
safe. Also, because some herbal and other dietary supplements can interfere with
prescription medications or cause dangerous interactions, talk to your healthcare
provider before taking any supplements.

Coping and support

Persistent depressive disorder makes it hard to engage in behavior and activities that
can help you feel better. In addition to the treatments recommended by your doctor or
therapist, consider these tips:

 Focus on your goals. Dealing with persistent depressive disorder is an ongoing

process. Set reasonable goals for yourself. Stay motivated by keeping your goals in mind.
But give yourself permission to do less when you feel down.

 Simplify your life. Cut back on obligations when possible. Structure your time by

planning your day. You may find it helps to make a list of daily tasks, use sticky notes as
reminders or use a planner to stay organized.

 Write in a journal. Journaling as part of your treatment may improve mood by allowing

you to express pain, anger, fear or other emotions.

 Read reputable self-help books and websites. Ask your doctor or therapist to

recommend books or websites to read.

 Stay connected. Don't become isolated. Try to participate in social activities, and get
together with family or friends regularly. Support groups for people with depression can
help you connect with others facing similar challenges and share experiences.

 Learn ways to relax and manage your stress. Examples include meditation,

progressive muscle relaxation, yoga and tai chi.

 Don't make important decisions when you're down. Avoid decision-making when

you're feeling depressed, since you may not be thinking clearly.
Preparing for your appointment

You may decide to schedule an appointment with your primary care doctor to talk about
your concerns or you may decide to see a mental health specialist, such as a
psychiatrist or psychologist, for evaluation.

What you can do

Prepare for your appointment by making a list of:

 Any symptoms you've had, including any that may seem unrelated to the reason for
which you scheduled the appointment

 Key personal information, including any major stresses or recent life changes

 All medications, vitamins, supplements or herbal preparations that you're taking, and

the doses

 Questions to ask your doctor

Taking a family member or friend along can help you remember something that you
missed or forgot.

Basic questions to ask your doctor may include:

 Why can't I get over this depression on my own?

 How do you treat this type of depression?

 Will talk therapy (psychotherapy) help?

 Are there medications that might help?

 How long will I need to take medication?

 What are some of the side effects of the medication you're recommending?

 How often will we meet?

 How long will treatment take?

 What can I do to help myself?

  Are there any brochures or other printed materials that I can have?

 What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor may ask you several questions, such as:

 When did you first notice symptoms?

 How is your daily life affected by your symptoms?

 What other treatment have you had?

 What have you tried on your own to feel better?

 What things make you feel worse?

 Have any relatives had any type of depression or another mental illness?

 What do you hope to gain from treatment?

Dysthymia
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What is dysthymia?

Dysthymia is a milder, but long-lasting form of depression. It’s also called persistent
depressive disorder. People with this condition may also have bouts of major
depression at times.

Depression is a mood disorder that involves your body, mood, and thoughts. It affects
the way you eat and sleep, think about things, and feel about yourself. It’s not the same
as being unhappy or in a "blue" mood. It’s not a sign of weakness or something that can
be willed or wished away. People with depression can’t "snap out of it" and get better.
Treatment is key to recovery.

Dysthymia affects women twice as often as men. Some people may also have
depression or bipolar disorder.
What causes dysthymia?

There is no clear cause for this type of depression. Mental health professionals think it’s
a result of chemical imbalances in the brain. Many factors are thought to contribute to
depression. These include environmental, psychological, biological, and genetic factors.
Chronic stress and trauma have also been linked to this condition.

Dysthymia seems to run in families, but no genes have yet been linked to it.

What are the symptoms of dysthymia?

Dysthymia is  milder, yet more long lasting than major depression. Each person may
experience symptoms differently. Symptoms may include:

 Lasting sad, anxious, or “empty” mood

 Less ability to concentrate, think, and/or make decisions
 Less energy
 Fatigue
 Feeling hopeless
 Weight and/or appetite changes due to over- or under-eating
 Changes in sleep patterns, such as fitful sleep, inability to sleep, early morning
awakening, or sleeping too much
 Low self-esteem

To diagnose this condition, an adult must have a depressed mood for at least 2 years
(or one year in children and adolescents), along with at least 2 of the above symptoms.
The symptoms of this illness may look like other mental health conditions. Always talk
with a healthcare provider for a diagnosis.

How is dysthymia diagnosed?

Depression often happens with other conditions, such as heart disease, or cancer. It
may also happen with substance abuse or anxiety disorders. Often, people with
dysthymia grow accustomed to the mild depressive symptoms and do not seek help.
But, early diagnosis and treatment is key to recovery.

A diagnosis may be made after a careful psychiatric exam and medical history done by
a mental health professional.

How is dysthymia treated?

Treatment may include one or a combination of the following:

 Medicine. Many different medicines are available to treat depression. It often takes 4

to 6 weeks for anti-depressants to have a full effect. It’s important to keep taking the
medicine, even if it doesn’t seem to be working at first. It’s also important to talk to your
 healthcare provider before stopping. Some people have to switch medicines or add
medicines to get results.
 Therapy. This is most often cognitive behavioral or interpersonal therapy. It focuses
on changing distorted views of yourself and your environment. It also works to improve
relationship skills, and identify and manage stressors.

Because this condition usually last for longer than 5 years, long-term treatment may be
needed.

If you have depression, there are things you can do to help yourself. Depression can
make you feel exhausted, worthless, helpless, and hopeless. Such negative thoughts
and feelings may make you feel like giving up. It is important to realize that these
negative views are part of the depression and may not reflect reality. Negative thinking
fades as treatment begins to take effect. Meanwhile, consider the following:

 Get help. If you think you may be depressed, see a professional as soon as possible.
 Set realistic goals and don’t take on too much.
 Break large tasks into small ones. Set priorities, and do what you can as you can.
 Try to be with other people and confide in someone. It’s usually better than being alone
and secretive.
 Do things that make you feel better. Going to a movie, gardening, or taking part in
religious, social, or other activities may help. Doing something nice for someone else
can also help you feel better.
 Get regular exercise.
 Expect your mood to get better slowly, not right away. Feeling better takes time.
 Eat healthy, well-balanced meals.
 Stay away from alcohol and drugs. These can make depression worse.
 It is best to postpone big decisions until the depression has lifted. Before making a big
change -- change jobs, get married or divorced -- discuss it with others who know you
well and have a more objective view of your situation.
 Remember: People rarely "snap out of" a depression. But they can feel a little better
day-by-day.
 Try to be patient and focus on the positives. This may help replace the negative thinking
that is part of the depression, and the negative thoughts will disappear as your
depression responds to treatment.
 Let your family and friends help you.

Key points

 Dysthymia is a milder, yet more chronic form of major depression. People with this
illness may also have major depression at times.
 There is no clear cause of this disorder, but mental health professionals think it’s a result
of chemical imbalances in the brain. Some types of depression seem to run in families,
but no genes have yet been linked to depression.
 In general, nearly everyone with depression has ongoing feelings of sadness, and may
feel helpless, hopeless, and irritable. Without treatment, symptoms can last for many
years.
 This condition is most often treated with medicine, therapy, or a combination of both.
Next steps
Tips to help you get the most from a visit to your healthcare provider:

 Know the reason for your visit and what you want to happen.
 Before your visit, write down questions you want answered.
 Bring someone with you to help you ask questions and remember what your provider
tells you.
 At the visit, write down the name of a new diagnosis, and any new medicines,
treatments, or tests. Also write down any new instructions your provider gives you.
 Know why a new medicine or treatment is prescribed, and how it will help you. Also
know what the side effects are.
 Ask if your condition can be treated in other ways.
 Know why a test or procedure is recommended and what the results could mean.
 Know what to expect if you do not take the medicine or have the test or procedure.
 If you have a follow-up appointment, write down the date, time, and purpose for that visit.
 Know how you can contact your provider if you have questions.

Dysthymic Disorder
Forlorn and Overlooked?

Randy A. Sansone, MD  and Lori A. Sansone, MD

Author information Copyright and License information Disclaimer

This article has been cited by other articles in PMC.

Abstract
Go to:

Introduction
In this edition of The Interface, we review the mood disorder, dysthymia. Dysthymia, or
dysthymic disorder (DD), is a longstanding mood disorder that is characterized by fluctuating
dysphoria that may be punctuated by brief periods of normal mood. Far less symptomatically
dramatic than its cousin major depression, DD is fairly common in the community and in
primary care and mental health settings. While no consistent biological findings are evident, DD
appears to have a genetic predisposition. In both psychiatric and primary care settings, DD can
be difficult to detect. Treatment may include both pharmacotherapy and psychotherapy, although
responses to either may be modest and/or short-lived. The course of DD may be lengthy and a
number of prognostic factors are associated with poor outcome.
Go to:
Definition of the Disorder
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM-IV-TR),1 DD is an Axis I mood disturbance distinguished by seemingly low-
grade depressive symptoms as well as symptom persistence (i.e., at least two years in duration).
Individuals with this disorder experience a depressed mood for most of the day, for more days
than not, as well as at least two of the following diagnostic symptoms: (1) poor appetite or
overeating; (2) insomnia or hypersomnia; (3) low energy or fatigue; (4) low self esteem; (5) poor
concentration or difficulty making decisions; and (6) feelings of hopelessness. Afflicted
individuals may experience fleeting periods of normal mood, but these cannot exceed two
months. In addition, during the first two years following onset, there can be no discernable
episodes of major depression.
Go to:

Prevalence of Dysthymia
According to the 1988 Epidemiological Catchment Area Study, the prevalence of DD in the US
general population is 3.1 percent2 whereas data from the 1994 National Comorbidity Survey
indicate a prevalence rate of 6.4 percent.3 In a 2004 analysis of the literature, investigators
determined a lifetime prevalence of DD in US communities of 3.6 percent.4 These rates of DD
appear comparable to those found in the Netherlands (4.6%).5 To summarize, the lifetime
prevalence rate of DD in US communities appears to be between 3 and 6 percent.
In US primary care settings, the prevalence of DD is somewhat higher than in community
samples. For example, Howland reported rates from 1.3 to 31.9 percent, with a pooled
prevalence rate of seven percent.6 Spitzer and colleagues found that most US primary care
settings harbored rates of DD between 5 and 15 percent.7
In comparison with US primary care settings, rates in international primary care settings seem to
vary more. For example, Lecrubier and Weiller8 reported that the point prevalence rate of DD in
primary care settings of 14 countries was 2.1 percent. Baldwin9 summarized the available
international data and reported lifetime prevalence rates in foreign primary care settings between
3.7 and 20.6 percent. In a recent study among primary care patients in Spain, Aragones et
al10 found a current prevalence rate of 4.8 percent.
As one might expect, the rates for DD are higher in psychiatric settings as well as among women
compared with men.
Go to:

Etiology of Dysthymia
No consistent or pervasive biological abnormality has been confirmed among patients with DD.
This may relate to clinical and/or etiological heterogeneity, which is associated with this
disorder. Sporadic abnormalities include polysomnographic sleep irregularities,1 elevations in
interleukin-1,11 serotonergic dysfunction,12 and lower platelet monoamine oxidase activity in
female patients.13
In dysthymic probands, family studies indicate higher rates of DD14 as well as major depression
and personality disorders.1 This implies some degree of genetic susceptibility. In addition, a
number of psychosocial factors may contribute to the disorder, such as stress in childhood and
adulthood, and unfavorable social circumstances (e.g., isolation, lack of support).15
Go to:

Clinical Assessment
The DSM approach. The DSM-IV-TR diagnostic criteria for DD were presented in the
introduction of this article. The DSM also notes one clinically relevant specifier—a distinction
between early versus late-onset DD, which is defined as symptom onset before or after age 21,
respectively. In comparison with late-onset DD, early-onset dysthymia is characterized by higher
relapse rates, more psychiatric hospitalizations, and a greater likelihood of comorbid major
depression and personality disorders.16
Comorbidity issues. DD is characteristically associated with high frequencies of psychiatric
comorbidity.17 Indeed, “pure” dysthymia is so uncommon that the National Institutes of Mental
Health Collaborative Study on the Psychobiology of Depression had to change recruitment
strategies to obtain sufficient participants for study.18 Common psychiatric comorbidities
include major depression (up to 75%), anxiety disorders (up to 50%), personality disorders (20–
40% or more among those with early-onset DD), somatoform disorders (2.8%–45.2%), and
substance abuse (up to 50%).19,20
Difficulties with the clinical detection of DD. Given the preceding assessment guidelines for
DD, there may be notable difficulties in detecting and diagnosing this disorder.
Soft mood symptoms. The fluctuating and/or seemingly modest nature of the symptoms21 may
lead to under-recognition by the patient as well as the clinician. Explicitly, the waxing and
waning, smoldering course of these symptoms can be readily masked by patients in social
situations, making it less likely for family and clinicians to detect the existence of underlying
depression. In addition, compared with other types of psychiatric disorders, the symptoms of DD
are relatively covert (e.g., concentration difficulties and low self esteem versus hallucinations in
schizophrenia, compulsive behaviors in obsessive-compulsive disorder, or purging in bulimia
nervosa). Likewise, because DD symptoms have varying amplitudes in different patients,
individuals with mild symptoms may be easily overlooked.
Distracting psychiatric comorbidity. DD rarely exists in a pure form. Therefore, in the majority
of cases, there will be comorbid psychiatric disorders that are competing for diagnostic attention.
As we noted previously, these include various mood and anxiety disorders as well as personality,
somatoform, and substance use disorders—all of which are likely to present with more dramatic
symptoms (e.g., major depression).
Distracting somatic comorbidity. In primary care settings, patients with DD oftentimes present
with somatic comorbidity, particularly those with lower education and milder
symptoms.22 Somatic symptoms may over-shadow the underlying mood disorder.
Lack of patient recognition in early-onset DD. When the symptoms of DD have been
longstanding (i.e., date back to childhood and/or adolescence), affected individuals may
conclude that their maladies are actually personality characteristics. In other words, they may not
identify the mood disturbance as separate from self.
Misdiagnosis of symptoms. Most primary care clinicians are fairly well-trained in the detection
and diagnosis of major depression. This is likely because the symptoms of major depression are
more dramatic and oftentimes anchored around identifiable alterations in neurovegetative
rhythms. Therefore, when patients broach the subject of “depression,” many clinicians promptly
cue to their mental templates for major depression, unintentionally overlooking the diagnosis of
DD. This phenomenon may also occur in mental health settings.
Discriminating depressive disorders: a simple approach. All patients with depression need to
be screened for DD. This can be easily accomplished by presenting the patient with a figure that
compares and contrasts DD and major depression (Figure 1). In explaining the differences to
patients, we emphasize that DD is characterized by an insidious onset, waxing/waning symptoms
of at least two years duration, and possibly brief periods of normal mood. In contrast, major
depression is characterized by a fairly well-defined onset, sustained symptoms, and discrete
episodes. We have found that simultaneously discussing these syndromes and illustrating them
with patients enables rapid determination of the offending syndrome.

Figure 1

Example of a figure that can be presented to patients to help illustrate the difference between dysthymia
disorder and major depressive disorder
Go to:

Treatment
Pharmacotherapy. According to Dunner, “all treatments for depressive mood disorders are
effective for dysthymia.”23 Indeed, with regard to pharmacotherapy, most if not all studies
confirm a degree of efficacy in the treatment of dysthymia, including those with newer
antidepressants such as duloxetine.24 However, despite statistically meaningful improvements in
symptoms in short-term studies, overall responses tend to be modest.24–26 This finding has resulted
in the recommendation of sufficient drug-evaluation trials (i.e., 3 months) as well as possibly
higher doses of antidepressants and the use of augmentation strategies.
While the duration of pharmacotherapy in the treatment of DD has not been established, from a
clinical perspective, ongoing or lifelong treatment seems likely in many cases. In addition, many
individuals experience relapses and/or a loss of medication efficacy over time such that ongoing
treatment is characterized by changes in antidepressants and/or adjustments in augmentation
strategies.
Psychotherapy. In addition to pharmacotherapy, psychotherapy may be helpful. However,
Dunner23 cautions that “treatment with psychotherapy is difficult.” A number of
psychotherapies have been advocated including cognitive behavioral analysis system of
psychotherapy (CBASP),27 interpersonal psychotherapy (IPT),28,29 cognitive behavioral
therapy,30 manualized group therapy,31 and problem-solving therapy.32 These do not exclude
the potential value of supportive or psychodynamic psychotherapies.
Pharmacotherapy vs. Psychotherapy. In comparing pharmacotherapy with psychotherapy,
studies are mixed in their conclusions. However, the recent empirical trend appears to be in
support of pharmacotherapy over psychotherapy. 29,33 This is not to exclude the possibility of
individuals with dysthymia who respond well to psychotherapy or that better outcomes may be
achieved with both types of interventions in some patients.
Go to:

Course and Prognosis

Long-term outcome studies in the treatment of DD are few in number, and study comparisons are
difficult because of varying methodologies. However, one theme continually emerges—a
substantial proportion of sufferers do not experience a sustained recovery. For example, Klein et
al34 described the 10-year outcome of a cohort of dysthymic patients and findings included
protracted symptoms and high relapse rates. Comorbid major depression, which nearly all DD
patients experience, may increase the risk for poor outcome.35 DD patients may also experience
low quality of life, disablity, and poor social support and marital adjustment.36 In addition, these
individuals seem to be more stress-responsive.37
A number of prognostic variables have been described in DD. Less favorable outcomes are
associated with early-onset of symptoms;38 history of sexual abuse, poor relationships with both
parents, family histories of drug abuse, and Cluster A personality disorders;39 comorbid anxiety
disorders, Cluster C personality features, chronic stress, and eating disorders;40 greater mood
symptoms and Axis II disturbance;41 older age, less education, concurrent anxiety disorder, a
positive family history of depression, a poorer maternal relationship in childhood, and sexual
abuse;42 and poor medication adherence, lower self efficacy in managing depression, and
histories of childhood trauma.43 To summarize, the outcome for DD appears to be greatly
diminished by comorbid psychopathology, history of trauma, poor early family relationships, and
stress.
Go to:

Conclusions
DD is a common and debilitating mood disorder that can easily escape clinical detection. When
assessing depression, either in psychiatric or primary care settings, we encourage all clinicians to
 consider DD in the differential diagnosis. The differentiation between DD and major depression
can be easily accomplished with patients by providing them simultaneously with a figure
contrasting the two disorders and a verbal explanation. This disorder is treatable, although the
results may be modest and short-lived, and the course troublesome. Clearly, DD is a forlorn
mood disorder than is prone to being overlooked in all clinical settings.

Persistent Depressive
Disorder (Dysthymia)
 Symptoms

 Causes

 Diagnosis

 Treatments

 Outlook

What Is Persistent Depressive

Disorder (PDD)?
Persistent depressive disorder (PDD) is a form of chronic depression. It’s a relatively
new diagnosis that combines the two earlier diagnoses dysthymia and chronic major
depressive disorder. Like other types of depression, PDD causes continuous feelings
of deep sadness and hopelessness. These feelings can affect your mood and behavior
as well as physical functions, including appetite and sleep. As a result, people with the
disorder often lose interest in doing activities they once enjoyed and have difficulty
finishing daily tasks.

These symptoms are seen in all forms of depression. In PDD, however, the symptoms
are less severe and longer lasting. They can persist for years and may interfere with
school, work, and personal relationships. The chronic nature of PDD can also make it
more challenging to cope with the symptoms. However, a combination of medication
and talk therapy can be effective in treating PDD.

Symptoms of Persistent Depressive

Disorder
The symptoms of PDD are similar to those of depression. However, the key difference
is that PDD is chronic, with symptoms occurring on most days for at least two years.
These symptoms include:

 persistent feelings of sadness and hopelessness

 sleep problems
 low energy
 a change in appetite
 difficulty concentrating
 indecisiveness
 a lack of interest in daily activities
 decreased productivity
 poor self-esteem
 a negative attitude
 avoidance of social activities

The symptoms of PDD often begin to appear during childhood or adolescence.

Children and teens with PDD may appear to be irritable, moody, or pessimistic over
an extended period. They may also display behavior problems, poor performance at
school, and difficulty interacting with other children in social situations. Their
symptoms may come and go over several years, and the severity of them may vary
over time.

Causes of Persistent Depressive

Disorder
The cause of PDD isn’t known. Certain factors may contribute to the development of
the condition. These include:

 a chemical imbalance in the brain

 a family history of the condition
 a history of other mental health conditions, such as anxiety or bipolar disorder
 stressful or traumatic life events, such as the loss of a loved one or financial
problems
 chronic physical illness, such as heart disease or diabetes
 physical brain trauma, such as a concussion
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Diagnosing Persistent Depressive
Disorder
To make an accurate diagnosis, your doctor will first perform a physical examination.
Your doctor will also perform blood tests or other laboratory tests to rule out possible
medical conditions that may be causing your symptoms. If there’s no physical
explanation for your symptoms, then your doctor may begin to suspect that you have a
mental health condition.

Your doctor will ask you certain questions to assess your current mental and
emotional state. It’s important to be honest with your doctor about your symptoms.
Your responses will help them determine whether you have PDD or another type of
mental illness.

Many doctors use the symptoms listed in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) to diagnose PDD. This manual is published by the
American Psychiatric Association. The PDD symptoms listed in the DSM-5 include:

 a depressed mood almost every day for most of the day

 having a poor appetite or overeating
 difficulty falling asleep or staying asleep
 low energy or fatigue
 low self-esteem
 poor concentration or difficulty making decisions
 feelings of hopelessness

For adults to be diagnosed with the disorder, they must experience a depressed mood
most of the day, nearly every day, for two or more years.
For children or teens to be diagnosed with the disorder, they must experience a
depressed mood or irritability most of the day, nearly every day, for at least one year.

If your doctor believes you have PDD, they’ll likely refer you to a mental health
professional for further evaluation and treatment.

Treating Persistent Depressive

Disorder
Treatment for PDD consists of medication and talk therapy. Medication is believed to
be a more effective form of treatment than talk therapy when used alone. However, a
combination of medication and talk therapy is often the best course of treatment.

Medications

PDD can be treated with various types of antidepressants, including:

 selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and

sertraline (Zoloft)
 tricyclic antidepressants (TCAs), such as amitriptyline (Elavil) and amoxapine
(Asendin)
 serotonin and norepinephrine reuptake inhibitors (SNRIs), such as
desvenlafaxine (Pristiq) and duloxetine (Cymbalta)

You may need to try different medications and dosages to find an effective solution
for you. This requires patience, as many medications take several weeks to take full
effect.

Talk to your doctor if you continue to have concerns about your medication. Your
doctor may suggest making a change in dosage or medication. Never stop taking your
medication as directed without speaking to your doctor first. Stopping treatment
suddenly or missing several doses may cause withdrawal-like symptoms and make
depressive symptoms worse.

Therapy

Talk therapy is a beneficial treatment option for many people with PDD. Seeing a
therapist can help you learn how to:

 express your thoughts and feelings in a healthy way

 cope with your emotions
 adjust to a life challenge or crisis
 identify thoughts, behaviors, and emotions that trigger or aggravate
symptoms
 replace negative beliefs with positive ones
 regain a sense of satisfaction and control in your life
 set realistic goals for yourself

Talk therapy can be done individually or in a group. Support groups are ideal for those
who wish to share their feelings with others who are experiencing similar problems.

Lifestyle Changes

PDD is a long-lasting condition, so it’s important to participate actively in your

treatment plan. Making certain lifestyle adjustments can complement medical
treatments and help ease symptoms. These remedies include:

 exercising at least three times per week

 eating a diet that largely consists of natural foods, such as fruits and
vegetables
  avoiding drugs and alcohol
 seeing an acupuncturist
 taking certain supplements, including St. John’s wort and fish oil
 practicing yoga, tai chi, or meditation
 writing in a journal

Long-Term Outlook for People with

Persistent Depressive Disorder
Since PDD is a chronic condition, some people never recover completely.
Treatment can help many people manage their symptoms, but it isn’t
successful for everyone. Some people may continue to experience severe
symptoms that interfere with their personal or professional lives.

Persistent Depressive Disorder

(Dysthymia)
What Is It?
Published: March, 2019

Persistent depressive disorder (dysthymia) is a form of depression. It may be less

severe than major depression, but — as the name suggests — it lasts longer. Many
people with this type of depression describe having been depressed as long as they can
remember, or they feel they are going in and out of depression all the time.

The symptoms of persistent depressive disorder are similar to those of major

depression. In this disorder, the long duration is the key to the diagnosis, not the
intensity of symptoms. As with major depression, mood may be either low or irritable.
An individual with persistent depressive disorder may feel less pleasure and a lack of
energy. He or she may feel relatively unmotivated and disengaged from life. Appetite
and weight can increase or decrease. The person may sleep too much or have trouble
sleeping. Indecisiveness, pessimism and poor self-image may also be present.
 Symptoms can grow into a full-blown episode of major depression. People with
persistent depressive disorder have a greater-than-average chance of developing major
depression.

While major depression often occurs in episodes, persistent depressive disorder is

defined as more constant, lasting for years. The disorder sometimes starts in childhood.
As a result, a person with persistent depressive disorder tends to believe that
depression is part of his or her character, and so self-defining that he or she may not
even think to talk about this depression with doctors, family members or friends.

Persistent depressive disorder, like major depression, tends to run in families. It is more
common in women than in men, but in men it may be underdiagnosed because men are
less likely to talk to their doctors about their mood. Some people with persistent
depressive disorder have experienced a major loss in childhood, such as the death of a
parent. Others describe being under chronic stress. But it is often hard to know whether
people with the disorder are under more stress than other people or if the disorder
causes them to perceive more stress than others do.

Symptoms

The main symptom of persistent depressive disorder is a long-lasting low or sad mood.
People with persistent depressive disorder also can be irritable. Other symptoms
include:

 Increased or decreased appetite or weight

 Lack of sleep or sleeping too much
 Fatigue or low energy
 Low self-esteem
 Difficulty concentrating
 Indecisiveness
 Hopelessness or pessimism

Diagnosis

Many primary care doctors can recognize when one of their patients has some form of
depression, which may lead to a referral to a mental health professional for a full
evaluation. Clinicians diagnose the depression as persistent depressive disorder when
a person has had low mood, along with some of the other depressive symptoms, for two
years or more.

It is not necessary to wait for two years before getting help! Someone who has
symptoms for less than two years may still be treated for any persistent or distressing
symptoms.

Since many people with this disorder are embarrassed or ashamed to be labeled
"depressed," they may be reluctant to raise the subject with a clinician.
 Sometimes the symptoms are the leading edge of another one of the mood disorders,
such as

 major depression — a form of depression with symptoms that may be shorter in

duration, but with severe symptoms
 bipolar disorder — depressive episodes occur, but also periods of elevated or irritable
mood called manic episodes
 cyclothymic disorder — a milder form of bipolar disorder
There are no laboratory tests to diagnose persistent depressive disorder. (However, a
doctor may order tests to investigate medical conditions that can be a cause of
depressive symptoms, such as thyroid disease or anemia.)

Expected Duration

Persistent depressive disorder can start early in life, even in childhood. There can be
ups and downs in mood, but lower moods dominate and are persistent. Treatment can
reduce how long it lasts and the intensity of the symptoms.

Prevention

There is no known way to prevent persistent depressive disorder.

Treatment

The best treatment is a combination of psychotherapy and medication.

The most helpful type of psychotherapy depends on a number of factors, including the
nature of any stressful events, the availability of family and other social support, and
personal preference. Therapy will usually include emotional support and education
about depression. Cognitive behavioral therapy is designed to examine and help correct
faulty, self-critical thought patterns. Psychodynamic, insight-oriented or interpersonal
psychotherapy can help a person sort out conflicts in important relationships or explore
the history behind the symptoms.

People with persistent depressive disorder who think that "feeling blue" is just part of
their life may be surprised to learn that antidepressant medication can be very helpful.
Antidepressants recommended for this disorder are the selective serotonin reuptake
inhibitors (SSRIs such as fluoxetine), serotonin-norepinephrine reuptake inhibitors
(SNRIs such as venlafaxine), mirtazapine and bupropion.

Side effects vary among these choices. Problems with sexual functioning are common
in most except bupropion. Anxiety may increase in the early stages of treatment,
although that feeling usually subsides. Although it is relatively uncommon, any
psychoactive medication can make a person feel worse rather than better. Based on
concerns that in rare cases these drugs can cause the onset of suicidal thinking, the
U.S. Food and Drug Administration required antidepressant manufacturers to put
prominent warning labels on their products.
The scientific community continues to debate how great the risk of suicide is when
antidepressant treatment is started. Many experts take the position that — in the
population as a whole — antidepressant treatment has reduced the number of suicides.
They worry that the black box warnings have scared off people who might otherwise
benefit from the drugs. Others note that doctors and patients should stay alert to the
possibility that suicidal thinking can be triggered by an antidepressant. Both arguments
have merit.

In fact, the risk of leaving depression untreated is probably far greater than the risk of
treatment with an antidepressant. But a small number of people using the medications
do feel strikingly worse rather than better when they take them. The best way to avoid
danger is to monitor your response to any medication carefully. You should therefore
keep all follow-up appointments and immediately report any troubling changes to your
doctor.

Older antidepressants — tricyclic antidepressants and monoamine inhibitors — are still

in use and can be very effective for those who do not respond to the newer medications.
In all, there are dozens of antidepressants available. Any may be worth trying
depending on the situation.

It usually takes two to six weeks of antidepressant use to see improvement. The dose
usually must be adjusted to find the right dose for you. It can take up to a few months
for the full positive effect to be seen.

Also, the first medication may not work for you. You may need to try several different
antidepressants before finding one that provides relief.

Sometimes, two different antidepressant medications are prescribed together, or your

doctor may add a drug from a different class to your treatment, for example, a mood
stabilizer or antianxiety medication. Antipsychotic medication in low doses is
occasionally very useful for symptoms that have otherwise been resistant to treatment.
It can sometimes take persistence to find the combination that works best.

When To Call a Professional

Contact a health care professional if you suspect that you or a loved one has this
disorder.

Prognosis

With treatment, the outlook for someone with this disorder is excellent. The duration and
intensity of symptoms is often diminished significantly. In many people, the symptoms
go away completely. Without treatment, the illness is more likely to persist, the person is
likely to have a reduced quality of life and has an increased risk of developing major
depression.
Even when treatment is successful, maintenance treatment often is required to prevent
symptoms from returning.

Understanding Dysthymia





JAN. 17, 2018

By Luna Greenstein

If someone mentioned that they have depression, most people would likely have some idea of
what that means. They might imagine a person feeling tired, gloomy or empty. They might even
know some of the accompanying symptoms such as changes in weight or sleep patterns. But
what many people don’t know is that there are actually different types of depression.
The most common form is major depressive disorder, which affects about 16 million adults in
the U.S. This is what most people associate with the term “depression.” Other forms
include depression with a seasonal pattern, which usually occurs in late fall and
winter; postpartum depression, affecting women after childbirth; and dysthymia, which is a long-
term form of depression that lasts for years.
All forms of depression have similar symptoms: issues with sleep, low energy, low self-esteem,
poor concentration, difficulty making decisions, feelings of hopelessness.
What distinguishes them is timing and consistency of symptoms. And the primary distinction
with dysthymia (also known as persistent depressive disorder) is that it’s the only depressive
disorder where symptoms are present for at least two years, and typically longer.
What Is Dysthymia Like?

While someone with major depressive disorder will typically “cycle” through episodes of feeling
severely depressed and then be symptom-free for periods of time, dysthymia presents with
persistent symptoms for years.

An episode of depression usually represents a break from someone’s normal life and outlook,
while dysthymia is often embedded into a person’s life and outlook because they experience
symptoms for such prolonged periods of time. In fact, an adult must experience depression for at
least a two-year period to receive a diagnosis (one year for children and teenagers).

Dysthymia often has an early and subtle onset during childhood, adolescence or early adulthood.
However, it can be challenging to detect because its less severe and lingering nature can make
the condition feel “normal” for that person.
Also making it a challenge to diagnose is the fact that about 75% of people with dysthymia will
also experience a major depressive episode. This is referred to as “double depression.” After the
major episode ends, most people will return to their usual dysthymia symptoms and feelings,
rather than feel symptom-free.
What Can I Do?
If you think you may have dysthymia, it’s essential to seek help. Seeing a mental health
professional is the first step to recovery. Taking the time to go to therapy is an investment in
your health and well-being; the condition will not go away on its own. Typically, a combination
of both psychotherapy and medication leads to the best outcomes.
Further, according to a study that followed people experiencing dysthymia for nine years, one of
the most important factors of recovery is having confidence in your health care providers. This
may mean trying out different therapists and psychiatrists until you find one that best fits your
needs.

The study also notes that participants who recovered felt like they gained “tools to handle life,”
including understanding themselves and their condition, having self-acceptance and self-
compassion and focusing on solving problems that create distress.

Learning these tools and preparing yourself to handle difficult symptoms requires patience. It can
be challenging to have hope for recovery when depression is your norm—when feeling good
seems more like a memory than a possibility. But recovery is possible. It takes effort and
commitment, but you deserve to feel better.
Dysthymia
Major depression is not the only variety of depressive disorder. Dysthymia, or persistent
depressive disorder, is yet another, and while its symptoms aren’t as acute or debilitating as those
of major depression, dysthymia is still a life-altering mental health condition. Spontaneous
remission of dysthymia is unlikely, and the best way to avoid significant problems down the road
is to seek treatment for depression whenever symptoms occur, regardless of their strength and
intensity.
Page Contents

 What Is Dysthymia?
 Facts and Statistics
 Dysthymia Symptoms and Diagnosis
 Causes and Risk Factors for Dysthymia
 Co-Occurring Disorders
 Dysthymia Treatment and Prognosis
What Is Dysthymia?
Depression is always serious but not always disabling. People who suffer from persistent
depressive disorder, or dysthymia, experience the typical symptoms of depression, but in a
relatively manageable form.
Under the influence of dysthymia, men and women experience persistent, long-term symptoms
of low-grade depression that can linger indefinitely. Through at least the first few months of the
illness, they may be able to meet most if not all of their personal, financial, and familial
obligations. Unless they choose to share what they’re feeling, friends and family members may
never suspect anything is wrong—and if they do suspect, they are unlikely to identify depression
as the culprit.
Over time, however, dysthymia takes its toll. Even in low-grade form depression is still
depression, and happiness and contentment will be impossible to find as long as a person is
trapped by the feelings of emptiness and meaninglessness that dysthymia causes. If treatment for
persistent depressive disorder is not provided—and people suffering from dysthymia often fail to
realize they need help—the condition can cause a host of life problems that leave sufferers
struggling to hang on.
Facts and Statistics

Major depression affects more than 16 million adults in the United States. But many people
don’t realize there is such a thing as high-functioning depression, which is yet another name for
dysthymia.
While dysthymia isn’t as common as major depressive disorder, it still touches the lives of
approximately 3.5 million Americans each year, which represents about 1.5 percent of the
adult population. The lifetime rate for persistent depressive disorder is about 3.6 percent,
and those who experience the chronic, long-term symptoms of this disorder only seek treatment
for their conditions about 60 percent of the time.
Even though dysthymia isn’t normally thought of as disabling, one-half of those who develop the
disorder have it in an acute form, meaning it will cause difficulties if no help is provided.
Dysthymia Symptoms and Diagnosis

While the symptoms of persistent depressive disorder don’t reach the level of major depression,
they are still quite similar in their makeup. People who’ve developed dysthymia will quickly
realize that something is wrong, even if their closest companions only notice subtle changes.
Some of the common symptoms of dysthymia include:
 Low motivation
 Lack of energy
 Muted emotional responses
 Inability to take pleasure in favored hobbies or activities
 Detachment from friends and family life
 Feelings of unworthiness and shame
 Chronic anxiety
 Pessimism or fatalism about the future
 Overeating or eating too little
 Changes in sleeping habits, with at least some insomnia
  Poor focus, concentration, and memory
 Inability to complete tasks, or to complete them correctly or on time
 Impulsive actions, often including sudden changes in jobs or relationships
Dysthymia manifests as a vague yet persistent sense of unease and emptiness. Its symptoms may
worsen over time, but even if they don’t they can be expected to last longer than symptoms of
major depression should treatment not be provided.
Diagnosing Dysthymia
Persistent depressive disorder may be diagnosed by a mental health practitioner if two of the
following symptoms are detected:
 Feelings of despair, emptiness, and hopelessness
 Chronic feelings of self-doubt and poor self-esteem
 Changes in weight and appetite
 Changes in sleeping patterns
 Moodiness marked by frequent irritability
 Difficulties in focusing and concentrating
 Inhibitions or inconsistencies in decision-making
Low-grade depression can be hard to identify, and professionals must rely on the complete and
honest testimony of their patients to diagnose this elusive disorder. To a certain extent dysthymia
mimics major depression, but without the dramatic interruptions in functioning or profoundly
overwhelming feelings of sadness that make the latter condition easier to spot.
Major depression can be diagnosed if symptoms persist for as little as two weeks, but dysthymia
must be present for two years or more, with no symptom-free periods lasting for more than two
months, before it can be classified as a true mental health condition.
Call for a Free Confidential Assessment.
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Causes and Risk Factors for Dysthymia

Everyone is potentially at risk for chronic, low-intensity depression. This condition is largely a
response to troubling, confusing, stressful, disappointing, or traumatic life experiences, and the
chances of developing dysthymia are greater if the feelings associated with such experiences are
not addressed in therapy at the time they first arise.
Some of the specific risk factors for persistent depressive disorder include:
 Family history of depression or other types of mental illness. Genetic factors play some role in
creating this connection, but home environmental influences during childhood and adolescence
are implicated as well.
 Exposure to trauma or neglect. The chances for depression increase significantly for those who
experience abuse of some kind during childhood, but traumatic exposures later in life can also
predispose a person to dysthymia or major depressive disorder.
 Negative personality traits. People who lack self-confidence and self-esteem and are generally
pessimistic or fatalistic are likely to develop some form of depression.
 Stressful lifestyle. Bodies and minds under constant stress and emotional duress may eventually
break down, and depression is one possible consequence of stress if it is prolonged.
  Previous history of mental health problems. Anxiety disorders are frequently diagnosed in
people with depression, and those who suffer from anxiety are likely to experience depression
symptoms eventually.
Dysthymia is linked to neurological changes that affect mood management and emotional
balance. Over time, brains can be reprogrammed to respond to stress and anxiety more
constructively, which is an important remedy for depressive disorders.
Co-Occurring Disorders

There is a strong connection between mood disorders and anxiety disorders. Research has
revealed that as many as 70 percent of people with major depression or dysthymia have a
co-occurring anxiety disorder, while up to 60 percent of anxiety disorder sufferers will also
battle depression.
The frequent comorbidity of anxiety and depression is common knowledge, but what is less
well-known is the striking association between personality disorders and depression. Perhaps
because of the relationship troubles and social turmoil people with personality disorders often
face, they are highly vulnerable to depression—and to dysthymia in particular.
Among men and women who’ve been diagnosed with persistent depressive disorder, an
astounding 85.7 percent in one study also demonstrated symptoms consistent with at least one
personality disorder. Borderline personality disorder was the condition most commonly
diagnosed in these individuals, with a 20-percent occurrence rate, and the relationship between
borderline traits and depression has been found to hold across cultures and nationalities.
Even though dysthymia and major depression are separate disorders, in some instances there can
be overlap. Some people diagnosed with persistent depressive disorder will develop a limited
number of severe symptoms that are more characteristic of major depression than dysthymia, and
these individuals may be re-diagnosed with double depression, a complex condition that could
require intensive therapy.
The frequent co-occurrence of other health conditions is one of the main reasons why people
suffering from the symptoms of dysthymia should seek evaluation and treatment, even if they are
still able to function. With multiple mental health disorders they won’t be able to function
indefinitely, and the sooner they seek help the better their chances of making a full and
successful recovery.
Dysthymia Treatment and Prognosis

Unfortunately, many people learn to live with dysthymia. They may see it as an unavoidable
consequence of modern life, or they may convince themselves that superficial changes will
eventually make their feelings of sadness and emptiness disappear.
But dysthymia is a chronic mental health condition that seldom vanishes on its own. Left
unchecked, it will limit achievement and undermine contentment, while slowly eroding a
person’s sense of confidence and self-worth. Without treatment, people who suffer from
dysthymia will be unable to maintain their emotional and psychological equilibrium, and their
capacity to learn, develop, accomplish, and prosper may be severely restricted over the long haul.
The failure of many people with dysthymia to seek help prevents health and happiness, since
this condition is highly amenable to treatment. Like major depressive disorder, persistent
depressive disorder responds well to a combination of psychotherapy and medication, offered in
a structured outpatient or inpatient treatment program at a licensed a mental health treatment
facility.
While in treatment, clients attend daily therapy sessions in individual, group, and/or family
formats, where all the underlying issues involved in their depression can be identified and
discussed. Various antidepressant medications may be administered for the symptoms of
depression, and the mixture of talk therapy with medicinal intervention can dramatically
decrease the frequency and intensity of those symptoms over the course of a 30- to 90-day
inpatient or outpatient treatment program.
Outpatient programs are often the first choice for dysthymia, but residential inpatient programs
are a superior choice for those who have comorbid conditions that require additional treatment
services. Aftercare services are also vital to help recovering depression sufferers stay focused on
healing, and that is especially true if they have been diagnosed with co-occurring anxiety
disorders, personality disorders, or substance use disorders.
Dysthymia should not be accepted as normal or dismissed as a small concern. Depression is
always unwelcome, and no one who experiences it in any form should be content to suffer
through it in silence.

The Facts on Dysthymia

Many people haven't heard of dysthymia, but it's a very common — yet less severe —
form of depression that can still interfere with your life.

By Krisha McCoyMedically Reviewed by Kevin O. Hwang, MD, MPH

Last Updated: August 24, 2011
Dysthymia, also called dysthymic disorder, affects 2 percent of the American population
in a given year, according to the National Institute of Mental Health. Like most types of
depression, it strikes more women than men. And while dysthymia is usually less
severe than major depression, the symptoms — low self-esteem, sadness, fatigue, and
more — are very real.

It is not clear exactly what causes dysthymia, but scientists believe that an imbalance of
the brain chemical called serotonin may be involved. Personality factors, medical
illnesses, and stressful life situations may also contribute to the development of this
condition, which can begin in childhood or adulthood. You have to have symptoms for
two years or longer to be diagnosed with dysthymic disorder.

A Look at Dysthymia Symptoms

Depression symptoms associated with dysthymia are similar, but usually less intense,
than symptoms of major depression. However, these symptoms, in which people fight
feelings of low self-esteem, despair, and hopelessness, can still interfere with daily life,
 causing problems at home, school, or work. Its mildness makes it difficult for people to
pinpoint when their dysthymia began.

Everyone's symptoms are different, and can include:

 Feelings of sadness
 Feelings of hopelessness
 Fatigue
 Trouble concentrating
 Changes in sleep habits — oversleeping or not sleeping enough
 Changes in appetite — overeating or poor appetite

Many people with dysthymia also experience episodes of major depression. They also
may have periods of up to two months when their mood is normal, so family members
and friends may not realize that their loved one is depressed. Although this type of
depression is relatively mild, it can make it hard for a person to function at home,
school, or work.

Dysthymia Diagnosis and Treatment

If you have been dealing with mild to moderate depression symptoms for two years or
more, and your symptoms are interfering with your life, you may have dysthymia. Talk
with your doctor, who can evaluate your symptoms and medical history. A diagnosis of
dysthymia involves a careful assessment of your depression symptoms. Your doctor will
ask you questions about your mood and feelings, sleep habits, energy level, and ability
to concentrate and remember things. He or she may also perform tests to determine if
there is a medical reason, such as a thyroid problem or a medication you are taking, for
your symptoms.

Depending on your symptoms and the severity of your dysthymia, treatment may
include antidepressant medications, psychotherapy, or lifestyle modifications. Your
doctor may refer you to a mental health professional who is experienced in treating
dysthymia and other forms of depression. In addition to following your doctor's advice
on how to treat your condition, participating in activities you enjoy, eating a healthful
diet, avoiding drugs and alcohol, and exercising regularly may help lift your spirits.

Antidepressant drugs are not as effective for dysthymia as they are for depression. It
also may take longer for you to feel better after you start taking medication. Some
studies suggest that combining medication with talk therapy may lead to the greatest
improvement.
Dysthymia
Treatment New York, NY

Dysthymia is a mild depressive disorder that causes a person to be constantly depressed

though mostly functional. Which is why the disorder is also known as persistent
depressive disorder, but you can learn to control it with dysthymia treatment.

What dysthymia lacks in severity it makes up for with longevity. The disorder is mild
enough to allow a person to function. However, it often lasts two years or more,
punctuated with periods of major depression. These spells of severe depression are
referred to as double depression because a person now has to deal with two sets of
depression.

Luckily, you do not have to make peace with dysthymia. By learning more about the
condition and seeking dysthymia treatment, you can live a full and fulfilled life.

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Causes of dysthymia

It is a known fact that the flu is caused by flu viruses and that broken skin is caused by trauma or
a cut. The cause of chronic depressive disorder is not that clear cut. Like with severe depression,
dysthymia is thought to occur as a result of one or more several causes like:

1. Altered brain chemistry

Neurotransmitters are brain chemicals that carry signals between nerve endings. Think of these
chemicals like battery acid, with the nerve endings being the terminals.
It is thought that changes in mood can happen when there is a change in how the
neurotransmitters function or affect the nerves.

2. Major life events

A change in circumstances or a traumatic event can trigger persistent but mild depression that
can be mistakenly shrugged off as regular sadness.

Money troubles, the end of a relationship or bereavement are some of the things that can trigger
dysthymia.

3. A family history

Many mental health conditions run in families, so a person with relatives that suffer from
depression is more likely to suffer from a form of depression.

Symptoms of dysthymia

At its onset, dysthymia is often explained away as the sadness that follows a distressing event.
The thing that sets it apart from sadness is its persistence and the occasional spells of severe
depression that come with it.

Common symptoms of dysthymia are:

 A feeling of sadness, emptiness or despair

 A lack of interest in day to day routines

 The person will avoid social contact

 Change in eating and sleeping patterns

 Fatigue and listlessness

 Low self-esteem and an unfounded lack of belief in one's capabilities

 The person will constantly beat themselves up over past failures, whether real or perceived

 An inability to make decisions, remember things or concentrate

 Irritability

Usually, a person will show one or more of these symptoms, which will work together to make
the person feel that life is a slog. When these feelings persist for months on end, a person or their
loved ones should seek medical help.
Dysthymia treatment
Left untreated, dysthymia can affect a person's relationships, work, school and their overall
physical and mental health. A person who goes to the doctor will be examined to rule out other
causes of the symptoms.

Once the doctor confirms persistent depressive disorder, they will create a treatment plan using
or more of the following approaches:

 Psychotherapy to identify and work through the root cause of the dysthymia. Therapy also gives the
patient tools to manage their symptoms and navigate life more successfully

 Medication

 Stress reduction techniques like meditation, exercise, art therapy or volunteering

 Lifestyle changes like a healthy diet, exercise, a better-lit home and therapy animals

Take control of dysthymia and your life

Persistent depressive disorder is an illness like any other, so you should give it the attention it
deserves. Luckily, you can beat it with dysthymia treatment and life changes that will get you
feeling better about life in general and about yourself specifically.

What to expect from a depression screening

By JENNIFER LARSON | OCTOBER 8, 2020

Medically reviewed by SCOTT DERSHOWITZ, LMSW, CMC

What is a depression screening? | How to access a screening | Who needs a

screening | Questions to expect | Screening results | Diagnosis | Treatment

When you arrive at your doctor’s office for your appointment, the receptionist asks
for a copy of your insurance card—then, hands you a brief questionnaire, asking
about how you’ve been feeling lately. Many healthcare providers have some sort of
depression screening tool used to help them recognize early signs of a mood
disorder that could justify some further evaluation.

In honor of National Depression Screening Day on Oct. 8, learn more about how a
depression screening can help you assess your mental health status and needs. It
could be the first step toward understanding your moods and improving your
quality of life.

What is a depression screening?

A depression screening tool is just what it sounds like: a screening measure. It’s
designed to screen for symptoms of depression. It may be referred to colloquially
as a “depression test,” but it isn’t a true “test” like a blood pressure check that
measures exact levels of something. Rather, a depression screening is an
instrument that uses subjective answers to give a provider insight into your mental
health.

“A depression screening is intended to identify symptoms that might put a person

at risk for having depression,” explains Crystal Clark, MD, an associate professor of
psychiatry and behavioral sciences and obstetrics and gynecology at Northwestern
Feinberg School of Medicine. 

A commonly used screening tool is the Patient Health Questionnaire-9 (PHQ-9). It’s
a list of questions that asks you to think about things like your appetite and your
energy levels. You complete this questionnaire so that you and your doctor can
determine if you’re frequently experiencing certain common symptoms of
depression such as persistent sadness and loss of interest in your favorite
activities. 

A screening flags many symptoms that you might have. It’s an indicator that could
help you decide when it’s time to see a mental health professional. “Depending on
what you score, you’ll know if you need to move forward or not,” says Lindsay
Israel, MD, a psychiatrist and the chief medical officer of Success TMS.

How do I access a depression screening tool? 

Your primary care provider might give you a copy to fill out in the waiting room. Or
you might receive a questionnaire to complete when waiting to see a specialist.

You can also go online to complete a self-assessment. Organizations like the United

States Preventive Services Task Force (USPSTF) and the Anxiety and Depression
Association of America (ADAA) offer depression screening tools like the PHQ-9 on
their websites. However, none of these self-assessments are substitutes for a formal
evaluation by a mental health professional.

Do I need a depression screening?

The U.S. Preventive Services Task Force recommends regular screening for
depression in adults, including pregnant and postpartum women, as well as
procedures for follow-up. 

Why? Depression is a very common health condition—one that affected more

than 17 million adults in the U.S. in 2017. In fact, according to the National Institute
of Mental Health (NIMH), more than 7% of the adult population of the U.S. has
experienced at least one major depressive episode. 

Since so many people are affected, just about anyone could benefit from doing a
screening, according to Dr. Clark. “I feel like everyone should sit down and do it, but
definitely anyone who feels like something is not quite right,” Dr. Clark explains. 

You might be aware that you’ve been experiencing some symptoms of depression.
But, you might not—or you may not realize that your feelings are symptoms of
depression. A depression screening can pick up on the signs that you may have
missed. 

But if you’ve recently been diagnosed with a condition like heart disease, stroke, or
cancer, a depression screening might be an especially good idea. Depression and
other mental health conditions often go hand-in-hand with other health conditions
or medical comorbidities. 

In fact, depression is considered a risk factor for some conditions like

cardiovascular disease. Research suggests that as many as 40% of people who have
experienced a serious cardiac event meet the criteria for a major depressive
disorder (MDD). The American Cancer Society also estimates that 1 out of every
4 people with cancer also suffers from major depression. 

And unfortunately, depression can make a bad situation worse. For example,
research shows that people with cardiovascular disease who also suffer from
depression tend to have poorer outcomes. Depression can make it very hard for
people with a serious illness to manage that illness. 

After all, the mind and body are connected, says Clark. “So, if a patient is truly
depressed and also has a physical illness, they are less likely to tend to that physical
illness than they would if they were feeling better,” she says. 

What questions are asked in a depression screening?

A typical depression screening will ask you to think about how you’ve been feeling
over the past two weeks. The PHQ-9 will ask you to assess how often you’ve
experienced the following:

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling asleep, staying asleep or sleeping too much

 4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself

7. Trouble concentrating

8. Moving or speaking so slowly that other people could have noticed? Or the opposite

—being so fidgety or restless that you have been moving around a lot more than

usual

9. Thoughts that you would be better off dead or hurting yourself

You’ll go down the list and assign a frequency to each question. Your choices are:

 Not at all

 Several days

 More than half the days

 Nearly every day

The important thing is to be honest with your responses. You’re trying to learn
more about your mental health, and this is a good entry point for doing so. 

“It’s not foolproof, like anything, but it’s another tool that we can use,” explains
Anandhi Narasimhan, MD, a child, adolescent, and adult psychiatrist in a private
clinical practice in California who also serves as staff psychiatrist at Masada Homes
in Gardena, California.

What do my depression screening results mean?

Your responses are just supposed to be used as a guide. You won’t get a
depression diagnosis from a screening. But you may get some advice to pursue
additional evaluation that may (or may not) eventually lead to an accurate
diagnosis. 
If you’re taking the screening questionnaire at your doctor’s office, your healthcare
provider may want to discuss the results of the screening with you. Depending on
the results, they may refer you to a mental health professional for a conversation.

If you choose to do a self-assessment online, it’s important to note that you cannot
diagnose yourself. Screenings that are available online are just designed to serve as
a guide. For example, the ADAA recommends that you download the PHQ-9,
complete the survey, and then take the results to your doctor and discuss them. It
won’t give you a score or a description of your situation. But the answers can help
your doctor understand what you’re going through. Then you can have a
conversation about it. 

Can I diagnose depression in myself?

You cannot officially diagnose yourself with depression. You do need a healthcare
professional for that, says Dr. Narasimhan.

To assess you, a psychiatrist will use the criteria from a handbook for assessing and
diagnosing mental illnesses that’s known as the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (also known as the DSM-5). You need to have at
least five symptoms to receive a diagnosis of major depressive disorder. Your
doctor will also consider the frequency and duration of your symptoms when
making a diagnosis. 

Your doctor may also want to rule out other medical conditions that can sometimes
cause symptoms of depression to appear. According to the American Psychiatric
Association, a brain tumor, certain vitamin deficiencies, and thyroid disorders are
among these conditions. Substance abuse and other mental health conditions can
also cause similar symptoms.
But that doesn’t mean that you can’t take a proactive role in learning more about
your own mental and emotional well-being. 

You can learn the symptoms of depression and monitor yourself for them. Though,
always remember that some people aren’t aware that certain feelings are actually
symptoms of depression, even if they occur regularly. 

Take the classic depression symptom of experiencing decreased pleasure in

activities that you normally like to do. “That, to me, is one of the best markers that a
patient can recognize,” Dr. Israel says. “They’ll say, “I used to love to play golf.’ Or ‘I
used to love to go to the gym.’ Or ‘I used to love to cook.’ And now they’re not doing
any of that. That, to me, is a pretty black-and-white change that you can put your
finger on.”

You can also learn more about your own risk factors. For example, women are
more likely than men to develop depression. Research also suggests that a family
history of depressive disorders can increase your risk. So can a major life change or
a traumatic event. Depression is also common among older adults, although
the National Institute on Aging emphasizes that it’s not a normal part of the aging
process. 

The bottom line: Recognizing and understanding your risk factors can put you at
heightened awareness—and that may make it easier for you to seek help. 

How do I get treatment after my depression screening? 

It’s important to remember: Depression can be treated. 

If your depression screening leads you to seek out a mental health professional for
an evaluation, you may receive a diagnosis. There are numerous possible
diagnoses; two of the most common are major depression (also known as clinical
depression) and persistent depressive disorder. 
Your recommended treatment will depend on your specific diagnosis. You might be
a good candidate for an antidepressant or other medication. You may benefit from
psychotherapy. Or you may find that a combination of medication, behavioral
health strategies, and therapy are the most effective way to help you, along with
some self-care measures. 

And it’s always possible to change things up if they don’t work well. For example, if
the first medication you try isn’t effective or the dose is not right, your doctor can
always adjust the dose or suggest that you switch antidepressants.  

Just as it’s important to be honest when answering the questions in a screening

questionnaire, it’s important to be honest with your provider—and yourself—about
what you are experiencing. Your provider needs to know what you’re feeling so that
you can get a correct diagnosis and effective treatment. That’s the only way you’ll
be able to get the help that you need.

“Hiding it or minimizing it is not going to get you the help you need,” Dr. Israel says. 

A depression screening tool is not just a one-time thing. Your situation may change,
and you may develop depressive symptoms later. So you may encounter them in
future doctor’s office visits, and your answers might be different.

You can also use a depression screening tool to help you monitor your progress
after receiving a diagnosis and beginning treatment. 

What Happens in Depression Treatment?

 IN THIS ARTICLE
 How Treatment Starts
 Antidepressants
 Psychotherapy
 Electroconvulsive Therapy
 Other Forms of Brain Stimulation
 What Else You Can Do
Depression is a serious illness, and there’s no single way to treat it.
Different people are affected differently by the condition. But if you need
help, there are certain things to expect from treatment.
How Treatment Starts

If you think you’re depressed, see a doctor. That could be your primary
care physician or a specialist in mental health.
They’ll start by asking you some questions about how you’re feeling.
These are designed to help figure out whether you have the symptoms of
depression, another mental health condition, or whether your problem
might have a physical cause. For instance, you might be asked to give
a blood sample so doctors can look for signs of thyroid problems, which
also can cause depression.
If your doctor thinks you’re depressed, your first treatment will depend on
what the doctor thinks is going on.

 Your doctor may prescribe an antidepressant. These are medications

designed to relieve the symptoms of depression by adjusting how
certain chemicals in your brain affect brain circuits that control your
mood.
 Your doctor might refer you to a mental health specialist. That could
be a psychiatrist, psychologist, or some other type of counselor. They
would talk with you about your problems and feelings, and figure out
how to address them. This is psychotherapy or “talk therapy.”
  Most likely, your treatment will involve some combination of the
two.
Antidepressants

Antidepressants can help you feel better. Scientists believe they work by

helping brain circuits that regulate mood work more efficiently. The most
common types of antidepressants work by increasing levels of serotonin in
the brain. Serotonin helps transmit messages from one area of the brain
area to another. If you’re given antidepressants, it may take 2 to 4 weeks
for the medication to start producing a noticeable effect. Your doctor will
most likely want you to take a drug for at least several months, maybe up
to a year.
Doctors typically start with medications called selective serotonin reuptake
inhibitors (SSRIs) because they have the fewest side effects. Still, with any
antidepressant, you could experience:

 Nausea
 Nervousness or trouble sleeping
 Dry mouth
 Restlessness
 Diarrhea or constipation
 Drowsiness
 Dizziness, headaches, or blurred vision
 Sexual problems, such as trouble keeping an erection or having
an orgasm
The FDA warns that anyone taking antidepressants should be watched closely, particularly in the
first few weeks. Children, teenagers, and young adults might have more negative thoughts,
possibly even suicidal thoughts or behaviors while taking antidepressants.
You may need to try a few different antidepressants before you find one that works well for you.
You might have side effects during the first few weeks of taking an antidepressant. These usually
get better. If you’ve given it a few months and it doesn’t seem to help, or if side effects are
making it hard for you to take it, go back to your doctor. They might recommend a different
drug. But don’t stop taking your medication on your own. That can cause more problems. When
it’s time to stop, your doctor will slowly reduce your dose to let your body readjust.
 Psychotherapy
This involves sitting down with a mental health professional who can help you better understand
your thoughts, feelings, and emotions. Together, you’ll try to figure out what helps you feel
better.
Psychotherapy can help you figure out why you feel the way you do and how to manage difficult
emotions better. It might help you to overcome certain fears, or change behaviors that aren’t
helping you manage your feelings.
Sessions take place on a regular schedule, maybe once or twice a week depending on what you
need. The sessions are meant to be neutral, nonjudgmental, and confidential. While your
medications take time to work, a mental health professional can:

 Show you how your thoughts, emotions, and behavior affect your condition
 Help you manage stress
 Offer ways to improve your dealings with other people
 Help you spot early signs of a problem and get help
 Help you confront and overcome fears that aren’t helping you

This type of therapy can take months or more than a year, depending on how serious
your depression is. But some patients feel better in a matter of weeks. You and your therapist
will decide when you’ve made enough progress to stop.
You may need to try a few different therapists to find one you are comfortable sharing your
feelings with.

What Happens in Depression Treatment?

IN THIS ARTICLE
 How Treatment Starts
 Antidepressants
 Psychotherapy
 Electroconvulsive Therapy
 Other Forms of Brain Stimulation
 What Else You Can Do
Electroconvulsive Therapy

If your depression is severe enough, and drugs and psychotherapy aren’t

helping, your doctor might recommend electroconvulsive therapy, or ECT.
This involves sending a small, painless electric current through your brain
while you’re asleep under general anesthesia, which causes a
brief seizure that can relieve the symptoms of depression.
ECT is also known as electroshock therapy. It has a controversial history
but is now considered an effective treatment for depression.
Modern ECT is performed in a series of sessions (either inpatient or
outpatient) over up to 4 weeks. You’ll be given anesthesia to make you
sleep, and you won’t feel the current or the seizure. But it has some side
effects. They can include headaches, nausea, confusion, disorientation, and
memory loss, which can last for several months. If your doctor is
recommending ECT, be sure to talk about the pros and cons before
agreeing.
Other Forms of Brain Stimulation

Besides ECT, other technologies have been developed in recent years.

They treat depression by stimulating areas of the brain that are believed to
control mood. They’re used when other depression treatments haven’t
worked.

 Repetitive transcranial magnetic stimulation (rTMS) is an FDA-

approved procedure that uses a magnetic coil to stimulate specific
brain areas over a series of treatments lasting several weeks.  Patients
are wide awake and feel no pain or discomfort. 
 Vagal nerve stimulation (VNS) is an operation that puts a device
under the collarbone and then attaches a thin wire to the vagus nerve
in your neck. The device sends signals to regions of the brain that
affect mood. 
 Deep brain stimulation (DBS) is an experimental procedure that puts
thin electrodes deep within the brain to directly stimulate areas that
handle emotions.
 Ketamine

 Ketamine is a medication that can be administered intravenously to

treat severe depression. It is becoming more widely available for
depression that is not treatable with conventional means.

 
What Else You Can Do

No matter what your treatment includes, your doctor may also suggest you
do some things your own, such as get more exercise, eat better, and lose
weight. All of these can help your mood.
It’s also important that you get enough sleep. If you’re having problems
sleeping, let your doctor know. It may also help to cut back on caffeine and
alcohol.
Your doctor may also suggest you join a support group. They can put you
in touch with people who are facing the same thing. They may be able to
offer you advice and fellowship when you hit a rough patch.

Depression and Anxiety:

How to Identify and Treat
Coexisting Symptoms
 Signs and symptoms

 Self-help test

 Tips for management

 Talk to your doctor

 Clinical diagnosis

 Treatment

 Outlook

What’s the link?

Depression and anxiety can occur at the same time. In fact, it’s been
estimated that 45 percent of people with one mental health condition meet the
criteria for two or more disorders. One study found that halfTrusted Source of
people with either anxiety or depression have the other condition.

Although each condition has its own causes, they may share similar
symptoms and treatments. Read on to learn more, including tips for
management and what to expect from a clinical diagnosis.

What are the symptoms of each

condition?
Some symptoms of depression and anxiety overlap, such as problems with
sleep, irritability, and difficulty concentrating. But there are several key
differences that help distinguish between the two.

Depression

Feeling down, sad, or upset is normal. It can be concerning feeling that way
for several days or weeks on end.

Physical symptoms and behavioral changes caused by depression include:

  decreased energy, chronic fatigue, or feeling sluggish frequently
 difficulty concentrating, making decisions, or recalling
 pain, aches, cramps, or gastrointestinal problems without any clear
cause
 changes in appetite or weight
 difficulty sleeping, waking early, or oversleeping

Emotional symptoms of depression include:

 loss of interest or no longer finding pleasure in activities or hobbies

 persistent feelings of sadness, anxiety, or emptiness
 feeling hopeless or pessimistic
 anger, irritability, or restlessness
 feeling guilty or experiencing feelings of worthlessness or helplessness
 thoughts of death or suicide
 suicide attempts

Anxiety

Anxiety, or fear and worry, can happen to anyone from time to time, too. It’s
not unusual to experience anxiety before a big event or important decision.

But, chronic anxiety can be debilitating and lead to irrational thoughts and

fears that interfere with your daily life.

Physical symptoms and behavioral changes caused by generalized anxiety

disorder include:

 feeling fatigued easily

  difficulty concentrating or recalling
 muscle tension
 racing heart
 grinding teeth
 sleep difficulties, including problems falling asleep and restless,
unsatisfying sleep

Emotional symptoms of anxiety include:

 restlessness, irritability, or feeling on edge

 difficulty controlling worry or fear
 dread
 panic

Suicide prevention
If you think someone is at immediate risk of self-harm or hurting another
person:

 Call 911 or your local emergency number.

 Stay with the person until help arrives.
 Remove any guns, knives, medications, or other things that may cause
harm.
 Listen, but don’t judge, argue, threaten, or yell.

If you or someone you know is considering suicide, get help from a crisis or
suicide prevention hotline. Try the National Suicide Prevention Lifeline at 800-
273-8255.
A self-help test may help you identify
the signs
You know what’s normal for you. If you find yourself experiencing feelings or
behaviors that aren’t typical or if something seems off, this might be a sign
you need to seek help from a healthcare provider. It’s always better to talk
about what you’re feeling and experiencing so that treatment can begin early if
it’s necessary.

With that being said, some online self-diagnosis tests are available to help you
better understand what may be happening. These tests, while helpful, aren’t a
replacement for a professional diagnosis from your doctor. They can’t take
other conditions that may be impacting your health into account, either.

Popular self-help tests for anxiety and depression include:

 depression test and anxiety test

 depression test
 anxiety test
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How to manage your symptoms
In addition to a formal treatment plan from your doctor, these strategies may
help you find relief from symptoms. It’s important to know, though, that these
tips may not work for everyone, and they may not work each time.

The goal of managing depression and anxiety is to create a series of

treatment options that can all work together to help, to some degree,
whenever you need to use them.

1. Allow yourself to feel what you’re feeling — and

know that it’s not your fault

Depression and anxiety disorders are medical conditions. They aren’t the
result of failure or weakness. What you feel is the result of underlying causes
and triggers; it’s not the result of something you did or didn’t do.

2. Do something that you have control over, like

making your bed or taking out the trash

In the moment, regaining a bit of control or power can help you cope with
overwhelming symptoms. Accomplish a task you can manage, such as neatly
restacking books or sorting your recycling. Do something to help give yourself
a sense of accomplishment and power.
3. You could also create a morning, evening, or even
daily routine

Routine is sometimes helpful for people with anxiety and depression. This
provides structure and a sense of control. It also allows you to create space in
your day for self-care techniques that can help you control symptoms.

4. Do your best to stick to a sleep schedule

Aim for seven to eight hours each night. More or less than that may
complicate symptoms of both conditions. Inadequate or poor sleep can cause
problems with your cardiovascular, endocrine, immune, and nervous
symptoms.

5. Try to eat something nutritious, like an apple or

some nuts, at least once a day

When you’re feeling depressed or anxious, you may reach for comforting

foods like pasta and sweets to alleviate some of the tension. However, these
foods provide little nutrition. Try to help nourish your body with fruits,
vegetables, lean meats, and whole grains.

6. If you’re up for it, go for a walk around the block

ResearchTrusted Source suggests exercise can be an effective treatment for

depression because it’s a natural mood booster and releases feel-good
hormones. However, for some people, exercise or a gym can trigger anxiety
and fear. If that’s the case for you, look for more natural ways to move, such
as walking around your neighborhood or looking for an online exercise
video you can do at home.
7. Do something that you know brings you comfort,
such as watching a favorite movie or flipping through
a magazine

Give yourself time to focus on you and the things you like. Down time is a
great way to let your body rest, and it can distract your brain with things that
bring you a boost.

8. If you haven’t left the house in a while, consider

doing something you find soothing, like getting your
nails done or getting a massage

Relaxation techniques can improve your quality of life and may reduce
symptoms of depression and anxiety. Find an activity that feels right for you
and you can practice regularly, such as:

 yoga
 meditation
 breathing exercises
 massage

9. Reach out to someone you’re comfortable talking to

and talk about whatever you feel like, whether that’s
how you’re feeling or something you saw on Twitter

Strong relationships are one of the best ways to help you feel
better. Connecting with a friend or family member can provide a natural boost
and let you find a reliable source of support and encouragement.

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When to talk to your doctor
Symptoms that last two weeks or more may be an indication you have
depression, anxiety, or both. Severe symptoms may include:

 problems with sleep

 unexplained emotional changes
 sudden loss of interest
 feelings of worthlessness or helplessness

If you’re not feeling like yourself and want help understanding, make an
appointment to see your doctor. It’s important to be open and honest so they
can fully understand what’s happening and get a clear picture of what you’ve
been feeling.

How to get a clinical diagnosis

There’s no single test that can diagnose depression or anxiety. Instead, your
doctor will likely conduct a physical exam and a depression or anxiety
screening test. For this, they’ll ask you a series of questions that help them
get a better insight into what you’ve been experiencing.

If the results aren’t clear or if your doctor suspects the symptoms may be the
result of another condition, they may order tests to rule out underlying issues.
Blood tests can check your thyroid, vitamin, and hormone levels.

In some cases, general practitioners will refer you to a mental health expert,
such as a psychiatrist or psychologist, if they don’t feel equipped to properly
manage your symptoms and conditions or if they suspect you’re experiencing
more than one condition.
What to expect from treatment
Although depression and anxiety are two separate conditions, they share
many of the same treatments. A combination of these may be used to treat
both conditions at the same time.

Therapy

Each type of therapy has unique characteristics that make it more suited to
some people and not others. Your doctor may recommend one or more of the
following:

 Cognitive behavioral therapy (CBT). With CBT, you’ll learn to adjust

your thoughts, behaviors, and reactions to be more even and rational.
 Interpersonal therapy. This type focuses on learning communication
strategies that can help you express yourself better.
 Problem-solving therapy. This therapy focuses on using coping skills
to manage symptoms.

You can book an appointment with a mental health professional in your area
using our Healthline FindCare tool.

Medication

Several types of medication may be used to treat depression, anxiety, or both.

Because the two conditions overlap in many ways, one medication may be
enough to treat both conditions. Your doctor may prescribe:

 Antidepressants. Several classes of this drug are available,

including selective serotonin reuptake inhibitors (SSRIs) and serotonin-
norepinephrine reuptake inhibitors (SNRIs). Each carry unique benefits
 and risks. The type you use will depend largely on the severity of your
symptoms.
 Antianxiety medications. These drugs can help reduce symptoms of
anxiety but may not help with all symptoms of depression. Some of
these medications should only be used for a short amount of time due to
risk of addiction.
 Mood stabilizers. These drugs may be used to stabilize mood when
antidepressants don’t work by themselves.

Alternative therapy

Hypnotherapy isn’t widely used in psychotherapy treatments,

but research suggests this alternative approach may actually help ease some
symptoms of both conditions. This includes loss off focus, greater emotional
control, and better management of feelings of self-consciousness.

The bottom line

You don’t have to live with unusual feelings, thoughts, or other symptoms of
either depression or anxiety. Talk with your doctor if these feelings or changes
last longer than a week or two. Early treatment is the best way to manage the
conditions and find treatments that are effective in the long-term.

Finding the right treatment for you may take some time. Most medications
require two weeks or more to be effective. Likewise, you may have to try
several medications to find the right option for you. Your doctor will work with
you to find the best option.

What to Expect When Seeing a Doctor for

Depression
By 

Nancy Schimelpfening 

 Medically reviewed by 

Steven Gans, MD 

Updated on November 16, 2020

Print 

FatCamera / EyeEm / Getty Images

In the United States, over 7% of adults and children (over the age of 12)
experience depression within any two-week period.1 In fact, depression is one of the most
common chronic health conditions listed by doctors on their patients' medical records.

While depression is common, if you think you have it, you may be unsure about where to begin.
Here are the steps to getting your mental health treated, so you can feel well.

See Your Primary Care Doctor

If you suspect you may have depression, your first visit should be to your family doctor
or primary care physician for a thorough checkup. While most doctors do screen for depression,
it's best to tell your doctor your concerns about your mood.2 Your doctor is there to help you, so
don't hold back.
Questions Your Doctor May Ask

 Are you sleeping more than usual or having difficulty sleeping? 

 Are you having trouble concentrating or making decisions?
 Do you think of death or have thoughts of suicide? 
 How long have you been feeling sad or down?
 How is your appetite? Have you lost weight or gained weight?
 How is your energy level?

Your answers to these questions (and others) will help your doctor pinpoint whether or not you
have major depressive disorder, often referred to simply as depression. Before confirming a
diagnosis, however, your doctor will need to rule out other health problems.
Symptoms of several medical conditions can mimic those of depression. This is especially true in
older adults with new-onset depression. These conditions include:3

 Anemia
 Calcium or other electrolyte abnormalities
 Low blood sugar
 Hypothyroidism
 Kidney or liver problems
  Vitamin deficiencies (for example, vitamin B12 deficiency)

While blood tests cannot be used to diagnose depression, they can rule out some of these above
conditions. Less commonly, your doctor may order an imaging test, like a brain MRI. This can
rule out structural brain diseases, like stroke, especially if the doctor notices evidence of
cognitive problems or neurological signs upon physical examination.
Some medications may also cause symptoms of depression as a side effect. Be sure to tell your
doctor all of the medications you are taking, including both prescription and over-the-counter
drugs.
Lastly, note that sometimes other mental health conditions can be difficult to differentiate from
depression.3 For instance, bipolar disorder may be misdiagnosed initially as depression.
Often this misdiagnosis occurs because symptoms of mania may be overlooked, as depressive
symptoms are the ones that feel so bad and first prompt the doctor visit. Substance use, either
intoxication or withdrawal, can also cause symptoms that overlap with depression. Try to remain
patient as your doctor sorts through your symptoms.
 Warning Signs That You Might Be Depressed

See a Mental Health Professional

If your doctor diagnoses you with depression, you may then be referred to a mental health
professional, such as a psychiatrist.3 The psychiatrist will further evaluate your mood and
determine whether or not medication is needed. 
Some people will do fine being treated by their primary care physician. Others may benefit from
seeing a psychiatrist, especially if symptoms are not improving with the first trial of an
antidepressant or the depression is severe from the start.
Research suggests that the combination of medication and therapy is most effective for treating
depression. If you would benefit from psychotherapy, your psychiatrist may handle this as well,
although some elect to refer patients to another mental health professional, like a psychologist.3
 The Best Online Help Resources for Depression

Treatment
It's important to note the treatment of depression is not as simple as receiving a prescription
for an antidepressant. The individual causes of depression are diverse and poorly understood.
The medications used to treat it are just as diverse, so matching a drug with an individual is not a
clear-cut process.3
When your doctor chooses your antidepressant, they will consider many factors to try to make
this match. These include your specific symptoms, any co-existing illnesses you have,
your tolerance of side effects, and any medications you have previously tried.3

Treatment can take some time. It typically takes a few weeks to feel the full effect of your
medication. Antidepressants typically take at least four weeks to begin working and
psychotherapy typically does not produce significant results for at least four to six weeks,
depending on the type of therapy.

Be sure to communicate regularly with your doctor, especially if you are experiencing
bothersome side effects. If you are noticing very little or no improvement in your symptoms after
two to four weeks, your doctor may increase your dose, add another medication to increase its
effect, or switch your medication.4
Depression Discussion Guide

Get our printable guide to help you ask the right questions at your next doctor's appointment.

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A Word From Verywell

The most important thing to remember about seeking treatment for your depression symptoms is
simply to speak up and ask. Depression is not a sign of weakness or laziness. It's a sign that
something is out of balance. With proper treatment, which usually entails the two-pronged
approach of medication and psychotherapy, you can feel well again.

Depression in Men
Feeling depressed isn’t a sign of weakness and you don’t have to tough it out. These
tips can help you overcome depression and start feeling happier and more hopeful
today.
What is male depression?

As men, we like to think of ourselves as strong and in control of our emotions. When we
feel hopeless or overwhelmed by despair we often deny it or try to cover it up. But
depression is a common problem that affects many of us at some point in our lives, not
a sign of emotional weakness or a failing of masculinity.

Depression impacts millions of men of all ages and backgrounds, as well as those who
care about them—spouses, partners, friends, and family. Of course, it’s normal for
anyone to feel down from time to time. Dips in mood are an ordinary reaction to losses,
setbacks, and disappointments in life. However, male depression changes how you
think, feel, and function in your daily life. It can interfere with your productivity at work or
school and impact your relationships, sleep, diet, and overall enjoyment of life. Severe
depression can be intense and unrelenting.

Unfortunately, depression in men often gets overlooked as many of us find it difficult to

talk about our feelings. Instead, we tend to focus on the physical symptoms that often
accompany male depression, such as back pain, headaches, difficulty sleeping, or
sexual problems. This can result in the underlying depression going untreated, which
can have serious consequences.

Men suffering from depression are four times more likely to take their own lives than
women, so it’s vital to seek help with depression before feelings of despair become
feelings of suicide. Talk honestly with a friend, loved one, or doctor about what’s going
on in your mind as well as your body. Once correctly diagnosed, there is plenty you can
do to successfully treat and manage male depression and prevent it from coming back.

Signs and symptoms of depression in men

Men tend to be less adept at recognizing symptoms of depression than women. A man

is more likely to deny his feelings, hide them from himself and others, or try to mask
them with other behaviors. And while men may experience classic symptoms of
depression such as despondent mood, loss of interest in work or hobbies, weight and
sleep disturbances, fatigue, and concentration problems, they are more likely than
women to experience “stealth” depression symptoms such as anger, substance abuse,
and agitation.

The three most commonly overlooked signs of depression in men are:

1. Physical pain. Sometimes depression in men shows up as physical symptoms—such as

backache, frequent headaches, sleep problems, sexual dysfunction, or digestive disorders—
that don’t respond to normal treatment.
2. Anger. This could range from irritability, sensitivity to criticism, or a loss of your sense of
humor to road rage, a short temper, or even violence. Some men become abusive or
controlling.
 3. Reckless behavior. A man suffering from depression may exhibit escapist or risky
behavior such as pursuing dangerous sports, driving recklessly, or engaging in unsafe sex. You
might drink too much, abuse drugs, or gamble compulsively.
How to know if you’re depressed

If you identify with several of the following, you may be suffering from depression.

1. You feel hopeless and helpless

2. You’ve lost interest in friends, activities, and things you used to enjoy
3. You’re much more irritable, short-tempered, or aggressive than usual
4. You’re consuming more alcohol, engaging in reckless behavior, or self-medicating
5. You feel restless and agitated
6. Your sleep and appetite has changed
7. You can’t concentrate or your productivity at work has declined
8. You can’t control your negative thoughts

If you’re feeling suicidal…

Problems don’t seem temporary—they seem overwhelming and permanent. But if you
reach out for help, you will feel better.

Read HelpGuide’s Suicide Prevention articles or call the National Suicide Prevention

Lifeline in the U.S. at 1-800-273-8255. For help outside the U.S., visit Befrienders
Worldwide.

Triggers for depression in men

There’s no single cause of depression in men. Biological, psychological, and social

factors all play a part, as do lifestyle choices, relationships, and coping skills.

While any man can suffer from depression, there are some risk factors that make a man
more vulnerable, such as:

 Loneliness and lack of social support

 Inability to effectively deal with stress

 A history of alcohol or drug abuse

 Early childhood trauma or abuse

 Aging in isolation, with few social outlets

 Depression and erectile dysfunction
Impotence or erectile dysfunction is not only a trigger of depression in men, it can also
be a side effect of many antidepressant medications.

 Men with sexual function problems are almost twice as likely to be depressed as those
without.

 Depression increases the risk of erectile dysfunction.

 Many men are reluctant to acknowledge sexual problems, thinking it’s a reflection on their
manhood rather than a treatable problem caused by depression.

Getting help for male depression

Don’t try to tough out depression on your own. It takes courage to seek help—from a
loved one or a professional. Most men with depression respond well to self-help steps
such as reaching out for social support, exercising, switching to a healthy diet, and
making other lifestyle changes.

But don’t expect your mood to improve instantly. You’ll likely begin to feel a little better
each day. Many men recovering from depression notice improvements in sleep patterns
and appetite before improvements in their mood. But these self-help steps can have a
powerful effect on how you think and feel, helping you to overcome the symptoms of
depression and regain your enjoyment of life.

Tip 1: Seek social support

Work commitments can often make it difficult for men to find time to maintain
friendships, but the first step to tackling male depression is to find people you can really
connect with, face-to-face. That doesn’t mean simply trading jokes with a coworker or
chatting about sports with the guy sitting next to you in a bar. It means finding someone
you feel comfortable sharing your feelings with, someone who’ll listen to you without
judging you, or telling you how you should think or feel.

You may think that discussing your feelings isn’t very macho, but whether you’re aware
of it or not, you’re already communicating your feelings to those around you; you’re just
not using words. If you’re short-tempered, drinking more than usual, or punching holes
in the wall, those closest to you will know something’s wrong. Choosing to talk about
what you’re going through, instead, can actually help you feel better.

Finding social support 

For many men—especially when you’re suffering from depression—reaching out to

others can seem overwhelming. But developing and maintaining close relationships are
vital to helping you get through this tough time. If you don’t feel that you have anyone to
turn to, it’s never too late to build new friendships and improve your support network.

How to reach out for depression support

Look for support from people who make you feel safe and cared for. The person you
talk to doesn’t have to be able to fix you; they just need to be a good listener-someone
who’ll listen attentively and compassionately without being distracted or judging you.

Make face-time a priority. Phone calls, social media, and texting are great ways to
stay in touch, but they don’t replace good old-fashioned in-person quality time. The
simple act of talking to someone face to face about how you feel can play a big role
in relieving depression and keeping it away.

Try to keep up with social activities even if you don’t feel like it. Often when you’re
depressed, it feels more comfortable to retreat into your shell, but being around other
people will make you feel less depressed.

Find ways to support others. It’s nice to receive support, but research shows you get
an even bigger mood boost from providing support yourself. So find ways-both big and
small-to help others: volunteer, be a listening ear for a friend, do something nice for
somebody.

Care for a pet. While nothing can replace the human connection, pets can bring joy and
companionship into your life and help you feel less isolated. Caring for a pet can also
get you outside of yourself and give you a sense of being needed-both powerful
antidotes to depression.

Join a support group for depression. Being with others dealing with depression can
go a long way in reducing your sense of isolation. You can also encourage each other,
give and receive advice on how to cope, and share your experiences.

Invite someone to a ballgame, movie, or concert. There are plenty of other people

who feel just as awkward about reaching out and making friends as you do. Be the one
to break the ice.

Call or email an old buddy. Even if you’ve retreated from relationships that were once
important to you, make the effort to reconnect.

Tip 2: Support your health

Positive lifestyle changes can help lift depression and keep it from coming back.

Aim for eight hours of sleep. Depression typically involves sleep problems; whether

you’re sleeping too little or too much, your mood suffers. Get on a better sleep schedule
by learning healthy sleep habits.
Keep stress in check. Not only does stress prolong and worsen depression, but it can
also trigger it. Figure out all the things in your life that stress you out, such as work
overload, money problems, or unsupportive relationships, and find ways to relieve the
pressure and regain control.

Practice relaxation techniques. A daily relaxation practice can help relieve symptoms

of depression, reduce stress, and boost feelings of joy and well-being. Try yoga, deep
breathing, progressive muscle relaxation, or meditation.

Spend time in sunlight. Getting outside during daylight hours and exposing yourself to

the sun can help boost serotonin levels and improve your mood. Take a walk, have your
coffee outside, do some yard work, or double up on the benefits by exercising outdoors.
If you live somewhere with little winter sunshine, try using a light therapy box.

Develop a “wellness toolbox” to deal with depression

Come up with a list of things that you can do for a quick mood boost. The more “tools”
for coping with depression, the better. Try and implement a few of these ideas each
day, even if you’re feeling good.

1. Spend some time in nature.

2. List what you like about yourself.
3. Read a good book.
4. Watch a funny movie or TV show.
5. Take a long, hot shower.
6. Take care of a few small tasks.
7. Play with a pet.
8. Talk to friends or family face-to-face.
9. Listen to music.
10. Do something spontaneous.

Tip 3: Exercise for greater mental and physical health

When you’re depressed, just getting out of bed can seem like a daunting task, let alone
working out. But exercise is a powerful depression fighter—and one of the most
important tools in your recovery arsenal. Research shows that regular exercise can be
as effective as medication for relieving depression symptoms. It also helps prevent
relapse once you’re well.
To get the most benefit, aim for at least 30 minutes of exercise per day. This doesn’t
have to be all at once-and it’s okay to start small. A 10-minute walk can improve your
mood for two hours.

Exercise is something you can do right now to boost your mood

Your fatigue will improve if you stick with it. Starting to exercise can be difficult
when you’re depressed and feeling exhausted. But research shows that your energy
levels will improve if you keep with it. Exercise will help you to feel energized and less
fatigued, not more.

Find exercises that are continuous and rhythmic. The most benefits for depression
come from rhythmic exercise—such as walking, weight training, swimming, or martial
arts—where you move both your arms and legs.

Add a mindfulness element, especially if your depression is rooted in unresolved

trauma or fed by obsessive, negative thoughts. Focus on how your body feels as you
move—such as the sensation of your feet hitting the ground, or the feeling of the wind
on your skin, or the rhythm of your breathing.

Pair up with an exercise partner. Not only does working out with others enable you to
spend time socializing, it can also help to keep you motivated. Try joining a running
club, seeking out tennis partners, or enrolling in a soccer or volleyball league.

Take a dog for a walk. If don’t own a dog, you can volunteer to walk homeless dogs for
an animal shelter or rescue group. You’ll not only be helping yourself but also be
helping to socialize and exercise the dogs, making them more adoptable.

Tip 4: Eat a healthy diet to improve how you feel

What you eat has a direct impact on the way you feel.

Minimize sugar and refined carbs. You may crave sugary snacks, baked goods, or
comfort foods such as pasta or French fries, but these “feel-good” foods quickly lead
to a crash in mood and energy.

Reduce your intake of foods that can adversely affect your mood, such as
caffeine, alcohol, trans fats, and foods with high levels of chemical preservatives or
hormones.

Eat more Omega-3 fatty acids to give your mood a boost. The best sources are fatty
fish (salmon, herring, mackerel, anchovies, sardines), seaweed, flaxseed, and walnuts.

Try foods rich in mood-enhancing nutrients, such as bananas (magnesium to

decrease anxiety, vitamin B6 to promote alertness, tryptophan to boost feel-good
serotonin levels) and spinach (magnesium, folate to reduce agitation and improve
sleep).

Avoid deficiencies in B vitamins which can trigger depression. Eat more citrus fruit,
leafy greens, beans, chicken, and eggs.

Tip 5: Challenge negative thinking

Do you feel like you’re powerless or weak? That bad things happen and there’s not
much you can do about it? That your situation is hopeless? Depression puts a negative
spin on everything, including the way you see yourself and your expectations for the
future.

When these types of thoughts overwhelm you, it’s important to remember that this is
a symptom of your depression and these irrational, pessimistic attitudes—known as
cognitive distortions—aren’t realistic. When you really examine them they don’t hold up.
But even so, they can be tough to give up.

You can’t break out of this pessimistic mind frame by telling yourself to “just think
positive.” Often, it’s part of a lifelong pattern of thinking that’s become so automatic
you’re not even completely aware of it. Rather, the trick is to identify the type of negative
thoughts that are fueling your depression, and replace them with a more balanced way
of thinking.

Negative, unrealistic ways of thinking that fuel male depression

All-or-nothing thinking. Looking at things in black-or-white categories, with no middle

ground (“If I fall short of perfection, I’m a total failure.”)

Overgeneralization. Generalizing from a single negative experience, expecting it to

hold true forever (“I can’t do anything right.”)

The mental filter. Ignoring positive events and focusing on the negative. Noticing the
one thing that went wrong, rather than all the things that went right.

Diminishing the positive. Coming up with reasons why positive events don’t count
(“She said she had a good time on our date, but I think she was just being nice.”)

Jumping to conclusions. Making negative interpretations without actual evidence. You

act like a mind reader (“She must think I’m pathetic”) or a fortune teller (“I’ll be stuck in
this dead-end job forever.”)

Emotional reasoning. Believing that the way you feel reflects reality (“I feel like such a
loser. I really am no good!”)
‘Shoulds’ and ‘should-nots.’ Holding yourself to a strict list of what you should and
shouldn’t do, and beating yourself up if you don’t live up to your rules.

Labeling. Classifying yourself based on mistakes and perceived shortcomings (“I’m a

failure; an idiot; a loser.”)

Put your thoughts on the witness stand

Once you identify the destructive thoughts patterns that contribute to your depression,
you can start to challenge them with questions such as:

 “What’s the evidence that this thought is true? Not true?”

 “What would I tell a friend who had this thought?”

 “Is there another way of looking at the situation or an alternate explanation?”

 “How might I look at this situation if I didn’t have depression?”

As you cross-examine your negative thoughts, you may be surprised at how quickly
they crumble. In the process, you’ll develop a more balanced perspective and help to
relieve your depression.

Professional treatment for depression in men

If support from family and friends and positive lifestyle changes aren’t enough, seek
help from a mental health professional. Be open about how you’re feeling as well as
your physical symptoms. Treatments for depression in men include:

Therapy. You may feel that talking to a stranger about your problems is ‘unmanly,’ or
that therapy carries with it a victim status. However, if therapy is available to you, it can
often bring a swift sense of relief, even to the most skeptical male.

Medication. Antidepressant medication can help relieve some symptoms of depression,

but it doesn’t cure the underlying problem and is rarely a long-term solution. Medication
also comes with side effects. Even if you decide that medication is right for you, always
pursue self-help steps as well. Therapy and lifestyle changes can address the
underlying causes of your depression to prevent it returning when you’re able to come
off antidepressants.  

How to help a man with depression

It often takes a wife, partner, or other family member to recognize a man’s symptoms of
depression. Even if a man suspects he’s depressed, he may be ashamed that he’s
unable to cope on his own and only seek help when pressured to do so by a loved one.
Talking to a man about depression

Many men don’t exhibit typical depressive symptoms such as a despondent mood, so
you may want to avoid using the word “depression” and try describing his behavior as
“stressed” or “overly tired.” It could help him to open up.

Point out how his behavior has changed, without being critical. For example, “You
always seem get stomach pains before work,” or “You haven’t played racquetball for
months.”

Suggest a general check-up with a physician. He may be less resistant to seeing a

family doctor than a mental health specialist at first. The doctor can rule out medical
causes of depression and then make a referral.

Offer to accompany him on the first visit with a doctor or mental health specialist.
Some men are resistant to talking about their feelings, so try to remove roadblocks to
him seeking help.

Encourage him to make a list of symptoms to discuss. Help him focus on his

feelings as well as physical ailments, and to be honest about his use of alcohol and
drugs.

How to support a man with depression

Engage him in conversation and listen without judgement. Don’t disparage any of
the feelings he expresses, but do point out realities and offer hope.

Take any remarks about suicide seriously. In the U.S., call the National Suicide
Prevention Lifeline at 1-800-273-8255 or find a suicide helpline in another country
at Befrienders Worldwide.

Invite him for social activities, whether it’s simply a walk together or lunch with
friends. If your invitation is refused, keep trying.

Encourage him to participate in activities that once gave him pleasure, such as

hobbies, sports, or cultural activities. But don’t push him to undertake too much too
soon.

Don’t tell him to ‘just snap out of it.’ Instead, reassure him that, with time and
support, he will start to feel better.

Monitor whether he is taking prescribed medication or attending therapy. If he’s

prescribed antidepressants, encourage him to follow orders about the use of alcohol.
Remember, you can’t “fix” someone else’s depression. You’re not to blame for your
loved one’s depression or responsible for his happiness. While your support can be
crucial to his recovery, ultimately, it’s in his hands.

Authors: Lawrence Robinson, Melinda Smith, M.A., Jennifer Shubin, and Jeanne
Segal, Ph.D.

Types of depression
There are different types of depressive disorders. Symptoms can range from
relatively minor (but still disabling) through to very severe, so it's helpful to be
aware of the range of conditions and their specific symptoms.

Major depression
Major depression is sometimes called major depressive disorder, clinical
depression, unipolar depression or simply 'depression'. It involves low mood
and/or loss of interest and pleasure in usual activities, as well as other
symptoms. The symptoms are experienced most days and last for at least two
weeks. Symptoms of depression interfere with all areas of a person's life,
including work and social relationships. Depression can be described as mild,
moderate or severe; melancholic or psychotic (see below).
Melancholia

This is the term used to describe a severe form of depression where many of
the physical symptoms of depression are present. One of the major changes
is that the person starts to move more slowly. They're also more likely to have
a depressed mood that is characterised by complete loss of pleasure in
everything, or almost everything.

Psychotic depression

Sometimes people with a depressive disorder can lose touch with reality and
experience psychosis. This can involve hallucinations (seeing or hearing
things that aren't there) or delusions (false beliefs that aren't shared by
others), such as believing they are bad or evil, or that they're being watched or
followed. They can also be paranoid, feeling as though everyone is against
them or that they are the cause of illness or bad events occurring around
them.

Antenatal and postnatal depression

Women are at an increased risk of depression during pregnancy (known as

the antenatal or prenatal period) and in the year following childbirth (known as
the postnatal period). You may also come across the term 'perinatal', which
describes the period covered by pregnancy and the first year after the baby's
birth.

The causes of depression at this time can be complex and are often the result
of a combination of factors. In the days immediately following birth, many
women experience the 'baby blues' which is a common condition related to
hormonal changes and affects up to 80 per cent of women. The 'baby blues',
or general stress adjusting to pregnancy and/or a new baby, are common
experiences, but are different from depression. Depression is longer lasting
and can affect not only the mother, but her relationship with her baby, the
child's development, the mother's relationship with her partner and with other
members of the family.
Almost 10 per cent of women will experience depression during pregnancy.
This increases to 16 per cent in the first three months after having a baby.

Bipolar disorder
Bipolar disorder used to be known as 'manic depression' because the person
experiences periods of depression and periods of mania, with periods of
normal mood in between.

Mania is like the opposite of depression and can vary in intensity – symptoms
include feeling great, having lots of energy, having racing thoughts and little
need for sleep, talking quickly, having difficulty focusing on tasks, and feeling
frustrated and irritable. This is not just a fleeting experience. Sometimes the
person loses touch with reality and has episodes of psychosis. Experiencing
psychosis involves hallucinations (seeing or hearing something that is not
there) or having delusions (e.g. the person believing he or she has
superpowers).

Bipolar disorder seems to be most closely linked to family history. Stress and
conflict can trigger episodes for people with this condition and it's not
uncommon for bipolar disorder to be misdiagnosed as depression, alcohol or
drug abuse, attention deficit hyperactivity disorder (ADHD) or schizophrenia.

Diagnosis depends on the person having had an episode of mania and,

unless observed, this can be hard to pick. It is not uncommon for people to go
for years before receiving an accurate diagnosis of bipolar disorder. If you're
experiencing highs and lows, it's helpful to make this clear to your doctor or
treating health professional. Bipolar disorder affects approximately 2 per cent
of the population.

Cyclothymic disorder
Cyclothymic disorder is often described as a milder form of bipolar disorder.
The person experiences chronic fluctuating moods over at least two years,
involving periods of hypomania (a mild to moderate level of mania) and
periods of depressive symptoms, with very short periods (no more than two
months) of normality between. The duration of the symptoms are shorter, less
severe and not as regular, and therefore don't fit the criteria of bipolar disorder
or major depression.

Dysthymic disorder
The symptoms of dysthymia are similar to those of major depression but are
less severe. However, in the case of dysthymia, symptoms last longer. A
person has to have this milder depression for more than two years to be
diagnosed with dysthymia.
Seasonal affective disorder (SAD)
SAD is a mood disorder that has a seasonal pattern. The cause of the
disorder is unclear, but it's thought to be related to the variation in light
exposure in different seasons. It's characterised by mood disturbances (either
periods of depression or mania) that begin and end in a particular season.
Depression which starts in winter and subsides when the season ends is the
most common. It's usually diagnosed after the person has had the same
symptoms during winter for a couple of years. People with SAD depression
are more likely to experience a lack of energy, sleep too much, overeat, gain
weight and crave for carbohydrates. SAD is very rare in Australia and more
likely to be found in countries with shorter days and longer periods of
darkness, such as in the cold climate areas of the Northern Hemisphere.

Remember, depression is treatable and effective treatments are available.

The earlier you seek support, the better.

Signs and symptoms

You may be depressed if, for more than two weeks, you've felt sad, down or miserable most
of the time, or have lost interest or pleasure in usual activities, and have also experienced
several of the signs and symptoms across at least three of the categories below.

It’s important to remember that we all experience some of these symptoms from time to time,
and it may not necessarily mean you're depressed. Equally, not everyone who is experiencing
depression will have all of these symptoms.

Behaviour
 not going out anymore

 not getting things done at work/school

 withdrawing from close family and friends

 relying on alcohol and sedatives

 not doing usual enjoyable activities

 unable to concentrate

Feelings
 overwhelmed

 guilty

 irritable

 frustrated

 lacking in confidence

 unhappy

 indecisive

 disappointed

 miserable

 sad

Thoughts
 'I’m a failure.'

 'It’s my fault.'

 'Nothing good ever happens to me.'

 'I’m worthless.'

 'Life’s not worth living.'

 'People would be better off without me.'

Physical
 tired all the time

 sick and run down

 headaches and muscle pains

 churning gut
  sleep problems

 loss or change of appetite

 significant weight loss or gain

If you think that you or someone you know may be experiencing depression, completing our
checklist is a quick, easy and confidential way to give you more insight. The checklist won't
provide a diagnosis – for that you'll need to see a health professional – but it can help to guide
you and provide a better understanding of how you're feeling. 
 What is mental health?
 Anxiety and depression checklist (K10)
 Depression
o What causes depression?
o Signs and symptoms
o Types of depression
o Treatments for depression
o Who can assist
o Other sources of support
 Anxiety
 Suicide prevention
 Supporting someone
 Pregnancy and early parenthood
 Grief and loss
 Drugs, alcohol and mental health

Get support
Find out more about depression and anxiety, available treatments and where to get
help in your local area.

Get started nowFind a health professional

Stories
 Mental health had never been talked about with me and I had no idea
what was happening to me
Amanda, 17
Read story
 I look back on it now as a huge challenge and one I have to fight with
every day 
Denise
Read story
 I was unable to attend my children's school concerts or take them to the
pictures as I would have panic attacks 
Brett - Beyond Blue
Read story
 I masked my depression/anxiety with alcohol for a number of years
Eden

10 Things People With Depression Want You

to Know

 Health and Wellbeing

Depression is more than just feeling unhappy or fed up for a

few days. Depression affects people in different ways and
can cause a wide variety of symptoms. Young Scot, Dionne
McFarlane, has shared her experiences of living with
depression.  
For people living depression it can be difficult for the people that are close to them
to understand. Depression is the most common mental health issue in the UK. Through
my experience of living with depression, this is what I think is important for people
to know and try to understand. 
1. We can't just snap out of it

This can be frustrating to hear, and it shows that the

person you're speaking to really doesn't understand
how you're feeling. You can't just snap out of
depression - it’s impossible. I'd describe depression as
feeling like drowning - no matter how hard you try
to fight back it overpowers you and there's nothing you
can do about it. Depression feels like a constant battle and it's
exhausting. 

2. We don't always have a reason as to why we’re feeling depressed

This is something I've noticed others find hard to

understand. To someone who hasn't ever experienced
depression it can be easy to assume that it's caused
by an event in someone's life. Depression can be
triggered by life events such as bereavement or losing
your job, but there doesn't always have to be a reason
as to why someone is depressed. Depression can
affect anyone and it's an illness. I used to find that
before people were understanding about
my depression they used to expect there to be a
reason as to why I was feeling low and having a bad
day when there wasn't a reason and I couldn't explain
why I felt the way I was feeling. 
3. I don't want to hurt you
 For friends and family it can be hard to watch
someone you love suffer from depression, and it can
be difficult to understand how to help and what to do.
Depression is a very selfish illness and I find that often
we can push people away in order to protect them.
With depression there is also feelings of guilt and fear
of letting people down. We may take things personally
or say something that is horrible but we don't mean it.
It can be hard to love and care for someone with
depression but standing by someone and showing
them unconditional love and care is one of the best
things you can ever do for us.
4. Depression and being sad are not the same thing

Depression and sadness mean two different things.

Sadness is a normal emotion and if something bad
was to happen then you may feel sad, but that
sadness will lift after a few days. However, depression
is a persistent sadness - it can last for weeks, months
or even years. It can affect you in various ways such
as changing your personality, interests and the way
you see the future.  
5. Depression isn't a choice

We don't choose to be depressed. It can affect various

things in your life such as relationships, work and
education. We don't choose to have a low mood all
the time and find everything an effort. Depression is
out of our control we can't do anything to stop it from
happening to us. We aren't weak because we have
depression. 
6. We can feel like a burden and that we’re too much to deal with

Depression can cause us to feel like an inconvenience

to others, leading us to become feeling isolated and
finding it difficult to talk to others. We can sometimes
feel that we're too much to deal with and that we’re
bringing others down. When feeling low we can avoid
other people in order to hide how we feel from our
family and friends. This is when friends and family
need to be compassionate and reassure their loved
ones that they're not a burden to them. By letting us
know that we can talk to you about how we are
feeling, we can gain a sense of safety and support
around us.  
7. Achievements that you see as small are big to me

Achieving goals that we set for ourselves makes us

feel proud. Other people's goals may be to get high
grades or get a job but sometimes just getting out of
bed or talking to someone about how you're feeling is
an achievement. Be proud of us when we achieve
these goals. These achievements bring us a step
closer to recovery and some day we will be able to
achieve bigger things, but for now it's about putting
one foot in front of the other and achieving little things
to give us that sense of accomplishment.
8. We can still have some good days

We aren't always having bad days we can still have a

good day. We can still have days that are hard but we
can also have days when we feel okay and are able to
do things. People think that depression is all about
having bad days. Truth is, moods fluctuate quite a lot
and on good days we can feel like we are in control
and that we can achieve something, even just going
out with a friend for a coffee. Depression is a mixture
of good and bad days. The quote that is one of my
favourites is;
"Every day may not be good, but there is something
good in every day."
9. We appreciate your kind words and how you're trying to help

It can be hard to know what to say and what to do to

help. Sometimes offering some kind words can be
helpful and we may not seem like we appreciate it but
 we really do. It can be hard for us to show feelings
of gratefulness but the kindness shown really does
mean a lot to us.  
10. We’re trying our best to get through it

Depression is something that we have to work

through. I've learned that recovery isn't something you
choose once - you have to choose it over and over
again. We can't just let go and ignore depression,
it has to be treated appropriately by a medical
professional. If we have to use therapy and/or
medication as a way of working through
our depression please do stand by us. There's no
shame in asking for help. Depression can make us
feel isolated and lonely and having someone by our
side can make us feel less alone.

Depression
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7. Everyday Life
 Advertisement

What is depression?
Depression is a medical illness. Someone who has depression has symptoms nearly
every day, all day, for 2 weeks or longer. This is considered major depression. There
are other forms of depression that may have less severe symptoms. All the various
forms of depression share the same usual causes and often the same treatments.

Read More

Depression can affect people of all ages and is different for every person. A person
who has depression can’t control his or her feelings. If you or your child, teen, or
older relative is depressed, it’s not his or her fault. Left untreated, depression can last
for weeks, months, or even years.
Women are twice as likely as men to experience depression. The reason for this is
unknown. Changes in a woman’s hormone levels may be related to depression.

Symptoms of depression
Symptoms are different for every person. You may have one or many of the
symptoms listed below. Your symptoms may appear as emotional, physical, or a
combination of both. The symptoms of depression may be different for children,
teens, and seniors.

Emotional symptoms include:

 Crying easily or for no reason.

 Feeling guilty or worthless.

 Feeling restless, irritated, and easily annoyed.

 Feeling sad, numb, or hopeless.

 Losing interest or pleasure in things you used to enjoy (including sex).

 Thinking about death or suicide.

Physical symptoms include:

 Changes in appetite (eating more than usual, or eating less than usual).

 Feeling extremely tired all the time.

 Having other aches and pains that don’t get better with treatment.
 Having trouble paying attention, recalling things, concentrating, and making
decisions.

 Headaches, backaches, or digestive problems.

 Sleeping too much, or having trouble sleeping.

 Unintended weight loss or gain.

When a patient is diagnosed with depression, I’m trained to provide care ranging
from prescribing antidepressants to helping find other resources.  Read More
by Dr. Michael Bevins

What causes depression?

Depression is typically caused by one or more factors. This includes genetic,
biological, environmental, and psychological causes.

For example, depression may be caused by an imbalance of chemicals in the brain.

Sometimes there aren’t enough chemical messengers (called neurotransmitters) in the
brain. Neurotransmitters that affect your mood are serotonin, norepinephrine, and
dopamine. A chemical imbalance in the brain may be caused by one or more of the
following:
 Your genes. Sometimes depression is hereditary. This means it runs in your
family. You may be more at risk for having depression if you have a parent or
sibling who has depression.

 A medical condition. Problems with your thyroid or nutrient deficiencies may

be associated with an increased risk of depression.

 Events in your life. Depression can be triggered by stressful events in your

life. These can include the death of someone you love, a divorce, chronic illness,
or loss of a job.

 Medicines, drugs, or alcohol. Taking certain medicines, abusing drugs or

alcohol, or having other illnesses can also lead to depression.
Depression is not caused by personal weakness, laziness, or lack of willpower.

Can giving birth cause depression?

In the days following the birth of a baby, it is common for some mothers to have
mood swings. They may feel a little depressed or have a hard time concentrating.
They may lose their appetite or find that they can’t sleep well even when the baby is
asleep. This is called the baby blues and goes away within 10 days after delivery.
However, some women have worse symptoms or symptoms that last longer. This is
called postpartum depression.

How is depression diagnosed?

Tell your doctor about your symptoms. Don’t expect your doctor to guess that you’re
depressed just by looking at you. You may feel embarrassed. It may be hard for you to
imagine treatment will actually help you feel better. But don’t wait to talk to your
doctor. The sooner you seek treatment, the sooner the depression will lift.

Once you tell your doctor how you’re feeling, he or she may ask you some questions
about your symptoms, your health, and your family history. Your doctor may also
give you a physical exam and do some tests. It is important to tell your doctor about
any medicines that you are taking.

Reasons to get help early:

 Early diagnosis and treatment helps keep depression from getting worse or
lasting a long time.

 Diagnosis and treatment can help you return to your “normal” self and enjoy
life.

 Treatment can help prevent depression from coming back.

 Thoughts of suicide are common in people with major depression. The risk of
suicide is higher the longer you wait to treat it. When depression is successfully
treated, thoughts of suicide go away.

Can depression be prevented or

avoided?
Generally, depression is a condition that cannot be prevented. There are lifestyle
changes you can make that can boost your mood and minimize symptoms of
depression (see depression treatment).
Depression treatment
Depression can be treated with medicines, with counseling, or with both. Lifestyle
changes can help. This includes a nutritious diet, regular exercise, and avoiding
alcohol, drugs, and too much caffeine.

Depression usually can be treated through visits to your doctor. You may need in-
hospital treatment if you have other medical conditions that could affect your
treatment. In-hospital treatment is required if you’re at high risk of suicide.

Medicine
Your doctor may prescribe medicine to treat your depression. These are
called antidepressants. They help increase the number of chemical messengers
(serotonin, norepinephrine, dopamine) in your brain.

Antidepressants work differently for different people. They also have different side
effects. So, even if one medicine bothers you or doesn’t work for you, another may
help. You may notice improvement as soon as 1 week after you start taking the
medicine. But you probably won’t see the full effects for about 8 to 12 weeks. You
may have side effects at first. They tend to decrease after a couple of weeks. Don’t
stop taking the medicine without checking with your doctor first.

Counseling
Counseling may be a good treatment option for mild to moderate depression. For
major depression and for some people with minor depression, counseling may not be
enough. A combination of medicine and talk therapy is usually the most effective way
of treating more severe depression. If you continue the combination treatment for at
least a year, you are less likely to have depression come back.

In psychotherapy, you talk with a trained therapist or counselor about things that are
going on in your life. The focus may be on your thoughts and beliefs, on things that
happened in your past, or on your relationships. Or the focus may be on your
behavior, how it’s affecting you, and what you can do differently. Psychotherapy
usually lasts for a limited time, such as 8 to 20 visits.

In more serious cases, your doctor may suggest the use of electroconvulsive therapy
(also called ECT or electroshock therapy). This is a procedure used to treat certain
mental illnesses. Electric currents are passed through the brain in order to trigger a
seizure (a short period of irregular brain activity). It lasts about 40 seconds. Medicine
is given during ECT to prevent damage to muscles and bones.

Electroconvulsive therapy may help people who have the following conditions:

 Severe depression that does not respond to antidepressants (medicines used to

treat depression) or counseling.

 Severe depression in patients who can’t take antidepressants.

 Severe mania that does not respond to medicine. Symptoms of severe mania
may include agitation, confusion, hallucinations, or delusions.

 Schizophrenia that does not respond to medicine.

Living with depression
The most important part of living with depression is not giving up. If you stay focused
and are consistent with treatment, your mood will improve over time.

Consider these dos and don’ts as you work toward recovery.

Do:
 Pace yourself.

 Get involved in activities that make you feel good or feel like you’ve achieved
something. This includes volunteering or joining a club.

 Avoid drugs and alcohol. Both make depression worse. Both can cause
dangerous side effects with antidepressant medicines.

 Exercise regularly. It makes your body feel better. Exercise causes a chemical
reaction in the body that can boost your mood. Your goal should be exercising 4
to 6 times a week for at least 30 minutes each time.

 Eat balanced meals and healthy foods. Avoid junk food and processed food.

 Get plenty of sleep. Keep your sleep routine consistent (waking up and going to
bed at the same time each day).

 Take your medicine and/or go to counseling as often as your doctor

recommends. Your medicine won’t work if you only take it occasionally.

 Set small goals for yourself if you have low energy.

 Encourage yourself.

 Get as much information as you can about depression and how to treat it.

 Call your doctor or the local suicide crisis center right away if you have
thoughts of suicide.

Don’t:
 Don’t isolate yourself. Stay in touch with friends, family, your spiritual advisor,
and your doctor.

 Don’t let negative thoughts linger in your mind. Don’t talk badly about
yourself. Don’t expect to fail. This type of thinking is typical of depression. These
thoughts will go away as your depression lifts.

 Don’t blame yourself for your depression. You didn’t cause it.

 Don’t make major life decisions while you are depressed. This includes
marriage, divorce, separation, quitting your job, etc. You may not be thinking
clearly while you are depressed. If you must make an important decision, ask
someone you trust to help you.

 Don’t expect to do everything you normally can. Set a realistic schedule.

 Don’t get discouraged. It will take time for your depression to lift fully. Be
patient with yourself.

 Don’t give up.

Complications
People who have depression sometimes think about suicide. This thinking is a
common symptom of the depression. If you have thoughts about hurting yourself, tell
someone. Tell your doctor, your friends, or your family. 

Coping With Dysthymia

Symptoms of dysthymia may not be as severe as major depression, but they can be just
as debilitating. Learn about this milder, chronic form of depression, and how to get the
right kind of help.

By Chris Iliades, MDMedically Reviewed by Pat F. Bass III, MD, MPH

Last Updated: April 24, 2012

Many people are familiar with major depression, but they may not be aware of
dysthymia, a condition that can be just as insidious. Dysthymia, also called dysthymic
disorder, is a chronic mood disorder characterized by mild symptoms of depression.
According to the National Institute of Mental Health, dysthymia affects about 1.5 percent
of adults in the United States in a given year. It’s somewhat like major depression, but
with some key differences. Most importantly, dysthymia symptoms aren’t as severe as
symptoms of major depression, but they last a lot longer. The word dysthymia is Greek
for "bad state of mind."

"Dysthymia used to be called depressive personality disorder because people with dysthymia
seemed to have a negative view of life," says Murali Rao, MD, department chair of psychiatry
and behavioral neurosciences at Loyola University Medical Center in Chicago. "Symptoms of
dysthymia come on gradually and may not be as severe as those of of major depression, but it’s
a misunderstanding to consider dysthymia a ‘minor’ form of depression."

Diagnosing Dysthymia

Dysthymia is clinically defined as a depressed mood that is present most of the time for
at least two years. "Major depression can be diagnosed after only two weeks if a person
has five major depression symptoms," Dr. Rao explains. "For a diagnosis of dysthymia,
 you need to have at least two symptoms of the condition for at least two years."
Symptoms of dysthymia may include:

 Insomnia
 Excessive sleeping
 Poor appetite or overeating
 Fatigue
 Low energy
 Hopelessness
 Low self-esteem
 Poor concentration
 Difficulty functioning well at work or school
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There can be a lot of overlap between dysthymia and major depression. Like major
depression, dysthymia is more common in women than in men. About 50 percent of
people who have dysthymia will have at least one episode of major depression. And like
major depression, dysthymia often runs in families. A doctor can help distinguish which
form of depression you’re dealing with.

Getting Help for Dysthymia

Dysthymia is treated with many of the same approaches used to treat major depression,
such as talk therapy (also called psychotherapy) and antidepressant medications.
However, the condition may not improve as much or as quickly.
 A significant stumbling block to successful treatment is that many people with dysthymia
simply don’t get treated compared to those with major depression. "Because their
depression is so long-lasting, people with dysthymia tend to become accepted as just
being negative people by their families, themselves, and even their doctors," Rao says.
"They may go years without being treated, leading to high risk for unemployment, poor
relationships, and suicide. This can make their prognosis even worse than it is for
people with major depression."

However, there’s no reason to ignore or accept a persistent depressed mood, especially

one that goes on for years. In addition to being diagnosed and treated by an
experienced doctor, certain lifestyle changes can help manage the symptoms of
dysthymia. Rao suggests trying these tactics:

 Get smart. The more you know about dysthymia, the more you can help yourself. Ask
your doctor for literature or do online research on reputable Web sites like Psych Central.
 Get organized. You may have trouble getting motivated — a simple, organized plan for
each day can get you going.
 Get involved. Dysthymia often leads to isolation. Spend time with friends and loved
ones to stay connected and boost your mood.
 Get support. Talking about your feelings can help you better cope with a blue mood.
Joining a depression support group allows you to create a network of people you can relate to.
 Get some relief. Stress can dampen your outlook on life. Get a fresh perspective with
exercise, meditation, or a mind-body activity like yoga or tai chi.
 Get the care you need. Dysthymia tends to ruin your self-esteem. Take good care of
yourself by eating well, getting enough restful sleep, and resisting destructive behaviors.

Dysthymia is a condition that usually responds to the right treatment — it’s not a
personality type or a character flaw. If you or someone you know has two or more of
these symptoms of depression for two or more years, don’t let any more time go by
before talking to your doctor.
Dysthymia and Apathy: Diagnosis and Treatment
Junko Ishizaki 1, 2 , and Masaru Mimura 3 ,*

Author information Article notes Copyright and License information Disclaimer

This article has been cited by other articles in PMC.

Abstract
Go to:

1. Dysthymia
Dysthymia is a depressive mood disorder that is characterized by chronic, persistent but mild
depression, affecting 3–6% of individuals in the community [1, 2] and as many as 36% of
outpatients in mental health settings [3]. Although by definition, the depressed mood of
dysthymia is not severe enough to meet the criteria for major depressive disorder, it is
accompanied by significant subjective distress or impairment of social, occupational, or other
important activities as a result of mood disturbance [4]. Dysthymia manifests as a depressed
mood persisting for at least two years (one year for children or adolescents) that lasts for most of
the day, occurs on more days than not, and is accompanied by at least two of the following
symptoms:
1. poor appetite or overeating,
 2. insomnia or hypersomnia,
3. low energy or fatigue,
4. low self-esteem,
5. poor concentration or difficulty making decisions,
6. feelings of hopelessness.
To diagnose dysthymia, major depressive episodes must not have occurred during the first two
years of the illness (one year in children or adolescents), and there should be no history of mania.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR) [5] states that transient euthymic episodes lasting for up to two months may occur
during the course of dysthymia. In the past, dysthymia has had several other names, including
depressive neurosis, neurotic depression, depressive personality disorder, and persistent anxiety
depression.
DSM-IV-TR categorizes dysthymia according to several course specifiers: (1) early onset if
symptoms begin before the age of 21 years, (2) late onset if symptoms begin at age 21 or later,
and (3) dysthymia with atypical features if symptoms include increased appetite or weight gain,
hypersomnia, a feeling of leaden paralysis, and extreme sensitivity to rejection.
It is often difficult to differentiate dysthymia from major depression specifically in patients with
partial remission or partial response to treatment. Major depressive disorder, dysthymia, double
depression, and some apparently transient dysphorias may all be manifestations of the same
disease process. These varieties of depressed mood states, while distinct diagnostic entities, share
similar symptoms and respond to similar pharmacologic and psychotherapeutic approaches. Due
to the stigma still associated with depression, many people with this disorder may be
unrecognized and untreated. Although dysthymia has long been considered to be less severe than
major depression, the consequences of this condition are increasingly recognized as potentially
grave, including severe functional impairment, increased morbidity from physical disease, and
even an increased risk of suicide.
The pathophysiology of dysthymia is not fully understood. Approximately 30% of individuals
with dysthymia show a switch to hypomanic episodes at some stage [6]. Most people, especially
those with early onset dysthymia, have a family history of mood disorders, including bipolar
disorder. One or both parents may have suffered from major depression. A family history of this
illness makes it more likely for dysthymia to appear in the teenage years or early 20s. Compared
with major depression, patients with dysthymia tend to have more subjective symptoms and less
dramatic psychomotor disturbance or neurovegetative symptoms including abnormalities of
sleep, appetite, and energy levels. A longitudinal prospective study revealed that 76% of
dysthymic children develop major depression, and 13% develop bipolar disorder over follow-up
periods of 3–12 years [7]. In the other study, it should be noted that around 75% of people with
dysthymia meet the criteria for at least one major depressive episode, and this combination is
referred to as double depression [8]. Persons with dysthymia who have major depressive
episodes tend to suffer from depression for long periods and spend less time fully recovered [9].
In a 10-year follow-up study of persons with dysthymia, 73.9% showed recovery from
dysthymic disorder, with a median time to recovery of 52 months, but the estimated risk of
relapse into another period of chronic depression including dysthymia was 71.4%, most
commonly within three years [10].
The validity of making a distinction between depressive personality disorder and dysthymia has
been a matter of debate since depressive personality disorder and dysthymia are both classified
among the lesser severity spectrum of depressive disorders. Depressive personality disorder is
characterized by a gloomy or negative outlook on life, introversion, a tendency toward self-
criticism, and pessimistic cognitive processes, with fewer than mood and neurovegetative
symptoms, seen in dysthymia. Dysthymia or depression may coexist with depressive personality
disorder, and persons who have depressive personality disorder are at greater risk of developing
dysthymia than healthy persons after followup for 3 years [11].
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2. Treatment for Dysthymia

The best treatment for dysthymia appears to be a combination of psychotherapy and medication.
The positive clinical response to medications like selective serotonin reuptake inhibitors (SSRIs)
[12–19], serotonin norepinephrine reuptake inhibitors (SNRIs) [20, 21], and tricyclic
antidepressants (TCAs) [14, 15] suggests that serotoninergic and noradrenergic systems involve
the mechanism of dysthymia. A systematic review [22, 23] of antidepressant treatment for
dysthymia suggests that SSRIs, TCAs, and monoamine oxidase inhibitors are all equally
effective, but SSRIs may be slightly better tolerated. Success has also been reported with more
noradrenergic agents, such as mirtazapine, nefazodone, venlafaxine, duloxetine, and bupropion.
Second-generation antipsychotics showed beneficial effects compared to placebo for major
depressive disorder or dysthymia, but most second-generation antipsychotics have shown worse
tolerability, mainly due to sedation, weight gain, or laboratory data abnormalities such as
prolactin increase. Some evidence indicated beneficial effects of low-dose amisulpride for
dysthymic people [24].
Psychotherapy and medication are both effective treatment modalities for dysthymia and their
use in combination is common. There are many different types of psychotherapy, including
cognitive behavioral therapy, psychodynamic, and insight-oriented or interpersonal
psychotherapy, which are available to help persons with dysthymia. Cognitive Behavioral
Analysis System of Psychotherapy (CBASP) [25] has been attracting more attention for the
treatment of chronic depression. CBASP is a form of psychotherapy that was specifically
developed for patients with chronic depression. Its core procedure is called “situational analysis”
and is a highly structured technique that teaches chronically depressed patients how to handle
problematic interpersonal encounters. It encourages patients to focus on the consequences of
their behavior and to use a social problem-solving algorithm to address interpersonal difficulties.
CBASP is more structured and directive than interpersonal psychotherapy and differs from
cognitive therapy by focusing primarily on interpersonal interactions, including interactions with
therapists. Through this psychotherapy, patients come to recognize how their cognitive and
behavioral patterns produce and perpetuate interpersonal problems and learn how to remedy
maladaptive patterns of interpersonal behavior. The combination of medication and
psychotherapy may be much more effective than either one alone [26].
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3. Apathy
Dysthymia is essentially defined by the existence of depressive symptoms at some level.
However, some patients who are treated for dysthymia only present with loss of interest and do
not have a depressed mood. This condition should be regarded as apathy. The term “apathy” is
derived from the Greek “pathos” meaning passion, that is, apathy means “lack of passion”.
Marin [27] defined the apathy syndrome as a syndrome of primary lack of motivation, that is,
loss of motivation that is not attributable to emotional distress, intellectual impairment, or
diminished consciousness. Starkstein [28] described the features of apathy as lack of motivation
characterized by diminished goal-oriented behavior and cognition, and a diminished emotional
connection to goal-directed behavior. Levy and Dubois [29] proposed that apathy could be
defined as the quantitative reduction of self-generated voluntary and purposeful behavior. At
present, apathy is treated symptomatically. There is no decision tree for apathy in DSM-IV-TR,
but there is a possibility that apathy will come to be managed independently from mood
disorders if the mechanisms involved or treatment strategy is more fully established in the future.
Marin [27] and Starkstein [30] have suggested diagnostic criteria for this condition. As the basis
of specific diagnostic criteria for apathy, abnormalities in aspects of emotion, cognition, motor
function, and motivation have been suggested. Marin has also developed an apathy rating scale
[31], while diagnostic criteria for apathy have been proposed by Starkstein et al. (Table 1).

Table 1
Diagnostic criteria for apathy.

Lack of motivation relative to the patient's previous level of functioning or the standards of his or her age and
culture,

as indicated either by subjective account or observation by others. Presence, with lack of motivation, of at least
one

symptom belonging to each of the following three domains.

(i) Diminished goal-directed behavior:

 (a) lack of effort,

  (b) dependency on others to structure activity.

(ii) Diminished goal-directed cognition:

 (a) lack of interest in learning new things or in new experiences,

 (b) lack of concern about one's personal problems. 

(iii) Diminished emotion:

 (a) unchanging affect,

 (b) lack of emotional responsivity to positive or negative events.

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas
of

functioning.  The symptoms are not due to a diminished level of consciousness or the direct physiological effects
of a

substance (e.g., a drug of abuse, a medication).

Adapted from Starkstein [30].

Apathy has received increasing attention because of its effects on emotion, behavior, and
cognitive function. It seems likely that apathy in persons with depression results from alterations
of the emotional and affective processing, but it may typically occur in the absence of a
depressed mood (Figure 1).

Figure 1

Apathy versus depression.

Apathy occurs in persons with a variety of psychiatric and neurological disorders including
schizophrenia [32, 33], stroke [34, 35], traumatic brain injury [36], Parkinson's disease
[28, 37, 38], progressive supranuclear palsy [38], Huntington's disease [39, 40], and dementias
such as Alzheimer's disease [30, 41, 42], vascular dementia [43], frontotemporal dementia
[41, 42], and dementia due to HIV [44]. Marin et al. [45] evaluated five subgroups (healthy
elderly adults, patients with left hemispheric stroke, right hemispheric stroke, Alzheimer's
disease, and major depression) by using the apathy evaluation scale [31] and the Hamilton rating
scale for depression [46]. Mean apathy scores were significantly higher than healthy elderly
scores in right hemispheric stroke, Alzheimer's disease, and major depression. Elevated apathy
scores were associated with low depression in Alzheimer's disease, high depression in major
depression, and intermediate scores for depression in right hemispheric stroke. The prevalence of
elevated apathy scores ranged from 73% in Alzheimer's disease, 53% in major depression, 32%
in right hemispheric stroke, 22% in left hemispheric stroke, and 7% in normal subjects. They
found that the level of apathy and depression varied among diagnostic groups although apathy
and depression were significantly correlated within each group. Thus, apathy is most often seen
clinically within the setting of depression, dementia, or stroke, and problems related to apathy
tend to be important because of its frequency, increasing prevalence, impact on daily life, poorer
rehabilitation outcomes after stroke, and burden on caregivers.
Levy et al. [42, 47] found that patients with frontotemporal dementia and progressive
supranuclear palsy could be discriminated from patients with Alzheimer's disease by their more
severe apathy and relatively less severe depression. Furthermore, they reported that apathy was
not correlated with depression in a combined patient sample, including those with Alzheimer's
disease, frontotemporal dementia, progressive supranuclear palsy, Parkinson's disease, and
Huntington's disease. Apathy, but not depression, was correlated with lower cognitive function
as measured by the mini mental state examination [48]. These results imply that apathy might be
a specific neuropsychiatric syndrome that is distinct from depression but is associated with both
depression and dementia. Symptomatologically, it is important to understand that apathy can
occur concomitantly with depression, but is usually different from it. Depression is a “disorder of
emotion”, while apathy is a “disorder of motivation”. Starkstein et al. [34] studied the frequency
of apathy among stroke patients with major depression, minor depression, or no depression. A
fairly large number (23%) of their patients had significant apathy. The apathetic patients were
older, had a higher frequency of major (but not minor) depression, had more severe physical and
cognitive impairment, and had lesions involving the posterior limb of the internal capsule. In
their study, there was a significantly higher frequency of apathy among the patients with major
depression but not those with minor depression or no depression. These findings indicate that
although major depression and apathy occur independently, apathy remains significantly
associated with major depression (but not with minor depression). This is consistent with the
results of previous studies that have differentiated between major and minor depression,
including differences of cognitive function and cortisol suppression after dexamethasone
administration [49, 50], which were seen in patients with major depression but not minor
depression.
Apathy is often seen in patients with lesions of the prefrontal cortex [51, 52] and is also frequent
after focal lesions of specific structures in the basal ganglia such as the caudate nucleus, the
internal pallidum, and the medial dorsal thalamic nuclei [53–56]. Apathy is, therefore, one of the
clinical sequelae of disruption of the prefrontal cortex-basal ganglia axis, which is one of the
functional systems involved in the origin and control of self-generated purposeful behavior.
Anatomical localization of regional dysfunction associated with apathy and depression appears
to overlap considerably. Depression has been reported to be more frequent when focal lesions are
anterior and left-sided [57]. Levy and Dubois [29] proposed that the mechanisms responsible for
apathy could be divided into three subtypes of disrupted processing: “emotional-affective”,
“cognitive”, and “autoactivation” loss of psychic self-activation.
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4. Treatment for Apathy (Table 2)

Table 2
Possible medications for apathy.
Category Class Main background disease Representative drug
name

Antidepressants SSRIs* Depression Fluvoxamine,

SNRIs** Paroxetine
NaSSAs*** Sertraline
DNRIs**** Milnacipran
Tetracyclic Mirtazapine
antidepressants Bupropion
Tricyclic Maprotiline
antidepressants Amoxapine
Nortriptyline

Dopamine stimulants Dopamine agonists Parkinson's disease, Bromocriptine

depression (?) Pramipexrole
Ropinirole
Amantadine

MAO-B inhibitor Selegiline

Antipsychotic agents Atypical antipsychotic Negative symptoms (apathy- Clozapine,

agents like symptoms) of Risperidone,
Category Class Main background disease Representative drug
name

schizophrenia Olanzapine,
Quetiapine,
Ziprasidone

Psychostimulants Dopaminergic agents Primary apathy or apathy Methylphenidate

syndrome Pemoline
Amphetamine
Modafinil

Antidementia agents Cholinesterase Alzheimer's disease Donepezil

inhibitors Galantamine
Rivastigmine
Metrifonate
Tacrine

Pyrrolidone-type Stroke, Alzheimer's disease Nefiracetam

nootropic agent
 Category Class Main background disease Representative drug
name

Cerebral circulation and Ergot alkaloid Stroke Nicergoline

metabolism stimulants

Antiplatelet drugs Phosphodiesterase Cilostazol

inhibitor

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*Selective serotonin reuptake inhibitors: there have been a few reports that SSRIs are not effective for apathy.
**Serotonin-noradrenaline reuptake inhibitors. ***Noradrenergic and specific serotonergic antidepressants.
****Noradrenaline-dopamine reuptake inhibitors.

Taking into consideration the facts that apathy is related to cognitive function and disruption of
the prefrontal cortex-basal ganglia axis, apathy can be considered to resemble subcortical
dementia and to be treatable using dopaminergic agents in central nervous system. A growing
number of reports have documented the treatment of apathy with a variety of psychoactive
agents. Various small studies have indicated that psychostimulants, dopaminergics, and
cholinesterase inhibitors might be of benefit for this syndrome. However, there is no current
consensus about treatment for apathy, and information on pharmacotherapy for this condition
mainly depends upon underlying etiology and background disease. For example, dopamine
agonists appear to be promising for ameliorating apathy in patients with Parkinson's disease
while atypical antipsychotics used in schizophrenia and cholinesterase inhibitors have been
reported to be useful for treating apathy in Alzheimer's disease and other dementias. Therefore,
the treatment of apathy should be selected according to its etiology. Depressed patients with
apathy should be given antidepressants, which may also alleviate other symptoms. However,
caution has been raised about using SSRIs for depressed elderly persons because it may worsen
apathy [58]. Since frontal lobe dysfunction is considered to be one of the causes of apathy,
patients with primary apathy may respond to psychostimulants such as methylphenidate or
dextroamphetamine. There have also been reports about improvement of apathy and cognitive
function after stroke by treatment with cilostazol [59]. As nonpharmacological methods, cranial
electrotherapy stimulation for apathy after traumatic brain injury [60], and cognitive stimulation
therapy for neuropsychiatric symptoms in Alzheimer's disease [61] might have some value, but
evidence awaits future studies.
Apathy syndrome is associated with many diseases, but whether medications are applicable
across this spectrum of background diseases remains unknown. For example, would
cholinesterase inhibitors that are used in patients with Alzheimer's disease be effective for apathy
associated with major depression? These issues should be examined in future studies.

Dysthymia
Major depression is not the only variety of depressive disorder. Dysthymia, or persistent
depressive disorder, is yet another, and while its symptoms aren’t as acute or debilitating as those
of major depression, dysthymia is still a life-altering mental health condition. Spontaneous
remission of dysthymia is unlikely, and the best way to avoid significant problems down the road
is to seek treatment for depression whenever symptoms occur, regardless of their strength and
intensity.
Page Contents

 What Is Dysthymia?
 Facts and Statistics
 Dysthymia Symptoms and Diagnosis
 Causes and Risk Factors for Dysthymia
 Co-Occurring Disorders
 Dysthymia Treatment and Prognosis
What Is Dysthymia?

Depression is always serious but not always disabling. People who suffer from persistent
depressive disorder, or dysthymia, experience the typical symptoms of depression, but in a
relatively manageable form.
Under the influence of dysthymia, men and women experience persistent, long-term symptoms
of low-grade depression that can linger indefinitely. Through at least the first few months of the
illness, they may be able to meet most if not all of their personal, financial, and familial
obligations. Unless they choose to share what they’re feeling, friends and family members may
never suspect anything is wrong—and if they do suspect, they are unlikely to identify depression
as the culprit.
Over time, however, dysthymia takes its toll. Even in low-grade form depression is still
depression, and happiness and contentment will be impossible to find as long as a person is
trapped by the feelings of emptiness and meaninglessness that dysthymia causes. If treatment for
persistent depressive disorder is not provided—and people suffering from dysthymia often fail to
realize they need help—the condition can cause a host of life problems that leave sufferers
struggling to hang on.
Facts and Statistics
Major depression affects more than 16 million adults in the United States. But many people
don’t realize there is such a thing as high-functioning depression, which is yet another name for
dysthymia.
While dysthymia isn’t as common as major depressive disorder, it still touches the lives of
approximately 3.5 million Americans each year, which represents about 1.5 percent of the
adult population. The lifetime rate for persistent depressive disorder is about 3.6 percent,
and those who experience the chronic, long-term symptoms of this disorder only seek treatment
for their conditions about 60 percent of the time.
Even though dysthymia isn’t normally thought of as disabling, one-half of those who develop the
disorder have it in an acute form, meaning it will cause difficulties if no help is provided.
Dysthymia Symptoms and Diagnosis

While the symptoms of persistent depressive disorder don’t reach the level of major depression,
they are still quite similar in their makeup. People who’ve developed dysthymia will quickly
realize that something is wrong, even if their closest companions only notice subtle changes.
Some of the common symptoms of dysthymia include:
 Low motivation
 Lack of energy
 Muted emotional responses
 Inability to take pleasure in favored hobbies or activities
 Detachment from friends and family life
 Feelings of unworthiness and shame
 Chronic anxiety
 Pessimism or fatalism about the future
 Overeating or eating too little
 Changes in sleeping habits, with at least some insomnia
 Poor focus, concentration, and memory
 Inability to complete tasks, or to complete them correctly or on time
 Impulsive actions, often including sudden changes in jobs or relationships
Dysthymia manifests as a vague yet persistent sense of unease and emptiness. Its symptoms may
worsen over time, but even if they don’t they can be expected to last longer than symptoms of
major depression should treatment not be provided.
Diagnosing Dysthymia
Persistent depressive disorder may be diagnosed by a mental health practitioner if two of the
following symptoms are detected:
 Feelings of despair, emptiness, and hopelessness
 Chronic feelings of self-doubt and poor self-esteem
 Changes in weight and appetite
 Changes in sleeping patterns
 Moodiness marked by frequent irritability
 Difficulties in focusing and concentrating
 Inhibitions or inconsistencies in decision-making
Low-grade depression can be hard to identify, and professionals must rely on the complete and
honest testimony of their patients to diagnose this elusive disorder. To a certain extent dysthymia
mimics major depression, but without the dramatic interruptions in functioning or profoundly
overwhelming feelings of sadness that make the latter condition easier to spot.
Major depression can be diagnosed if symptoms persist for as little as two weeks, but dysthymia
must be present for two years or more, with no symptom-free periods lasting for more than two
months, before it can be classified as a true mental health condition.
Call for a Free Confidential Assessment.
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Causes and Risk Factors for Dysthymia

Everyone is potentially at risk for chronic, low-intensity depression. This condition is largely a
response to troubling, confusing, stressful, disappointing, or traumatic life experiences, and the
chances of developing dysthymia are greater if the feelings associated with such experiences are
not addressed in therapy at the time they first arise.
Some of the specific risk factors for persistent depressive disorder include:
 Family history of depression or other types of mental illness. Genetic factors play some role in
creating this connection, but home environmental influences during childhood and adolescence
are implicated as well.
 Exposure to trauma or neglect. The chances for depression increase significantly for those who
experience abuse of some kind during childhood, but traumatic exposures later in life can also
predispose a person to dysthymia or major depressive disorder.
 Negative personality traits. People who lack self-confidence and self-esteem and are generally
pessimistic or fatalistic are likely to develop some form of depression.
 Stressful lifestyle. Bodies and minds under constant stress and emotional duress may eventually
break down, and depression is one possible consequence of stress if it is prolonged.
 Previous history of mental health problems. Anxiety disorders are frequently diagnosed in
people with depression, and those who suffer from anxiety are likely to experience depression
symptoms eventually.
Dysthymia is linked to neurological changes that affect mood management and emotional
balance. Over time, brains can be reprogrammed to respond to stress and anxiety more
constructively, which is an important remedy for depressive disorders.
Co-Occurring Disorders

There is a strong connection between mood disorders and anxiety disorders. Research has
revealed that as many as 70 percent of people with major depression or dysthymia have a
co-occurring anxiety disorder, while up to 60 percent of anxiety disorder sufferers will also
battle depression.
The frequent comorbidity of anxiety and depression is common knowledge, but what is less
well-known is the striking association between personality disorders and depression. Perhaps
because of the relationship troubles and social turmoil people with personality disorders often
face, they are highly vulnerable to depression—and to dysthymia in particular.
Among men and women who’ve been diagnosed with persistent depressive disorder, an
astounding 85.7 percent in one study also demonstrated symptoms consistent with at least one
personality disorder. Borderline personality disorder was the condition most commonly
diagnosed in these individuals, with a 20-percent occurrence rate, and the relationship between
borderline traits and depression has been found to hold across cultures and nationalities.
Even though dysthymia and major depression are separate disorders, in some instances there can
be overlap. Some people diagnosed with persistent depressive disorder will develop a limited
number of severe symptoms that are more characteristic of major depression than dysthymia, and
these individuals may be re-diagnosed with double depression, a complex condition that could
require intensive therapy.
The frequent co-occurrence of other health conditions is one of the main reasons why people
suffering from the symptoms of dysthymia should seek evaluation and treatment, even if they are
still able to function. With multiple mental health disorders they won’t be able to function
indefinitely, and the sooner they seek help the better their chances of making a full and
successful recovery.
Dysthymia Treatment and Prognosis

Unfortunately, many people learn to live with dysthymia. They may see it as an unavoidable
consequence of modern life, or they may convince themselves that superficial changes will
eventually make their feelings of sadness and emptiness disappear.
But dysthymia is a chronic mental health condition that seldom vanishes on its own. Left
unchecked, it will limit achievement and undermine contentment, while slowly eroding a
person’s sense of confidence and self-worth. Without treatment, people who suffer from
dysthymia will be unable to maintain their emotional and psychological equilibrium, and their
capacity to learn, develop, accomplish, and prosper may be severely restricted over the long haul.
The failure of many people with dysthymia to seek help prevents health and happiness, since
this condition is highly amenable to treatment. Like major depressive disorder, persistent
depressive disorder responds well to a combination of psychotherapy and medication, offered in
a structured outpatient or inpatient treatment program at a licensed a mental health treatment
facility.
While in treatment, clients attend daily therapy sessions in individual, group, and/or family
formats, where all the underlying issues involved in their depression can be identified and
discussed. Various antidepressant medications may be administered for the symptoms of
depression, and the mixture of talk therapy with medicinal intervention can dramatically
decrease the frequency and intensity of those symptoms over the course of a 30- to 90-day
inpatient or outpatient treatment program.
Outpatient programs are often the first choice for dysthymia, but residential inpatient programs
are a superior choice for those who have comorbid conditions that require additional treatment
services. Aftercare services are also vital to help recovering depression sufferers stay focused on
healing, and that is especially true if they have been diagnosed with co-occurring anxiety
disorders, personality disorders, or substance use disorders.
Dysthymia should not be accepted as normal or dismissed as a small concern. Depression is
always unwelcome, and no one who experiences it in any form should be content to suffer
through it in silence.
 Persistent Depressive Disorder
(Dysthymia)
What Is It?
Published: March, 2019

Persistent depressive disorder (dysthymia) is a form of depression. It may be less

severe than major depression, but — as the name suggests — it lasts longer. Many
people with this type of depression describe having been depressed as long as they can
remember, or they feel they are going in and out of depression all the time.

The symptoms of persistent depressive disorder are similar to those of major

depression. In this disorder, the long duration is the key to the diagnosis, not the
intensity of symptoms. As with major depression, mood may be either low or irritable.
An individual with persistent depressive disorder may feel less pleasure and a lack of
energy. He or she may feel relatively unmotivated and disengaged from life. Appetite
and weight can increase or decrease. The person may sleep too much or have trouble
sleeping. Indecisiveness, pessimism and poor self-image may also be present.

Symptoms can grow into a full-blown episode of major depression. People with
persistent depressive disorder have a greater-than-average chance of developing major
depression.

While major depression often occurs in episodes, persistent depressive disorder is

defined as more constant, lasting for years. The disorder sometimes starts in childhood.
As a result, a person with persistent depressive disorder tends to believe that
depression is part of his or her character, and so self-defining that he or she may not
even think to talk about this depression with doctors, family members or friends.

Persistent depressive disorder, like major depression, tends to run in families. It is more
common in women than in men, but in men it may be underdiagnosed because men are
less likely to talk to their doctors about their mood. Some people with persistent
depressive disorder have experienced a major loss in childhood, such as the death of a
parent. Others describe being under chronic stress. But it is often hard to know whether
people with the disorder are under more stress than other people or if the disorder
causes them to perceive more stress than others do.

Symptoms

The main symptom of persistent depressive disorder is a long-lasting low or sad mood.
People with persistent depressive disorder also can be irritable. Other symptoms
include:

 Increased or decreased appetite or weight

 Lack of sleep or sleeping too much
 Fatigue or low energy
 Low self-esteem
 Difficulty concentrating
 Indecisiveness
 Hopelessness or pessimism

Diagnosis

Many primary care doctors can recognize when one of their patients has some form of
depression, which may lead to a referral to a mental health professional for a full
evaluation. Clinicians diagnose the depression as persistent depressive disorder when
a person has had low mood, along with some of the other depressive symptoms, for two
years or more.

It is not necessary to wait for two years before getting help! Someone who has
symptoms for less than two years may still be treated for any persistent or distressing
symptoms.

Since many people with this disorder are embarrassed or ashamed to be labeled
"depressed," they may be reluctant to raise the subject with a clinician.

Sometimes the symptoms are the leading edge of another one of the mood disorders,
such as

 major depression — a form of depression with symptoms that may be shorter in

duration, but with severe symptoms
 bipolar disorder — depressive episodes occur, but also periods of elevated or irritable
mood called manic episodes
 cyclothymic disorder — a milder form of bipolar disorder
There are no laboratory tests to diagnose persistent depressive disorder. (However, a
doctor may order tests to investigate medical conditions that can be a cause of
depressive symptoms, such as thyroid disease or anemia.)

Expected Duration

Persistent depressive disorder can start early in life, even in childhood. There can be
ups and downs in mood, but lower moods dominate and are persistent. Treatment can
reduce how long it lasts and the intensity of the symptoms.

Prevention

There is no known way to prevent persistent depressive disorder.

Treatment

The best treatment is a combination of psychotherapy and medication.

The most helpful type of psychotherapy depends on a number of factors, including the
nature of any stressful events, the availability of family and other social support, and
personal preference. Therapy will usually include emotional support and education
about depression. Cognitive behavioral therapy is designed to examine and help correct
faulty, self-critical thought patterns. Psychodynamic, insight-oriented or interpersonal
psychotherapy can help a person sort out conflicts in important relationships or explore
the history behind the symptoms.

People with persistent depressive disorder who think that "feeling blue" is just part of
their life may be surprised to learn that antidepressant medication can be very helpful.
Antidepressants recommended for this disorder are the selective serotonin reuptake
inhibitors (SSRIs such as fluoxetine), serotonin-norepinephrine reuptake inhibitors
(SNRIs such as venlafaxine), mirtazapine and bupropion.

Side effects vary among these choices. Problems with sexual functioning are common
in most except bupropion. Anxiety may increase in the early stages of treatment,
although that feeling usually subsides. Although it is relatively uncommon, any
psychoactive medication can make a person feel worse rather than better. Based on
concerns that in rare cases these drugs can cause the onset of suicidal thinking, the
U.S. Food and Drug Administration required antidepressant manufacturers to put
prominent warning labels on their products.

The scientific community continues to debate how great the risk of suicide is when
antidepressant treatment is started. Many experts take the position that — in the
population as a whole — antidepressant treatment has reduced the number of suicides.
They worry that the black box warnings have scared off people who might otherwise
benefit from the drugs. Others note that doctors and patients should stay alert to the
possibility that suicidal thinking can be triggered by an antidepressant. Both arguments
have merit.

In fact, the risk of leaving depression untreated is probably far greater than the risk of
treatment with an antidepressant. But a small number of people using the medications
do feel strikingly worse rather than better when they take them. The best way to avoid
danger is to monitor your response to any medication carefully. You should therefore
keep all follow-up appointments and immediately report any troubling changes to your
doctor.

Older antidepressants — tricyclic antidepressants and monoamine inhibitors — are still

in use and can be very effective for those who do not respond to the newer medications.
In all, there are dozens of antidepressants available. Any may be worth trying
depending on the situation.

It usually takes two to six weeks of antidepressant use to see improvement. The dose
usually must be adjusted to find the right dose for you. It can take up to a few months
for the full positive effect to be seen.
Also, the first medication may not work for you. You may need to try several different
antidepressants before finding one that provides relief.

Sometimes, two different antidepressant medications are prescribed together, or your

doctor may add a drug from a different class to your treatment, for example, a mood
stabilizer or antianxiety medication. Antipsychotic medication in low doses is
occasionally very useful for symptoms that have otherwise been resistant to treatment.
It can sometimes take persistence to find the combination that works best.

When To Call a Professional

Contact a health care professional if you suspect that you or a loved one has this
disorder.

Prognosis

With treatment, the outlook for someone with this disorder is excellent. The duration and
intensity of symptoms is often diminished significantly. In many people, the symptoms
go away completely. Without treatment, the illness is more likely to persist, the person is
likely to have a reduced quality of life and has an increased risk of developing major
depression.

Even when treatment is successful, maintenance treatment often is required to prevent

symptoms from returning.

Dysthymia
Published: March, 2014

Psychotherapists and patients confront the high cost of "low-grade" depression.

Depression is a word with many meanings — anything from a passing mood of sadness
or discouragement to a condition of inconsolable misery, suicidal thoughts, and even
delusions as well as severe physical symptoms. It's regarded as a clinical disorder when
depressed mood and related symptoms are serious enough or last long enough to
interfere with work, social life, family life, or physical health.

The Greek word dysthymia means "bad state of mind" or "ill humor." As one of the two
chief forms of clinical depression, it usually has fewer or less serious symptoms than
major depression but lasts longer. The American Psychiatric Association defines
dysthymia as depressed mood most of the time for at least two years, along with at
least two of the following symptoms: poor appetite or overeating; insomnia or excessive
sleep; low energy or fatigue; low self-esteem; poor concentration or indecisiveness; and
hopelessness.

Dysthymia and major depression naturally have many symptoms in common, including
depressed mood, disturbed sleep, low energy, and poor concentration. There are also
parallel symptoms: poor appetite, low self-esteem, and hopelessness in dysthymia,
corresponding to the more severe symptoms of weight change, excessive guilt, and
thoughts of death or suicide in major depression. Major depression may also include
two symptoms not found in the standard definition of dysthymia: anhedonia (inability to
feel pleasure) and psychomotor symptoms (chiefly lethargy or agitation). An episode of
major depression requires at least five symptoms instead of three, but it need last only
two weeks rather than two years.

Dysthymia is a serious disorder. It is not "minor" depression, and it is not a condition

intermediate between severe clinical depression and depression in the casual colloquial
sense. In some cases it is more disabling than major depression. Still, dysthymia is so
similar to major depression that the American Psychiatric Association's diagnostic
manual also suggests, as a possibility for further investigation, an alternative definition
with symptoms including anhedonia, social withdrawal, guilt, and irritability but not
appetite or sleep disturbance. The purpose is to distinguish dysthymia more clearly from
major depression by emphasizing mood and personal relations over physical
symptoms.

Dysthymia is about as common as major depression. Given its chronic nature, that
makes it one of the disorders most often seen by psychotherapists. About 6% of the
population of the United States has had an episode of dysthymia at some time, 3% in
the last year. As many as a third of patients in psychotherapy may be suffering from
dysthymia. Like major depression, it is more common in women than in men, but it
tends to arise earlier in life. The American Psychiatric Association distinguishes
between this early-onset form and a form that occurs later in life and often comes on
less gradually.

More than half of people with dysthymia eventually have an episode of major
depression, and about half of patients treated for major depression are suffering from
this double depression. Many patients who recover partially from major depression also
have milder symptoms that persist for years. This type of chronic depression is difficult
to distinguish from dysthymia.

Is there a depressive personality?

In principle, personality is usually lifelong, while moods come and go. But dysthymia has
to last longer than any other psychiatric disorder in the manual. That can make it difficult
to distinguish from a personality disorder — especially the group that includes avoidant,
dependent, and obsessive-compulsive personality, with their symptoms of timidity,
excessive worry, helplessness, and social withdrawal.

Some would prefer to speak of a depressive personality disorder instead. That

diagnosis was removed from the official manual in 1980 but has been re-introduced as
a possible topic of investigation. The proposed symptoms include a strong tendency to
be critical of oneself and others, pessimism, guilt, brooding, and gloominess. Anhedonia
and physical symptoms are not part of the definition, but this personality disorder
otherwise has a great deal in common with dysthymia.
Mood and personality are the emotional weather and emotional climate of individuals,
so the symptoms of mood and personality disorders naturally overlap. The thought
schemas that cognitive therapists find at the roots of major depression and dysthymia
— certain beliefs about the self, the world, and the future — are also the basis of
depressive personality. Disturbances in mood can have effects on a person's emotional
state and social life that resemble a personality disorder. And people are more easily
demoralized and recover more slowly from any stress or misfortune if they are
pessimistic and self-critical by nature — or emotionally unstable, impulsive, and
hypersensitive to loss.

Looking for causes

Like major depression, dysthymia has roots in genetic susceptibility, neurochemical

imbalances, childhood and adult stress and trauma, and social circumstances,
especially isolation and the unavailability of help. Depression that begins as a mood
fluctuation may deepen and persist when equilibrium cannot be restored because of
poor internal regulation or external stress.

Dysthymia runs in families and probably has a hereditary component. The rate of
depression in the families of people with dysthymia is as high as 50% for the early-onset
form of the disorder. There are few twin or adoption studies, so it's uncertain how much
of this family connection is genetic. Nearly half of people with dysthymia have a
symptom that also occurs in major depression, shortened REM latency — that is, they
start rapid eye movement (vivid dreaming) sleep unusually early in the night.

The stress that provokes dysthymia, at least the early-onset form, is usually chronic
rather than acute. Studies show that it usually has a gradual onset and does not follow
distinct upsetting events. In old age, dysthymia is more likely to be the result of physical
disability, medical illness, cognitive decline, or bereavement. In some older men, low
testosterone may also be a factor. Physical brain trauma — concussions and the like —
can also have surprising long-term effects on mood that often take the form of
dysthymia.

At least three-quarters of patients with dysthymia also have a chronic physical illness or
another psychiatric disorder such as one of the anxiety disorders, drug addiction, or
alcoholism. In these cases, it is difficult to distinguish the original cause, especially
when there is a vicious cycle in which, say, depression exacerbates alcoholism or heart
disease exacerbates depression.

The same vicious cycle exists in many other situations. For a person who is vulnerable
to depression, every problem seems more difficult to solve and every misfortune causes
more suffering. Depressed people give discouraging interpretations to every event in
their lives, and these interpretations make them still more depressed. Depression often
alienates others, and the resulting isolation and low social support make the symptoms
worse. The experience of chronic depression may sensitize the brain to stress,
heightening its vulnerability to further depression.
Treatment

Most people with dysthymia are undertreated. They usually see only their family
doctors, who often fail to diagnose the problem. They may only complain about physical
symptoms, or fail to complain at all because the disorder has become so much a part of
them that they believe that is simply how life is. In older people, dysthymia may be
disguised as dementia, apathy, or irritability.

A physician might ask an open question like, "How are things at home?" — follow with,
"Have you been feeling down, depressed, or sad?" — then go on to ask whether the
symptoms have affected a patient's home life, work, or personal relations. There are
also several brief screening questionnaires, including the Hamilton Rating Scale for
Depression and the Patient Health Questionnaire. If the answers suggest dysthymia, a
standard clinical interview can be used to confirm the diagnosis.

Like major depression, dysthymia is treated with psychotherapy and medications —

usually the same medications and the same kinds of psychotherapy. The most common
drug treatments are selective serotonin reuptake inhibitors like fluoxetine (Prozac) and
sertraline (Zoloft), or one of the dual action antidepressants such as venlafaxine
(Effexor). Some patients may do better with a tricyclic antidepressant like imipramine
(Tofranil).

Supportive therapy provides advice, reassurance, sympathy, and education about the
disorder. Cognitive therapy identifies and corrects thought patterns that promote self-
defeating attitudes. Behavioral treatment improves social skills and teaches ways to
manage stress and unlearn learned helplessness. Psychodynamic therapy helps
patients resolve emotional conflicts, especially those derived from childhood
experience. Interpersonal therapy helps patients cope with personal disputes, loss and
separation, and transitions between social roles.

Resources

Depression and Bipolar Support Alliance800-826-3632 (toll free)www.dbsalliance.org

Depression Awareness, Recognition, and Treatment Program of the National Institute of

Mental Health www.nimh.nih.gov/publicat/index.cfm

MacArthur Foundation Initiative on Depression and Primary Care www.depression-

primarycare.org

National Alliance for the Mentally Ill800-969-6642 (toll free)www.nmha.org

Drugs or psychotherapy?

A 2003 review of controlled research found that medication is slightly superior to

psychotherapy in the treatment of dysthymia. But a statistical difference among a large
number of patients in many different situations is not necessarily a guide for any
individual case. Some patients — especially older people — will not or cannot take
drugs, sometimes because of side effects or drug interactions. For many others, a
combination of long-term psychotherapy and medication may be most effective. A solid
relationship with a psychotherapist or other professional can be important in maintaining
a willingness to continue medications.

Recovery from dysthymia often takes a long time, and the symptoms often return. One
study found that 70% recovered in an average of about four years, and 50% had a
recurrence. Another study found an average time to recurrence of nearly six years. After
recovery, many patients find it helpful to continue doing whatever made them well —
whether it was a drug or psychotherapy.

While the search continues for better drugs and better forms of psychotherapy, the
problem remains that, despite much improvement, most people with dysthymia are not
receiving even the imperfect available treatments. Even when they do see
professionals, they may not fill their prescriptions or take their drugs consistently, and
they may abandon psychotherapy too soon.

A study based on a telephone survey of more than 800 adults with dysthymia found that
only 20% had seen a mental health professional; only one-quarter had received any
medication and only one-third some kind of counseling, usually brief. And a survey
commissioned by the National Depressive and Manic Depressive Association (now the
Depression and Bipolar Support Alliance) found that doctors and patients often
communicate poorly about the symptoms and treatment. Patients may stop taking drugs
because they do not receive enough information about side effects or routine follow-up
visits. For both the public and professionals, what is most important may be recognizing
that dysthymia is a treatable disorder, identifying it, and following through.

The Dilemma of High-Functioning

Depression
High-functioning depression, or dysthymia. may
be harder to detect than major depressive
disorder (MDD) because the people living with it
are often high achievers who make you think
everything is all right all the time.
Article by:
 Sherry Amatenstein, LCSW
Jump to: Dealing with High Functioning Depression   Therapy   Mental Health Stigma   Coping

Mechanisms   Alternative Coping Mechanisms   Mental Health Acceptance   Invisible Illness

I had a difficult time beginning this piece because the topic hit very close to home.  I’ve
suffered from depression pretty much my entire life.

I have supportive and loving friends, family, meaningful work and engaging hobbies. I
have a good appetite and sleep through the night—albeit with a few pee breaks and the
occasional need for melatonin gummies.  While there are periods I exist in a miasma of
sadness, more commonly my daily experience is a slight impairment of an ability to fully
enjoy life. There is an ever-present emotional chalkboard scrape reminding me that to
live means to co-exist with knowledge of human and animal suffering that I cannot
prevent. Which is why I won’t leave home without my daily anti-depressant. (I’ve been
taking medication for more than a decade.)

Dealing with High-Functioning Depression

My situation is far from rare.  Over 6.7% of adults in the United States—16.2 million!—
endure at least one major depressive episode annually.  My brand of misery—dysthymia,
known as chronic low-level depression, occurs in 1.5% of adults in the United States
annually.

While the stigma against seeking mental health treatment is lessening, there remain some
dangerous myths. Such as that if depression isn’t severe and persistent—involving
frequent bouts of uncontrollable weeping, emotional paralysis, and suicidal thoughts—
then there isn’t a real problem and one should just tolerate pain with stiff-lipped silence.

Article continues below

Do you feel depressed?

Take our 2-minute Depression quiz to see if you may benefit from further diagnosis and
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Indeed, the catch-22 of high-functioning depression is that sufferers often believe that
since they can push through their sadness while barely missing a step, it would be
indulgent to seek help. But that’s like believing one’s own happy-on-the-surface social
media status updates.

Therapists, Therapy, and Therapists in Therapy

Ashley has extensive professional and personal experience in coping with high-
functioning depression. The Nashville-based therapist admits, “I started therapy as an
adolescent and began taking psych meds as a young adult.” Ashley, who started her
private practice 10 years ago, adds, “The meds allow me to feel normal, like myself.”
The therapist has many friends, including mental health professionals who take psych
meds and/or are in therapy for depression and anxiety.  She explains, “Many of my
patients are high-functioning. You’d see them on the street and not know something is
wrong.”

Awareness of what depression and anxiety feel like helps Ashley get into the psyche of
her patients. But she suffers bouts of self-stigma over what sometimes feels like a clash
between her professional and personal selves.  She admits, laughing, “Once I mentioned
to my shrink I felt shame about being a therapist and in treatment. My therapist said,
“Ashley, I’m in therapy too.”
Overcoming Mental Health Stigma
Myths and misinformation about mental illness delayed Claire’s depression diagnosis
until age 20. “I had certain characteristics of depression as a teenager, such as irritability
and crying jags, but my parents wouldn’t take me for help. They figured, ‘Oh, you’re a
girl. You’re just emotional.’”

Now, at age 26, Claire manages to hold down a high-stress job as a legal office manager
for a multimillion-dollar law firm despite battling not only a depressive disorder but also
type 1 diabetes and kidney disease.

She says, “There are times when depression affects my productivity because it’s so
intrusive. I’m fine, until all of a sudden I’m not. I try to stay on top of my meds as much
as possible.”

Therapy has helped her identify triggers such, as “negative thought trains” and lethargy,
that signal a potential oncoming depressive episode.
Another major trigger is her physical health. “I can run a million dollar law firm but I
sometimes feel as if I can’t make my body work,” Claire sighs adding,  “I might be
having back pain, kidney stones, and/or unstable blood sugar.” Summer is especially
difficult for Claire:  “When the weather’s nice and everyone is outdoors enjoying
physical activity or socializing and I’m not well, I feel really left out.”

Combatting Depressive Episodes

Claire now has an array of coping mechanisms, such as journaling, to help forestall major
emotional slides. Other helpful activities that relax and focus her include cooking and
exercise.  “I’ve heard meditation is very good for depression, but I’m afraid it will turn
into rumination.  That can be a slippery slope for me. I’d rather distract myself.”

Claire’s primary “distraction” is burying herself in her consuming job. “I work 11 hours a
day.  For me, being productive gives me a purpose, which helps mitigate some of the
depression.” (Other common forms of distraction people might resort to as a way to avoid
tough emotions include hobbies, playing video games and drinking or using drugs.)

She has good days and knows how to handle the bad ones. Still: “I know I’m never going
to wake up and say, ‘I don’t have depression.’”

Other  Coping Methods

*Ellen calls herself, “A high-functioning person who also has bipolar disorder.”  Seven
years ago, the now 36-year-old, experienced a bout of mania as a reaction to an anti-
depressant she was taking. Being a problem-solver, the financial executive, wife, mother
and perennial volunteer leaped into action to find a way to “bail out the leaky ship.”

These days she employs “a variety of techniques” to keep herself well. “I can tell the
difference when I slough off. It’s not recovery, but an ongoing journey.”

She goes to therapy (psychodynamic and occasionally EMDR, a type of therapy

involving eye movements) sees her psychiatrist, exercises, gets acupuncture and allows
herself to sleep more than average knowing fatigue is a side effect of the psych meds.
Ellen says, “I have occasional bouts of depression but over-all I’m doing really well.”
Accepting Your Mental Health
The secret ingredient to Ellen feeling content, she says, is acceptance of her illness. 
When depression bites at her, Ellen is gentle with herself. “I enjoy my fast-paced life and
normally being busy helps combat the sadness, but when I need to I give myself
permission to slow down, play with my daughter, take a day or two off from work…

She explains, “I can hide my depression so well that people around me have no idea what
I’m dealing with unless I clue them in. What I wish everyone realized is that allowing
yourself to reach out for help is half the battle.  The other half is continuing to help
yourself because depression can always be there waiting to trick you with these awful,
untrue thoughts like: ‘You’re worthless,’ ‘You’re no good,’ ‘No one cares.’”
Seeing is Believing: The Challenge of an Invisible Illness
For people with high-functioning depression, the “invisible illness” aspect of the mental
state can feel particularly searing. A few years ago, after shoulder surgery, my arm was in
a sling. People fell over themselves to cluck with sympathy at my pain—socially
sanctioned pain.  It felt good to be the object of so much caring.

But on the days when listening to the sorrows of others exacerbates my own and I feel
spent, I typically stay silent, not wanting to advertise my own vulnerability. Why is it so
much easier to let others in on pain when it’s physical?

It was difficult to begin this article, but writing it has helped free me from a shame-
shackle:  My name is Sherry and I’ve suffered from depression pretty much my entire life.  And
I’m okay with that. My mental struggles have made me a more insightful, caring person
and a better therapist than I would have been with fewer cracks beneath my emotional
veneer.

Debugging Dysthymia: Overcoming

Chronic Fatigue
I've been exhausted for over a decade.

Imagine recovering from a bad cold. The symptoms are gone, but there's a
lingering sense of overwhelming weariness: like your body needs to use all of the
energy it has available just to keep existing.
That's how I felt almost every day for ten years.

It's as fun as it sounds.

What's Wrong With Me?!

“You are tired more often than anyone I've ever met in my entire life.”

Kelsey, my wife, to me, in 2013

I've struggled with low-level chronic fatigue 1 since college. Every day, I'd wake up
feeling low-energy, and that feeling persisted throughout the day. It didn't matter
what I did the day before:

 4-7 hours of sleep? Tired.

 8-9 hours of sleep? Tired.
 12+ hours of sleep? Tired.
 Vitamins and supplements? Tired.
 Amino acids? Tired.
 Stressful day? Tired.
 Easy day? Tired.
 Exercise? Tired.
 No exercise? Tired.
 Blue light in the morning? Tired.

This wasn't "tired" as in wanting to sleep: it was "tired" as in "don't have the
energy to do anything today." Any extended physical, mental, or social effort just
made it worse.

I've tried everything over the years: I've read all of the books, tried all of the weird
supplements and interventions, drastically changed my diet and sleep habits in
various ways, had all of the medical tests.

Nothing worked. Nothing helped.

All of the typical biological factors related to fatigue were normal: thyroid was
normal, cortisol was normal, testosterone was normal, et cetera. Medically
speaking, my body was fine along all of the common parameters.

I noticed a few patterns over the years, but they didn't really point to a consistent
cause or potential solution:
  Getting 9+ hours of sleep made it more likely I'd have a better-than-
average day, which was the best I could hope for. Days were never
really great in terms of energy.
 Removing gluten from my diet helped, but didn't fix the issue.
 Exercise made me feel more tired, not less, which was odd: most people
report that exercise increases energy.

Every day, I'd do the best I could with the energy I had. I could still function: I
just had less energy to work with than I used to have, and way less energy than
other people seemed to have.

Social interaction decreased: at first, I chalked it up to introversion, but over

time, it was clear that the fatigue was the major limiting factor. Being social took
energy I didn't have, so over time I spent less and less time in social situations.

To make matters worse, I also started having issues with middle-of-the-night

insomnia: I'd wake up between 1:00-2:30am for no reason, and not be able to fall
back asleep until 5:00 to 6:00am. The next day, I'd be completely exhausted: a
night of broken sleep destroyed any hope of productivity.

This situation made the early years of life with each of my children quite difficult.
Every parent experiences a certain level of chronic sleep deprivation in the first
few years of child-rearing: there's really no avoiding it, unless you go full
aristocrat and have your child tended to by night nurses in a separate wing of
your estate.

The trouble was that any sort of night disturbance would trigger the insomnia:
once I was up, I was up (but still exhausted), and there was a high probability
that the next day would be a wash. With kids, the probability of night disturbance
approached 100%, and that made a bad situation much, much worse.

I run my business by myself: when I stop, progress on my business stops. That's

quite a liability when your body isn't cooperating with your plans. I mentioned to
a friend that my productivity seemed to be attached to a random number
generator: there was no way to predict which days would be decent or bad. All of
the most valuable professional things I do require long stretches of sustained
mental effort, and a poor night's sleep would kill a day or two of productivity.

I was at the mercy of my biology.

Even worse, this type of fatigue makes it difficult to be a good parent and spouse:
patience is one of the first things to go when you're tired, and Kelsey covered way
more than her share of child wrangling over the years, particularly on my bad
days. Her support meant a lot to me: every day, I wished it wasn't necessary.

That's how I've lived for a decade now: trying to get as much done as I could on
the good days, weathering the bad days, and looking for a solution to this weird,
unpredictable fatigue that's made everything in my life more difficult than it
should have been.

A few months ago, however, I tested something I've never tried before… and it
changed my life.

Standard Disclaimer: I Am Not Your Doctor

In the remainder of this post, I'm going to discuss the solution to my chronic
fatigue and why it worked. Please note that I am not a doctor, and you shouldn't
take medical advice from random essayists on the internet.

If anything in this post sounds familiar, treat it as a testable hypothesis and talk
to your doctor before you do anything else. Everyone is different, the human body
is a horrifically complex system, and any issues that you experience are likely to
have different causes and effects.

In any case, if you're experiencing something out of the ordinary, the best first
course of action is to pay close attention to what's happening, write it down in
detail, spend time doing research using credible sources to form hypotheses, and
discuss those hypotheses with your doctor. From there, your MD can recommend
the best course of action, given your unique body, medical history, and potential
side effects, which can be dangerous. DO NOT SELF-DIAGNOSE.

A New Hypothesis: Dysthymia

One of the first potential causes you find in any sort of research about low
energy / sleep disturbance / insomnia is depression: they're very common
symptoms of major depressive disorder.

The diagnosis didn't fit, though: I didn't have any of the other symptoms. I was
still engaged with my family and my work, my appetite was fine, and my thoughts
and feelings weren't the issue. Most of the negative thoughts and feelings I
experienced stemmed from my fatigue. I was frustrated and down, of course: I
had things to do, and I was sick and tired of not having the the energy to do them.
Given the circumstances, it seemed like I was handling it okay psychologically
and thinking about the situation in in a rational way. It felt like a body issue, not
a mood or mental issue.

As a result, I'd always discounted depression as the root cause of the fatigue: it
just didn't make sense.

That changed somewhat when, after two solid months of extremely low energy, I
once again started researching to figure out why I felt so terrible. I found an
article from the Columbia University Mood Disorders Research Center that was
closer to what I was experiencing than anything else I'd read:

Dysthymic disorder (abbreviated as DD) is chronic low-grade depression. It is

one subtype of what the DSM-5 now calls "Persistent Depressive Disorder," or
PDD. […]

The main symptoms of DD include: depressed mood (lasting 2 or more years);

feelings of hopelessness; poor concentration or difficulty making decisions; low
self-esteem; low energy or fatigue; poor sleep; and poor appetite or overeating.

Most of the time when people talk of “depression,” they have meant what the
DSM-5 would call “acute major depressive disorder.” Major depressive episodes
are generally severe, and may be fairly brief in duration—lasting perhaps weeks
or months. In major depression, mood drops markedly, and is usually
accompanied by poor sleep, loss of appetite, weight loss, hopelessness, and often
with suicidal ideas. In contrast, [dysthymic disorder] is not as severe on a day-to-
day basis, and (by definition) it lasts for years (even decades) rather than weeks
or months.

[T]he symptom profile presented by people with PDD or DD is striking,

particularly because it is so long-lasting and persistent within one person's
experience, even though specific symptoms may differ from one person to the
next. Whereas normal sadness or unhappiness generally improve once one's life
circumstances improve, the typical person we see for our dysthymia program
describes being 'depressed as long as I can remember' or since primary school,
middle school, or 'over the past ten years.'

PDD is one of the most common mood disorders. It affects as many as 3 to 5% of

the general population. It occurs about equally in men as in women, though
women are generally more likely to seek treatment. Different studies suggest that
the percentage of people with 'pure' dysthymia, or without a history of major
depression, is about 1-2 %, and the rest of people with PDD have either
intermittent or chronic episodes of major depression.
Regardless of subtype, many people with PDD have no idea that they have a
mood disorder. They often think that they are “meant” to be depressed, or that
negativity, pessimism, sadness, low energy and so on are just part of their
“personality.”

That's… me. That's what I've been experiencing. I officially had a new hypothesis
to test.

Why did it take me so long to find this?!

Answer: dysthymic disorder was added to the DSM-5 in 2013. When I was doing
my initial research, it didn't formally exist as a diagnosis. Most of the high-quality
resources on the topic from credible research institutions are new, written in the
last two years. No wonder.

Testing The Hypothesis

A few years ago, I signed up for MDVIP, a subscription medical service, partly

due to this issue. One of the major benefits is that your primary care physician
conducts an extremely thorough medical examination every year, of the type that
C-level executives of public corporations have annually to ensure they're fit
enough to do the job. The routine testing is extensive, and your doctor spends
about an hour and a half with you discussing the results. As a result, I have a
great working relationship with my MD, with years of detailed medical history.

So here's what I did: I compiled my research on dysthymia with my log of

symptoms, spent a day conducting a literature review using resources
like PubMed and Examine.com to find potential treatment options, and went to
talk to my doctor.

I narrowed my "first things to try" list to three options, each of which had
performed in clinical testing as well (or better) than both standard medication
and placebo, with excellent safety and minimal reported side effects:

 St. John's Wort

 SAM-e
 Saffron

The idea was to try each of these options first, then move to testing more
traditional prescription anti-depressants if they didn't work.

My MD confirmed my hypothesis as reasonable and gave the go-ahead to test

each of the options in isolation.
My testing didn't start off well. St. John's Wort, which has many of the same
effects as prescription antidepressants like SSRIs, produced terrible side effects:
acute, persistent feelings of anxiety along with severe insomnia. I discontinued
after two days.

Not terribly encouraging.

SAM-e was another story.

SAM-e: The Missing Keystone

S-Adenosyl Methionine (SAM-e) is a vital part of the human body's one-carbon

cycle, which involves the production of a dizzying array of molecules essential to
human metabolic function, including the production of neurotransmitters. SAM-
e is essentially methionine (an essential amino acid) bound to an ATP molecule,
and is produced within the body as a part of normal metabolism.

When the body doesn't produce enough SAM-e, however, the deficiency can
create a host of issues, including symptoms of depression. Supplementing SAM-e
can, in theory, correct this deficiency and restore normal function, in the same
way that supplementing other amino acids can help correct other forms of
deficiency. 2

Clinical research shows that SAM-e supplementation is very effective at reducing

a wide variety of symptoms with excellent safety, very few reported side effects,
and very low risk of toxicity at typical doses. Everyone reacts differently, of
course, but it was an obvious thing to test.

I took 400mg of enteric-coated SAM-e, then waited.

It didn't take long: I felt better within hours of the first dose.

I slept better than I'd slept in years that night, and I woke up feeling refreshed.

I had energy again: everything was better. I was in a good mood, exercise felt
normal, and social interaction was no longer draining.

Given the strength and immediacy of my body's response, it's very likely that I've
been SAM-e deficient for many years: potentially since high school, which is the
last time I've remember having consistently restful sleep.

SAM-e deficiency also makes other observations make sense: a few of my very
worst years coincided with adopting a vegan diet, which I adopted as a test to see
if it helped. Unfortunately, vegan diets are typically very low in folate, B6, and
B12, which are cofactors the body needs to synthesize and process SAM-e. In
retrospect, it was one of the worst dietary choices I could make, given that my
body wasn't producing enough SAM-e in the first place. 3

After experimenting with dosage, 800mg of SAM-e twice a day on an empty

stomach + a B-vitamin complex for cofactors produced the best results. All of my
symptoms, including the insomnia, disappeared completely, and have not
returned.

In my case, dysthymia (in the form of chronic fatigue and lack of restful sleep)
was the result of SAM-e deficiency. I found the needle in a haystack: the solution
to my most pressing personal problem.

There was, however, a nagging worry: is this just the placebo effect? Will it stop
working over time?

It's been several months now, and the effects are consistent and stable. All of my
symptoms have resolved. I'm sleeping well, waking up refreshed, and have
enough energy to exercise, be social, and be productive again.

I feel like a new person.

This is the best case scenario, really: assuming that SAM-e deficiency is the root
cause, correcting it is likely to continue to have the same effects, and the efficacy
is not likely to decrease over time.

Everything changes, however: fixing this doesn't preclude having future issues.
I'm investing a good portion of my newfound energy in things that make it more
likely I'll be healthy, happy, and energetic long-term: exercise, social interaction,
and self-care.

It's good to be back.

Lessons Learned

 The human body is extremely complex: an imbalance or deficiency in any

area can have huge effects on the entire system. I really wonder how many
common medical issues have a root cause in some sort of deficiency.
 Research works. Even in areas like health, where it's important to listen to
experienced / credible professionals, doing your own research to form
hypotheses is a good use of time. Your medical provider may only have a
few minutes to spend researching your case, and has many other patients.
You are able to spend much more time researching your particular
 situation than your medical provider can. Anything you can do to provide
relevant information and reduce the search space for your medical
providers is helpful.
 If you have a persistent medical issue, don't give up. The more consistently
you track symptoms, research potential hypotheses, and try potential
treatments (under medical supervision), the more likely you are to find
something that works. It may take a while, but it's worth it.