Common forms of depression, but lasting longer than acute major depressive disorder.
Frequently misdiagnosed because the correct criteria to diagnose this condition are often not applied. The DSM-5, published by the American Psychiatric Association, developed new diagnostic criteria for persistent depressive disorder, which includes both chronic major depressive disorder and the previous category of dysthymic disorder (dysthymia), or chronic low-grade depression. The DSM-5 includes specifiers to identify different pathways to the diagnosis of persistent depressive disorder and various presentations based on severity and clinical characteristics.
Associated with significant functional impairment (including unemployment, difficulty establishing intimate relationships, greater healthcare utilisation, greater utilisation of public entitlements).
Patients may respond to pharmacotherapy, psychotherapy, or a combination of both.
Patients require a longer treatment period, more psychotherapy sessions, and/or higher doses of antidepressant medication compared with patients with acute forms of depression.
Like other mood disorders, it is frequently comorbid with other psychiatric and medical conditions.
Persistent depressive disorder (PDD) is a category that includes various forms of chronic depression in which depressive symptoms are present 'more days than not' over at least a 2-year period (1 year in children and adolescents). Subtypes of PDD include:
1) Pure dysthymia (low-grade chronic depression), without full criteria for major depression during the preceding 2 years
2) Persistent major depressive episode
3) Intermittent major depressive episodes with current major depression
4) Intermittent major depressive episodes without current major depressive disorder (MDD) episode.
PDD may have early onset (before age 21 years) or late onset (at age 21 years or older). In addition, there may be the presence of ‘anxious distress’, which includes feelings of being keyed up or on edge, restlessness, worry, feelings of doom, and fears of loss of control. Also it may have ‘atypical features’, which include mood reactivity; weight gain; increased sleep; heavy, leaden, feelings in limbs; and sensitivity to interpersonal rejection.
NOTE: It is important to specify that the term 'persistent depressive disorder' includes the 4 different categories noted above. Prior research, including outcome studies, epidemiological studies, and meta-analyses and other reviews have generally followed DSM-IV categories, not the consolidated DSM-5 category. Hence, previous studies of ‘dysthymia’ generally include patients presenting in subtypes 1) (pure dysthymia) and 4) (current dysthymia, prior MDD), with a small number of studies of pure dysthymia (category 1 alone). Other studies have been conducted for category 2) (chronic major depression). Those patients presenting with category 3) (dysthymia with current MDD, or so-called 'double depression') are generally included in studies of major depressive disorder, and comorbid dysthymia may or may not be specified. In general, in studies cited in this topic, if they refer to 'dysthymic disorder', the subtypes 1 and 4 are included; if they refer to 'chronic major depression', they include subtype 2. Also of note, studies of 'major depression' often include patients with co-existing dysthymia, and may or may not specify the percentage of patients with chronicity.
History and exam
- chronic mood disorder lasting greater than 2 years
- depressive symptoms present for most of the day, most days
- no periods of euthymia in the past 2 years (1 year for children or adolescents)
- symptoms of major depression may be continuously present for 2 or more years
- no symptoms of mania/hypomania or schizophrenia
- absence of underlying medical conditions, medication use, or substance abuse that could cause the mood disorder
- fatigue or low energy
- low self-esteem
- poor concentration
- feelings of hopelessness
- weight changes
- sleep disturbance
David J. Hellerstein, MD
Professor of Clinical Psychiatry
Columbia University Medical Center
Director, Depression Evaluation Service
New York State Psychiatric Institute
DJH has received grant support from Eli Lilly, Pfizer, Forest Pharmaceuticals, GlaxoSmithKline, Bristol-Myers Squibb, GeneSight, Marinus, Takeda, Intracellular Therapies, and Compass Pathways. He is an author of a number of references cited in this topic.
Dr David J. Hellerstein would like to gratefully acknowledge Dr David L. Dunner, a previous contributor to this topic. DLD has received grant support from Cyberonics. DLD has received fees for consulting from: Eli Lilly, Pfizer, GlaxoSmithKline, Wyeth, Bristol-Myers Squibb, Forest, Cyberonics, Roche Diagnostics, Cypress, Corcept, Janssen, Novartis, Shire, Somerset, Otsuka, Healthcare Technology Sys, Jazz Pharma, Sanofi-Aventis, and MedAvante. DLD is on the Speaker's Bureau for: Eli Lilly, Pfizer, GlaxoSmithKline, Wyeth, Bristol-Myers Squibb, Organon, Jazz Pharma, Neuronetics, and Astra-Zeneca. DLD is an author of several references cited in this topic.
Ricardo Gusmao, MD, PhD
Professor of Psychiatry and Mental Health
National Coordinator of the OSPI-Europe and EAAD projects
Mental Health Department of the Faculty of Medical Sciences
New University of Lisbon (UNL)
RG has been paid by Bristol-Myers Squibb for being on the advisory board.
Stuart Seidman, MD
Columbia University College of Physicians & Surgeons
SS declares that he has no competing interests.
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