Persistent depressive disorder

Last reviewed: 23 Aug 2023
Last updated: 25 Jul 2023



History and exam

Key diagnostic factors

  • 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
More key diagnostic factors

Other diagnostic factors

  • 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 or difficulty making decisions
  • feelings of hopelessness
  • poor appetite or overeating
  • sleep disturbance
Other diagnostic factors

Risk factors

  • positive family history
  • female sex
More risk factors

Diagnostic investigations

1st investigations to order

  • medical evaluation
  • CBC
  • thyroid function tests
  • metabolic panel
  • vitamin D
  • Patient Health Questionnaire (PHQ-9)
  • Beck Depression Inventory (BDI)
  • Quick Inventory of Depressive Symptoms (QIDS)
More 1st investigations to order

Investigations to consider

  • vitamin B12
  • urine test
  • ECG
More investigations to consider

Treatment algorithm


all patients



David J. Hellerstein, MD
David J. Hellerstein

Professor of Clinical Psychiatry

Columbia University Medical Center

Director, Depression Evaluation Service

New York State Psychiatric Institute

New York



DJH has received research grants (through the Research Foundation for Mental Hygiene) from Compass Pathways, Relmada, Marinus, Intracellular Therapies, Beckley Foundation, and from Velocity Foundation (through Columbia University). DJH serves on scientific advisory board for Reset Pharmaceuticals. DJH has received royalties from Johns Hopkins University Press, and Columbia University Press.


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.

Peer reviewers

Dean F. MacKinnon, MD

Associate Professor

John Hopkins University




DK declares that he has no competing interests.

James H. Kocsis, MD


Weill Cornell Medicine

New York



JK has professionally collaborated with the authors.

Neil Nixon, BSc, MMedSci, MBBS, FRCPsych

Associate Professor in Psychiatry

Institute of Mental Health

University of Nottingham




NN is a member of the current NICE GDG for depression in adults. NN has met with Jansen in a non-remunerative capacity. He has various research collaborations including a funded trial and is author on a number of papers.

  • Differentials

    • Major depressive disorder
    • Bipolar disorders (bipolar I, bipolar II, bipolar disorder not otherwise specified)
    • Cyclothymic disorder
    More Differentials
  • Guidelines

    • Screening for depression and suicide risk in adults: US Preventive Services Task Force recommendation statement​
    • Depression in adults: treatment and management
    More Guidelines
  • Patient leaflets

    Depression in adults: what is it?

    Persistent depressive disorder (long-term depression)

    More Patient leaflets
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