Persistent depressive disorder includes 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.
In contrast to the DSM-5, which combined the diagnosis with dysthymic disorder with other forms of chronic depression into the category of persistent depressive disorder, the ICD-11 has retained a separate classification of dysthymic disorder.
Associated with significant functional impairment (including unemployment, difficulty establishing intimate relationships, greater healthcare utilization, greater utilization 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, 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 (full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode)
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, epidemiologic studies, and meta-analyses and other reviews, has 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 coexisting dysthymia, and may or may not specify the percentage of patients with chronicity.
In contrast to the DSM-5, which combined the diagnosis of dysthymic disorder with other forms of chronic depression into the category of persistent depressive disorder, the ICD-11 has retained a separate classification of dysthymic disorder.
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
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
- feelings of hopelessness
- weight changes
- sleep disturbance
- positive family history
- female sex
1st investigations to order
- medical evaluation
- thyroid function tests
- metabolic panel
- vitmain D
- Patient Health Questionnaire (PHQ-9)
- Beck Depression Inventory (BDI)
- Quick Inventory of Depressive Symptoms (QIDS)
Investigations to consider
- vitamin B12
- urine test
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, and 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.
Dean F MacKinnon, MD
John Hopkins University
DK declares that he has no competing interests.
James H Kocsis, MD
Weill Cornell Medicine
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.
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