A recent study shows that dysthymic disorder leads to more disability than major depressive disorder. How should we think about dysthymic disorder?

Dysthymic disorder is one of those diagnoses in the DSM-IV that seems to be characterized by ambiguity. I think that many psychiatrists like me do not use this category very often because we see it as a fall-back diagnosis. For example, if you don't think that the patient has a serious depression, you might call it dysthymic disorder.

The finding of Dr. Jonathan W. Stewart and his colleagues that dysthymic disorder causes a “significant public health burden” that carries with it a significant amount of disability (“Dysthymic Disorder Causes More Disability Than Major Depression” ) is in line with what I've seen over the years. Coming up with effective treatment for these patients is particularly challenging.

My approach is to do a careful assessment of a patient who complains of depression. If I don't believe that supporting evidence of major depressive disorder exists (MDD), I will call it dysthymic disorder and look for a “major” diagnosis for the patient. I always use dysthymia as a secondary condition. The patient talks depressed but doesn't look depressed. Since the entire category of depression is under affective disorders in the DSM-IV, I expect a great deal of affective symptomatology for MDD and still some in dysthymic disorder.

Inability to Work Is Key

An important component is the degree of impairment in these patients. They can't get to work and are inconsistent. According to Dr. Stewart, “dysthymia is what ruins people's lives.” Work history, history of success, and failure in social settings are clearly part of dysthymic disorder. These patients also consume more Medicare, Medicaid, and Social Security Disability Insurance than do people with other forms of depression. These patients also had fewer full-time jobs than did those with other diagnoses.

These objective findings are important, because patients with dysthymic disorder do not have a lot of symptoms. They know they do not feel good; instead they are sad, not joyous, and have a lot of self-blame and guilt. The patient's failure in social engagement and poor work history are important factors to note. The patient rarely has a lot of vegetative signs. Sleep is the exception. The dysthymic disorder patient has some sleep disturbance, but not of the degree found in MDD or bipolar illness.

I was trying to provide a case history for this essay and couldn't come up with a patient who had a pure DD. As I said in the beginning, the diagnosis reminds me of “not otherwise specified” or the way in which the ER physician decides that the patient has a psychiatric illness–he can't find anything physiologically definitive to affirm a diagnosis in his mind.

When I interview a patient who has been on the inpatient service, there is a group of them who respond to my question, “When did you first become depressed,” with a quick, “I've been depressed all my life.” When I get that answer, I search for a history of physical, sexual, and/or emotional abuse early in that person's life. The person sitting in front of me might not be clearly depressed, but between major depressions–the sense of a lifetime of depression might actually be dysthymic.

If we were to plot the illness, perhaps it would look like a sine curve graph. This is just a conjecture, but it might look like this: dysthymic–MDD–suicide attempt–dysthymic disorder–MDD–suicide attempt, and so on. We have all seen patients like this. Nothing is accomplished; the patient has no job and usually no attachments; the family is not interested. I would like to hear from others who have seen this kind of syndrome or life history. We know that when a patient says she has been depressed her whole life, that is that patient's impression retrospectively to what happened between major episodes. I have found that major depressive episodes are aborted by a suicide attempt, usually with hospitalization and a discharge. But discharge to what?

The dysthymic patient needs a support system that he usually does not have. And he does not know how to reach out and build such a system.

One man I saw who fit this description had had four intense affairs with women but was unable to consummate any of the relationships into marriage. Of course, he took no responsibility for the breakdown between him and any of the women.

In long-term outpatient cases, we see the diagnosis changing from year to year. In one patient I saw for more than 2 decades, his condition varied over time. He was never free of complaint and sometimes would talk of his depression, which generally was not visible. Yet, there were times in which he became seriously depressed with a lot of crying and discomfort. Again, at other times, his affect was not deeply impaired. Looking back, I would say that this patient had dysthymia at those times.