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Depression & Anxiety


The Depression That Won't Quit

Major depression, the sort that disrupts almost every aspect of one's life, is not hard to identify. But what about the "never-ending blues"—a chronic down-in-the-dumps feeling? Too often, this mild depression goes unrecognized and untreated. Not long ago, such lingering malaise was considered a personality trait. But a revised psychiatric manual issued in 1980 classified chronic depression as a mood disorder, called dysthymic disorder or dysthymia (meaning "sad mind"). And recent studies show it to be a treatable illness. Because it is so common, dysthymia is considered by some experts to be a major public health problem. What's more, the long-lasting effects of dysthymia may be as damaging as major depression. Yet too few people even suspect they have it, and too few doctors inquire about its symptoms.

Dysthymia is marked by mild to moderate depressive symptoms that last at least two years. One study found that 3% of the general population has dysthymia. But the rate is significantly higher in older people. A study from the Late Life Depression Clinic at Columbia University, which treats patients aged 60 and over, found that 40 of 224 patients (about 18%) had dysthymia. Symptoms began when patients were around age 55. Unlike younger dysthymic patients, who are more often women, older patients are as likely to be men.

Degrees of depression

Dysthymia is defined, to some extent, by how it differs from major depression. If depression is a flash fire, dysthymia is a slow burn. But as with any untended fire, it can be quite destructive. People with dysthymia have fewer symptoms than those with major depression, but the symptoms last longer and develop more slowly. While symptoms can wax and wane, on average they last 16 years before there is a diagnosis.

Just what causes dysthymia is unclear. There is some evidence that changes in the brain associated with the neurotransmitter serotonin are at least partly responsible. The disorder is also more common in people with other mental illnesses such as major depression (in which case the diagnosis is double depression, and treatment is more difficult); certain personality disorders such as social phobia; and in those confronted with major life stresses. Older patients who develop dysthymia are less likely to have other mental illnesses, but are vulnerable to life stressors—such as loss of a spouse or family member, change in income, or illness—which occur more often with advancing years.

Easing sadness

Some people believe that the symptoms of dysthymia are an unavoidable consequence of aging, which is simply not true. Dysthymia is not something that must be endured, and symptoms merit a trip to your doctor. Many of the treatments used for major depression can also treat dysthymia effectively. A recent study in the Archives of General Psychiatry evaluated two antidepressants in 416 people aged 25 to 65 with dysthymia. In a 12-week trial, both drugs relieved symptoms significantly.

The newer antidepressants that enhance the activity of serotonin are often the best drug choices in older patients, because they have few side effects and are least likely to interfere with medications for other conditions. Called the selective serotonin reuptake inhibitors (SSRIs), this group includes Prozac, Zoloft, and Paxil. Zoloft was the SSRI used in the Archives study. Another study, in patients over 60 years old, found that 60% of 20 subjects with dysthymia responded to treatment with Prozac, and few experienced side effects.

The SSRIs take four to six weeks to work for major depression, but may take even longer for dysthymia. A three-month trial may be required to determine if the medication is effective. If the drugs provide relief, they should be continued for at least two years, and lifetime use may be warranted. Because antidepressants tend to provide only partial relief, psychotherapy may also be beneficial. And steps should be taken to provide support for ongoing stress, such as illness.


From The Johns Hopkins Medical Letter: Health After 50, February 1997.



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