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 stressorssuch
as loss of a spouse or family member, change in income, or illnesswhich
occur more often with advancing years.
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
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.