Millions Suffer From Persistent Depression

For more than 7 million Americans life is no bowl of cherries, the glass is nearly always half empty, the clouds have no silver lining.

They have a little-known and often medically ignored yet treatable emotional disorder called dysthymia.

Dysthymia (pronounced disTHIGH-mee-a) is a mild but chronic depression that can spread a veil of sadness over people’s lives for years, even decades, sometimes seemingly from the cradle to the grave.

Others may see the people with dysthymia as pessimistic, self-critical, underachieving and lacking in motivation, spontaneity or a sense of adventure.

Sufferers may see themselves as suffering from a lack of energy, dissatisfaction, an overall negativism and a belief that things will never get better. They are less likely than others to get married and more likely to be divorced and unemployed or underemployed, although some become high achievers despite their depressed mood.

The sleep and appetite disorders common to major depression are less typical of dysthymia. But some patients are plagued by headaches and other pain and chronic fatigue. Their multiple visits to doctors rarely result in an accurate diagnosis.

Still, many people with dysthymia have joined the Prozac generation, often at the urging of friends who themselves have found that this or some other anti-depressant lifts the cloudy filter from their lives.

The word dysthymia was coined in the late 1970s by Dr. Robert Spitzer, a psychiatrist at the New York State Psychiatric Institute in New York, to replace “neurotic depression” or “depressive personality,” as the condition formerly was called.

First included in the psychiatric diagnostic manual in 1980, its definition was revised as more was learned.

A study of five communities conducted by Dr. Myrna M. Weissman and colleagues at the Psychiatric Institute found that at any given time about 3 percent of American adults have dysthymia. Other studies indicate that at least 6 percent of people, possibly many more, experience dysthymia at some time.

For some, the problem seems to have been present almost since birth.

As children, they may have been irritable and difficult, had trouble making or keeping friends or fallen short of their potential in school.

For others, the negative feelings do not begin until adolescence, young adulthood or midlife. Their lowgrade depression may be precipitated by a life crisis, like a divorce, job loss or death of a loved one.

Or their problem may begin with an episode of major depression that, with or without treatment, abates but never entirely disappears. A condition classified as “major depressive disorder in partial remission,” its symptoms are indistinguishable from classic dysthymia.

People with dysthymia are also prone to intermittent attacks of major depression, a condition called double depression. If anything, it is the major depressive episode, not the chronic mild depression, that prompts someone with dysthymia to seek psychotherapeutic assistance.

“We often see dysthymic features in children or adolescents that are the precursors of major depression,” said Dr. David Kupfer, director of research at Western Psychiatric Institute in Pittsburgh.

Dysthymia runs in families, he added, and the children of people with major depression are at increased risk of developing the milder disorder.

“Even if you’ve been depressed all your life, that’s no reason not to seek treatment,” said Dr. John C. Markowitz, a research psychiatrist at New York Hospital-Cornell Medical Center in New York.

Kupfer said: “Within the last few years it’s become increasingly clear that the usual treatments for depression are also very effective in dealing with dysthymia.”

Dr. James H. Kocsis at New York Hospital-Cornell Medical Center has reported that about two-thirds of patients with dysthymia get significantly better with antidepressants.

The same drugs used to treat major depression, including tricyclic antidepressants such as imipramine (Tofranil), MAO inhibitors like phenelzine (Nardil) and serotonin uptake inhibitors like fluoxetine (Prozac), are effective for dysthymia.

However, many patients do not improve with medication, and others resist taking drugs or find their side effects intolerable. For them one or more psychotherapeutic techniques may be very helpful.

The two that have been most effective in treating depression are cognitive-behavioral therapy, developed by Dr. Aaron Beck at the University of Pennsylvania in Philadelphia, and interpersonal therapy, developed by the late Dr. Gerald L. Klerman at Cornell and now being studied for dysthymia by Markowitz. Both approaches are relatively brief and focus on reversing the negativistic thoughts and selfdefeating behavior characteristic of depression.