Persistent Depressive Disorder Requires Personalized Care

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For decades, psychiatrists regarded a particularly insidious form of depression once known as dysthymia as more of a personality trait, not a reason for rehabilitation. Now understood as major depression, the renamed persistent depressive disorder is more likely to be treated by individualized programs with long-term care.

What is persistent depressive disorder?

This is chronic depression that begins early in life. Often starting in childhood or the teenage years, it carries a high risk of addictive behaviors in an attempt to self-medicate.  People who live with this disease tend to face two clusters of challenges:

  • Sometimes people with this disorder primarily struggle with anxiety. They fail to develop the self-esteem they need to face life’s challenges. They lack direction. They are devastated by rejection. They often try to treat themselves with alcohol, opiates, marijuana, benzodiazepines, and food. They occasionally become so overwhelmed that they make low-lethality suicide attempts, but they usually respond to antidepressants of the selective serotonin reuptake inhibitor class.
  • Sometimes people with this disorder struggle with a collection of challenges that mental health professionals call anergy. These are people who are low-energy. They may want to sleep all the time. They may suffer anhedonia, an inability to enjoy experiences and relationships. They may not have any goals in life, not because they lack self-esteem, but because they can’t imagine enjoying the results of their efforts. People who have persistent depression of this time usually don’t make dramatic suicide attempts. And they usually don’t respond well to selective serotonin reuptake inhibitors. They usually need medications that modify dopamine and/or norepinephrine, rather than serotonin.

Both forms of persistent depression take the joy out of living. They rob young people of purpose. But the appropriate treatment is never to write a prescription for the same antidepressant a physician prescribes as if one pill works for all. Treatment for persistent depressive disorder has to be highly personalized.

Successful treatment for persistent depression requires restructuring everything about the person’s life. Genetic predisposition and family dynamics may trigger the disease, but usually a series of dysfunctional coping behaviors sustain it. Overcoming persistent depression may require breaking old habits of rumination, talking yourself into self-medication and talking yourself out of personal growth. It may require learning how to lose the loser label, taking appropriate steps to meet life challenges. It may require treating the antisocial, borderline, dependent, or histrionic traits that develop when people with this disorder live without appropriate treatment.

Overcoming persistent depression isn’t about taking medication. It is about changing direction. The best way to restart a life for purpose, productivity, and joy is an in-patient stay at rehab facility. Don’t put your hope in medication. Work with a rehab center to build your joy in life and your faith in yourself.

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McCullough JP Jr, Klein DN, Borian FE, Howland RH, Riso LP, Keller MB, et al. Group comparisons of DSM-IV subtypes of chronic depression: validity of the distinctions, part 2. J Abnorm Psychol. 2003 Nov. 112(4):614-22.

Niculescu AB 3rd, Akiskal HS. Proposed endophenotypes of dysthymia: evolutionary, clinical and pharmacogenomic considerations. Mol Psychiatry. 2001 Jul. 6(4):363-6.

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