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Abstract
Dysthymia is an under-diagnosed mood spectrum disorder that is almost as common as major depression and, if left untreated,
has a chronic course which can impact negatively on a patient’s quality of life. Whilst symptoms are not as numerous or severe
as in major depressive disorder (MDD), morbidity associated with dysthymia can be serious owing to the long duration of the
distressing syndrome. Consistently depressed mood can lead to impairment in workplace functioning, as well as compromised
management of interpersonal, marital and familial relationships. Optimal management involves a combination of pharmacological
treatment with antidepressant medications (e.g. selective serotonin reuptake inhibitors) and various forms of psychotherapy.
S Afr Pharm J 2011;78(3):38–43
distinguishes between them on the basis of symptomatology Symptoms common to both MDD and dysthymia include
and chronicity.1 The cardinal symptom of both illnesses is depressed mood, disturbed sleep (either insomnia or
depressed or low mood. However, this has to have been hypersomnia), low energy, poor concentration and
present for only two weeks for a diagnosis of MDD, compared indecisiveness. In addition, there are several “parallel symptoms”
with two years for dysthymia. For MDD, the low mood has to be which are expressed in a more overt form in MDD, but can be
accompanied by at least five other symptoms on the DSM-IV equated with a corresponding symptom in dysthymic patients.
checklist, whereas a diagnosis of dysthymia requires only two These include poor appetite or, conversely, overeating in
other symptoms (as listed in Table I). dysthymia, compared with frank weight changes in depressed
patients; low self-esteem in dysthymia, which is expressed as
When comparing these straightforward diagnostic criteria, it excessive guilt in depressed patients; and hopelessness in
may seem that MDD is the more serious diagnosis in terms of dysthymia, which can become suicidal ideation in depressed
morbidity. However, if treatment is initiated promptly, patients patients. From these common and parallel symptoms, it is
can be reassured that the debilitating symptoms of the disease apparent that dysthymia and MDD are not two separate
will abate. In contrast, although fewer symptoms are necessary entities, but rather different points along a spectrum of
for a diagnosis of dysthymia, the long period before diagnosis depressed mood.13 It is, therefore, not surprising that such a
contributes to great suffering and also perpetuates a pessimistic high number of patients initially diagnosed with dysthymia
go on to experience episodes of major depression. When the
and hopeless world view. Such negative thinking can impact
two disorders occur concurrently, such patients are classified as
adversely on the success of treatment and eventual recovery.12
suffering from “double depression”.14
Table II: Antidepressants used in the treatment of dysthymia and their major adverse effects
Selective serotonin Dual reuptake Noradrenergic Tri- and Monoamine Mixed action
reuptake inhibitors inhibitors drugs tetracyclic oxidase
antidepressants inhibitors
Fluoxetine Venlafaxine Reboxetine Amitriptyline Tranylcypromine Mianserin
Paroxetine Duloxetine Mirtazapine Dothiepin Moclobemide Trazodone
Sertraline Bupropion Clomipramine
Fluvoxamine Imipramine
Citalopram Lofepramine
Escitalopram Trimipramine
Maprotiline
Insomnia, agitation, Insomnia, Increased heart Sedation, anticho- Insomnia, dietary Sedation, priapism
nausea, diarrhoea, gastrointestinal rate and blood linergic effects, restrictions (trazodone)
sexual dysfunction effects, seizures pressure, weight weight gain, with irreversible
gain cardiotoxicity in inhibitor
overdose
Cognitive therapy targets the symptoms of low self-esteem and days.27 It has an insidious onset in childhood and progresses
hopelessness in dysthymia. The therapist sensitises the patient into adulthood, such that a patient develops a pessimistic
to recognise that negative thought patterns provoke negative world view and may have little insight into normal mood and
emotions and feelings. Such negative “self-talk” can perpetuate functioning. The high incidence of psychiatric and physical co-
the patient’s pessimistic view of the world, which can impede morbidities complicates treatment. Whilst dysthymic patients
recovery. Learning to identify and interrupt negative thoughts may have fewer symptoms that those with MDD, the long-
is the first step in developing a more realistic outlook.24 term consequences of continuous negative thinking and low
self-esteem can be severe. Treatment with antidepressant
Behavioural therapy is often used in tandem with cognitive medications and various forms of psychotherapy is currently the
therapy and is then termed “cognitive–behavioural therapy”. regimen of choice. However, more research into the genetics,
Once the dysthymic patient learns how to recognise and disrupt aetiology and management of the condition is warranted.
negative thinking, behavioural therapy introduces alternate,
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Fluoxetine Prozac®, A-Lennon Fluoxetine®, Deprozan, Flutinol®, Lilly-Fluoxetine®, Lorien®, Nuzak®, Prohexal®,
Ranflocs®, Rezak®, Sandoz-Fluoxetine®, Trizac®, Zydus-Fluoxetine®
Reboxetine Edronax®
Tranylcypromine Parnate®
Lofepramine Emdalen®
Maprotiline Ludiomil®
Mianserin Lantanon®
Trazodone Molipaxin®