Persistent Depressive Disorder: What to Know About Symptoms and Treatments

By the time Amanda Stern was in her mid-40s, she no longer suffered from clinical depression. And her panic attacks, which had started in childhood, were mostly gone. But instead of feeling happier, she said, “I felt wallpapered in an endless, flat sadness.”

Confused, she turned to her therapist, who suggested that she had dysthymia, a mild version of persistent depressive disorder, or P.D.D.

Ms. Stern, an author based in New York City, often writes about mental health, but she had never heard the term. She soon realized that she had experienced dysthymia on and off for decades. “I am not suffering from it right now,” she added, “but I imagine I’ll live with it again.”

She decided to write about it in her newsletter, How to Live, describing what it felt like to exist in a “constant state of ‘emptiness’” and sharing the tools that eventually helped her feel better.

It is not well understood why some cases of depression persist, but The New York Times has asked experts to share what they know about P.D.D.

Persistent depressive disorder is chronic depression that lasts for at least two years in adults. As with many types of mental illness, there are different levels of severity.

The term “dysthymia,” a Greek word that can mean “low spirits,” “moodiness” or “dejection” is no longer included in the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., but it is still used by some mental health practitioners to refer to the milder form of P.D.D.

Marnie Shanbhag, the senior director of independent practice at the American Psychological Association, said that less severe P.D.D. is often diagnosed when people come to therapy for another issue, like marital problems or job stress, and reveal that they feel an ongoing, low-level sadness, flatness or emotional numbness.

There may not appear to be a reason behind it. “You’re just sort of ‘meh,’” Dr. Shanbhag said. “And you get used to being that way.”

For Ms. Stern, clinical depression “knocks me out. I can’t get out of bed, shower, eat or walk my dog.” With dysthymia, however, she can still function. She may not want to do the dishes, for example, but she “won’t feel obliterated” by the task.

Those who have the more severe form of P.D.D., referred to in the past as chronic major depressive disorder, might be unable to get out of bed after a night of insomnia, lose their appetite, have such difficulty concentrating that they cannot get their work done, or feel too exhausted to clean the house or prepare dinner, said Dr. Paul S. Appelbaum, a professor of psychiatry at Columbia University and the leader of the group that oversees revisions of the D.S.M.

It is estimated that about 2 percent of adults in the United States have had some form of P.D.D. in the past year, and it is thought to be more common among women than men. It is difficult to know its full scope, however, because experts say the disorder tends to be underdiagnosed.

P.D.D. is diagnosed in adults who report feeling depressed for “most of the day, for more days than not,” for at least two years, Dr. Appelbaum said. And if they do find relief from their symptoms, he added, it does not last longer than two months.

Children and adolescents can also have P.D.D. (To make a diagnosis, Dr. Appelbaum said, the symptoms will need to have lasted for at least one year.)

“Like other forms of depression, it causes significant distress or impairment, and it is associated with an increased risk of suicide,” Dr. Appelbaum said.

Patients with the disorder will also experience at least two of the following symptoms:

  • Poor appetite or overeating

  • Insomnia or excessive daytime sleepiness

  • Low energy or fatigue

  • Low self-esteem

  • Poor concentration or difficulty making decisions

  • Feelings of hopelessness

P.D.D. is typically treated with therapy and antidepressants.

There isn’t a cure, but people can become “symptom free, and the intensity of recurrences, if any, can be minimized,” Dr. Appelbaum said.

Because P.D.D. can be long lasting — and does not always disrupt a patient’s day-to-day life — those with the disorder may assume that their milder depressive symptoms are simply character traits.

“It’s hard to convince people that they’re not just the negative person in their family, or the Debbie Downer,” said Dr. Jessi Gold, a psychiatrist in St. Louis. But if someone is experiencing distress or symptoms that interfere with daily life, then it makes sense to seek treatment rather than to simply say, “this is the way I am,” she added.

Ms. Stern can relate. When people she was close with asked how she was doing, she would tell them that she was fine, but, she said, “a profound sadness would rise to the top, letting me know I wasn’t fine at all.”

She urged those who feel consistently unmotivated, apathetic or lacking interest in things that they once enjoyed to seek help.

“You may feel alone, but you are not,” she said.

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