Persistent depressive disorder, what used to be called dysthymia, is the diagnosis for guys who've been depressed for so long they don't remember what…
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Persistent depressive disorder, what used to be called dysthymia, is the diagnosis for guys who’ve been depressed for so long they don’t remember what not-depressed feels like, which means they don’t think of themselves as depressed. They think this is who they are. It’s a chronic, low-grade baseline misery that lasts at least two years by definition, often decades by the time anyone catches it, and it doesn’t get the attention major depression does because nobody is in crisis, they’re just dimmed. Living at a four out of ten for twenty years, hitting their numbers at work, paying the mortgage, never quite enjoying anything. The horror of it is that it’s invisible.
These are the guys who get described as serious, intense, no-nonsense, kind of a downer. Their wife loves them but says they haven’t really laughed in years. They have a steady job, they pay the mortgage, they go to their kid’s games. They’re functional. They’ve also been mildly miserable for the entirety of their adult life and nobody, including them, has ever named it. The serious-guy persona is doing a lot of work covering for what’s actually a treatable mood disorder, and the cultural admiration of stoic dependability keeps the diagnosis from being made for years.
What it actually looks like
The DSM criteria are dysphoric mood (the low-grade flat-to-irritable mood that doesn’t quite hit major depression but isn’t anything anyone would call good) most of the day, more days than not, for at least two years, plus two of the following: appetite changes, sleep changes, low energy, low self-esteem, poor concentration, or hopelessness. That sounds like a lot, but in practice these patients often have most of those, just at a low enough level that none of them individually look like a crisis.
The functional cost is that they don’t enjoy things they used to. Their motivation for stuff outside of obligations is gone. They’re tired all the time but not in a way that points at anything medical. They drink more than they want to, often a couple of beers every night without ever calling it a drinking problem because it’s not getting worse, just steady. They snap at their kids and feel bad about it. They’ve lost interest in sex with their wife, and it’s been long enough that nobody talks about it anymore.
If you said any of that out loud to most of these guys they’d tell you that’s just life, that’s just being an adult, that’s just being a man with responsibilities. That’s the whole problem. They’ve come to think this is what living feels like, and the people around them have come to think this is just how he is.
Why it gets so under-recognized
Major depression looks like depression. People stop functioning, they call out of work, they can’t get out of bed, the situation is obviously bad and somebody intervenes. Persistent depressive disorder doesn’t look like that. The patient is going to work, doing his job, showing up. The dimming is internal and chronic, and the culture doesn’t have good language for chronic low-grade misery in a man who’s still functional. It gets called being stoic, or being mature, or just being a guy. So nobody catches it. The wife sometimes does, but she’s been told for years that this is just his personality, and after twenty years she stops asking.
The other reason this gets missed is that the patient himself wouldn’t endorse the symptoms if asked. Ask him if he’s depressed and he says no. Ask him if he enjoys things, and he says sure, the usual stuff. Push him on what he actually enjoys and the list is empty. He’s mistaken “tolerating my life” for “enjoying my life” because he hasn’t had the contrast in so long. Calling that depression to him feels like an overreach. It isn’t. The contrast just isn’t available, which is part of what makes the diagnosis hard to land in one visit.
Naming what’s actually going on
You can’t change shit you won’t name. A guy who’s been calling his persistent depressive disorder “my personality” for twenty years isn’t going to look for treatment, because you don’t treat your personality. The naming step is most of the work, and it’s slow because every patient pushes back on the label the first time it comes up. “I’m not depressed, I’m just realistic.” “I’m not depressed, I’m just intense.” “I’m not depressed, I’ve always been this way.” Each of those might be partly true and is also mostly cover for the underlying diagnosis that’s been running unchecked for decades.
The reframe that works for a lot of these guys is asking when the last time was that they laughed at something without trying to. Not a polite laugh. Not the chuckle at a coworker’s joke. An actual involuntary laugh. Most of them have to think about it for a long time, and the answer is usually somewhere in college or early twenties. That gap, between when they last laughed for real and now, is the thing the diagnosis is pointing at. Calling it “my personality” doesn’t survive that question.
Treatment realities
Persistent depressive disorder responds to treatment but more slowly than major depression and not always as dramatically. The standard is an SSRI (selective serotonin reuptake inhibitor, the standard antidepressant class, Lexapro and Zoloft and that crew) plus therapy, usually CBT (cognitive behavioral therapy, the structured worksheet-and-homework kind of therapy, not the talk-about-your-mother kind) or interpersonal therapy (a therapy that focuses on the patient’s actual current relationships rather than digging into childhood). The medication piece often takes longer to show benefit, sometimes twelve to sixteen weeks before any real movement, and the dose may need to be on the higher end of the range. The therapy piece is doing a lot of work in these cases because the patient has often built an identity around the low baseline, and untangling that takes time.
About half of these patients have a meaningful response to first-line treatment. Of the ones who don’t, augmentation (adding a second medication that hits a different system instead of swapping the first one out) with bupropion (Wellbutrin, a dopamine-and-norepinephrine antidepressant that’s particularly good for energy and motivation issues), sometimes lithium at sub-bipolar doses, sometimes a second antidepressant, gets most of the remainder. A small subset are genuinely treatment-resistant and the next step is ketamine (the dissociative anesthetic that, at low doses, has antidepressant effects within hours instead of weeks) or TMS (transcranial magnetic stimulation, the six-weeks-of-outpatient-sessions one where a magnetic coil pulses over the front of your skull). The point is most of these guys can feel better, but it requires more patience than acute depression treatment does.
If you want medication, you get medication. The provider’s job is the honest take, the patient’s job is the choice. For persistent depressive disorder specifically, the medication often does meaningful work because the patient has been white-knuckling life for so long that even partial relief feels like a lot. The autonomy piece still applies, and patients who want to try the therapy and the behavior work without medication first can do that, and a real fraction of them do okay. The treatment that works best is usually both.
They’ve come to think this is what living feels like. That’s the whole problem.
What’s nice to hear about this one
The good news, since this whole post is about how miserable these guys have been for decades, is that this treats well. Not fast. Not dramatically in week two. But by month four or five most of these patients start noticing that things they used to find tolerable have become genuinely enjoyable. They laugh at the TV. They notice food again. They want to be around their wife, not just out of obligation but actually want to. The line a lot of them say at month six is some version of “I didn’t realize how much of my life I’d been getting through versus living.” That’s the part of this that doesn’t go on a marketing brochure but is what makes the slow treatment worth it.
The wife usually notices first. The patient himself often takes longer to register the change because the baseline he’s coming from is so flat that the early improvements feel modest from the inside. The wife is the one who tells him he laughed at a joke on TV and she can’t remember the last time he’d done that. That data point is usually what convinces him the treatment is working when his own internal sense of it is still catching up.
The pattern that comes up most
Say you’ve got a guy in his early fifties, professional job, married twenty-plus years, grown or nearly-grown kids. Comes in because his wife told him to. She said he hasn’t been happy since they got married and she’s tired of it. He takes offense, then thinks about it for a week, then makes the appointment.
His history is textbook. He’s been quietly miserable since high school. He thinks of himself as a serious person. His dad was the same way. He’s never been in crisis, never been on a med, never seen a therapist. He just lives his life at about a four out of ten and assumes that was normal.
Start sertraline, eventually get him to 150mg. Get him into CBT with a therapist who’s actually structured about it, not just doing supportive listening. The first three months he doesn’t notice much. Month four, his wife notices first. She says he laughed at a joke on TV and she couldn’t remember the last time he’d done that. By month six he’s reporting that work feels different, that he’s looking forward to things, that he has energy left over at the end of the day for the first time in his adult life.
What to do if this is you
If you’ve been quietly miserable for as long as you can remember, that’s not your personality. That’s a diagnosis with a treatment. The treatment isn’t quick and isn’t dramatic, but the change at month six is the kind of change that gets your wife saying she got her husband back. Worth more than whatever the four-out-of-ten life is offering you.
The first step is naming it, which is the part most patients balk at because the label feels heavier than the symptoms they’ve been living with. The label isn’t the heavier thing. The twenty years of dim life is the heavier thing. The label is just what makes the dim life addressable, and that’s worth the discomfort of admitting it’s a thing that has a name.
Two-plus years, low-grade, still functional
Dysphoric mood most of the day, more days than not, for at least two years, plus two of: appetite, sleep, energy, self-esteem, concentration, or hopelessness issues. Patient still functions. Usually called “his personality” instead of what it is.
SSRI plus structured CBT, twelve to sixteen weeks
First-line is SSRI at a real dose plus structured therapy. The response timeline is longer than for acute depression, often twelve to sixteen weeks before real movement. Half respond to first-line, augmentation gets most of the remainder.
When did you last laugh involuntarily
Ask a patient when the last time he actually laughed at something without trying to. If the answer is in his twenties and he’s now in his fifties, that gap is the diagnosis pointing at itself. Most patients can’t name a recent involuntary laugh.
Bottom line
Persistent depressive disorder is the depression hiding in plain sight, because the patients who have it have never not had it and don’t know any different. It’s diagnosable, it’s treatable, and the patients who get treated usually report afterwards that they didn’t realize how much they’d been missing. That’s not a small thing. That’s most of your life.
Sources
- Cuijpers P, van Straten A, Schuurmans J, van Oppen P, Hollon SD, Andersson G. Psychotherapy for chronic major depression and dysthymia: a meta-analysis. Clin Psychol Rev. 2010;30(1):51-62. PMID 19781837.
- Keller MB, Hirschfeld RM, Hanks D. Double depression: a distinctive subtype of unipolar depression. J Affect Disord. 1997;45(1-2):65-73. PMID 9268776.
- Keller MB, Gelenberg AJ, Hirschfeld RM, et al. The treatment of chronic depression, part 2: a double-blind, randomized trial of sertraline and imipramine. J Clin Psychiatry. 1998;59(11):598-607. PMID 9862606.
- Howland RH. Chronic depression. Hosp Community Psychiatry. 1993;44(7):633-9. PMID 8354502.
