Does the chronological relationship between the onset of dysthymia and major depression influence subsequent response to antidepressants?

Mental health service use by patients with dysthymic disorder: treatment use and dropout in a 7 1/2-year naturalistic follow-up study

Little is known about long-term treatment use among patients with dysthymia. This paper describes patterns of treatment use by 85 outpatients with dysthymic disorder and a comparison group of 36 outpatients with nonchronic (episodic) major depression in a naturalistic follow-up. Patients with dysthymia had higher rates of treatment use across 7 1/2 years compared with patients with episodic major depression. Baseline variables that predicted which patients with dysthymia dropped out of treatment before recovering from dysthymic disorder included age, ethnicity, Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition Axis II pathology as obtained from informant reports, higher self-reported autonomy, and receiving psychotherapy alone as compared to receiving a combination of psychotherapy and medication. Dysthymic disorder places a significant burden on the mental health services system, yet many outpatients with dysthymia may be receiving inadequate treatment. Younger patients, ethnic minority patients, and patients with personality disorders may be at increased risk of dropping out from treatment for depression. Combination treatments may increase treatment retention.

Major depression versus dysthymia: Comorbid psychiatric disorders, psychotropic medication patterns, and psychotherapy sessions

The objective of this study was to examine, among those with major depression versus dysthymia, relationships with comorbid psychopathol-ogy, patterns of psychotropic medication prescription, and number of psychotherapy sessions utilized. Using a retrospective approach, a single investigator reviewed the medical records of individuals diagnosed with major depression or dysthymia (those with both disorders were excluded from analysis) in an adult, university-based, outpatient psychiatry clinic. Records were examined for demographic information, Axis I and II diagnoses, number and type of psychotropic medications, and number of psychotherapy sessions. There were no demographic differences between groups. Compared to those with major depression, individuals with dysthymia had a similar number of Axis I diagnoses, but were significantly more likely to be diagnosed with a personality disorder. Those with major depression were prescribed a significantly greater number of psychotropic medications, and all seven patients who received antipsychotics were diagnosed with major depression. Finally, there were no between-group differences in the number of psychotherapy sessions. These data indicate that, compared with major depression, dysthymia may have significantly greater Axis II, but not Axis I, psychiatric comorbidity. The implications of greater psychotropic medication prescription among the subsample with major depression, and similar psychotherapy utilization between groups, is discussed. Qnt] Psych Clin Pract 2004; 8: 61-63).

Dysthymia: a review of pharmacological and behavioral factors

Although dysthymia, a chronic, low-grade form of depression, has a morbidity rate as high as that of major depression, and increases the risk for major depressive disorder, limited information is available concerning the etiology of this illness. In the present report we review literature concerning the biological and characterological features of dysthymia, the effectiveness of antidepressant treatments, the influence of stressors in the precipitation and maintenance of the disorder, and both quality of life and psychosocial correlates of the illness. We also provisionally suggest that dysthymia may stem from disturbances of neuroendocrine and neurotransmitter functioning (eg, corticotropin releasing hormone and arginine vasopressin within the hypothalamus, or alternatively monoamine variations within several extrahypothalamic sites), and may also involve cytokine activation. The central disturbances may reflect phenotypic variations of neuroendocrine processes or sensitization of such mechanisms. It is suggested that chronic stressor experiences or stressors encountered early in life lead to the phenotypic neurochemical alterations, which then favor the development of the dysthymic state. Owing to the persistence of the neurochemical disturbances, vulnerability to double depression is increased, and in this instance treatment with antidepressants may attenuate the symptoms of major depression but not those of the basal dysthymic state. Moreover, the residual features of depression following treatment may be indicative of underlying neurochemical disturbances, and may also serve to increase the probability of illness recurrence or relapse.

Early- versus late-onset dythymic disorder: comparison in out-patients with superimposed major depressive episodes

BACKGROUND

This study examined the validity of the early-late onset subtyping distinction in dysthymic disorder.

METHODS

Participants were 340 out-patients meeting DSM-III-R criteria for dysthymia and a concurrent major depressive episode (MDE). The sample was drawn from a 12-site double-blind randomized parallel group trial comparing the efficacy of sertraline and imipramine in the treatment of chronic depression. All patients received comprehensive evaluations using semi-structured interviews and rating scales.

RESULTS

73% of the sample met criteria for the early-onset, and 27% for the late-onset, subtype. The early-onset patients had a significantly longer index MDE, significantly higher rates of personality disorders and lifetime substance use disorders, and a significantly greater proportion had a family history of mood disorder. The subgroups did not differ in symptom severity or functional impairment at baseline, nor in response to a 12-week trial of antidepressants.

LIMITATIONS

Further work is needed to extend these findings to dysthymic disorder without superimposed MDEs.

CONCLUSIONS

These results support the distinction between early-onset and late-onset dysthymic disorder.