Persistent Depressive Disorder (Dysthymia)

Finding The Right Treatment

Treatment for Dysthymia

Treatment for dysthymia is important. Without treatment, this form of depression continues to linger, and symptoms can intensify over time. The good news is that most people recover from dysthymia with a combination of therapy, medications, and lifestyle modifications.

Finding a therapist

While medications are often a catalyst for change in individuals with dysthymia, therapy has been proven to yield major improvements in the lives of those who are struggling. A therapist can assist with the early recognition of symptoms that lead to a depressive episode, an understanding of how the past might impact an individual, and developing an awareness of current thoughts and behaviors. Over time therapy can help people become more contented versions of themselves. Most therapists have experience working with adults who have dysthymia.

There are different kinds of professionals that can provide effective therapy, including:

• Clinical psychologists (PhD)
• Licensed clinical social workers (LCSW or LMSW)
• Licensed professional counselors (LPC)
• Licensed clinical professional counselors (LCPC)
• Licensed Marriage and Family Therapists (LMFT)
• National certified counselors (NCC)

There are several styles of therapy that can be helpful for dysthymia including psychodynamic, interpersonal, and supportive therapy. In recent years, more therapists employ cognitive behavioral therapy (CBT), which is a method that helps the individual identify unhelpful thought patterns, challenge self-destructive cognitions, and replaces them with more constructive thinking. Therapists will also help the individual identify behaviors that may help bring increased pleasure or a return to a sense of confidence.

Many individuals with dysthymia find therapy to be one of the best ways to prevent future depressive episodes. Recognizing the triggers and signs of an oncoming episode assists people in navigating the natural ups and downs of life. A good therapist will partner with an individual to create a treatment plan that addresses their concerns, needs, and goals.

The decision to start therapy

Many people try to cope with their distress on their own, and then feel disappointed when they find that this is very difficult to do. Deciding to start therapy can be hard; it takes courage.

For some people, it can take time to warm up to the idea of sharing one’s intimate thoughts or disclosing details of one’s life, especially for those who grew up in a culture where seeking psychological help was frowned upon.

Psychotherapy is increasingly accepted as not only a way to improve mental health symptoms, but also a means for self exploration and personal growth. No problem is too small for a trained therapist: an individual need not worry that others may have it worse. The willingness to reach out for help is increasing: in 2020, one out of every six Americans (men and women) reported seeing a therapist.

Seeing a therapist with whom one feels comfortable, and a sense of connection, and who also participates in their insurance network, is essential. It may take a couple tries to find a therapist who feels like the right fit. If therapy didn't help the first time around, it can be helpful to give another therapist a try because therapeutic styles vary so much from therapist to therapist.

Where to start

Requesting one’s physician to make a referral is often a good place to start. Many health insurance cards have websites or 1-800 numbers to call for a list of in-network providers.

To find a therapist who takes one's insurance, the National Institute of Mental Health offers a comprehensive list of resources.

Psychology Today also lists therapists by type, location and insurance.

The decision to start medication

Medications often play a central role in the lives of people with dysthymia. Finding the right medication is not always straightforward, as individuals metabolize and react to medications differently. Adjusting dosages to manage and prevent depression can be expected during the treatment process.

Multiple categories of medications for depression

There are multiple categories, or classes, of medications that the Food and Drug Administration (FDA) has approved to treat depression. Each class is often prescribed for a different scenario or type of depression. This report focuses on a basic roadmap for medication treatment, so that individuals can gain a sense of the major classes of antidepressants. Treatment protocols and insurance companies often call for “step-therapy,” or trying medications in a certain order, usually starting with inexpensive options. Insurance companies typically restrict access to more expensive medications. When an individual’s previous treatments are organized, it may help their provider to better advocate for the brand name medication if needed.

First-line treatment

For most types of depression, the first step is to try a medication in the category of selective serotonin reuptake inhibitors (SSRIs or SRIs) medications, which include fluoxetine (Prozac), escitalopram (Lexapro), and a few others. Research has shown that there is a relationship between depression levels and the amount of serotonin available in the brain. SSRIs prevent serotonin from being taken out of the system too quickly (reuptake inhibition). The other group of commonly used medications are classified as serotonin norepinephrine inhibitors (SNRIs) and they increase the levels of both serotonin and norepinephrine.

SSRIs and SNRIs often take 10 days to two weeks to begin having any effect. The full therapeutic benefit of the medication is typically achieved in 8-12 weeks.

If one of the “first-line” medications is not effective, a prescriber has many options. The first is to ensure that the SSRI/SNRI is dosed adequately. Before abandoning a “first-line” treatment, a provider may suggest a higher dosage. Sometimes, however, higher doses are not tolerated due to side effects. In those situations, a provider may employ other strategies.

Second-line treatment

Some people who take antidepressants either do not tolerate the SSRIs/SNRIs or do not see clinical benefit. In these situations, prescribers may suggest bupropion (Wellbutrin). Bupropion is a dopamine and norepinephrine reuptake inhibitor (DNRI). It has significant antidepressant properties, particularly as the dose increases from the starting dose of 150 mg to maintenance dose of 300-450 mg. Bupropion does not have serotonin properties, and for this reason, it typically does not cause sexual side effects. On the downside, bupropion is not as effective against anxiety as some of the SSRIs/SNRIs.

Bupropion can be used alone, and in situations of Recurrent MDD, a provider may recommend a higher dose. Not uncommonly, a provider may add bupropion to an SSRI/SNRI.

Other medications

The strategies discussed above are considered “first-line” treatments. Most of the medications described are generic, and less expensive than brand name drugs. The techniques of combining the medications are well established, and can be done in the primary care setting. The majority of patients receiving treatment for depression are given one of these “first-line” options. Fortunately, other options exist for individuals who don’t respond to them.

Vortioxetine (Trintellix) works by a combination effect of decreasing serotonin reuptake and interacting with selective serotonin receptors. It can be highly effective in combating symptoms of depression. It is distinguished because it is associated with less weight gain and sexual dysfunction than the SSRIs/SNRIs. A small number of individuals taking vortioxetine (Trintellix) notice significant nausea early on, in those cases the medicine is taken with the largest meal of the day. While its effectiveness and minimal side effects are noteworthy, vortioxetine (Trintellix) is a more expensive agent, and therefore, protocols suggest trials of SSRIs/SNRIs first.

Vilazadome (Vybriid) also works as a serotonin reuptake inhibitor, and a selective serotonin agonist. It is distinguished from the SSRIs/SNRIs in that it causes less emotional blunting, meaning the people who take it report experiencing a full range of emotions. Like Trintellix, it has a favorable side effect profile, causing less weight gain and sexual dysfunction than SSRIs/SNRIs. Nausea is associated with Vybriid, although it typically diminishes within the first week.

Adjunctive treatments

When the above medications are not effective, a provider might prescribe an adjunctive treatment, which are sometimes referred to as augmentation strategies. For the treatment of depression, adjunctive medications are always prescribed with an SSRI or an SNRI. Usually, adjunctive treatments are added only after the SSRI or SNRI has been taken for at least a month without benefit.

Antidepressant medications used for sleep

Since sleep issues often accompany depression, providers sometimes use other antidepressant medications to reduce insomnia and augment the antidepressant effect. There are other medications that are not specifically antidepressants which directly improve sleep.

Psilocybin, medical marijuana & CBD

Some physicians are achieving promising results with formerly-maligned drugs such as ketamine, psilocybin, cannabinoids, and medical marijuana. Recently, researchers are studying micro-doses of psilocybin, a hallucinogenic drug, for patients with addictions who are depressed and not responsive to standard antidepressants.

The active ingredient of tetrahydrocannabinol (THC) in marijuana may relieve depression in some patients. Some report improvement in depressive symptoms with CBDs or cannabinoids, which do not contain THC.

The medical legal use of these substances and/or legalized recreational use for adults varies widely from state to state. It is important to note that in some states possession of these drugs is a crime. Taking these substances also poses a risk of drug induced psychosis, or other unintended effects, depending upon a person's family history and any co-occurring mental or medical health conditions. Due to these risks, it is extremely important to consult a healthcare provider about such options.

Healthcare providers that can prescribe medications

Psychiatrists, psychiatric nurse practitioners, and physician assistants are practitioners who are trained to diagnose and treat mental health conditions by prescribing medications. Sometimes it's hard to find a psychiatric provider because there are so many people who need them. So, individuals often choose to see a different kind of provider who can prescribe. This could be a doctor they already see, like a primary care doctor, family doctor or OB/GYN, or a new primary doctor.

FDA warning about suicide risk with antidepressants

Some research exists that, occasionally, newly initiated anti-depressants may increase the risk of suicide. If an individual begins to have these thoughts after starting an anti-depressant, please stop this medicine and contact a prescriber immediately. This risk is more evident in children, adolescents, and young adults.

Dietary supplements

There are an increasing number of supplements, such as an herb, vitamin, mineral, and other supplements claiming to improve sleep, depression, stress, restlessness, or anxiety. While it is possible for a supplement to improve one’s symptoms, their effects are often unproven.

Be aware that dietary supplements are not controlled by the FDA and, therefore, are not subject to the standards of quality, uniformity, and testing for efficacy and safety as regulated medications. It is important to share a list of all medications and supplements with one's treating provider because some of them may interact with the medications they prescribe.