Persistent depressive disorder

Overview

Persistent depressive disorder is a continuous, long-term form of depression. You may feel sad and empty, lose interest in daily activities and have trouble getting things done. You may also have low self-esteem, feel like a failure and feel hopeless. These feelings last for years and may interfere with your relationships, school, work and daily activities.

If you have persistent depressive disorder, you may find it hard to be upbeat even on happy occasions. You may be described as having a gloomy personality, constantly complaining or not able to have fun. Persistent depressive disorder is not as severe as major depression, but your current depressed mood may be mild, moderate or severe.

Because persistent depressive disorder is long term, coping with depression symptoms can be challenging. A combination of talk therapy and medicine can be effective in treating this condition.

Symptoms

Persistent depressive disorder symptoms usually come and go over a period of years. The intensity of symptoms can change over time. But symptoms usually don't disappear for more than two months at a time. Also, major depression episodes may occur before or during persistent depressive disorder.

Symptoms of persistent depressive disorder can cause major problems in your life and may include:

• Sadness, emptiness or feeling down.
• Loss of interest in daily activities.
• Tiredness and lack of energy.
• Low self-esteem, self-criticism or feeling you're not capable.
• Trouble focusing clearly and trouble making decisions.
• Problems getting things done well and on time.
• Quickly becoming annoyed, impatient or angry.
• Avoidance of social activities.
• Feelings of guilt and worries over the past.
• Poor appetite or overeating.
• Sleep problems.
• Hopelessness.

In children, symptoms of persistent depressive disorder may include depressed mood and being irritable, which means easily becoming annoyed, impatient or angry.

When to see a doctor

If these feelings have been going on for a long time, you may think they'll always be part of your life. But if you have any symptoms of persistent depressive disorder, seek medical help.

Talk to your health care provider about your symptoms or seek help from a mental health professional. Or you can reach out to someone else who may be able to help guide you to treatment. This could be a friend or loved one, a teacher, a faith leader, or another person you trust.

If you think you may hurt yourself or attempt suicide, call 911 in the U.S. or your local emergency number immediately. Or contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Or use the Lifeline Chat. Services are free and confidential. The Suicide & Crisis Lifeline in the U.S. has a Spanish language phone line at 888-628-9454 (toll-free).

Causes

The exact cause of persistent depressive disorder is not known. As with major depression, it may involve more than one cause, such as:

• Biological differences. People with persistent depressive disorder may have physical changes in their brains. It's not clear how these changes affect the disorder, but they may eventually help determine the causes.
• Brain chemistry. Neurotransmitters are naturally occurring brain chemicals. Research indicates that changes in neurotransmitters may play a large part in depression and its treatment.
• Inherited traits. Persistent depressive disorder appears to be more common in people whose blood relatives also have the condition. Researchers are trying to find genes that may be involved in causing depression.
• Life events. As with major depression, traumatic events such as the loss of a loved one, financial problems or a high level of stress can trigger persistent depressive disorder in some people.

Risk factors

Persistent depressive disorder often begins early — in childhood, the teen years or young adult life — and continues for a long time. Certain factors appear to increase the risk of developing persistent depressive disorder, including:

• Having a first-degree blood relative, such as a parent or sibling, with major depressive disorder or other depressive disorders.
• Traumatic or stressful life events, such as the loss of a loved one or major financial problems.
• Personality traits that include negativity, such as low self-esteem, being too dependent or self-critical, or always thinking the worst will happen.
• History of other mental health disorders, such as a personality disorder.

Complications

Conditions that may be linked with persistent depressive disorder include:

• Lower quality of life.
• Major depression, anxiety disorders and other mood disorders.
• Substance misuse.
• Relationship difficulties and family conflicts.
• School or work problems and trouble getting things done.
• Continuing pain and general medical illnesses.
• Suicidal thoughts or behavior.
• Personality disorders or other mental health disorders.

Prevention

There's no sure way to prevent persistent depressive disorder. Because it often starts in childhood or during the teenage years, identifying children at risk of the condition may help them get early treatment.

Strategies that may help reduce or prevent symptoms include the following:

• Take steps to control stress, to increase your ability to recover from problems — which is called resilience — and to boost your self-esteem.
• Reach out to family and friends, especially in times of crisis, to help you get through rough spells.
• Get treatment at the earliest sign of a problem to help prevent symptoms from worsening.
• Consider getting long-term treatment to help prevent a relapse of symptoms.

Diagnosis

If your health care provider thinks that you may have persistent depressive disorder, exams and tests may include:

• Physical exam. Your health care provider may do a physical exam and ask in-depth questions about your health to determine what may be causing your depression. In some cases, it may be linked to an underlying physical health problem.
• Lab tests. Your provider may recommend lab tests to rule out other medical conditions that may cause depressive symptoms. For example, you may have a blood test to find out whether your thyroid is not making enough thyroid hormone, which is called hypothyroidism.
• Psychological evaluation. This includes talking about your thoughts, feelings and behavior. It may include completing a questionnaire. This evaluation can help determine if you have persistent depressive disorder or another condition that can affect mood, such as major depression, bipolar disorder or seasonal affective disorder.

For a diagnosis of persistent depressive disorder, the main indication for an adult differs somewhat from that of a child:

• For an adult, depressed mood occurs most of the day for two or more years.
• For a child, depressed mood or irritability occurs most of the day for at least one year.

Symptoms caused by persistent depressive disorder can vary from person to person. When persistent depressive disorder starts before age 21, it's called early onset. If it starts at age 21 or older, it's called late onset.

Treatment

The two main treatments for persistent depressive disorder are medicines and talk therapy. What your health care provider recommends depends on factors such as:

• How severe your symptoms are.
• Your desire to explore emotional or other issues affecting your life.
• Previous treatment methods.
• Your ability to tolerate medicines.
• Other emotional problems you may have.
• What type of treatment you prefer.

Talk therapy may be the first option suggested for children and teenagers with persistent depressive disorder, but that depends on the individual. Sometimes antidepressants also are needed.

Medicines

The types of antidepressants most commonly used to treat persistent depressive disorder include:

• Selective serotonin reuptake inhibitors (SSRIs)
• Tricyclic antidepressants (TCAs)
• Serotonin and norepinephrine reuptake inhibitors (SNRIs)

Talk with your health care provider or pharmacist about possible side effects.

Finding the right medicine

You may need to try several medicines or a combination before you find one that works. This requires patience. Some medicines take several weeks or longer for full effect. It can also take this long for side effects to ease as your body adjusts.

Don't stop taking an antidepressant without talking to your health care provider. When it's time, your provider can help you gradually and safely decrease your dose. Stopping treatment suddenly or missing several doses may cause withdrawal-like symptoms. And quitting a medicine suddenly may cause depression to quickly get worse.

When you have persistent depressive disorder, you may need to take antidepressants long term to keep symptoms under control.

Antidepressants and pregnancy

If you're pregnant or breastfeeding, some antidepressants may pose an increased health risk to your unborn baby or nursing child. Talk to your health care provider if you become pregnant or are planning on becoming pregnant.

FDA alert on antidepressants

Antidepressants are generally safe when taken as directed. But the U.S. Food and Drug Administration (FDA) requires all antidepressants to carry a warning: In some cases, children, teens and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants. This may be more of a risk in the first few weeks after starting or when the dose is changed. So watch closely for worsening depression or unusual behavior during these times.

If your teen or young adult has suicidal thoughts while taking an antidepressant, immediately contact a health care provider or mental health provider or get emergency help. Keep in mind that antidepressants are more likely to reduce suicide risk in the long term by improving mood.

Talk therapy

Talk therapy, also called psychotherapy, is a general term for treating depression by talking with a mental health provider about your thoughts, feelings, behavior, relationships and related issues.

Different types of psychotherapy, such as cognitive behavioral therapy, can be effective for persistent depressive disorder. You and your therapist can discuss your goals for therapy and other issues, such as the length of treatment.

Talk therapy can help you:

• Adjust to a crisis or other current difficulty.
• Identify issues that contribute to your depression and change behaviors that make it worse.
• Identify negative beliefs and behaviors and replace them with healthy, positive ones.
• Find better ways to cope with and solve problems.
• Explore relationships and experiences, and develop positive interactions with others.
• Regain a sense of satisfaction and control in your life and help ease depression symptoms, such as hopelessness and anger.
• Learn to set realistic goals for your life.

Lifestyle and home remedies

Persistent depressive disorder generally is not a condition that you can treat on your own. But along with professional treatment, these self-care steps can help:

• Stick to your treatment plan. Don't skip therapy sessions or appointments. Even if you're feeling well, don't skip your medicine. Give yourself time to improve gradually.
• Learn about persistent depressive disorder. Education about your condition can empower you and motivate you to follow your treatment plan. Encourage your family to learn about the disorder to help them understand and support you.
• Pay attention to warning signs. Work with your health care provider or therapist to learn what might trigger your symptoms. Make a plan so that you know what to do if symptoms get worse or return. Contact your health care provider or therapist if you notice any changes in symptoms or how you feel. Consider involving family members or friends to watch for warning signs.
• Take care of yourself. Eat a healthy diet, be physically active and get plenty of sleep. Consider walking, jogging, swimming, gardening or another activity that you enjoy. Sleeping well is important for both physical and mental well-being. If you're having trouble sleeping, ask your provider what you can do.
• Avoid alcohol and recreational drugs. It may seem like alcohol or drugs lessen depression-related symptoms. But over time, they generally worsen depression and make it harder to treat. Talk with your provider or therapist if you need help dealing with alcohol or drug use.

Alternative medicine

Make sure you understand the risks as well as the possible benefits if you decide to use alternative or complementary therapy. Avoid replacing conventional medical treatment or talk therapy with alternative medicine. When it comes to depression, alternative treatments are not a substitute for medical care.

For example, the herbal supplement called St. John's wort is not approved by the FDA to treat depression in the U.S., though it's available. It may help improve mild or moderate depression, but the overall evidence is not conclusive.

St. John's wort can interfere with a number of medicines, including blood-thinning drugs, birth control pills, chemotherapy, HIV/AIDS medicines and drugs to prevent organ rejection after a transplant. Also, avoid taking St. John's wort while taking antidepressants because the combination can cause serious side effects.

The FDA does not monitor supplements

Unlike medicines, dietary supplements aren't approved and monitored by the FDA. You can't always be certain of what you're getting and whether it's safe. Some herbal and other dietary supplements can interfere with prescription medicines or cause dangerous interactions. Talk to your health care provider before taking any supplements.

Coping and support

Persistent depressive disorder makes it hard to engage in behavior and activities that can help you feel better. In addition to the treatments recommended by your doctor or therapist, consider these tips:

• Focus on your goals. Dealing with persistent depressive disorder is an ongoing process. Set reasonable goals for yourself. Stay motivated by keeping your goals in mind. But give yourself permission to do less when you feel down.
• Simplify your life. Cut back on obligations when possible. Structure your time by planning your day. You may find it helps to make a list of daily tasks, use sticky notes as reminders or use a planner to stay organized.
• Write in a journal. Journaling as part of your treatment may improve mood by allowing you to express pain, anger, fear or other emotions.
• Read reputable self-help books and websites. Ask your doctor or therapist to recommend books or websites to read.
• Stay connected. Don't become isolated. Try to participate in social activities, and get together with family or friends regularly. Support groups for people with depression can help you connect with others facing similar challenges and share experiences.
• Learn ways to relax and manage your stress. Examples include meditation, progressive muscle relaxation, yoga and tai chi.
• Don't make important decisions when you're down. Avoid decision-making when you're feeling depressed, since you may not be thinking clearly.

Preparing for an appointment

You may decide to schedule an appointment with your primary health care provider to talk about your concerns. Or you may decide to see a mental health provider, such as a psychiatrist or psychologist, for evaluation.

You may choose to take a family member or friend along to help you remember something that you missed or forgot.

What you can do

Prepare for your appointment by making a list of:

• Any symptoms you've had, including any that may seem unrelated to the reason for the appointment.
• Key personal information, including any major stresses or recent life changes.
• All medicines, vitamins, supplements or herbal preparations that you're taking, and the doses.
• Questions to ask your health care provider.

Basic questions to ask may include:

• Why can't I get over this depression on my own?
• How do you treat this type of depression?
• Will talk therapy help?
• Is there a medicine that might help?
• How long will I need to take the medicine?
• What are some of the side effects of the medicine that you're recommending?
• How often will we meet?
• How long will treatment take?
• What can I do to help myself?
• Are there any brochures or other printed materials that I can have?
• What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your provider may ask you several questions, such as:

• When did you first notice symptoms?
• How is your daily life affected by your symptoms?
• What other treatment have you had?
• What have you tried on your own to feel better?
• What things make you feel worse?
• Have any relatives had any type of depression or another mental health disorder?
• What do you hope to gain from treatment?

Your health care provider or mental health provider will ask more questions based on your responses, symptoms and needs. Prepare and anticipate questions to make the most of your appointment time.