What is the role of medications in the treatment of persistent depressive disorder (dysthymia)?

Updated: Oct 01, 2019
  • Author: Jerry L Halverson, MD; Chief Editor: David Bienenfeld, MD  more...
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Answer

Antidepressants are effective in treating dysthymia; the mean response for any antidepressant in a review study was 55% among dysthymic patients (compared with 31% response for placebo). Doses are the same as those used for major depression. A systematic review of antidepressant treatment in dysthymia suggested that SSRIs, tricyclic antidepressants, and monoamine oxidase inhibitors (MAOIs) are all equally effective, but SSRIs may be slightly better tolerated. Success has also been reported with more noradrenergic agents such as mirtazapine (Remeron), nefazodone (Serzone), venlafaxine (Effexor), duloxetine (Cymbalta), and bupropion (Wellbutrin).

Comparisons of agents within or between classes have not been reported for dysthymia. A 2007 research summary by the Agency for Healthcare Research and Quality (AHRQ) identified no head-to-head trial comparing different second-generation antidepressants for treatment of dysthymia; comparison between placebo-controlled trials was stymied by significant differences in population characteristics.

The AHRQ noted that in a fair-quality placebo-controlled study, a subgroup of patients older than 60 years showed a significantly greater improvement on paroxetine than did those on placebo, whereas paroxetine was no more effective than placebo in a subgroup of patients younger than 60 years. [32]

While the older antidepressants, such as tricyclics and MAOIs, are effective, the SSRIs are the medications most commonly used for dysthymia, likely because of their relative safety and milder side-effect profile. Given that dysthymia is a chronic condition, tolerability is important to facilitate compliance over the long-term.

Little data exist for choosing one antidepressant over another unless (1) the risk of a particular adverse effect is to be avoided, (2) the patient has a history of prior response to a particular drug, or (3) a drug is known to have been effective for a member of the patient's family.

Of note, antidepressants may cause a temporary worsening of anxiety symptoms; lower doses, slower titration, or temporary use of benzodiazepines (if not contraindicated, for example, because of a substance use disorder) may mitigate anxiety and improve tolerability.


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