The long-term outcome of dysthymia in private practice: clinical features, temperament, and the art of management.

BACKGROUND: With the clinical availability of fluoxetine in the United States, we were interested in documenting improvements in the clinical care of dysthymic patients beyond what was reported from our clinic 2 decades earlier during the "tricyclic (TCA) era."
METHOD: In open treatment of 42 consecutive DSM-III-R primary dysthymic patients who were personally followed up in our mood clinic since 1988, response was defined as sustained remission, i.e., no longer meeting criteria for dysthymia and achieving DSM-III-R Axis V Global Assessment of Functioning (GAF) score > 70 throughout much of the mean follow-up of 5 years.
RESULTS: Compared to patients with nondysthymic episodic major depressive disorder (N = 42), dysthymic patients had a significantly earlier mean age at onset (12.6 vs. 34 years), were more likely to have never been married, had a greater frequency of superimposed major depressive episodes (except for the 14% [N = 6] with "pure" dysthymia), and had more psychiatric and fewer medical comorbidities; furthermore, patients with dysthymia had significantly greater familial loading of both unipolar and bipolar disorders. Continued treatment with TCA-type antidepressants or fluoxetine (including various augmenting strategies) led to an overall robust and sustained response rate of 76% (N = 32) among dysthymic patients; in tandem, major depressive episodes and suicidality were prevented in all responders. Females treated with fluoxetine had the highest response rate (85% [N = 17]); some were able to walk out of dependent abusive relationships for the first time in their lives. However, dramatic responses with "hyperthymic" switches in temperament occurred in only 12% of dysthymic patients; nearly all were males with bipolar family history. The more prototypic positive change among dysthymic responders consisted of coping with daily hassles without being overwhelmed. Qualitatively, the highest level of adaptive functioning was observed among fluoxetine-treated dysthymics (50% of responders [N = 12] achieved DSM-III-R GAF score of 81-90). Of TCA-treated patients, 39% had intolerable side effects, necessitating switch-over to fluoxetine. Agitation occurred in 11% of fluoxetine-treated patients (N = 4) and was associated with nonresponse and/or dropout; otherwise, this selective serotonin reuptake inhibitor was well tolerated, thereby contributing to long-term compliance. More provocatively, patients with dysthymia who had required extensive psychotherapeutic attention prior to state-of-the-art pharmacotherapy no longer required such therapy.
CONCLUSION: These data extend and enrich what has been learned from controlled trials among dysthymic patients. With sustained pharmacotherapy and specialized clinical care in a private mood clinic, 3 of 4 patients immersed in gloom for much of their lives achieved for the first time good to superior levels of functioning that were maintained for an average of 5 years. Although the art of clinical management of dysthymia should be fully grounded in understanding the interpersonal context of depression, we submit that SSRIs such as fluoxetine appear broadly efficacious in areas previously deemed to be the domain of formal psychotherapy.