Major depression can make you feel like you’re underwater. The intense sadness submerges you and drowns out every other part of your life. But after some time, the episode may end. You emerge from the abyss and start to feel like yourself again.
Persistent depressive disorder is different. “It’s like walking through viscous fluid, where you feel weighed down in sadness that just doesn’t lift,” explains Ron Elson, MD, a psychiatrist at UC Berkeley Health Services and a member of our editorial board. That is, rather than coming in waves as major depression tends to, persistent depressive disorder is more constant, and everything you do is harder and takes more effort and more time.
Nearly one in three Americans experience at least one bout of major depression in their lifetime, according to a 2023 Gallup survey. Far fewer have persistent depressive disorder, but for those who do live with this long-term sadness, it can be even more debilitating than full-blown major depression. When symptoms are severe, persistent depressive disorder can lead to hospitalization and even suicide.
Clarifying the condition
Persistent depressive disorder is such a complex and poorly understood condition that even experts have had trouble agreeing on a definition. In the past, it was called “dysthymic disorder” or simply “dysthymia,” to describe a milder form of depression that lasted for at least two years. It was once even considered a personality disorder, rather than a mood disorder.
When the American Psychiatric Association released its fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013, it gave the disorder a new name to reflect the evolving understanding that long-term persistent depression can also cause more severe symptoms and overlap with major depression.
It’s important to keep in mind that sadness—or melancholy or however else it may be described—lies on a continuum, says Dr. Elson. And feeling “depressed” is normal under many circumstances. We get sad about things that happen; we feel grief; we mourn. These are normal responses to situations and may not warrant “treatment” or help beyond friends, activities, or other forms of support. But when it’s not clear that there is a precipitating event, or if these approaches don’t work, Dr. Elson advises that it’s time to think about getting a consultation with a mental health professional (as discussed below).
What causes it?
Just like major depression, persistent depressive disorder may have its roots in the nervous system. Researchers have discovered changes in levels of chemical messengers like serotonin and dopamine, as well as differences in the brain structure of people who are depressed. But although this biological neurotransmitter model is often cited to explain depressive disorders, the exact cause still hasn’t been confirmed. And it is not the whole story. Problems with the immune system and alterations in sleep patterns might also be involved, as well as other factors such as exercise (lack of), diet, medication side effects, physical ailments, and psychosocial issues.
Both persistent depressive disorder and major depression tend to run in families, which suggests a genetic component. If one of your parents or siblings has or had persistent depression, you’re also more likely to have it. Both these mood disorders are more common in women than in men, which suggests that hormones may play a role.
One unique part of persistent depressive disorder is that it might in some cases have its roots in childhood trauma, such as abuse, neglect, or the death of a parent. Healing from trauma is therefore an important part of treatment.
A symptom checklist
Because the symptoms of major depression and persistent depressive disorder are so similar, time is the main way to differentiate these two conditions. People with major depression have periods of low mood that last for at least two weeks, followed by periods where they’re symptom-free. Those with persistent depressive disorder are sad for most of the day on more days than not, and these feelings last for at least two years. And even if there is an uptick in mood sometimes, it is the low mood that predominates over time.
Along with depressed mood, people with persistent depressive disorder have at least two of these symptoms, according to DSM-5, and these don’t go away for more than two months at a time.
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
How do you know if you have it?
You may not. Because the day-to-day symptoms are often (but not always) milder than major depression and are so constant, they’re easy even for doctors to miss. And since you feel down on more days than not, you might mistakenly think that sadness is your normal way of being and not ask a doctor or mental health provider about it.
To confuse matters even more, having persistent depressive disorder increases your risk for major depression—and you can have both at the same time. Doctors call this “double depression.” After a bout of major depression ends, you go back to your previous persistent depressive state.
Finding relief
Before attributing a long-lasting depressed mood to a mental condition, it’s important to rule out other possible causes, such as a health condition (like hypothyroidism) or a challenging job or marriage. That is, says Dr. Elson, a useful question to ask is “what is the nature of the problem to be solved?”
If treatment is warranted for persistent depressive disorder, it isn’t much different than it is for major depression. The most effective approach often combines antidepressants with psychotherapy. It often takes several weeks on medication to begin to see any improvement, and you might have to make a few medication changes or dose adjustments to get significant symptom relief.
Among the types of therapy that can be effective is cognitive behavioral therapy (CBT), which helps you identify and change troublesome thought patterns and behaviors. Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is a newer treatment that not only helps you change problematic behaviors but also promotes recovery from trauma. CBASP, which was designed specifically for chronic depression, is not available everywhere.
Since persistent depressive disorder is not a single clear entity, however, and because people differ, there is no single treatment. The course of treatment should therefore be tailored to the individual.
Will it ever go away?
Persistent depressive disorder can be managed, but how much relief you get depends on the severity of your symptoms and whether you get on the right treatment—and stick with it.
But the expectation shouldn’t be that medication or therapy will suddenly transform one’s life, says Dr. Elson. “If we’re successful in whatever treatment approach is used, it’s as though the viscosity of the fluid lessens. With treatment, you may still never like the task, or love your life, but things at least become easier.”
It’s also important, Dr. Elson stresses, to recognize that a depressed mood does not—and should not—define a person. It is not your core identity, “who you are,” but rather a “state” of being, even if that state lasts a long time. Even with persistent depressive disorder, one’s experience can change, diminish, or sometimes even go away, at least for a long period of time.
BOTTOM LINE: If you feel sad, depressed, melancholic, down, blue, or whatever word best fits for your mood day after day, it’s important to get help. A psychologist, psychiatrist, or other mental health professional can determine if you have persistent depressive disorder (or other forms of depression) by asking about your symptoms and how long you’ve had them. Without treatment, persistent depressive disorder could extend its grip on every part of your life, interfering with your work, relationships, and health. But if you pursue appropriate care and stay on the recommended treatment plan, you may finally be able to lift the fog you’ve been living under.
