Dysthymia and Chronic Depression: Introduction,

Classification, Risk Factors, and Course

Daniel N. Klein and Neil J. Santiago

State University of New York at Stony Brook

Chronic forms of depression are more common and impairing than is

generally recognized. This article introduces an In Session issue devoted
to dysthymic disorder and chronic depression, and it reviews current knowl-
edge about these disorders. First, we discuss nosological issues, followed
by a summary of potential risk factors. Finally, the naturalistic course of
chronic depression is described and implications for clinical practice are
discussed. 2003 Wiley Periodicals, Inc. J Clin Psychol/In Session 59:
807816, 2003.

Keywords: dysthymic disorder; chronic depression; depression; classification;

psychotherapy; pharmacotherapy

Depressive disorders have been conceptualized traditionally as episodic, remitting con-

ditions. Only within the past 10 to 20 years has it been recognized widely that a signifi-
cant proportion of depressive disorders have a chronic course. For example, over 6% of
the United States population has experienced an episode of dysthymic disorder at some
point in their lives, and over 3% have had dysthymia in the past year (Kessler et al.,
1994). The risk for dysthymic disorder and other chronic depressions is approximately
two times greater for women than for men, which is similar to the sex difference in
episodic depressions. Chronic depression also is among the most-common conditions
seen in clinical settings, with studies reporting that 22 to 36% of outpatients meet criteria
for dysthymic disorder.
Chronic depressions are associated with significant impairment in occupational, inter-
personal, marital, and family functioning. Indeed, functional impairment in even milder
forms of chronic depression, such as dysthymic disorder, is at least as great as in the
classic forms of major depression.
Chronic depressions often co-occur with other Axis-I and Axis-II disorders. Co-
morbidity with anxiety, substance-use, and personality disorders is particularly common.

Correspondence concerning this article should be addressed to: Daniel N. Klein, Ph.D., Department of
Psychology, State University of New York at Stony Brook, Stony Brook, NY 11794 2500; e-mail:
dklein@notes.cc.sunysb.edu.

JCLP/In Session, Vol. 59(8), 807816 (2003) 2003 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10174
808 JCLP/In Session, August 2003

The most-frequent co-occurring Axis-II disorders are borderline, histrionic, avoidant,

and dependant personality disorders. Comorbid personality disorders are significantly
more common in chronic than in episodic forms of depression, particularly in those with
an early onset.
Due to the high comorbidity and functional impairment in these patients, clinicians
often overlook the presence of chronic depression and focus on the florid comorbid symp-
tomatology and pressing life problems. In addition, many patients with early onset chronic
depressions consider their dysphoria normal or a part of their usual self, and fail to report
it to clinicians or even consider that it may be an appropriate target for treatment. There-
fore, chronic depression often is undertreated, even in patients seeking psychological or
medical treatment. This is unfortunate, as recovery is infrequent and generally short lived
without appropriate treatment. However, as reviewed in this issue, targeted and intensive
treatments can be highly effective in treating most patients with chronic depressive
conditions.

Introduction to the Issue

This issue of In Session features recent developments in the treatment of dysthymic
disorder and chronic depression with contributions from leading experts in the field. This
opening article discusses the classification, risk factors, and course of chronic depression.
The next group of articles present psychodynamic (David Mark, Jacques P. Barber,
& Paul Crits-Cristoph), interpersonal (John C. Markowitz), and cognitive (Lawrence P.
Riso & Cory F. Newman) approaches to the psychotherapy of chronic depression. Although
these approaches are used widely with episodic forms of depression, the authors provide
detailed suggestions on tailoring treatment to meet the special challenges posed by patients
with dysthymia and chronic depression. As an alternative to modifying existing treat-
ments, James P. McCullough, Jr., has developed a new integrative treatmentthe Cog-
nitive Behavioral Analysis System of Psychotherapy (CBASP)that specifically targets
chronic depression. McCullough presents the theoretical rationale and procedures for
CBASP in his article.
As many of the contributors to this issue note, chronic depression often emerges
within a dysfunctional interpersonal context. Gabor I. Keitner and colleagues discuss one
means of intervening directly on the interpersonal milieu through family systems treatment.
It is equally important for psychotherapists to be aware of advances in the psycho-
pharmacological treatment of dysthymic disorder and chronic depression. James H. Koc-
sis provides a thorough overview of this rapidly growing area. Finally, Bruce A. Arnow
and Michael J. Constantino conclude the issue with a practice-responsive review of the
empirical research on the psychotherapy of dysthymia and chronic depression.

Classification of Chronic Depression

Chronic depression can take a number of forms, which vary in their severity over time.
The two major categories of chronic depression in the fourth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV) are dysthymic disorder and major
depressive disorder, chronic type.

Dysthymic Disorder
Dysthymic disorder is a mild chronic-depressive condition defined by a chronic course
(depressed most of the day, more days than not, for at least two years), persistent symptoms
 Classification, Risk Factors, and Course 809

(no symptom-free periods of longer than two months), and an insidious onset (no major
depressive episode within the first two years of the disturbance). It can present with the
full gamut of depressive symptoms, although cognitive (e.g., low self-esteem, hopeless-
ness), affective (dysphoric mood), and social-motivational (e.g., loss of interest or plea-
sure, social withdrawal) symptoms are more common than vegetative symptoms (e.g.,
sleep or appetite disturbance). The DSM-IV currently requires at least two of the follow-
ing six sets of symptoms: Decreased energy or fatigue, insomnia or hypersomnia, increased
or decreased appetite, low self-esteem, poor concentration or difficulty making decisions,
and helplessness. However, patients who meet the chronicity and persistence criteria for
dysthymic disorder typically have many more than the required two depressive symp-
toms. Moreover, as described below, although dysthymic disorder may appear to be rel-
atively mild at any given point, the cumulative burden of persistent depressive symptoms
and impaired functioning is substantial and probably greater than most episodic major
depressions.
Dysthymic disorder can have an onset at any age, from childhood to old age (Devanand
et al., 1994; Kovacs, Akiskal, Gatsonis, & Parrone, 1994). However, the age of onset of
dysthymia is correlated with a number of important clinical and possibly etiological
factors that suggest that early and late-onset dysthymic disorder represent different devel-
opmental pathways (Akiskal, 1983; Devanand et al., 1994). For example, onset in child-
hood or adolescence is associated with a higher familial loading for mood disorders,
greater childhood adversity (e.g., abuse, parental rejection), and increased comorbidity
with Axis-I and Axis-II disorders. By contrast, late onset, particularly in old age, appears
to be associated with major losses and health problems. DSM-IV recognizes the impor-
tant role of age of onset in dysthymic disorder by including early and late-onset subtypes,
defined on the basis of whether or not the onset occurred before age 21.
Most persons with dysthymic disorder experience exacerbations that meet criteria
for a major depressive episode. Indeed, the development of a superimposed major depres-
sive episode is often what leads individuals with dysthymia to seek treatment. In cross-
sectional studies, approximately 75% of persons with dysthymic disorder report having
experienced a major depressive episode at some point in their lives (Keller et al., 1995).
In prospective longitudinal studies, the rate exceeds 90% (Klein, Schwartz, Rose, &
Leader, 2000). Conversely, approximately 25% of patients presenting with a major depres-
sive episode have an antecedent dysthymic disorder.
A major depressive episode superimposed on an antecedent dysthymic disorder has
been referred to as double depression (Keller & Shapiro, 1982) and, in DSM-IV,
such patients are diagnosed as having both major depressive disorder and dysthymic
disorder. Unfortunately, this implies that dysthymic disorder and major depressive dis-
order are two distinct comorbid conditions. Instead, it is more likely that the dysthymia
and major depressive episodes in patients with double depression represent different
phases of a single condition that waxes and wanes, often in response to stressful life
events.

Chronic Major Depression

Major depressive episode, chronic type refers to depressive episodes that meet full crite-
ria for major depression for a minimum of two years. The research indicates that approx-
imately 15 to 20% of patients with a major depressive episode have a chronic course. In
the National Institute of Mental Health Collaborative Study of the Psychobiology of
Depression, the largest and methodologically most-rigorous study of the course of major
810 JCLP/In Session, August 2003

depression, 19% of patients had episodes lasting over two years. The longer the episode,
the lower the chances were of recovering in each subsequent year. Thus, 12% of the
original cohort had still not recovered after five years and 7% had not recovered after 10
years (Mueller et al., 1996).
Age of onset also plays a role in chronic major depression. An earlier onset is asso-
ciated with longer and more frequent episodes, greater comorbidity, and a higher familial
loading for mood disorders.
The DSM-IV includes several additional episode and course specifiers relevant to
chronic depression. In coding the severity of the current major depressive episode, DSM-IV
includes an option for patients who are in partial remission. That is, patients have recov-
ered to the extent that they no longer meet full criteria for a major depressive episode, but
they continue to experience significant symptoms. The distinction between full and par-
tial remission is important because the persistence of subthreshold symptoms is associ-
ated with significant impairment in social functioning and an increased risk of recurrence
(Judd et al., 2000). In many cases, these subthreshold depressive symptoms can persist
for many years. Such cases can be considered another form of chronic depression. If
these patients experience a recurrence, they qualify for the DSM-IV longitudinal course
specifier, recurrent major depression without full inter-episode recovery.

Significance of Nosological Distinctions

Only a few studies have compared these forms of chronic depression; at this point, their
similarities appear to be greater than their differences. For example, as noted above, most
individuals with dysthymic disorder experience superimposed major depressive episodes
at some point in their lives, and therefore could be considered to have double depression.
The few studies that have compared directly patients with dysthymic disorder who do and
do not have a history of superimposed major depression have not found differences in
familial psychopathology, early adversity, comorbidity, and long-term course. Several
recent studies have compared patients with double depression to patients with chronic
major depression and found virtually no differences between the groups on demographic
variables, clinical characteristics, comorbidity, family history, early adversity, social func-
tioning, depressogenic cognitions, coping style, and response to medication and psycho-
therapy (e.g., McCullough et al., 2000). Thus, there is little evidence that the distinctions
between various forms of chronic depression are clinically useful or diagnostically mean-
ingful. On the other hand, as we will discuss below, there appear to be important differ-
ences between chronic and episodic forms of depression.

Risk Factors

Here we summarize the literature on potential risk factors for dysthymic disorder and
chronic depression, highlighting the differences between chronic and episodic forms of
depression. Most of the existing literature is based on dysthymic disorder and double
depression, as few studies have compared chronic to non-chronic forms of major depres-
sion. In some instances, the risk factors appear to play a qualitative role in the sense that
they contribute to the development of chronic, but not episodic, depression. In most
cases, however, the risk factors appear to play a quantitative role, contributing to both
chronic and episodic depressions, but with higher levels of the risk factor increasing the
probability of chronicity.
 Classification, Risk Factors, and Course 811

Familial Psychopathology

A family history of mood and personality disorders appears to play an important role in
the development of chronic depression, particularly the early onset forms. Unfortunately,
twin and adoption studies of chronic depression have not been conducted, so it is impos-
sible to untangle genetic from environmental effects.
Patients with dysthymic disorder and patients with episodic major depression have
similar rates of major depression in their first-degree relatives, and both groups have
higher rates of major depression in their relatives than controls with no history of mental
disorder. In contrast, patients with dysthymic disorder have a significantly higher rate of
dysthymic disorder in their first-degree relatives compared to patients with episodic major
depression and controls with no history of mental disorder (Klein et al., 1995). These
findings suggest that there are both shared and unique familial risk factors in dysthymic
disorder and episodic major depression. In particular, there may be two distinct sets of
familial etiological factors, one of which predisposes to depression in general and the
other conferring a specific vulnerability to chronic depression.
Patients with dysthymic disorder also have a significantly higher rate of personality
disorders in their relatives compared to patients with episodic major depressive disorder.
In turn, however, patients with episodic major depression have a significantly higher rate
of personality disorders in their relatives than never mentally ill controls. This suggests
that family history of personality disorder may be a risk factor for depression in general,
and that the greater the familial loading for personality disorder, the greater the risk of
developing chronic depression.

Early Adversity

A growing number of studies have found that childhood adversity, including sexual and
physical abuse, as well as parental neglect and rejection, is associated with a poor out-
come in major depression. In addition, several studies have reported greater childhood
adversity in patients with dysthymic disorder than patients with episodic major depres-
sion (Riso & Klein, in press).
Early adversity appears to be a quantitative risk factor in the sense that there is a
relationship between the level of adversity and the degree of chronicity. Moderate levels
of adversity predispose people to episodic depressions and more-severe adversity predis-
poses to chronic depression. Childhood adversity is not specific to depression, however,
as it is a risk factor for many Axis-I and Axis-II disorders. Non-specific risk factors such
as early adversity may contribute to the high rates of comorbidity between depression and
non-mood disorders.
It is important to bear in mind that the literature on early adversity and chronic
depression is based on retrospective assessments of childhood events conducted many
years later when patients are depressed. However, despite considerable evidence for biases
in retrospective reports and for the influence of mood states on memory, patients reports
of early adversity tend to be consistent when they are depressed and after they have
recovered, and often are confirmed by other family members. Thus, it is likely that patients
reports of childhood adversity have at least moderate validity.
Psychopathology often has an adverse impact on parenting. This raises the possibil-
ity that the relationship between childhood adversity and chronic depression is due to the
high rates of psychopathology in the parents of chronically depressed patients. However,
recent research indicates that the relationship between early adversity and chronic depres-
sion persists after controlling for familial psychopathology. Given that the association
812 JCLP/In Session, August 2003

between childhood adversity and chronic depression cannot be explained by parental

psychopathology alone, adversity may mediate or moderate the effects of psychopathol-
ogy in parents. For example, parental psychopathology may increase risk to offspring by
increasing maladaptive parenting and family conflict (mediation). Alternatively, parental
psychopathology may interact with childhood adversity by amplifying the risk to off-
spring who experience both risk factors (moderation). The limited data do not support
either of these scenarios. Rather, parental psychopathology and early adversity appear to
have independent and additive effects on the risk for chronic depression (Riso & Klein, in
press).
Childhood adversity can precede chronic depression by many years. This suggests
that the influence of childhood adversity is mediated by more proximal processes. Child-
hood adversity may influence personality, interpersonal style, and/or the development of
cognitive schemas that in turn increase the risk for chronic depression. There also is
evidence that childhood adversity can have long-term effects on neurobiological func-
tioning that may increase the risk for depression.

Temperament, Personality, and Personality Disorders

Early descriptive psychopathologists, such as Emil Kraepelin, believed that there were
several types of temperament, such as the depressive temperament (or depressive person-
ality), that were precursors of the major mood disorders. The depressive temperament
includes such traits as a usual mood of dejection, gloominess, and joylessness; feelings of
inadequacy and low self-esteem; proneness to being self-critical and self-derogatory;
brooding and being given to worry; negativism and being judgmental of others; pessi-
mism; and proneness to feelings of guilt and remorse. The category of Depressive Per-
sonality Disorder was included in a DSM-IV appendix as a condition requiring further
study.
Although the depressive personality overlaps considerably with dysthymic disorder,
the two constructs are conceptually and empirically distinguishable (Klein & Vocisano,
1999). The depressive personality may be a precursor to, or alternative expression of,
chronic depression. Several studies have found elevated levels of depressive personality
traits in the relatives of patients with chronic, but not episodic, depression. Further, depres-
sive personality traits predict the first lifetime onset of dysthymic disorder, but not major
depression. These data suggest that depressive personality traits may be a qualitative risk
factor in that they are associated with chronic, but not episodic, depressions.
While the depressive personality typically has been conceptualized as a temperamen-
tal substrate for mood disorders (Akiskal, 1983), it is more likely that it represents a
socially and cognitively mediated elaboration of more-fundamental temperamental pro-
cesses. Most models of child temperament and adult personality include the higher-order
dimensions of positive emotionality (PE) and negative emotionality (NE). PE, also referred
to as extroversion, encompasses features like joy, enthusiasm, energy, affiliation, and
dominance. NE, also referred to as neuroticism, reflects sensitivity to negative stimuli
resulting in a range of negative moods, such as sadness, fear, anxiety, guilt, and anger.
Watson and Clark (1995) have hypothesized that low PE and high NE form the core of the
depressive temperament and predispose to depressive disorders.
PE and NE may play a particularly important role in chronic depression. Elevated
NE predicts a poorer course and outcome of depression over periods of up to 18 years. In
addition, several studies have found that individuals with chronic depression report lower
PE and higher NE than those with episodic major depression, both while in episode and
after recovery.
 Classification, Risk Factors, and Course 813

The rate of Axis-II comorbidity is higher in chronic than in episodic forms of depres-
sion. The nature of the relationship between chronic depression and personality disorders
is unclear and challenging to untangle. The interpersonal disruptions and chronic stress
generated by some personality disorders could give rise to chronic depression. Alterna-
tively, early onset chronic depression may affect adversely personality development, lead-
ing to a secondary personality disorder. It also is possible that some chronic depressions
and personality disorders share a common genetic or family environmental liability. For
example, there is evidence for shared familial etiological influences for dysthymic dis-
order and borderline personality disorders. Finally, Akiskal (1983) has suggested that
there are at least two distinct pathways to early onset dysthymic disorderone that evolves
directly from a depressive temperament and one that is a complication of unstable (e.g.,
antisocial, borderline, histrionic) personality disorders.

Interpersonal Factors

Coyne (1976) has argued that interpersonal difficulties play an important role in main-
taining and prolonging depressive episodes. According to Coyne, the depressed individ-
ual has a negative impact on others, particularly family members and friends, by excessively
seeking assurances of love and support. These demands eventually become aversive and
begin to erode relationships. The depressed individual perceives that the support he/she
is receiving is diminishing and escalates his/her demands on others, resulting in a vicious
cycle. Joiner (2000) has elaborated this model by describing a variety of self-propagating
processes that might serve to maintain depression, including stress generation, nega-
tive feedback seeking, excessive reassurance seeking, conflict avoidance, and blame
maintenance.
While few studies have tested directly these theories in patients with chronic depres-
sion, numerous studies have reported that low social support, conflicted family and mar-
ital relationships, and interpersonal difficulties are associated with a poorer course and
outcome of depression. In addition, several studies have found that chronic depressives
have poorer interpersonal relationships than do episodic depressives. Persons with chronic
depression continue to experience interpersonal difficulties even after recovery, indicat-
ing that these deficits are not due simply to the depressed state. However, longitudinal
studies are required to untangle the direction of the association between chronic depres-
sion and dysfunctional interpersonal relationships. As Coyne (1976) and Joiner (2000)
have suggested, it is unlikely that the influences are simple and unidirectional. Rather,
depression and maladaptive interpersonal processes probably have reciprocal effects, each
perpetuating the other.

Cognitive Factors

Personality and temperament may be expressed, in part, in the form of attributions and
information processing, particularly concerning emotional self-relevant information. Teas-
dale (1988) and Nolen-Hoeksema (1991) have proposed cognitive theories of the persis-
tence of depression. Teasdales differential activation hypothesis suggests that depression
activates certain negative constructs, which, in turn, create a negative interpretation of
new events. Nolen-Hoeksemas response-style theory suggests that rumination in response
to depressed mood (as opposed to active problem solving) prolongs depression.
There is some indication that other cognitive variables, such as dysfunctional atti-
tudes, depressive attributional style, and an overly general autobiographical memory, are
814 JCLP/In Session, August 2003

associated with a poorer course of depression. Recently, Riso and colleagues (2003)
found that patients with dysthymic disorder exhibited higher levels of dysfunctional atti-
tudes and maladaptive core beliefs than did patients with episodic major depression.
Prospective studies are needed to determine whether these cognitive variables precede
the development of chronicity, are a consequence of persistent depression, or each con-
tributes to maintaining the other in a reciprocal fashion.

Chronic Stress

Although depression is preceded frequently by stressful life events, chronic and episodic
depressions do not appear to differ in this respect. However, chronic depression appears
to be associated with increased levels of chronic stress. Like the interpersonal and cog-
nitive factors discussed above, chronic stress may result from, as well as maintain, chronic
depression. In some cases, severe and enduring stressors may initiate and maintain chronic
depression even in the absence of marked pre-existing vulnerabilities, particularly in the
context of limited environmental and psychosocial resources. For example, chronic depres-
sion can develop in the face of an incapacitating medical illness or the chronic illness of
a loved one.

Naturalistic Course
There are only a few longitudinal studies of the naturalistic course of chronic depression.
Naturalistic refers to the fact that the investigators did not attempt to influence treatment.
Thus, patients in these studies varied widely with respect to the type and duration of
treatment received, and many did not receive any treatment for substantial portions of the
study period. The available studies indicate that most patients eventually recover from
chronic depression, but the recovery process can be prolonged and recurrence is common.
In a nine year follow-up of 5- to 13-year-old outpatients with dysthymic disorder,
almost all of the children eventually recovered, although the median duration of the
episode was about four years (Kovacs et al., 1994). Over 75% of the sample developed a
first lifetime major depressive episode. In addition, the children met criteria for a mood
disorder for 52% of the follow-up period, a greater proportion than a comparison group
of children with major depressive disorder.
The course of dysthymic disorder in adults appears to be similar to that in children.
In a 7.5-year follow-up of adult outpatients with dysthymic disorder, we found that 70%
of the patients recovered from dysthymia. The median time to recovery was 4.3 years.
Recovery was defined as two consecutive months with minimal or no symptoms. How-
ever, of the patients who recovered from dysthymia, 52% went on to experience a recur-
rence that met full criteria for dysthymic disorder before the end of the follow up. Of the
patients who had never experienced a major depressive episode before entering the study,
77% developed a first lifetime major depression. Compared to outpatients with episodic
major depression, the dysthymic patients spent a greater proportion of the follow-up
period meeting criteria for a mood disorder (62% vs. 23%) and were more likely to
attempt suicide and have a psychiatric hospitalization. In addition, of those patients who
entered the study in a major depressive episode, a greater proportion of the dysthymics
than episodic major depressives experienced second and third major depressive episodes
during the follow-up period (Klein et al., 2000). These data suggest that while dysthymic
disorder may not appear to be severe at any given point in time, the cumulative burden of
dysthymic disorder may exceed that of episodic major depression.
 Classification, Risk Factors, and Course 815

A number of baseline variables in our study predicted a poorer outcome among the
dysthymic patients (Hayden & Klein, 2001). These included a family history of chronic
depression, childhood adversity, comorbid anxiety and personality disorders, and chronic
stress. Collectively, these variables accounted for 57% of the variance in depression 7.5
years later, which is quite impressive for psychological and psychiatric research, partic-
ularly when predicting over an extended period of time. As discussed earlier, many of
these same variables also distinguished dysthymic disorder from episodic major depres-
sion, highlighting their significance for predicting and understanding chronicity in
depression.
Finally, one group of investigators (Mueller et al., 1996) described the 10-year course
and outcome of a small group of patients with major depressive episodes who had not
remitted in the first five years of prospective follow up. Only 38% of these patients
recovered in years 6 through 10 of follow up. Failure to recover was associated with a
longer duration of depression before entry into the study and never having been married.

Conclusions
Chronic depressions vary in severity, ranging from dysthymic disorder, which is charac-
terized by milder symptoms, to chronic major depressive disorder, with more severe
symptoms. Nonetheless, these different forms of chronic depression appear to be more
alike than different, but differ in important ways from more episodic forms of depression.
Chronic depression is more common than generally is recognized and is associated
with high levels of comorbidity and functional impairment. The age of onset varies, with
early onset cases tending to develop from a matrix of familial psychopathology and
childhood adversity. Patients with chronic depression often have disturbed interpersonal
relationships, maladaptive cognitive and coping styles, and high levels of chronic stress.
As a result of the unrelenting nature of their symptoms, concomitant feelings of hope-
lessness, and passive emotion-focused coping, these patients pose a significant challenge
to even highly experienced clinicians.
At the same time, however, these characteristics suggest several important implica-
tions for treatment. First, the complex and longstanding nature of chronic depression
points to the need for integrative treatment. These patients also may require more-
structured treatments over a longer period of time than may patients with episodic major
depression. Second, in order to optimize treatment response, it may be necessary to com-
bine psychotherapy with pharmacotherapy. Third, chronic depression appears to be asso-
ciated with a high risk of recurrence. This suggests the importance of continuing treatment
even after patients have recovered, albeit perhaps at a less-intensive level (e.g., continu-
ation and maintenance treatment). As the articles in this issue indicate, it is becoming
increasingly clear that there are effective treatments for chronic depression, and there is
reason to be optimistic that even more effective treatments will be developed in the near
future.

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(1994). Is dysthymia a different disorder in the elderly? American Journal of Psychiatry, 151,
15921599.
816 JCLP/In Session, August 2003

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