Treatment of Dysthymia
Select a second-generation antidepressant (SSRI or SNRI) as first-line pharmacotherapy for dysthymia, choosing the specific agent based on adverse effect profile, cost, and patient preferences—particularly considering bupropion if sexual dysfunction is a concern, or avoiding paroxetine due to higher sexual side effects. 1
Evidence Base and Treatment Selection
The evidence for treating dysthymia specifically shows mixed results, with one good-quality and four fair-quality trials demonstrating variable efficacy for fluoxetine, paroxetine, and sertraline. 1 Despite this mixed evidence base, the American College of Physicians provides clear guidance that applies to dysthymic disorder as a depressive syndrome. 1
Pharmacotherapy Approach
When choosing pharmacologic treatment, select among second-generation antidepressants based on the following hierarchy:
No single antidepressant demonstrates superior efficacy over others for treating dysthymia or major depression, so selection should prioritize tolerability and patient-specific factors. 1
Consider bupropion first-line if the patient is concerned about sexual function, as it has the lowest risk of sexual dysfunction compared to fluoxetine or sertraline. 1, 2
Avoid paroxetine when possible, as it demonstrates higher rates of sexual dysfunction than fluoxetine, fluvoxamine, nefazodone, or sertraline. 1, 2
Sertraline has specific evidence in dysthymia, with studies showing 44.6% mean reduction in depression scores versus 33.2% for placebo, along with improvements across quality of life domains. 3
Dosing Strategy
Use therapeutic doses equivalent to those used for major depression, not lower doses, as dysthymia requires full antidepressant dosing despite being a milder chronic condition. 4
- Start sertraline at 50 mg daily with titration permitted to 200 mg daily as needed. 3
- Mean effective doses in dysthymia studies ranged from 78-98.7 mg/day. 5
Psychotherapy Consideration
Cognitive behavioral therapy (CBT) represents an equally valid first-line option to antidepressants and should be discussed with patients as an alternative or adjunctive treatment. 1
- Both CBT and second-generation antidepressants have moderate-quality evidence supporting their use. 1
- The choice between pharmacotherapy and psychotherapy should involve shared decision-making regarding treatment effects, adverse effects, cost, and accessibility. 1
Monitoring and Duration
Begin monitoring within 1-2 weeks of treatment initiation to assess therapeutic response and adverse effects. 1
Plan for prophylactic treatment duration of at least 2 years, given the chronic nature of dysthymia. 4
- 38% of patients do not achieve treatment response during 6-12 weeks, and 54% do not achieve remission with second-generation antidepressants. 1
- Early assessment allows for timely adjustment if response is inadequate. 1
Critical Safety Considerations
SSRIs carry an increased risk for nonfatal suicide attempts (odds ratio 1.57-2.25) compared to placebo, requiring vigilant monitoring especially during treatment initiation. 1
Common adverse effects to discuss with patients include:
- Nausea and vomiting (most common reasons for discontinuation) 1
- Constipation, diarrhea, dizziness, headache, insomnia, and somnolence 1
- Sexual dysfunction (often underreported in trials) 1, 2
Rare but serious adverse events to monitor:
- Bupropion: increased seizure risk (weak evidence) 1, 2
- Venlafaxine: cardiovascular events 1
- Nefazodone: hepatotoxicity 1
Common Pitfalls
Do not underdose antidepressants in dysthymia—use full therapeutic ranges as in major depression despite the milder symptom severity. 4
Do not assume all SSRIs have identical side effect profiles—specifically counsel patients about the higher sexual dysfunction risk with paroxetine and lower risk with bupropion. 1, 2
Do not discontinue treatment prematurely—dysthymia requires extended treatment (minimum 2 years) due to its chronic nature. 4