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Persistent Depressive Disorder (PDD): How to Treat It, and How to Beat It

elderly man comforting his depressed wife on a couch
This entry was posted in Depression on by .

Persistent depressive disorder (PDD) is a relatively new term to describe what was once called dysthymia. PDD is mild to moderate depression that lasts for two or more years (a year or more in adolescents). It comes with other symptoms as well.

But before we get to those, a key point: The level of depression you feel with PDD may be designated “mild to moderate,” but as anyone who has it will tell you, it doesn’t feel mild to moderate. It feels debilitating and never-ending. And it makes normal daily functioning far more difficult than it needs to be.

To help you or a loved one find the relief you deserve, in this article we’ll cover risk factors, causes, symptoms, and possible complications. Most important, you’ll learn about various treatments for PDD, including several emerging ones that are showing good promise.

General comment on PDD and other types of depression

At SunCloud Health, we very much empathize with people who are living with depression. This condition makes life harder. Even the simplest things—getting dressed, getting out the door for school or work, staying engaged in conversations, preparing dinner, packing for a vacation—can feel like overwhelming tasks.

And maybe the worst part of this? The symptoms of depression, including low energy, dark mood, poor concentration, and feelings of hopelessness, are exactly what make it hard for you to get help for it. And once you do seek help, there are the follow-up visits, sticking to your treatment plan, going to therapy, and staying on your meds. Those things can seem nearly impossible to stick with—because you’re depressed!

So please know that we understand and sympathize with all that, and want to help you get better. The information and advice in this article are a good place to start.

The basics of persistent depressive disorder (PDD)

PDD involves a sad or dark mood for most of the day, on most days of the week, for two years or more.

This condition can happen to anyone at any age, and the statistics show that 3% or more of the U.S. population will experience it at some point in their lives. Females are about twice as likely as males to have PDD, and a person’s risk is elevated if they have a close relative with the condition.

Regarding what causes it, researchers don’t know, but it’s likely due to a brain chemical imbalance. Most experts believe it’s related to low levels of serotonin, a natural hormone that affects feelings of well-being. PDD can also be triggered by a traumatic event such as losing a job, having a loved one die, or experiencing a traumatic event such as a violent crime or natural disaster. Long-term drug use can also trigger PDD.

How do you know if you have PDD?

There is no blood test or biological screening for PDD, but the main symptom is a long-lasting dark mood. Below we list other symptoms. Note: For a diagnosis of PDD, (1) two or more from this list must be present, (2) those symptoms cannot be absent for more than two months, and (3) the symptoms need to significantly affect daily functioning.

PDD symptoms include:

  • Fatigue
  • Feelings of hopelessness, worthlessness, or isolation
  • Lack of appetite or overeating
  • Lack of concentration
  • Limited energy
  • Low self-esteem
  • Difficulties at work or school
  • Trouble sleeping or sleeping too much

If you’re having two or more of these symptoms but haven’t yet received a diagnosis or treatment plan, see a doctor right away so you can discuss treatment options. Ignoring this condition and hoping it goes away is not the answer, because it doesn’t go away. Research has shown that the mean length of PDD is between 17 and 30 years.

Compared to acute (short duration) forms of depression, PDD also comes with: more damage to your physical well-being; more severe impairment in social, psychological, and emotional functions; more use of healthcare; and more frequent suicide attempts.

Causes and risk factors of persistent depressive disorder

Again, the specific cause of PDD is not yet known, and it may result from more than one cause. PDD often begins early—during childhood, adolescence, or young adulthood. Researchers have zeroed in on several possible causes. Among them:

  • Brain chemistry imbalance: Recent research has shown that changes in the function and interactions of certain brain chemicals may play a role in depression.
  • Heredity: PDD is more common among people with close relatives who also have the condition. Researchers have not found the gene that causes it.
  • Traumatic life events: The loss of a loved one, heavy financial strain or legal problems, and other stressful events can trigger PDD.

Alongside these possible causes, certain risk factors may also come into play. People with PDD often share personality traits such as negativity, low self-esteem, being overly dependent on others, and self-critical. A history of substance use or another mental health condition can also increase risk.

Treatment for persistent depressive disorder

Experts generally agree that combining psychotherapy (talk therapy) and medication is the gold standard of care for PDD and other forms of depression. Collaboration of care is also essential.

A note on collaboration. Oftentimes, when a person gets treated for PDD, they see a psychiatrist for their medication and a separate psychologist/counselor for their therapy, and those two providers are not in the same practice. In these instances, the two must communicate and collaborate via the patient’s electronic health record or some other format. If the one hand doesn’t know what the other is doing, the patient’s care will suffer.

Mental health practitioners also need to have a general understanding of the patient’s overall health. This way they can be aware of possible adverse drug interactions with other medications the patient is taking. They will also know about underlying physical conditions that may be affecting the patient’s mental state.

In these ways and others, collaborative care is vital. It is also important for the patient to have an advocate who can help with the collaboration. Sometimes, a psychiatric care nurse can coordinate with team members. Much of the time, however, that advocacy falls to the patient or the patient’s loved ones. If that’s you, it’s important to stay engaged, informed, and be ready to speak up and take action.

Psychotherapies that can help with persistent depressive disorder

Four types of talk therapy are often used for PDD, including:

  • Cognitive behavioral therapy (CBT)
  • Cognitive behavioral analysis system of psychotherapy (CBASP)
  • Interpersonal therapy (IPT)
  • Radically open dialectical behavior therapy (RO-DBT)

CBASP is a newer therapy that was developed specifically to help manage chronic depression. IPT aims to improve the quality of a patient’s interpersonal and social functioning to reduce their depression. RO-DBT is another newer therapy that has shown results for treatment-resistant depression.

CBT is the most popular therapy for PDD. A therapist or psychologist helps you examine your thoughts and emotions and how they affect your actions. Many people with depression experience distorted ways of thinking. CBT can help you “rewire” those thoughts, allowing you to change your outlook to be more positive.

Medications for PDD for consideration

Four main categories of antidepressants prescribed for PDD include:

  • Atypical antidepressants. The most well-known example is buproprion (Wellbutrin).
  • Selective serotonin reuptake inhibitors (SSRIs). These include fluoxetine (Prozac) and sertraline (Zoloft).
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs). Examples include desvenlafaxine (Pristiq) and duloxetine (Cymbalta).
  • Tricyclic antidepressants (TCAs). Two well-known types include amitriptyline (Elavil) and amoxapine (Asendin).

A key point with these categories of antidepressants, which all work in different ways, is that the first option you try may not be the most effective. The second may not be either. Often, a certain amount of trial and error must be endured before you land on the right drug at the right dose. This takes patience and can be exasperating to the extreme. The best advice? Keep your eyes on the prize and hang in there. Relief will be yours if you stay the course.

And remember, these medications almost always work best when combined with therapy as well as self-help strategies like regular exercise, good nutrition, and adequate sleep. As with treatment plans for addiction or other mental health conditions, the multi-pronged approach works best. The power is in the collective.

Further treatments and supplements showing success

If the first-line treatments mentioned above aren’t helping you enough, consider these options listed below, possibly to supplement what you’re doing now. Just be sure you always get the okay from your doctor before trying them. There may be important medical reasons not to use them.


Electroconvulsive therapy (ECT): With this procedure, done under general anesthesia, small electric currents are passed through the brain. ECT may cause changes in brain chemistry that can quickly reverse symptoms of certain mental health conditions, including depression.

Light therapy: Administered with a light therapy box that mimics outdoor light. The light may cause a chemical change in the brain that lifts your mood and eases symptoms such as constant fatigue and sleeping too much.

Transcranial magnetic stimulation (TMS): A noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. It involves delivering repetitive magnetic pulses, so it is sometimes called repetitive TMS, or rTMS.


  • N-acetylcysteine
  • Omega-3 fatty acids
  • Vitamin D
  • Sadenosyl-L-methionine (SAMe)
  • John’s wort

6 strategies for feeling better and staying positive

PDD can make it hard to stay engaged in life. These strategies may help:  

  1. Focus on your goals. Set reasonable goals for yourself, then stay motivated by keeping these goals in mind. Just be ready to permit yourself to do less when you feel down.
  2. Simplify your life. No need to take on extra obligations as a way to motivate yourself. That can backfire. Rather, keep things simple, stay organized, and structure your day with a short to-do list or by using a planner.
  3. Write in a journal. Journaling is great for getting that clutter out of your head and into your journal where you can see it more clearly—or dispense with it altogether.
  4. Stay connected. Try to participate in social activities. Make a point of getting together with family or friends regularly, even if you don’t feel like it. Many times, it will go better than you expected, and you will feel better for doing it.
  5. Learn ways to relax and manage your stress. This might mean meditation, muscle relaxation exercises, yoga, tai chi, or just a leisurely 30-minute walk around the neighborhood or on the treadmill.
  6. Don’t make important decisions when you’re down. This one’s key, because your judgment can become cloudy when you’re in a dark period. Wait until you’re feeling better to decide on the big stuff. Meanwhile, just keep treading water. That’s plenty when you’re in the dumps.

Final thoughts on PDD

Persistent depressive disorder, as with all forms of depression, is not for the faint of heart. It tests you every day, and can occasionally knock you back hard.

During those tough times especially, but really all the time, it’s important to remember that you can get better. PDD doesn’t have to define you. Life can get easier, and you can find your true self.

If you don’t have a treatment plan, make an appointment with a medical practitioner, get started on one, go into it with high standards and expectations, and keep them high.

Same for if you have had depression for years but your treatment isn’t working for you (only you can know that). Be determined to make necessary adjustments—starting now.

Bottom line: Feeling down on most days of the week is not how it needs to be. You deserve better, and you can get better.

Promise yourself today that you’re going to make that happen, with help from your family, friends, and your treatment team.

To learn more about the treatment at SunCloud, reach out today.

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