Let's Talk About Chronic Depression
Learning what makes this type of long-term depression unique can alleviate some self-blame—no, you’re not just “negative”—and help you stay focused till you find the best treatment.by Meirav Devash Wellness Writer
Anyone experiencing the numbness and despair that come with clinical depression is terrified that it’s going to last forever. For most people, depressive episodes pass. People with chronic depression deal with the type of depression that drags on for years (plural) or even decades. The gloomy black cloud overhead hangs around for so long that many people can’t even remember what it was like to not be depressed. They feel like they’ve always been exhausted, anti-social, emotionally hollow, and living on autopilot. We get it. But just because your depression is chronic doesn’t mean it’s who you are—nor all you’ll ever be. Let’s dive into this persistent form of depression and why you should never give up on getting better.
Our Pro Panel
We asked some of the nation’s top depression experts to bring you the most up-to-date information possible.
Charles B. Nemeroff, M.D., Ph.D.
Chief Medical Officer of the Anxiety and Depression Association of America, Professor and Chair of Psychiatry at Mulva Clinic for the Neurosciences
Dell Medical School, The University of Texas
Seema Desai, M.D.
Clinical Assistant Professor, Psychiatrist
Department of Child and Adolescent Psychiatry, NYU School of Medicine; NYU School of Medicine WTC Health Program Clinical Center of Excellence
New York, NY
Carol A. Bernstein, M.D.
Psychiatrist, Vice Chair for Faculty Development and Well-Being in the Departments of Psychiatry and Obstetrics and Gynecology
Montefiore Medical Center/Albert Einstein College of Medicine
The Bronx, NY
Just the duration, really. For a diagnosis of MDD, depressive symptoms must last a minimum of two weeks (though research puts the median duration at six months). Chronic depression (a.k.a. persistent depressive disorder, or PDD) lasts a minimum of two years, but often lingers much longer and is quick to return. Many people with chronic depression tend to slog through life with smoldering low-level symptoms all the time. Contrast that with people who have MDD. Their baseline mood is normal, interrupted by a depressive episode. After treatment, they return to a symptom-free life. (You can also have both, which docs call “double depression.”) However your depression presents itself, know that it can hang around—or keep coming around—forever, if it’s left untreated.
It certainly doesn’t need to. Let’s do the depressed-person thing and look at this in a glass-half-empty manner: Research shows that 12% of people with chronic depression did not recover after five years. That sucks! But what if you focus on the people who did get better? That’s 78% of chronically depressed people who actually reached remission after five years. And though it took a while to get there, that’s not too shabby. We’ve yet to speak to the doctor or mental health professional who considers PDD (persistent depressive disorder) a life sentence. The only way to ensure that your chronic depression stays chronic is to avoid dealing with the issue—so be sure to get in treatment, and stay in treatment, for as long as it takes.
Look, a negative attitude can’t make someone depressed, but depression can give someone’s worldview a negative spin. If simply telling someone to have a positive attitude worked, every depressed person would magically be cured by a pep talk from a well-meaning friend. That said, there are ways to challenge irrational thoughts and beliefs (docs call them “cognitive distortions”) that lead to negative thinking. Next time you catch yourself in a pessimistic loop (i.e., “Nobody loves me”), ask yourself how true that statement is. Maybe your mom or dad or other relative loves you. Maybe your dog or cat does. Maybe you make your lonely neighbor’s day by saying hello. If anyone loved you at any point, that means you are loveable. Once you recognize how much of your negative self-talk is actually false, it becomes easier to give it less weight. That results in a more balanced and realistic outlook. You might never be a smiley, chirpy optimist, but you can manage your negativity with a little legwork. To learn lots of great ways to reframe negative or inaccurate automatic thinking, consider CBT (cognitive behavioral therapy).
Combination treatments like psychotherapy plus antidepressant medications (usually SSRIs, SNRIs, MAOIs, TCAs, atypical antipsychotics) or psychotherapy plus another FDA-approved treatment such as Electroconvulsive Therapy (ECT) or Repetitive Transcranial Magnetic Stimulation (rTMS) are the best treatments for Persistent Depressive Disorder (PDD). Beyond that, there are a bunch of complementary approaches that can also lift your mood. Start by making your bed when you wake up in the morning. For a depressed person, knowing you’ve already accomplished one thing can provide the mini confidence boost you need to get out the door. A half hour of exercise releases endorphins, the body’s natural antidepressant, and provides a little added pep. Finally, get to bed on time and get a good night’s rest every night. Sleep deprivation causes irritability and stress, which is the last thing you need right now.
What Exactly Is Chronic Depression?
First things first. “Chronic depression” isn’t technically a diagnosis in the DSM-5, the official guide of mental disorders. That doesn’t mean it’s not a real thing, though. It’s just that most people have depressive episodes with a clear start and end (i.e. MDD, Major Depressive Disorder), so that’s how experts have framed the disorder.
Then What Do People Mean When They Say “Chronic Depression”?
In 2013, the DSM-5 changed some of the terms for depressive disorders. They combined dysthymia (mild, lingering depression not as severe as MDD) and chronic major depressive disorder (MDD that lasts two years or more) into one condition called persistent depressive disorder (PDD).
An estimated 1.3% of U.S. adults experience PDD at some time in their lives. However, recent research points to the possibility that some people who tick all the boxes for MDD—which requires depression for just two weeks—have been suffering from a persistent disorder rather than an episodic one all along.
A subset of people with depression have ongoing symptoms that never fully subside. Depression is so embedded in their everyday life and outlook that they may think it’s normal, or part of their personality. This is what we—and the general populace—means when they think of “chronic depression.”
This long-term, low-grade form of depression lasts two years at minimum. Doctors used to call this type of depression dysthymia, and people without medical degrees sometimes call it “smiling,” “hidden,” or “high-functioning” depression. (Though there’s certainly nothing to smile about when you’re hiding your depression and pretending you’re functioning at 100%.)
So…Chronic Depression Isn’t That Bad?
Not true at all—and this is one of a few problems with the current PDD and MDD categorizations, which emphasize the duration of your depression over the severity of symptoms. For example, some depressed people experience severe chronic symptoms every day for six or seven years—they don’t get back to “normal” in between depressive episodes. Neither the PDD nor the MDD diagnoses take into account these people who have major depression 24/7/365.
Plus, just because you have one form of depression doesn’t mean you can’t also have another. An unlucky 75% of people with dysthymia will also experience an MDD episode. So after the major depressive episode ends, these people return to their usual chronically depressed baseline instead of feeling symptom-free. Doctors call this “double depression.
Even if you do have typical PDD—which, per the official criteria is less intense depression than MDD—don’t just say “phew” and be complacent about it. Many people think that if you’re able to get up in the morning and make it through work or school without curling into the fetal position, you can’t be that depressed.
Well, guess what? You only think you’re not “depressed enough” to need help because you’re so used to feeling like crap! That’s what happens when your depression is chronic (a.k.a. persistent).
And just because your depression isn’t classified as severe doesn’t mean the constant weight of it all isn’t severely detrimental to you. Research shows that compared to MDD, PDD (reminder: what people often think of as chronic depression, or what used to be called dysthymia) causes more functional impairment and is more likely to come with other psychiatric conditions like anxiety, personality, and mood dysregulation disorders.
For our purposes here, “chronic depression” applies to both a PDD diagnosis (dysthymia + chronic MDD) and the old dysthymia-on-its-own diagnosis—because, as we explained, reality shows thata people can have either long-term depression that’s severe or mild.
What Causes Chronic Depression?
Honestly, scientists aren’t sure. The current explanation is that depressed people have a “chemical imbalance” in their brain chemistry—specifically, they have low levels of neurotransmitters like serotonin, norepinephrine, and dopamine, which all help regulate mood, sleep, and metabolism.
That’s the general gist, but it’s a little more complicated than that. For example, chronic depression runs in families, so there may be a genetic component. Like MDD, chronic depression is likely to be caused by a whole host of factors ranging from genes to childhood abuse or neglect to life stress to hormone fluctuations.
Do I Have the Symptoms of Chronic Depression?
Is your depression chronic (i.e. ongoing)? Then, yep, it meets the definition. Like we said, chronic depression isn’t a clinical diagnosis, so there’s no checklist of symptoms to tick off. If you’re wondering whether you qualify for a clinical diagnosis of persistent depressive disorder (PDD), here are the symptoms.
People with PDD experience depressed mood for a period of two years or longer, and two or more of the additional symptoms below. Your symptoms would be distressing and affect daily functioning, and you’d never be without them for more than two months at a time.
Every day feels like a bad day. You could be crying over laundry commercials or going emotionally numb during a crisis. If you wake up 100% certain you know what the day will be like—it’s going to suck—you’re living in the definition of a depressed mood. This is the #1 symptom of PDD.
You’re eating your feelings (or starving them out). If your relaxed-fit jeans are fitting more like skinny jeans these days, or vice versa, take note. Weight gain or weight loss might be an indicator of PDD.
You can’t sleep (or you can’t stop oversleeping). Are you having a hard time getting to sleep? Are you tossing and turning all night? What about waking up so exhausted that someone has to literally drag you out of bed in the morning? All types of sleep problems can be a sign of PDD.
You’re the most tired person alive. Everything seems like such a gigantic hassle that you’ve started wondering who put the bathroom so far away from the couch. If it’s nearly impossible to muster the energy to do the things you need to do, like go grocery shopping, wash your hair regularly, and get to work on time, you may have PDD.
You feel worthlessness. A little bit of insecurity is normal—no one is self-confident all the time (except for Kanye). However, having low self-esteem and constantly rehashing negative thoughts over and over in your mind are linked to depression.
You’ve lost hope. You don’t feel like the author of your own story, but you’re sure you know how it will end—with disappointment. You might feel alienated from the world, forsaken by your friends, and so uninspired that you wonder why people bother doing anything in the first place. You might not recognize that life can get better. (Know this: It can.)
How Do Doctors Diagnose Chronic Depression?
Well, they probably won’t since, as we mentioned, “chronic depression” isn’t an actual diagnosis per the DSM-5—it’s a colloquial term.
Your doctor will probably consult the DSM-5 and ask questions to see if your experience matches with the symptoms of PDD. Answering the questions to the best of your ability will lead to a more accurate diagnosis.
Since there’s no blood test or cheek swab that can determine if you have chronic depression, your doctor will need to rely on conversations with you to get a full history, including any depression symptoms in childhood, adolescence, and adulthood; what stressors you’re dealing with now; any physical symptoms you’re currently experiencing; your medical history, plus a family history of mental illness and major medical issues.
Your doctor may also want to rule out underlying medical causes, such as thyroid disease and vitamin deficiency, which can mimic symptoms of depression.
They may ask about any medications you’re taking, such as beta-blockers for hypertension, acid reflux drugs, anti-inflammatory corticosteroids, cholesterol-lowering statins, and more, or they might ask about your use of alcohol and street drugs. They’re not just being nosy—they’re trying to get to the root of the problem, and some of these substances are linked to depressive symptoms.
Before we move on to treatments, remember this—it’s important!
Even if you suspect you’re not depressed enough for professional help, seek help anyway. Because “you’re not depressed enough for help” is very likely a lie your depressed brain is telling you, and it’s the reason so many people with PDD don’t get the treatment they need.
Make an appointment with a doctor and/or mental health professional, such as a psychologist or psychiatrist—they can help you figure out if you’re chronically depressed and what to do about it.
What Are the Best Treatments for Chronic Depression?
Every person is affected differently by chronic depression, and there’s no single therapy that works for everyone. Whoever finally discovers it is going to be a bazillionaire.
Experts believe that the most effective treatment is a one-two punch of psychotherapy plus antidepressant medication, or psychotherapy plus another FDA-approved treatment, such as electroconvulsive therapy (ECT), electrical stimulation of the brain while patients are under anesthesia, or repetitive transcranial magnetic stimulation (rTMS), a type of brain stimulation using magnetic fields.
The most important part of treatment is to never give up. Never surrender! Persistent depression requires persistent treatment. It’s unlikely that you’ll stumble across the perfect remedy right off the bat. Trial and error is a big part of treating chronic depression, so be patient and remain open and willing to try new solutions.
Psychotherapy can help you stay actively engaged and focused on getting better through structured weekly appointments. In therapy, you’ll learn to identify and change your distorted view of the world and negative self-talk, plus how to manage your stress better.
There are several types of medications prescribed for chronic depression, including:
SSRIs (selective serotonin reuptake inhibitors)
SNRIs (serotonin and norepinephrine reuptake inhibitors)
MAOIs (monoamine oxidase inhibitors)
TCAs (tricyclic antidepressants)
Although you will notice a significant impact within 72 hours, sometimes it can take up to six weeks for antidepressants to take full effect, so you need to keep taking them even if it doesn’t look like they’re doing anything at first. You’ll likely have to adjust your dose of medication, switch drugs, or augment your medication with atypical antidepressants or antipsychotics to get optimal results.
Similarly, ECT and rTMS aren’t a surefire fix. Some people notice their depressive symptoms fading away after a series of brain stimulation treatments, while others see no result whatsoever.
Finding the right combination of treatment and lifestyle changes (aerobic exercise, yoga, meditation, a healthy diet) may take a maddeningly long time—but when you hit upon something that works for you, it can work quite well.
Since chronic depression usually lasts for several years, thinking long-term is a good idea. Remember, it’s worth it. The mental health professional you’re working with doesn’t want things to get a little bit better for you—they want to help you reach full remission. Stick with them and don’t give up.
MDD Prevalence & Recurrence: Archives of General Psychiatry, ncbi.nlm.nih.gov/pubmed/15939837
MDD Prevalence & Recurrence: Clinical Psychology Review, ncbi.nlm.nih.gov/pmc/articles/PMC2169519/
PDD Symptoms: DSM-5, ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t6/
PDD & MDD: Medscape, emedicine.medscape.com/article/290686-overview
PDD & MDD: Archives of Neuropsychiatry, ncbi.nlm.nih.gov/pmc/articles/PMC5353108/
PDD Treatment: Johns Hopkins Medicine, hopkinsmedicine.org/health/conditions-and-diseases/dysthymia
MDD duration and remission: Acta Psychiatrica Scandinavica, ncbi.nlm.nih.gov/pubmed/28512767
MDD duration and remission: Harvard Heath Publishing, health.harvard.edu/newsletter_article/dysthymia