PMID- 10485632
OWN - NLM
STAT- MEDLINE
DCOM- 19990917
LR  - 20221207
IS  - 0160-6689 (Print)
IS  - 0160-6689 (Linking)
VI  - 60
IP  - 8
DP  - 1999 Aug
TI  - The long-term outcome of dysthymia in private practice: clinical features, 
      temperament, and the art of management.
PG  - 508-18
AB  - BACKGROUND: With the clinical availability of fluoxetine in the United States, we 
      were interested in documenting improvements in the clinical care of dysthymic 
      patients beyond what was reported from our clinic 2 decades earlier during the 
      "tricyclic (TCA) era." METHOD: In open treatment of 42 consecutive DSM-III-R 
      primary dysthymic patients who were personally followed up in our mood clinic 
      since 1988, response was defined as sustained remission, i.e., no longer meeting 
      criteria for dysthymia and achieving DSM-III-R Axis V Global Assessment of 
      Functioning (GAF) score > 70 throughout much of the mean follow-up of 5 years. 
      RESULTS: Compared to patients with nondysthymic episodic major depressive 
      disorder (N = 42), dysthymic patients had a significantly earlier mean age at 
      onset (12.6 vs. 34 years), were more likely to have never been married, had a 
      greater frequency of superimposed major depressive episodes (except for the 14% 
      [N = 6] with "pure" dysthymia), and had more psychiatric and fewer medical 
      comorbidities; furthermore, patients with dysthymia had significantly greater 
      familial loading of both unipolar and bipolar disorders. Continued treatment with 
      TCA-type antidepressants or fluoxetine (including various augmenting strategies) 
      led to an overall robust and sustained response rate of 76% (N = 32) among 
      dysthymic patients; in tandem, major depressive episodes and suicidality were 
      prevented in all responders. Females treated with fluoxetine had the highest 
      response rate (85% [N = 17]); some were able to walk out of dependent abusive 
      relationships for the first time in their lives. However, dramatic responses with 
      "hyperthymic" switches in temperament occurred in only 12% of dysthymic patients; 
      nearly all were males with bipolar family history. The more prototypic positive 
      change among dysthymic responders consisted of coping with daily hassles without 
      being overwhelmed. Qualitatively, the highest level of adaptive functioning was 
      observed among fluoxetine-treated dysthymics (50% of responders [N = 12] achieved 
      DSM-III-R GAF score of 81-90). Of TCA-treated patients, 39% had intolerable side 
      effects, necessitating switch-over to fluoxetine. Agitation occurred in 11% of 
      fluoxetine-treated patients (N = 4) and was associated with nonresponse and/or 
      dropout; otherwise, this selective serotonin reuptake inhibitor was well 
      tolerated, thereby contributing to long-term compliance. More provocatively, 
      patients with dysthymia who had required extensive psychotherapeutic attention 
      prior to state-of-the-art pharmacotherapy no longer required such therapy. 
      CONCLUSION: These data extend and enrich what has been learned from controlled 
      trials among dysthymic patients. With sustained pharmacotherapy and specialized 
      clinical care in a private mood clinic, 3 of 4 patients immersed in gloom for 
      much of their lives achieved for the first time good to superior levels of 
      functioning that were maintained for an average of 5 years. Although the art of 
      clinical management of dysthymia should be fully grounded in understanding the 
      interpersonal context of depression, we submit that SSRIs such as fluoxetine 
      appear broadly efficacious in areas previously deemed to be the domain of formal 
      psychotherapy.
FAU - Haykal, R F
AU  - Haykal RF
AD  - Charter Lakeside Behavioral Health System, University of Tennessee, Memphis, USA.
FAU - Akiskal, H S
AU  - Akiskal HS
LA  - eng
PT  - Case Reports
PT  - Clinical Trial
PT  - Journal Article
PL  - United States
TA  - J Clin Psychiatry
JT  - The Journal of clinical psychiatry
JID - 7801243
RN  - 0 (Antidepressive Agents, Tricyclic)
RN  - 0 (Monoamine Oxidase Inhibitors)
RN  - 0 (Serotonin Uptake Inhibitors)
RN  - 01K63SUP8D (Fluoxetine)
SB  - IM
MH  - Adult
MH  - Age of Onset
MH  - Aged
MH  - Antidepressive Agents, Tricyclic/therapeutic use
MH  - Cohort Studies
MH  - Combined Modality Therapy
MH  - Comorbidity
MH  - Dysthymic Disorder/diagnosis/*drug therapy/epidemiology
MH  - Female
MH  - Fluoxetine/*therapeutic use
MH  - Humans
MH  - Longitudinal Studies
MH  - Male
MH  - Middle Aged
MH  - Monoamine Oxidase Inhibitors/therapeutic use
MH  - *Private Practice
MH  - Psychiatric Status Rating Scales/statistics & numerical data
MH  - Psychotherapy
MH  - Selective Serotonin Reuptake Inhibitors/*therapeutic use
MH  - Temperament
MH  - Treatment Outcome
EDAT- 1999/09/15 00:00
MHDA- 1999/09/15 00:01
CRDT- 1999/09/15 00:00
PHST- 1999/09/15 00:00 [pubmed]
PHST- 1999/09/15 00:01 [medline]
PHST- 1999/09/15 00:00 [entrez]
AID - 10.4088/jcp.v60n0802 [doi]
PST - ppublish
SO  - J Clin Psychiatry. 1999 Aug;60(8):508-18. doi: 10.4088/jcp.v60n0802.