Adult dysthymia: characteristics and clinical management

¶ … Adult Dysthymia

Dysthymia, Part B

A number of different sources of information were used to delineate the medical and psychological components of this case Study. These included a complete physical examination, a comprehensive panel of blood and urine laboratory tests, patient interview, patient's medical and psychological history, family history of medical and psychological diseases or conditions, and interviews with close friends and relatives when available (Bellino, Patria, Ziero, Rocca, and Bogetto, 2001).

A diagnosis of dysthymia was based on the diagnostic criteria in DSM-IV-TR (American Psychiatric Association [APA], 2000). The severity of depression was graded using the 24-item version of the HAM-D and patient interview. The patient was interrogated concerning major life stressors using the Interview for Recent Life Events (Bellino, Patria, Ziero, Rocca, and Bogetto, 2001). Cognitive functioning was also assessed using a 20-item Mini-Mental State Examination.

Background Information

The 69-year-old patient, Jack V. (JV), first sought medical care through his primary care physician. His visit was motivated by his wife of 35 years and his children, who suggested that he might be suffering from another bout of severe depression. A complete physical examination and laboratory tests were unremarkable, with the exception of hypertension and hyperlipidemia.

JV's family history reveals early-onset cardiovascular disease on his father's side of the family. Accordingly, an examination of JV's medical records revealed several invasive surgical procedures, first precipitated by a myocardial infarction at age 53. A triple coronary artery bypass surgery was done initially after the heart attack and then three years later a heart valve was replaced. At age 67, the heart valve had to be replaced again. JV is currently taking atorvastatin (hyperlipidemia), diltiazem (hypertension), terazosin (hypertension), and warfarin (anticoagulant) (Kroenke, 2002). Dietary modification and an exercise program were also recommended and JV was able to achieve a normal body mass index for his age and gender. Aside from the heart disease, JV is in fair to good physical condition.

Although his father and uncle also developed early onset cardiovascular disease, both failed to survive their first myocardial infarction in their 50s. JV has one sibling, a sister 3 years younger than he is and they have remained close. She has been on medications to control her hypertension and hyperlipidemia and has avoided having any significant cardiovascular events.

Interviews with JV or his family members did not reveal a significant family history of mental illness (Bellino, Patria, Ziero, Rocca, and Bogetto, 2001). Following the myocardial infarction at age 53, JV developed major depression and was prescribed venlafaxine XR (75 mg/day). The depressive symptoms responded to the medication and a year later JV was weaned off the antidepressant.

JV graduated from high school and immediately began work on an assembly line at a local automobile factory, where his father had also worked until his death. JV remembers his blue-collar childhood fondly, due primarily to a close and loving relationship with his parents and having established several friendships that have withstood the test of time.

At age 42, he was promoted to a middle management position where he remained until retirement at age 62. JV has been married twice, having been widowed at 28 years of age with one son. He fathered two more children after marrying his current wife four years later and all three children have gone to college and started their own families. When interviewed, JV reports feeling proud of his children and feels close to them. He reports that they visit frequently, but have become so concerned over his moods and apathy over the past seven years that they finally demanded that he seek medical care (Kroenke, 2002). JV reports that his marriage is strong and is still in love with his wife, but she too had become concerned about his mental health. When pressed, JV admits to sleeping more, having less energy, feeling apathetic towards his usual activities, is eating less, has trouble concentrating, experiences memory lapses, and occasionally catches himself ruminating on his health problems. Despite these symptoms, JV continues to participate in the usual activities. Interviews with his wife and children confirm these observations.

JV admits that the onset of these symptoms coincided with retirement at age 62, but also reported that some of the symptoms date back to the major depression episode following his heart attack and bypass surgery.

Diagnostic Indicators of Dysthymia

Dysthymia is diagnosed as persistent sadness experienced most days for at least 2 years (APA, 2000). In addition to sadness, a diagnosis requires the presence of at least two of the following: changes in appetite, sleep problems, fatigue, low self-esteem, feelings of hopelessness, and difficulty concentrating or making decisions.

The HAM-D score of 15 indicates JV is suffering from moderate depression (Serenity Programme™, 2010) and a score of 20/20 on the Mini-Mental State Examination revealed no evidence of cognitive impairment. The 64-item Interview for Recent Life Events revealed moderate to severe negative associations with current health status and retirement.

A preliminary analysis suggests JV is suffering from a partial remission of his major depression episode, a common outcome in older adults (Hybels, Blazer, and Steffens, 2006). The depressive symptoms were probably fueled by the recurrent major cardiovascular surgeries and retirement. Although the possibility of dementia was considered, there was no indication that JV was cognitively impaired during his interview (Kroenke, 2002). The Mini-Mental State Examination and the interviews of family members support this conclusion.

The possibility that the depressive symptoms represent secondary depression to a medical condition was ruled out by laboratory tests and a physical examination (Kroenke, 2002). Although a few of the depressive symptoms could be due to one or more of the medications JV is currently taking, the possibility that all of the symptoms are due to these drugs is remote.

Diagnosis, Treatment Recommendations, and Prognosis

The symptoms experienced by JV meet the criteria for major depressive disorder; however, the chronic and less severe nature of the symptoms is more consistent with a diagnosis of dysthymia (APA, 2000). This diagnosis is based on the symptoms having lasted for most of the past 16 years and JV continuing to engage in daily activities. The recommended treatment plan is therefore antidepressant medication, psychotherapy, and either getting a part-time job or committing to a volunteer position.