How Persistent Depressive Disorder Is Treated

Persistent depressive disorder is a mood disorder with chronic depressive symptoms. In general, the treatment of persistent depressive disorder is not much different from the treatment of major depressive disorder (MDD).

Individual treatment plans differ based on the particular presentation of symptoms, but the general principles of pharmacotherapy (i.e., medication) and psychotherapy remain the same.

Research shows that the combination of therapy and medication should be the first line of treatment for chronic depression, but more research is needed to identify which people can benefit most from which specific interventions.

Nonetheless, treatment plans that include prescription medication, therapy, lifestyle changes, or all of the above are often very helpful in relieving symptoms of persistent depressive disorder, which are discussed in this article.

Prescription Medications

Your healthcare provider or therapist can help you decide whether prescription medication is the right course of action for you. If antidepressant therapy is indicated, selective serotonin reuptake inhibitors (SSRIs) are often the first line of antidepressant medication to try, given their tolerability and acceptability.

Some common SSRI names you may have heard of are:

• Sertraline
• Fluoxetine

One meta-analysis of treating depression in the primary care setting showed that tricyclic and tetracyclic antidepressants (TCAs)—like SSRIs—have a solid evidence base compared to other classes of antidepressant medication (with SSRIs having slightly better acceptability).

However, TCAs have a “less favorable adverse event profile” than other classes of medications and should only be used in justified cases. Other categories of antidepressants such as serotonin norepinephrine reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs) also showed positive results.

The class of drugs called N-Methyl-D-Aspartate (NMDA) receptor antagonists is a newer category of antidepressants. Auvelity (dextromethorphan and bupropion) is the first oral NMDA receptor antagonist approved to treat MDD. 

Along that line, a common challenge with taking medication is having adverse effects from the medication or not responding to it (i.e., not feeling better). This can be extremely frustrating and often causes some people to discontinue or switch medication. Depending on the individual, if side effects are present, they may be tolerable or even ebb over time.

Nonetheless, it can be intimidating to know that there are medication side effects to consider, and it may be helpful to know up front that if you and your healthcare provider/therapist do decide to add medication to your treatment plan, it could take trying different medications before you find one that works well for you.

On the other hand, despite a host of research supporting the use of medication to treat persistent depressive disorder, researchers have long debated the efficacy of antidepressants, especially over the long term. Some research suggests that the efficacy of antidepressants is systematically overestimated.

Still, other researchers strongly state evidence for the effectiveness of antidepressants in treating mild to moderate depression, which is often the case for persistent depressive disorder.

While these arguments for and against standard—or “go-to”—medications as well as newer generation antidepressants continue to be debated in research, it may be comforting to know that:

• Your healthcare provider/therapist is there for you and will provide ongoing guidance.
• You have other options available, such as therapy.

Therapies

Psychotherapy is another useful tool in the toolbox for treating persistent depressive disorder.

There are several approaches to psychotherapy, including:

• Cognitive-behavioral therapy: This focuses on changing the automatic negative thoughts that contribute to and worsen depression.
• Cognitive behavioral-analysis system of psychotherapy: This is a form of psychotherapy that has been specifically designed for chronic depression. But it has shown mixed results as a solo therapeutic approach, or in combination with antidepressant medication, thus calling for more research before it can become a standard solo therapy for persistent depressive disorder. 
• Interpersonal therapy: This focuses on interpersonal relationships and social interactions and their contribution to depression. It is a well-studied type of psychotherapy for treatment of depression.
• Mindfulness-based cognitive therapy: This is a combination of cognitive therapy, meditation, and mindfulness, which may be quite useful in treating persistent depressive disorder as it has been shown to reduce the risk of recurrent depression (i.e., reduce the chronic cycle) by about 34%.

If you’re feeling overwhelmed by options, this may help: Research suggests that the type of therapy employed is less important than the general principles of therapy, such as strong therapeutic rapport (i.e., good relationship between therapist and patient).

A therapist can help you decide which approach works best for you, considering your personal history and your treatment goals. No one approach works for everyone, and it may take some looking around to find a therapist that uses the approach that works well for you and one that you get along well with.

Lifestyle

Some relief from chronic depressive symptoms may come from “do-it-yourself” lifestyle changes. Lifestyle factors influence your life in both the short and long term, and research suggests that challenges associated with modern Western lifestyles may impact mental health.

Some factors include:

• Sedentary behaviors (e.g., lack of sufficient physical activity)
• Poorer diet (e.g, higher intake of saturated fats and refined sugars)
• Sleep/wake cycle pressures (leading to low-quality or insufficient sleep)
• Substance misuse
• Psychosocial factors, such as more competition and time pressure

Technological advances that impact the activities we participate in and even the foods we eat, as well as other changes of modernity over the past few decades, have coincided with an increase in reported mental health issues, including depression. And since these changes occur over time and impact everyday life, they could be impacting your chronic low mood.

Deliberate lifestyle changes may help improve your mental health and alleviate depressive symptoms.

Diet

Years of evidence have suggested that poor diet may be a risk factor for the onset of depression. Though there is data to support the association of nutritional factors and depression, there is not yet significant evidence for specific dietary modifications in the treatment of depression.

Physical Activity

Physical activity is another significant lifestyle factor to consider in the treatment of persistent depressive disorder.

A ten-year prospective follow-up study showed that increased time spent in daily physical activity reduced the risk of depression, and the relationship was strongest when looking at high physical activity levels and low amount of time spent watching television.

In addition, researchers have shown that physical activity not only reduced depressive symptoms, but also boosts mental health and helps people maintain motivation to be physically active.

Again, getting physical activity when you can is generally good for you, and you may notice elevated mood post-exercise—a win-win.

Meditation

A meditative practice may also have a positive effect on mood. Mindfulness is a key part of meditation, but it is not clear which form of meditation is best for depression.

For example, trying a guided meditation on an app, let’s say, is a valiant effort, but if you’re feeling very stressed or down about something, a sitting meditation may not be very effective at all as you may not be able to focus enough at that moment to benefit from the meditation.

That is to say, a meditative practice takes time and patience to set in, and it is normal to not feel “mindful” from the get-go. Be patient with yourself, but also keep in mind other lifestyle factors should be addressed too.

Sleep

Sleep is a necessary ingredient of a healthy lifestyle, and it is especially important for managing depressive symptoms.

Sleep disturbance is a common symptom of depression, which has a reciprocal effect. For example, feeling depressed can disrupt your normal sleep cycle, which, in turn, can cause you to feel a low mood. This positive feedback loop between sleep and depression can be frustrating and difficult to break. As such, addressing sleep disturbances is a critical lifestyle component of treating depression.

Sleep hygiene is a common strategy to improve sleep. A standard sleep hygiene practice is establishing a nighttime routine. Increased exercise has also been shown to reduce sleep disorders for those with chronic sleep disturbances, which is yet another reason to get some physical activity.

Figuring out the sleep tactics that work best for you can have a positive impact on your depressive symptoms, which, in turn, can help you sleep better—again, a win-win. 

Substance Use

Another lifestyle factor that influences mental health is substance use.

Consequently, substance misuse is an important consideration when addressing lifestyle changes to help alleviate depression.

Alcohol dependence and abuse as well as cigarette smoking have been associated with an increased risk of depression.

In addition, since alcohol and smoking are coping mechanisms for depression, dependency and the use of these substances to cope with regular low mood may only worsen the chronicity of persistent depressive disorder. Thus, seeking treatment for chronic depression is also a good opportunity for seeking help with alcohol use disorders and/or tobacco cessation.

Social Interaction

Finally, social interaction is a key aspect of everyday life that impacts mental health.

Research suggests that the role social relationships play in supporting or undermining basic psychological needs explains the positive and negative impact, respectively, they have on the well-being of depressed individuals.

Some studies also show that negative exchanges between family and friends were associated with a greater occurrence of depression. Such research backs the commonly held idea that calling on those positive social relationships, such as strong, healthy relationships with friends, family, or partners, can help you feel better.

In the case of persistent depressive disorder, in which a regular low mood is a problem, having a quality relationship—that person or group of people you can count on no matter what—is even more valuable.

A Word From Verywell

The challenge of persistent depressive disorder is in its name: it persists. Having a low mood and other associated depressive symptoms day in and day out is not only disheartening and frustrating, but also makes it harder to be motivated to seek treatment.

However, it can be treated, and the research shows that a combined tactic of medication and psychotherapy, with the added benefit of lifestyle changes that you can do on your own, is effective in alleviating persistent depression.

The bottom line is that you can get help, and, more important than that, it’s okay to ask for it. You are certainly not alone in feeling this way, and you may be surprised by how much better you can feel day to day if you just ask for help.