PROBLEM

The patient is a 59-year-old woman with a history of hypertension who presents with myalgias and fatigue that have been troubling her "for months." She also reports insomnia and feelings of insecurity. On further questioning, she says that she has "always felt tired and low." Family history is significant for depression (both mother and sister) and alcoholism (father). The patient takes metoprolol (Lopressor) for hypertension.

APPROACH

Dysthymic disorder is a mood disorder characterized by chronic, mild depression. Patients are sad more days than not in a 2-year period and do not have symptom-free days for more than 2 months at a time. Patients tend to experience fewer vegetative symptoms (sleep, appetite, and weight changes and psychomotor symptoms) than in major depressive disorder. Symptoms such as loss of interest or pleasure, feelings of inadequacy and guilt, social withdrawal, and irritability predominate. However, it may be difficult to distinguish between these 2 diagnoses; acute major depressive episodes can complicate dysthymia. There is a 10% chance of developing major depressive disorder in the first year after a diagnosis of dysthymia.

Besides major depressive disorder, other diagnoses to consider are personality disorder, substance abuse, thyroid disease, bipolar disorder, and malignancy. In this patient, it is especially important to consider medical diagnoses such as polymyalgia rheumatica, hypothyroidism, substance abuse, and medication use.

MANAGEMENT

Patients with dysthymia often experience personal and social dysfunction. Selective serotonin reuptake inhibitors (such as sertraline [Zoloft] and escitalopram [Lexapro]) and tricyclic antidepressants (TCAs) (such as doxepin [Sinequan] and nortriptyline [Pamelor, Aventyl]) are effective in treating patients with mild depression. However, TCAs are more likely to cause adverse side effects. Psychotherapy may be equally effective in selected patients, and many benefit from a combination of medication and counseling.

This patient had a normal ESR and thyrotropin level, ruling out polymyalgia rheumatica and thyroid disease. She denied alcohol use. She met the criteria for dysthymic disorder and subsequently was started on sertraline, 50 mg/d, in addition to psychological counseling. She was also advised to discontinue her beta-blocker, and, after appropriate weaning of metoprolol, she was started on another antihypertensive medication not associated with depression.

CONTRIBUTOR
DEAN G. GIANAKOS, MD, Associate Professor of Clinical Family Medicine, University of Virginia; Associate Director, Lynchburg Family Medicine Residency, Lynchburg, Va; and a member of the Patient Care Board of Editors.

REVIEWER
KARL SINGER, MD, Medical Director of Patient Care; and family physician and general internist, Exeter Family Care, Exeter, NH.

What would you do if . . .

1. The patient expressed thoughts of suicide?
2. Insomnia continued to be a problem?

Answers

1. All patients with depression should be assessed for suicide risk. If patients describe a suicide plan and have taken steps to implement a plan (eg, bought a gun), hospitalization is indicated.
2. Consider short-term use of trazodone, 25 to 50 mg hs. It should be used with caution in men, since trazodone can cause priapism in rare cases.