Brief reportPrevalence of dysthymic disorder in primary care1
Introduction
Dysthymic disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) as a chronically depressed mood for most of the day, for more days than not, for at least 2 years (American Psychiatric Association, 1994). In order to meet DSM-IV criteria, individuals must report at least two of the following symptoms: changes in appetite, sleep disturbance, fatigue, low self-esteem, poor concentration, difficulty making decisions or feelings of hopelessness. Dysthymic disorders are divided by age into early onset (before age 21) and late onset (after age 21) types (American Psychiatric Association, 1994); typically, dysthymic disorder has an insidious onset at an early age with a fluctuating course of symptoms over time (Akiskal, 1983, Akiskal et al., 1995). Dysthymic disorder, also known as dysthymia (Brieger and Marneros, 1997), seems to appear equally in both sexes in children (Garrison et al., 1992); however, in adults it is almost twice as likely to occur in women (Weissman et al., 1988, Kessler et al., 1994). The US National Comorbidity Study reported that the 12-month prevalence of dysthymic disorder in the general population was 2.5% (Kessler et al., 1994), and estimates of lifetime prevalence range from 3.1% (Weissman et al., 1988) to 6.4% (Kessler et al., 1994). It is possible for an individual to have concurrent diagnoses of dysthymic disorder and another mood disorder, in particular major depressive disorder (MDD); this latter condition, known as `double depression' (Keller and Shapiro, 1982), has been the focus of much research.
The etiology of dysthymic disorder is still unknown, although the prevalence of comorbid affective disorders and the results of treatment studies with various antidepressants (Kocsis et al., 1988, Hellerstein et al., 1993, Thase et al., 1996, Lecrubier et al., 1997, Vanelle et al., 1997) suggest that some of the mechanisms of dysthymic disorder and other mood disorders may be shared. Family studies have also shown a strong familial relationship between dysthymic disorder and major depression, with higher rates of mood and personality disorders in first-degree relatives of patients with early onset dysthymic disorder (Klein et al., 1995) as well as in patients with double depression (Donaldson et al., 1997).
Patients with dysthymic disorder are most often seen in primary care. Lifetime prevalence rates from a handful of primary care studies range from 3.7% (Von Korff et al., 1987) to 8.3% (Burnam et al., 1988). There is some evidence to suggest that the majority of these individuals are never diagnosed or are not diagnosed until a more severe episodic mood disorder develops (Keller, 1994). Even when diagnosed, the majority of people with dysthymic disorder are often not treated effectively (Shelton et al., 1997). This is of particular concern as there is considerable data to suggest that chronic subacute depression is a significant risk factor for major depression and should therefore be the focus of efforts both to treat presenting symptoms and to prevent deterioration of mood toward major depression (Judd et al., 1997, Kessler et al., 1997).
The objective of this study was to determine the 12-month prevalence of Axis I psychiatric disorders (DSM-IV), and in particular dysthymic disorder, in a primary care Health Service Organization (HSO) in Ontario, Canada.
Section snippets
Methods
A prospective survey of adults between the ages of 18 and 75 was conducted as the baseline of a multi-arm research study. All individuals registered with a Canadian HSO who were able to provide informed consent were approached. The HSO is a primary health care unit with a roster of 11 000 patients located in Burlington, Ontario. Burlington (population, 137 000) comprises an English-speaking, middle-class, suburban, family community with a small percentage of visible minority groups. This
Results
Of the 6280 individuals who were eligible and were approached to participate in the study, 4327 (69%) agreed to participate (1930 refused and 23 were missed during recruitment). The subjects comprised 1758 males and 2569 females aged 18–75; the mean age of the participants was 46.4 (±15.1) years.
Of the 4327 respondents, 1279 (30%) met criteria for a psychiatric disorder within the past 12 months; 772 screened positive for a single disorder (Table 1), and 507 demonstrated psychiatric comorbidity
Discussion
Consistent with other studies of dysthymic disorder in primary care, the 12-month prevalence of dysthymia was almost twice that of the 12-month prevalence estimate cited for the general population (Kessler et al., 1994). This finding is important as there is increasing evidence that dysthymic disorder may cause significant somatic, social and occupational impairment (Weissman et al., 1988Broadhead et al., 1990Friedman, 1993Howland, 1993Leader and Klein, 1996). Spitzer et al. (1994)have reported
Acknowledgements
We are indebted to Annette Wilkins, Leslie Born and Janice Rogers for their assistance in the preparation of this manuscript, and to Michele Webb, Project Coordinator; to Ellen Jamieson, Data Analyst; to Sherri Colvin, Research Assistant; to the staff at the Caroline Medical Group and the St. Joseph's Hospital Laboratory. Research support: Medical Research Council–Pharmaceutical Manufacturers Association of Canada and Pfizer Canada Inc.
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Drs Steiner and Browne are co-principal investigators of this study.