# What to Do When Common Dysthymia Treatments Fail



## David Baxter PhD (Mar 13, 2012)

*What to Do When Common Dysthymia Treatments Fail*
By DOUG BRUNK, _Clinical Psychiatry News_
March 13, 2012

When it comes to  the pharmacologic treatment of patients with dysthymic disorder, the  best scientific evidence points to selective serotonin reuptake  inhibitors as a first-line treatment, Dr. Hagop S. Akiskal said during a  psychopharmacology conference sponsored by the Nevada Psychiatric  Association. This includes fluoxetine, sertraline, and citalopram, to a  maximum of 40 mg/per day. 

Suggested second-line interventions include  mirtazapine, duloxetine, venlafaxine, and bupropion, said Dr. Akiskal,  professor of psychiatry at the University of California, San Diego.

When first- and  second-line interventions for dysthymic disorder fail, consider trying  the tricyclic antidepressants desipramine or nortriptyline. Another  option is the reversible monoamine oxidase inhibitor (MAOI) moclobemide,  though this agent is not approved for use in the United States. "Don’t  forget phenelzine and tranylcypromine, with certain  dietary/pharmacologic restrictions," Dr. Akiskal said. "There’s also  selegiline, which has been used for a long time to treat Parkinson’s  disease, but it’s controversial as to whether dietary and pharmacologic  restrictions should be as vigorous with this agent as with phenelzine  and tranylcypromine. I would use it thinking it’s less problematic than  those two agents, but still be on your guard." 

He went on to highlight certain dietary and drug  restrictions with irreversible MAOIs to avoid hypertensive crises. These  include aged cheeses, concentrated yeast extracts, sauerkraut, broad  bean pods, tap beers (though other alcoholic beverages "might be safe if  consumed in moderation"), some aged meats, which "contain relatively  high levels of tyramine and require closer scrutiny," pickled fish, and  concomitant serotonergic antidepressants. 

Dr. Akiskal, who is also editor in chief of the  _Journal of Affective Disorders_, noted that dysthymic disorder shares  many similarities to major depressive disorder, including a familial  association, phase advance of REM sleep, diurnal variation, effects on  thyroid-stimulating hormone and thyrotropin-releasing hormone, elevated  levels of plasma corticotrophin-releasing factor, sleep deprivation  response, response to antidepressants, and treatment-emergent hypomania. 

On functional MRI, dysthymic patients show  significantly more right amygdala, right thalamic, right fusiform gyrus,  and left cerebellar activity, compared with controls for the  negative-neutral contrast. "The point is, dysthymia is presented in the  brain; it’s not in the ‘mind’ of the patient," Dr. Akiskal said. 

_Dr. Akiskal disclosed that he is a consultant for  the Lilly and the Lundbeck foundations. He also is a member of the  speakers bureau for AstraZeneca, BioMarin, Bristol-Meyers Squibb, Dey  Pharma, GlaxoSmithKline, Merck, and Sanofi._


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## Daniel (Mar 13, 2012)

> "The point is, dysthymia is presented in the  brain; it’s not in the ‘mind’ of the patient," Dr. Akiskal said.



Or both.


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## Wynnteri (Oct 4, 2012)

I believe (although I'm not a doctor of course) that my depression/dysthymia is my mind. It has nothing to do with my brain. My therapist, the one that specialized in Child Sexual Abuse Survivors..........She said it was all in the way my mind reacted to the abuse. It's like a bad habit that I can't seem to break. My depressions are a "thinkers" depression. It's got nothing to do with a chemical imbalance & therefore can't really be "FIXED!"
NOW THAT'S DEPRESSING!!!!!!!!!!!!! lol


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## David Baxter PhD (Oct 4, 2012)

Wynnteri said:


> I believe (although I'm not a doctor of course) that my depression/dysthymia is my mind. It has nothing to do with my brain.



How exactly do you distinguish between your mind and your brain?


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## Wynnteri (Oct 4, 2012)

I look at it like my mind is what I think. It's the thoughts & memories. My brain is the chemical stuff. lol. The neutrons, electrons, & such. I guess..... lol


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## David Baxter PhD (Oct 4, 2012)

They are one and the same. Your brain is your mind; your mind is your awareness of your brain.


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## MHealthJo (Oct 4, 2012)

The mind and body are connected and each affects the other... and when we talk about the brain, it's quite literal. The brain is the physicality of the mind - the nuts and bolts, the machinery of what the mind does.

If you get inside a computer and fiddle with the parts, you're going to have an effect on how that computer functions. 

You could fiddle with the programming, replace or tweak a physical part, or both.


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