The Challenge of "Double" Depression

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Have you ever encountered someone with seemingly incorrigible depression? It can be vexing for both the patient and provider when pharmaceutical intervention and therapy reduce acute symptoms, but there remains a relentless, "dull ache" of dysphoria. Eventually, it may leave both parties wondering if this affective gray cloud is somehow just part of who they are. The therapist can feel stymied in their wish to provide relief, while the patient feels defeated and hopeless.

If this situation sounds familiar, barring an underlying medical condition like hypothyroidism mimicking chronic, dull depression, chances are you're looking at "double depression." The concept may be unfamiliar to some readers, but is nothing new (e.g., Keller & Lavori, 1980; Wells et al., 1992; Hybels et al., 2008), and historically describes dysthymia, or long-term, low-grade depression (again, think Eeyore), with superimposed major depressive episodes (MDE).

Double depression isn't a diagnosis, but rather a clinical recognition of this two-depression landscape that helps conceptualize such patients' experiences. However, this "twofer" presentation is recognized by the specifiers for Persistent Depressive Disorder in the DSM-5/DSM-5 TR (2013, 2022). Specifically, it is noted that clinicians should identify if intermittent MDE has arisen (i.e., "Persistent Depressive Disorder (Dysthymia) with intermittent major depressive episodes").

Review of the Involved Depressive Disorders

• Dysthymia: This Greek term translates to "ill-humored" or "bad state of mind" (Harvard, 2014), and is perhaps best illustrated in popular culture by Eeyore in Winnie the Pooh. In a nutshell, individuals experiencing dysthymia have a chronic (at least two years in adults and one year in youth [DSM-5 TR]), "low-grade" depression. The classic picture tends to be a depressed mood, with obvious low self-esteem and low energy. Feelings of hopelessness and sleep and appetite disturbances are not unusual, either. This chronic, ill-humored demeanor can make it difficult to be around the person, or they may project their low self-worth and feel no one would want to associate with someone like them. This pattern of social isolation compounds the matter in that the sufferer can feel unsupported, reinforcing the low self-esteem and ill humor summed up by McCullough (1984) as an entrenched, negative lifestyle. While considered a milder form of depression, it is easy to see how, as noted in Harvard (2014) and by Schramm et al. (2020), it can be more disabling than MDE in that there are no sustained periods of relief. It might be helpful for readers to explore the similarities between dysthymia and depressive personality in "Depression or Depressive Personality?"
• Major Depressive Disorder: Perhaps the most widely known depressive condition, major depression disorder, tends to be more acutely caustic than dysthymia. There is often anhedonia, or lack of ability to experience any pleasure, and more suicidal thinking/attempts. Appetite and sleep disturbances are more intense, as are psychomotor abnormalities like agitation/retardation episodic than dysthymia. Psychotic features can arise, as can catatonia, and even superimposed hypomanic symptoms. While usually less insidious and enduring than dysthymia, MDE can be chronic. Therefore, if the 2-year adult/1 year in youth timeframe is met, it's considered persistent depressive disorder "with persistent major depressive episode." Generally, MDE duration varies from a couple of weeks to several months. Spijker et al. (2002) noted a 3-12 month mean duration, while Have et al. (2017) recorded a mean of about 6–10 months. As the researchers noted, this can depend on the definition of duration; are the patients in full remission or just no longer meet full MDE criteria?

Evaluating for Double Depression

Patients tend to seek treatment when at their worst. This means, chances are, they'll reach out to a therapist or psychiatrist, or perhaps be hospitalized while in the throes of an MDE. Given the treatment implications, elaborated on below, it will be important for practitioners to assess the nature of the patient's depressive experience beyond what's observable; inquiring not only if they've had other significant depressive experiences like the current one, but what they feel like at baseline.

To do this, I've found it helpful to ask, "If you had to describe your mood in general, before this episode, what old you say?" You may be told, "I felt normal," and thus it will be required to understand what "normal" meant. Normal could mean euthymic or something, perhaps, like "my old, irritable self" which may indicate a baseline dysphoria and possible dysthymia.

Interviewing family members to get a reading on the patient's long-term, "everyday" presentation can be helpful, also. Even if it is not very clear upon assessment, it becomes clear that dysthymia is at hand when MDE subsides, but the symptoms seem merely to have downshifted into a "cruising mode."

Treatment Implications

If it's discovered that dysthymia is present, stabilizing the MDE will be just the start of treatment if for no other reason than baseline mild depression, though the person may be generally functioning, could well be engendering spikes into MDE as the relentless gray cloud becomes burdensome. It was long ago realized that "... failure to treat both disorders with aggressive, long-term regimens of pharmacotherapy and psychotherapy is likely to maintain the condition of chronicity" (McCullough, et al., 1996). In effect, without addressing the dysthymia, the patient may be entering into a revolving door of superimposed MDE, adding insult to injury, and increasing risk.

As therapists notice a marked reduction in the patient's MDE, there may become apparent a months-long impasse in therapy gains. Here, the therapist still senses a "depressed flavor" with no further improvements despite both parties' efforts, and the patient complains of unabating, "softer" depressive symptoms. It could now be helpful to change strategies and become more exploratory, discussing what the impasse means to the patient. While this will obviously widely vary, a not-uncommon report, in my experience, is the patient explains that it signifies an inherent, insuperable flaw, and they'll never be relieved.

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It's easy to see how dysthymia could engender such thinking, which, of course, is conducive to maintaining it, and kindling the baseline dysthymia into further MDE. Here, it could be helpful to initiate detailed work on the patient's core schema, or the lenses they view life through, to combat gnawing issues of self-worth and learned helplessness.

Such negative cognitions may be the end result of unresolved trauma, particularly verbal abuse, where the person was regularly demeaned and/or neglected. It's thus easy to see how the person's dysthymia can be perpetuated by negative self-evaluation, which lends itself to projection that others see them as unworthy, and, ultimately, social isolation further encouraging depression (e.g., Weziak-Bialowowlska et al., 2022). Therefore, a more relational approach can be rather effective in working with dysthymia.

Dysthymia is a prime example of the tangled web providers must navigate and the need for patience in both practitioner and clientele for long-term gains. With that in mind, patience can feasibly become another topic of therapy for the more desperate, hopeless sufferers; there is plenty of grist for the mill.

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care from an individual’s provider or formal supervision if you’re a practitioner or student.

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