Persistent Depressive Disorder

Persistent depressive disorder is a mental disorder characterized by regular low mood, but where the symptoms are not as severe as a major depressive episode. Persistent depressive disorder is a new diagnosis in the DSM-5, which represents a consolidation of the DSM-IV-defined chronic major depressive disorder and dysthymic disorder.

Risk Factors

  • Temperamental: Factors predictive of poorer long-term outcome include higher levels of neuroticism (negative affectivity), greater symptom severity, poorer global functioning, and presence of anxiety disorders or conduct disorder.
  • Environmental: Childhood risk factors include parental loss or separation.
  • Genetic and physiological: There are no clear differences in illness development, course, or family history between DSM-IV dysthymic disorder and chronic major depressive disorder. Earlier findings pertaining to either disorder are therefore likely to apply to persistent depressive disorder. It is thus likely that individuals with persistent depressive disorder will have a higher proportion of first-degree relatives with persistent depressive disorder than do individuals with major depressive disorder, and more depressive disorders in general. A number of brain regions (e.g., prefrontal cortex, anterior cingulate, amygdala, hippocampus) have been implicated in persistent depressive disorder. Possible polysomnographic abnormalities exist as well.
Criterion A

Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.

In children and adolescents, mood can be irritable and duration must be at least 1 year.
Criterion B

Presence, while depressed, of at least 2 of the following:

  • Hopelessness
  • Energy low or fatigue
  • Self-esteem is low
  • Sleep decreased (insomnia) or increased (hypersomnia)
  • Appetite poor, or overeating
  • Difficulty making decisions or poor concentration
Criterion C

During the 2 year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

Criterion D

Criteria for a major depressive disorder may be continuously present for 2 years.

Criterion E

There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

Criterion F

The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Criterion G

The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g. hypothyroidism).

Criterion H

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Major depression or dysthymia?

Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted.


The mnemonic HE'S 2 SAD can be used to remember the criteria for persistent depressive disorder (dysthymia in DSM-IV).[1]

  • H Hopelessness
  • E Energy low
  • S Self-esteem
  • 2 2 years worth of symptoms
  • S Sleep decreased
  • A Appetite poor
  • D Difficulty making decisions

The rule of 2's is another way to remember the criteria:

  • 2 years of depressed mood (1 year in children and adolescents)
  • 2 of listed criteria (below)
  • Any symptom-free period always under 2 months


  • With anxious distress
  • With mixed features
  • With melancholic features
  • With atypical features
  • With mood-congruent psychotic features
  • With mood-incongruent psychotic features
  • With peripartum onset
  • In partial remission
  • In full remission
  • Early onset: If onset is before age 21 years.
  • Late onset: If onset is at age 21 years or older.
  • With pure dysthymic syndrome: Full criteria for a major depressive episode have not been met in at least the preceding 2 years.
  • With persistent major depressive episode: Full criteria for a major depressive episode have been met throughout the preceding 2-year period.
  • With intermittent major depressive episodes, with current episode: Full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode.
  • With intermittent major depressive episodes, without current episode: Full criteria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in at least the preceding 2 years.

Severity Specifier

  • Mild
  • Moderate
  • Severe