Is It Possible to Have High-Functioning Depression?

It took decades of effort, but with the 2013 release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the mental health community finally recognized chronic depression as a separate and distinct condition, not a subset of major depression.

According to Dr. James McCullough, a professor of psychology and psychiatry at Virginia Commonwealth University, that was a major step forward for the clinicians and researchers who long believed that dysthymia—the formal name for chronic, persistent depression—was a very different disorder. While major, episodic depression is far more prevalent (about 7 percent of the U.S. population), McCullough said there are approximately 14 million dysthymics in the U.S., a prevalence of 2-3 percent, costing the economy some $40 billion.

Dysthymia Diagnosis

“Dysthymics are frequently misdiagnosed, and thorough diagnosis is the only way I know to really tell what you’ve got,” said McCullough. “When I get a depressive, my first task is, have I got a chronic here or an acute episodic? If I’ve got a chronic, I’ve got a much more difficult case.”

Duration of the depression is one of the clinical hallmarks of chronic depression. Adults who have been depressed continuously for two years or more (one year or more for children or adolescents), are considered to be chronic. By working backward in time through questioning, the duration of symptoms can be assessed. For acute, episodic, major depression, just two weeks of continuous depression is required for the diagnosis.

Interviewing a patient can also uncover another distinguishing element of dysthymics: early maltreatment in the family, abuse or emotional deprivation. McCullough said 9 out of 10 dysthymics describe such disruptions in the early developmental years, which is not always true with major depression.

“There is a whole lot of research demonstrating that early developmental maltreatment and abuse is related to adolescent and adult depression,” McCullough noted. “It’s kind of a no-brainer—you beat around kids, and they pay the price.”

Signs and symptoms

Even though the symptoms of dysthymia are typically milder than with acute depression, its price can be steep and long-lasting.

McCullough has treated 2,200 dysthymic patients over the course of his 45-year career, and has seen recognizable patterns emerge.

“Major depression you’ve got a major shut-down in the system. Dysthymics still go to work, they stay married, but they’re no fun to be around,” he said. “The hallmark of chronic depression is hopelessness. ‘I’ll always be this way; I’ll always feel this way.’

Nothing is ever OK, it’s not sharp edges, it’s rounded. It’s a pessimistic view, and the damnable thing about dysthymia is that it’s a lifetime disorder unless it’s effectively treated. Episodic, major depression is not.”

When asked about the concept called “high-functioning depression,” McCullough flatly stated that there is no such thing, and that the term is a misleading misnomer.

“It’s a bear”

In McCullough’s opinion, acute depression is fairly simple to treat with cognitive behavioral therapy (CBT). “Dysthymia, on the other hand, is not very responsive to medication or psychotherapy,” he observed.

He has developed a treatment modality specifically designed to address the early developmental issues that plague dysthymics. It’s called the cognitive behavioral analysis system of psychotherapy, or CBASP. He said it is the only treatment that has been shown to be effective with chronic depressives.

“It’s an interpersonal model of psychotherapy. I don’t go after the way you’re thinking, as with CBT,” he said. “It’s not quite that simple with the chronics.” CBASP involves close personal consultation with the therapist, who helps the patient to modify behavior and develop needed problem-solving and interpersonal skills. “There is a lifestyle issue involved with chronic depression, and if you don’t change the way you live, you’re going to stay depressed.”

Dr. McCullough added that there is also a role for medication in treating dysthymia. “All of the chronics I see, I usually try to find a medication that makes them feel a little better. But hell, it’s a crapshoot, it’s trial and error.”

When told about the GeneSight^® pharmacogenomic test to help bypass that antidepressant trial and error approach, he enthused, “That’s great!”

His advice

What should someone do who suspects they may suffer from chronic depression but has never been diagnosed? “Tell them to go on Google and look up dysthymia—look up the symptoms, and also look at the length of time they’ve been feeling this way,” McCullough recommended.

If an individual feels he or she may meet the clinical criteria, it may be worthwhile to begin with Dr. McCullough’s writings, and seek a practitioner proficient in CBASP.