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‘HE’S 2 SAD’ detects dysthymic disorder

Vol. 7, No. 3 / March 2008

One-third of psychiatric outpatients meet criteria for dysthymic disorder,1 but the symptoms are easy to overlook or misdiagnose.2 This problem can be exacerbated by symptoms that overlap with major depressive disorder (MDD), heterogeneity of presentation, and clinician unfamiliarity with diagnostic criteria.3

Patients might not report symptoms unless directly asked because of dysthymic disorder’s insidious onset, limited severity, and chronicity. They may believe their symptoms are part of their “nature” rather than evidence of mental illness.3

Dysthymic disorder can diminish patients’ quality of life and increase their risk of developing MDD,3 but it can be treated successfully. Proper screening and accurate diagnosis are the first steps.

The “HE’S 2 SAD” mnemonic (Table)3 describes DSM-IV-TR diagnostic criteria for dysthymic disorder. To meet these criteria, adults need only 2 of the symptoms in addition to depressed mood during the initial 2 years and cannot be without symptoms >2 months at a time.3 Also, the patient cannot have met criteria for a major depressive episode during the first 2 years or have ever met criteria for a manic, mixed, or hypo manic episode.3

In children, mood may be irritable and symptoms need last only 1 year to meet dysthymic disorder’s diagnostic criteria.3 Dysthymic disorder is 2 to 3 times more prevalent in women than men, but no gender difference is seen among children.3


‘HE’S 2 SAD’: Diagnostic criteria for dysthymic disorder


Energy loss or fatigue

Self-esteem is low

2 years minimum of depressed mood most of the day, for more days than not

Sleep is increased or decreased

Appetite is increased or decreased

Decision-making or concentration is impaired

Additional clues

In addition to DSM diagnostic criteria, other features might point to dysthymic disorder:3

  • feelings of inadequacy
  • generalized loss of interest or pleasure
  • feelings of guilt or brooding about the past
  • feelings of irritability or excessive anger
  • decreased activity, effectiveness, or productivity.3

Although no American Psychiatric Association practice guidelines or FDA-approved treatments exist for dysthymic disorder, clinical improvement is possible with medication and psychotherapy. Antidepressants might have equivalent efficacy, as in MDD treatment, so base your choice on the drugs’ side effect profiles.


1. Markowitz J, Moran ME, Kocsis JH, Frances AJ. Prevalence and comorbidity of dysthymic disorder among psychiatric outpatients. J Affect Disord 1992;24:63-71.

2. Keller MB. Dysthymia in clinical practice: course, outcome and impact on the community. Acta Psychiatr Scand Suppl 1994;383:24-34.

3. Diagnostic and statistical manual of mental disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.

Dr. Christman is a fourth-year psychiatry resident, University of Texas Health Science Center, San Antonio.

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