‘HE’S 2 SAD’ detects dysthymic disorder

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

Table

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

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