Dysthymia therapyWhen low has become your normal.

The US National Institute of Mental Health describes persistent depressive disorder, formerly dysthymic disorder, as chronic low-level depression that is not as severe as major depressive disorder but may last longer; a diagnosis requires a combination of depressive symptoms for two years or more¹. Alongside low mood, people commonly describe changes in appetite or sleep, low energy, low self-esteem, poor concentration and feelings of hopelessness.

The US National Institute of Mental Health reports that an estimated 1.5% of US adults had persistent depressive disorder in the past year and 2.5% at some point in their lives, and that among those affected in the past year, almost half had serious impairment¹. These are US figures, but they show that the condition is common and far from mild in its impact.

As with other forms of depression, there is usually no single cause. Contributing factors can include family history, temperament, long-term stress, difficult early experiences, loss, loneliness and chronic health conditions. The WHO notes that people who have lived through abuse, severe losses or other stressful events are more likely to develop depression³. Over time, low mood shapes habits and beliefs, such as withdrawing, expecting disappointment and criticising yourself, which in turn keep the mood low.

A meta-analysis of 16 randomised trials of psychotherapy for chronic depression and dysthymia found that psychotherapy was effective compared with control conditions, though the effect was smaller than for shorter-lived depression². It also found that combined psychotherapy and medication was more effective than either alone, and there were indications that at least 18 sessions are needed for psychotherapy to reach its best effect². This is an honest message: dysthymia usually needs patient, steady work, and progress can be real even when it is gradual.

NICE guidance on depression in adults includes specific advice on managing chronic depression, as well as on preventing relapse⁴. Our therapists work in an integrative, evidence-informed way. For dysthymia, sessions often include:

• Understanding the long view: when the low mood started, what has kept it going and how it has shaped your life choices.
• Separating you from the depression: noticing which "personality traits" may actually be symptoms.
• Behavioural activation: gradually reintroducing activities that bring pleasure, mastery or connection, even before motivation returns.
• Techniques from cognitive behavioural therapy, where helpful, to examine long-held beliefs such as "nothing will change" or "I am not enough".
• Relationships: reducing isolation and addressing patterns in close relationships.
• Self-compassion: easing the self-criticism that often accompanies chronic low mood.
• Planning for the long term: recognising early signs of worsening and protecting the gains you make.

Low energy can make it hard to travel to appointments. Online sessions remove that barrier and support the regularity this work needs. A meta-analysis of randomised trials found that video-based psychotherapy for depression was roughly comparable to in-person therapy⁵.

Consider therapy if low mood has been present most days for months or years, if you feel you have "always been like this", or if it is affecting your work, relationships or health. Speak to a doctor as well, since some physical conditions and medicines can affect mood, and medication may be an option. We are happy to work alongside your doctor or psychiatrist.

Seek help urgently if you feel hopeless, have thoughts of not wanting to live or of harming yourself; see the information below.