08.06.09 - psychosocial impact of dysthymia a study among married patients

7/30/2019 08.06.09 - Psychosocial Impact of Dysthymia a Study Among Married Patients

1/6

Brief report

Psychosocial impact of dysthymia: A study among married patients

B.N. Subodh, A. Avasthi , S. Chakrabarti

Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Received 7 September 2007; received in revised form 16 November 2007; accepted 16 November 2007

Available online 31 December 2007

Abstract

Background: Unlike major depression, the psychosocial impact of dysthymia has received far less research attention. This study

attempted to assess the psychosocial consequences of dysthymia.

Methods: The sample consisted of 30 married patients with DSM-IV dysthymic disorder and a matched control group of 30 married

patients with recurrent major depressive disorder (RDD), diagnosed using structured interviews. Apart from ratings of severity of

depression, assessments of psychosocial impact included quality of life (QOL), disability, perceived social support and marital

adjustment. Psychosocial parameters were evaluated using vernacular versions of well-validated scales previously used in similar

populations. Matched normal/medically ill controls were derived from Indian studies which had assessed the same parameters using

the same instruments.

Results: Patients with dysthymia were significantly impaired on measures of QOL, disability, social support and marital adjustment

compared to normal/medically ill controls. On the other hand, the two groups of dysthymia and RDD were comparable on these

measures apart from significantly lower social support among patients with dysthymia. Duration of illness and severity of depression

emerged as the most important correlates, particularly of impaired QOL and disability levels.

Limitations: Small hospital-based sample, normal/medically ill controls derived from other studies and cross-sectional assessments

were the major limitations.

Conclusions: Dysthymia had considerable adverse psychosocial impact in terms of QOL, functioning (disability), social support

and marital adjustment. Severity and chronicity appeared to be important mediators of this negative psychosocial impact. Increased

awareness, improved recognition and adequate treatment might help negate some of the untoward social consequences of this

condition.

2007 Published by Elsevier B.V.

Keywords: Dysthymia; Disability; Quality of life; Social support; Marital adjustment

1. Introduction

Improved definitions and growing literature about

dysthymia have revitalized the efforts to characterize,

understand and treat this condition. Despite these

advances, clinicians are relatively ill informed about

this disorder and many might often fail to detect it.

This is unfortunate because a chronic psychiatric

condition such as dysthymia has the potential to ad-

versely affect several key areas of lives of patients and

their significant others. Given the enduring nature of

their complaints these patients report high degrees of

morbidity, impairment in a variety of health domains,

Journal of Affective Disorders 109 (2008) 199204

www.elsevier.com/locate/jad

Corresponding author. Department of Psychiatry, PGIMER,

Chandigarh-160012, India. Tel.: +91 0172 2756803; fax: +91 172

274440.

E-mail address: [email protected] (A. Avasthi).

0165-0327/$ - see front matter 2007 Published by Elsevier B.V.doi:10.1016/j.jad.2007.11.006
mailto:[email protected]://dx.doi.org/10.1016/j.jad.2007.11.006http://dx.doi.org/10.1016/j.jad.2007.11.006mailto:[email protected]


2/6

and problems in socio-occupational and other important

areas of functioning (Akiskal, 2001). This is further

reflected by studies which have clearly shown impair-

ments in quality of life (QOL), functioning, social support

and marital adjustment among patients with dysthymia

(Frances, 1993; Chakrabarti et al., 1993; McCulloughet al., 1994; Ron et al., 1995; Leader and Klein, 1996;

Kulhara and Chopra, 1996; Gupta et al., 1998; Zlotnick

et al., 2000; Bell et al., 2004).

However, the amount of research data on the subject

is still relatively scarce compared to the size of the

problem. The focus of such research has more often

been on patients with double depression, rather than

those with uncomplicated dysthymia (e.g. Bell et al.,

2004). Moreover, certain areas such as social support

and marital adjustment have remained relatively

unexplored.The current study attempted a more comprehensive

assessment of the psychosocial impact of dysthymia

in terms of QOL, disability, perceived social support

and marital adjustment among patients of dysthymia

without additional comorbidity. Comparisons were

carried out with patients with recurrent major depres-

sive disorder (RDD) and normal/medically ill con-

trols. Clinical and demographic factors which could

influence these psychosocial parameters were also

explored.

2. Method

2.1. Patients

Consecutive patients with a provisional diagnosis of

dysthymic disorder who attended the psychiatric facility

of a large multispeciality hospital in north-India were

screened.

To be included they had to have a DSM-IV (APA,

1994) diagnosis of dysthymic disorder, be married and

be of 1850 years of age. Those with comorbid psy-

chiatric disorders (e.g. double depression), substancedependence, psychosis, personality disorder, organic

brain syndrome, mental retardation or any major

debilitating physical illness were excluded.

2.2. Controls

2.2.1. RDD

Purposive sampling was used to identify a group of

patients with DSM-IV recurrent major depressive dis-

order matched on age, sex, education and duration of

illness with the dysthymic group. Patients had to have

had at least one episode of the depression in the last

2 years and had to be currently on antidepressant treat-

ment for a minimum of 4 weeks. Other selection criteria

were similar to patients.

2.2.2. Normal/medically ill controls

Age and sex matched normal/medically ill (diabetic)controls were derived from previous studies conducted

in the same centre (for QOL and social support), or from

other Indian studies (for disability and marital adjust-

ment), which had used the same scales to assess these

variables. Additionally, these studies had ruled out psy-

chiatric morbidity in their control populations, which

enhanced their suitability for inclusion as comparison

subjects in the current study.

2.3. Assessments

Diagnoses were established using the Structured

Clinical Interview for DSM-IV Axis-I Disorders, Clin-

ician Version (SCID I-CV First et al., 1997).

Sociodemographic and clinical data was recorded from

case notes. Severity of depression was rated using the

MontgomeryAsberg Depression Rating Scale (MADRS

Montgomery and Asberg, 1979).

2.3.1. Psychosocial indices

i) QOL was assessed using the WHO Quality of

Life-Bref Version (WHO-QOL-BREF Saxena

et al., 1988), a shorter version of the WHO-QOL-100, with different domains including general

wellbeing, physical health, psychological health,

social relationships and environment.

ii) Disability was evaluated using the Schedule for

Assessment of Psychiatric Disability (SAPD

Thara et al., 1988), a modification of the World

Health Organisation Disability Assessment Sche-

dule-II, with items grouped into 4 main areas of

personal, social, occupational and global disability.

iii) Social support was measured using the Social

Support Questionnaire (SSQ Nehra and Kulhara,1987), a modification of the original Pollack and

Harris questionnaire, with 18 items assessing per-

ceived social support.

iv) Marital adjustment was rated using a translated

version of the Dyadic Adjustment Scale (DAS

Spanier, 1976), a scale with 4 different domains

namely dyadic satisfaction, dyadic consensus, dyadic

cohesion and affectional expression.

All these four instruments were available in Hindi

(the local language). In addition, they had adequate

psychometric properties (internal consistency and/or

200 B.N. Subodh et al. / Journal of Affective Disorders 109 (2008) 199204


3/6

inter-rater reliability ranging from 0.75 to 0.96), and

had been used in several other studies from India.

2.4. Approval/consent

The project was approved by the Thesis and EthicsCommittees of the institute. Written informed consent

was obtained from all participants and other ethical

safeguards were followed during the conduct of the

study.

3. Results

3.1. Sample

Thirty five patients with (only) dysthymia were

identified during the study period of 8 months. Three ofthese did not satisfy DSM-IV criteria following the

SCID interview; 2 patients did not complete their as-

sessments, leaving 30 who could be inducted for the

study. Thirty patients with RDD formed the patient

control group.

3.2. Demographic and clinical profile: dysthymia and

RDD group (Table 1)

A majority (70%) of the patients were women.

Patients were in their late thirties. Although a majority

(70%) had secondary levels of education and most(57%) were employed, income levels were low in 80%

of cases. Patients were mostly from nuclear families

(62%) and urban localities (55%) They had been ill for

513 years; those with RDD had had an average of

about 3 episodes during this period. There were no

significant differences between the dysthymia and RDD

groups on any of the demographic parameters. Some-

what expectedly, patients with RDD had significantly

later ages of onset as well as higher MADRS scores

( Table 1).

3.3. Psychosocial impact of dysthymia

3.3.1. Comparison with RDD (Table 2)

Average scores of QOL, disability, perceived social

support and marital adjustment indicated that both

Table 1

Sociodemographic and clinical profile of dysthymia and RDD1

Dysthymia (N= 30) RDD (N= 30) Chi-square/ t-values

Age (in years) (Mean SD) 38.20 7.35 38.20 7.35 0.88

Gender

Male 08 10 0.31

Female 22 20

Years of schooling

Less than 10 10 08

10 or more 20 22 0.31

Occupation

Employed 11 15 0.60

Not employed 19 15

Income (in INR2)

Less than 3000/month 22 16

3000/month or more 08 14 2.58

Family type

Nuclear 19 18

Non-nuclear 11 12 0.07Locality

Urban 15 18

Rural 15 12 0.60

Age at onset in months (Mean SD) 339.20 95.11 393.93 98.70 2.19

Duration of illness in months (Mean SD) 112.40 62.43 86.80 63.00 1.18

No of depressive episodes (Mean SD) 02.9701.63

Ever hospitalised

Yes 00 03

No 30 27

MADRS3 scores (Mean SD) 11.57 4.55 15.47 8.94 2.13

t-values; p valueb0.05.

1: RDD Recurrent major depressive disorder.

2: INR

Indian National Rupees.3: MADRS MontgomeryAsberg Depression Rating Scale.

201B.N. Subodh et al. / Journal of Affective Disorders 109 (2008) 199204


4/6

groups of patients were impaired on these parameters.

However, the only significant difference between the

two groups was in the area of social support where

scores of patients with dysthymia were lower than those

of patients with RDD. This difference could not be

explained (Table 2).

3.3.2. Comparison with medically ill/normal controls

(Table 2)

These comparisons clearly showed that patients with

dysthymia were significantly impaired in the areas of QOL,

disability, perceived social support and marital adjustment,

compared to matched medically ill or normal controls.

Table 2

Psychosocial impact of dysthymia compared to RDD1, normal/medically ill controls

Comparison with RDD

Psychosocial parameter studied Dysthymia (N= 30) Mean SD RDD (N=30) Mean SD t-values

QOL2 (WHO-QOL-BREF)

General wellbeing 06.00 01.93 06.20 01.77 0.42Physical health 20.60 04.61 21.30 03.71 0.65

Psychological health 17.60 04.95 18.37 04.20 0.65

Social relationship 09.76 02.82 10.26 02.13 0.77

Environment 27.00 04.50 27.57 05.06 0.46

Total score 80.97 15.37 83.70 13.72 0.73

Disability (SAPD)

Overall behaviour 01.23 00.68 01.55 00.87 1.57

Social role 01.40 00.83 01.33 01.06 0.27

Occupational 00.83 00.75 01.10 01.03 1.15

Overall disability 01.43 00.73 01.56 00.90 0.63

Social support (SSQ)

Total 49.67 07.99 55.27 05.97 3.07

Marital adjustment (DAS)

Dyadic consensus 46.03 10.25 47.57 09.14 0.61

Dyadic cohesion 14.03 04.14 15.03 03.49 1.01

Affectional expression 07.40 02.09 08.00 01.91 1.16

Dyadic satisfaction 36.40 06.36 38.20 05.16 1.21

Total score 103.87 17.98 108.80 13.15 1.21

Comparison with normal and medically ill controls

Dysthymia-current study (N=30) Mean SD Medically ill/normal controls MeanSD Results of t tests

Disability (SAPD)

Overall disability 01.43 00.73 00.70 00.78 a 3.74

QOL (WHO-QOL-BREF)

Total scores 80.97 15.37 98.32 17.94 b 4.25

97.8510.40c

4.98

Social support (SSQ)

Total scores 49.67 07.99 64.75 05.42 d 7.5

60.9906.32 e 8.07

Marital adjustment (DAS)

Total scores 103.87 17.98 116.28 11.45 f 2.73

1: RDD Recurrent major depressive disorder.

2: QOL Quality of life.pb0.05; pb0.001; pb0.0001.

WHO-QOL-BREF WHO Quality of Life (WHO-QOL)-Bref Version.

SAPD Schedule for Assessment of Psychiatric Disability.

SSQ Social Support Scale.

DAS Dyadic Adjustment Scale.a

Controls with diabetes mellitus from Thara et al., 1988 (N=30).b Normal controls from Singh et al., 2005 (N=40).c Normal controls from Chand et al., 2004 (N=30).d Normal controls from Nehra and Kulhara, 1987 (N=21).e Normal controls from Nehra, 1993 (N=100).f Normal controls from Isaac and Shah, 2004 (N=20).



5/6

3.4. Correlates of psychosocial impairment in dysthymia

and RDD

Although there were a number of significant

associations (using the Spearman's correlation coeffi-

cient), the most consistent ones common to both patientgroups were:

i) Longer duration of illness demonstrated significant

negative correlations with general wellbeing domain

of QOL in both patients with dysthymia (pb0.05)

and RDD (pb0.05).

ii) Higher MADRS scores showed:

significant negative correlations with the overall

QOL score in both patients with dysthymia (pb0.01)

and RDD (pb

0.01). significant associations with lower scores in the

QOL domains of general wellbeing (pb0.01), physi-

cal health (pb0.01), psychological health (pb0.01)

and social relationship (pb0.05) among patients with

dysthymia.

significant negative correlations with scores in the

QOL domains of general wellbeing (pb0.01), physi-

cal health (pb0.01), psychological health (pb0.05)

and environment (pb0.01) among patients with

RDD.

significant associations with higher levels of

behavioural, social role, occupational and overalldisability levels among patients of dysthymia as well

as RDD (pb0.01 in all instances).

4. Discussion

In contrast to the psychosocial impact of depression,

fewer studies have assessed the impact of the depressive

spectrum disorders such as dysthymia. The current

study attempted this by focusing on relatively pure

patients of dysthymic disorder without associated co-

morbidity. Married patients were chosen to determinethe effects of dysthymia on people other than the

patients themselves. A comprehensive evaluation of

several psychosocial aspects was attempted, particularly

by including areas such as social support and marital

adjustment, which have received relatively little con-

sideration in previous studies. Standardized diagnoses

and well-validated instruments, previously used among

Indian patient populations, were used to increase the

relevance of the results. For a better perspective the

psychosocial impact of dysthymia was compared with

matched samples of RDD, and normal/medically ill

controls. However, normal/medically ill controls were

derived from other studies, albeit those using the same

scales among similar populations. Thus, uniformity of

assessments could not be completely ensured among

controls. This, apart from the relatively small number of

patients who were all hospital attendees and the cross-

sectional nature of assessments, were the obvious limi-tations of this study.

Nonetheless, the adverse psychosocial impact of

dysthymia found in the current study was in accord with

similar patterns of impaired QOL (Ron et al., 1995;

Leader and Klein, 1996; Gupta et al., 1998; Bell et al.,

2004), high levels of disability (Frances, 1993; Chakra-

barti et al., 1993; Bell et al., 2004), inadequate social

support (Kulhara and Chopra, 1996) and poor marital

adjustment (McCullough et al., 1994; Zlotnick et al.,

2000), found among patients with dysthymia in earlier

studies. Some of these studies (e.g. Ron et al., 1995)have shown that patients with dysthymia are signifi-

cantly more impaired in these areas than healthy adults

or people with chronic medical conditions such as hy-

pertension or diabetes mellitus. This was similar to the

significantly higher levels of impairment among patients

with dysthymia, compared to normal/medically ill con-

trols, of the present study. Furthermore, the lack of

major differences in psychosocial impairment between

dysthymia and RDD observed in this study echoed the

equivalent levels of impairment reported by several

other comparisons of dysthymia and major depression

(Frances, 1993; Ron et al., 1995; Leader and Klein,1996; Zlotnick et al., 2000). Severity of depression and

duration of illness emerged as important determinants of

the negative psychosocial impact of both dysthymia and

RDD, particularly of QOL and disability in the current

study. Others have similarly reported that severity of

depression, chronicity of illness and comorbidity are the

major determinants of the negative social impact of

dysthymia (Leader and Klein, 1996; Bell et al., 2004).

In addition to the above, results of the present study

also suggested that the psychosocial sequelae of

dysthymia in these areas is likely to be universal andcuts across cultures. They also highlighted the fact that

apart from being sizeable, such impairment is wide-

spread and pervasive since several areas of psychosocial

functioning are affected simultaneously.

Together with findings of earlier studies this helps to

further dispel the notion that minor depressive condi-

tions do not usually have untoward social effects. They

thus underline the need for increased awareness and

sensitivity among clinicians and researchers alike about

the unfavourable psychosocial impact of dysthymia.

The likelihood of factors such as severity, chronicity

and comorbidity being important correlates of such

203B.N. Subodh et al. / Journal of Affective Disorders 109 (2008) 199204


6/6

impairment raises the possibility of being able to

identify those at risk for these untoward social con-

sequences. These correlates might also be of help in

improving the poor recognition of the disorder. The

ultimate aim of improved identification would be the

provision of effective treatment. Fortunately, there isnow ample evidence that treatment with antidepressants

and psychotherapy can help lessen the suffering of

patients with dysthymia, even those without comorbid

major depression (e.g. Kocsis et al., 1997; Williams

et al., 2000). These trials have also shown the benefits of

such treatment in improving QOL and functioning of

patients of dysthymia. Given the chronic nature of dys-

thymia, the next challenge would be to document the

long-term effects of treatment on psychosocial outcomes.

This will require prospective, longitudinal follow-up of

larger, community-based samples. It can be hoped thatmore such studies will help delineate the true extent of the

negative psychosocial impact of dysthymia, and also

clarify the role of treatment in containing it.

Role of the funding source

Nothing declared.

Conflict of interest

There are no actual or potential conflicts of interest including any

financial, personal or other relationships with other people or

organizations within three (3) years of beginning the work submitted

that could inappropriately influence, or be perceived to influence, their

work.

Acknowledgements

We wish to thank all the patients and their spouses

who took part in the study.

References

Akiskal, H.S., 2001. Dysthymia and cyclothymiain psychiatricpractice a

century after Kraepelin. J. Affect. Disord. 62, 1731.

AmericanPsychiatric Association, 1994. Diagnostic and Statistical Manual

of Mental Disorders, 4th ed. American Psychiatric Association,

Washington DC.

Bell, B., Chalklin, L., Mills, M., Browne, G., Steiner, M., Roberts, J.,

Gafni,A., Byrne,C., Wallik, D.,Kraemer, J.,Webb, M.,Jamieson, E.,

Whittaker, S., Dunn, E., 2004. Burden of dysthymia and comorbid

illness in adults in a Canadian primary care setting: high rates of

psychiatric illness in the offspring. J. Affect. Disord. 78 (1), 7380.

Chakrabarti, S., Kulhara, P., Verma, S.K., 1993. The pattern of burden in

families of neurotic patients. Soc. Psychiatry Psychiatr. Epidemiol.

28, 172177.

Chand, P., Mattoo,S.K.,Sharan, P., 2004. Quality of lifeand itscorrelates

in bipolar disorder patients stabilized on lithium prophylaxis. Psy.

Clin. Neuroscience 58, 311318.

First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W., 1997. The

Structured Clinical Interview for DSM-IVAxis I Disorders-Clinician

Version (SCID-CV). American Psychiatric Press, Washington, DC.

Frances, A.J., 1993. An introduction to dysthymia. Psychiatr. Ann. 23,

607608.

Gupta, S.,Kulhara, P., Verma, S.K., 1998. Quality of lifein schizophrenia

and dysthymia. Acta Psychiatr. Scand. 97 (4), 290296.Isaac, R., Shah, A., 2004. Sex roles and marital adjustment in Indian

couples. Int. J. Social Psy. 50 (2), 129141.

Kocsis, J.H., Zisook, S., Davidson, J., Shelton, R., Yonkers, K.,

Hellerstein, D.J., Rosenbaum, J., Halbreich, U., 1997. Double-

blind comparison of sertraline, imipramine, and placebo in the

treatment of dysthymia: psychosocial outcomes. Am. J. Psychiatry

154, 390395.

Kulhara, P., Chopra, R., 1996. Social support, social dysfunction and

stressful life events in neurotic patients. Indian J. Psychiatry 38,

2329.

Leader, J.B., Klein, D.N., 1996. Social adjustment in dysthymia,

doubledepression and episodic major depression. J. Affect. Disord.

37 (23), 91101.

McCullough, J.P., McCune, K.J., Kaye, A.L., Braith, J.A., Friend, R.,Roberts, W.C., Belyea-Caldwell, S., Norris, S.W., Hampton, C.,

1994. One-year prospective replication study of an untreated

sample of community dysthymia subjects. J. Nerv. Ment. Dis. 182,

396401.

Montgomery, S.A., Asberg, M., 1979. A new depression scale

designed to be sensitive to change. Br. J. Psychiatry 134, 382389.

Nehra, R., 1993. Social support in relation to family typology,

socioeconomic status and neuroticism in married urban neurotic

females. Ph.D. thesis. Department of Psychiatry, PGIMER,

Chandigarh.

Nehra, R., Kulhara, P., 1987. Development of scale for the assessment

of social support: initial tryout in Indian setting. Indian J. Social

Psychiatry 4, 353359.

Ron, D.H., Kenneth, B.W., Cathy, D.S., William, R., Karen, S., 1995.

Functioning and well being out comes of patients with depression

compared with chronic general medical illnesses. Arch. Gen.

Psychiatry 52, 1119.

Saxena, S., Chandiramani, K., Bhargava, R., 1988. WHO-QOL-Hindi:

a questionnaire for assessing quality of life in health care setting in

India. Nat. Med. J. India 11, 160166.

Singh, J., Mattoo, S.K., Sharan, P., Basu, D., 2005. Quality of life and

its correlates in patients with dual diagnosis of bipolar affective

disorder and substance dependence. Biplor. Disod. 7 (2), 187191.

Spanier, G.B., 1976. Measuring Dyadic Adjustment: new scale for

assessing the quality of life and similar dyads. J. Marriage Fam. 38,

1528.

Thara, R., Rajkumar,S., Valecha,V., 1988. The Schedule for Assessmentof Psychiatric Disability a modification of the DAS-II. Indian

J. Psychiatry 30 (1), 4753.

Williams, J.W., Barrett, J., Oxman, T., Frank, E., Katon, W., Sullivan,

M., Cornell, J., Sengupta, A., 2000. Treatment of dysthymia and

minor depression in primary care. A randomized controlled trial in

older adults. JAMA 284, 15191526.

Zlotnick, C., Kohn, R., Keitner, G., Della-Grotta, S.A., 2000. The

relationship between quality of interpersonal relationships and

major depressive disorder: findings from the National Comorbidity

Survey. J. Affect. Disord. 59 (3), 205215.


08.06.09 - psychosocial impact of dysthymia a study among married patients

Documents