Uncovering the Signs and Cause of Hidden Chronic Depression

Darlene Lancer LMFT

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Chronic depression is common; however, many people are unaware that they're depressed. Because the symptoms are mild, most people with chronic depression wait ten years before seeking the depression treatment they need and deserve.

Persistent depressive disorder (PDD), also referred to as dysthymia, doesn't usually impair daily functioning, but it can make life feel empty and joyless. Sufferers have a diminished capacity to experience pleasure and may withdraw from stressful or challenging activities.

Like codependency, dysthymia causes changes in thinking, feelings, behavior, and physical well-being. Our emotions are dulled, though we may feel sad or melancholy or be irritable and angry easily. Unlike with major depression, we're not incapacitated yet have difficulty trying new things, socializing, and advancing in our careers. We may believe that our lack of drive and negative mood is part of our personality, rather than that we have an illness.


Dysthymia was renamed "persistent depressive disorder" in the 2013 edition of the Diagnostic Statistical Manual V. (I use the terms "dysthymia," "persistent depressive disorder," and "chronic depression" interchangeably.) It can start in adolescence. Teens act irritable, moody, or pessimistic over an extended period. They may also have behavior problems, perform poorly academically, and have difficulty in social situations.

Symptoms may be periodic, and the severity may fluctuate, but they must have persisted for at least two years (one year for children and teens) and include at least two of the following:

  • Low energy or fatigue
  • Sleep disturbances
  • Increased or decreased appetite
  • Irritable or angered easily (for children and teens)
  • Low self-esteem
  • Difficulty concentrating or making decisions
  • Feeling hopeless or pessimistic

The symptoms must create significant distress or impairment in social, occupational, educational or other important areas of functioning.

Although mood remains persistently "down," it may improve for several weeks of feeling better. Untreated, depression soon returns for longer periods. When people experience a major loss or a relationship or work problem that triggers more intense symptoms, they're more motivated to seek help.

When symptoms rise to the level of major depression, which can often occur in people with dysthymia (persistent depressive disorder), the diagnosis is "double depression" – major depression on top of dysthymia. Unlike chronic depression, an episode of major depression may only last a few weeks, but it makes a subsequent episode more likely.

Cause of Dysthymia

The cause of chronic depression may be biological, genetic, and/or environmental. It affects approximately 5.4 percent of the U.S. population age 18 and older. The numbers may be much higher since it often goes undiagnosed and untreated. Over half of dysthymic patients have a chronic illness or another psychological diagnosis, such as anxiety or drug or alcohol addiction. Dysthymia is more common in women (just as major depression is more common in women and depression when navigating divorce). There may not be an identifiable trigger; however, in cases of onset in childhood or adolescence, research suggests that there is a genetic component.

Although stress can be a factor in depression, some people don't experience a life event that triggered their depression. There are individuals with chronic depression who blame their mood on their relationship or work, not realizing that their outer circumstances are only exacerbating an internal problem.

Depression and Codependency

Depression is a symptom of codependency. Codependents often believe that they will feel fine when they achieve a goal or when a loved one changes or returns their love. They're unaware that the real cause is that they're striving to prove themselves to compensate for feeling inadequate, or that they have no life of their own, have sacrificed for someone else, or that their toxic shame leads them to feel unlovable and unworthy of love. They don't realize that their depression and emptiness stem from their childhood and codependency.

Codependents, by nature of their addiction to people, substances, or compulsive processes, lose touch with their innate self. This drains their vitality and can become a source of depression. Denial, the hallmark of addiction and codependency, and guilt can also lead to depression. Codependents deny their feelings and needs. They also deny problems and abuse and try to control things that they can't, which add to feelings of hopelessness about their life circumstances.

Other codependency symptoms, such as shame, intimacy issues, and lack of assertive communication and personal autonomy contribute to chronic depression. Internalized shame from abuse or emotional abandonment in childhood causes low self-esteem and can lead to depression. Untreated, the stages of codependency worsen over time, and feelings of hopelessness and despair deepen.

Codependency and depression can be caused by growing up in a dysfunctional family that's marked by emotional abuse, control, conflict, emotional abandonment, divorce, or illness. The ACE study demonstrated that adverse childhood experiences lead to chronic depression in adulthood. All subjects with a score of five or more were taking anti-depressants fifty years later. Other causes of dysthymia are isolation, stress, and lack of social support. (Research shows that people in abusive relationships aren't likely to disclose it.)

Dysthymia and Depression Treatment

Psychotherapy is the depression treatment of choice. It is more effective when combined with antidepressant medication. Research shows that women suffer from depression much more than men, and are more likely to seek therapy and get medication. Cognitive therapy has been shown to be effective by eliminating negative thinking to prevent the recurrence of depressive symptoms. It may mean healing trauma and PTSD from prior abuse.

In addition, patients need to develop better coping skills, heal the root cause, and change false shame-based beliefs that lead to feelings of inadequacy and being unworthy of love. Goals should be to increase self-esteem and confidence, self-efficacy, and assertiveness, and to restructure dysfunctional thinking and relationship patterns. Group therapy or support groups, such as Codependents Anonymous or other Twelve-Step Programs are effective adjuncts to psychotherapy. Lifestyle changes, such as exercise, maintaining healthy sleep habits, and participating in classes or group activities to overcome isolation are also ameliorative.

© Darlene Lancer 2015

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Darlene Lancer is a Licensed Marriage and Family Therapist and expert author on relationships, narcissism, and codependency. She’s counseled individuals and couples for over 30 years and coaches internationally. Her books include "Conquering Shame and Codependency: 8 Steps to Freeing the True You," "Dating, Loving, and Leaving a Narcissist - Essential Tools for Improving or Leaving Narcissistic and Abusive Relationships," and "Codependency for Dummies," plus seven ebooks, webinars, and other resource materials. Her books are available on Amazon, other online booksellers and her website, www.whatiscodependency.com, where you can get a free copy of “14 Tips for Letting Go.”

Los Angeles, CA

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