The dental profession is becoming more acutely aware of the everyday stressors facing practising dentists. If left unchecked, the effects of stress on dentists may lead to “professional burnout syndrome.”¹ In North America, professional burnout is normally attributed to an accumulation of significant occupational stress. Accordingly, dentists have been encouraged to limit the amount of stress in their practice by overcoming stress-producing habits such as perfectionism,² inefficient patient management^3,4 and even poor ergonomics.⁵ For some dentists, however, these strategies are either incorporated too late or with little zeal. Unfortunately for these individ uals, the symptoms of professional burnout syndrome — somatic complaints,¹ interpersonal problems, insomnia, irritability⁶ and suicidal ideation^7,8 - may begin to more closely resemble a psychological mood disorder known as dysthymia.

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Defining Dysthymia
Dysthymia is a chronic, pervasive mood disorder characterized by long periods of low mood and impaired functioning. Like professional burnout syndrome, additional symptoms of dysthymia may include feelings of inadequacy, despair, irritability or excessive anger, guilt, generalized loss of interest or pleasure, social withdrawal, chronic fatigue or tiredness, decreased activity levels or productivity, and poor concentration.

Dysthymia is an insidious mental disorder. Unlike the disabling functional symptoms normally associated with illnesses such as major depression, individuals affected by dysthymia generally suffer milder social and occupational dysfunction. For example, despite typical disturbances in their general interpersonal functioning,⁹ it is not unusual for dysthymics to work diligently in their profession and maintain a facade of normalcy.¹⁰ But eventually, the chronic nature of dysthymia means that the disease will negatively impede the development and maintenance of professional relations with clients and co-workers. Thus, in addition to compromising close interpersonal relationships, dysthymia may result in the loss of valued employees and clientele. A dentist who starts to lose staff or patients may become caught in a downward spiral leading to more serious consequences.

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Treatment Options
For individuals diagnosed with dysthymia, treatment may include antidepressant medication. Researchers have found that treating dysthymia with imipramine was an effective approach.¹¹ However, a significant number of people affected by dysthymia fail to respond to drug treatment because of side effects.⁹ In addition, some experts have argued that antidepressants have no specific antidepressant effect, but that their clinical impact is derived from a combination of other factors such as an enhanced placebo effect, emotional blunting and an energized stimulant effect.¹² In fact, Breggin states that the effects of antidepressants may make it more difficult for individuals to experience their feelings and to understand the source of their despair.¹²

Another intervention technique is interpersonal psychotherapy (IPT).⁹ Originally developed by Klerman and Weissman¹³ and used in the National Institute of Mental Health Treatment of Depression Collaborative Research Program,¹⁴ IPT is a manual-based, time-limited (12 to 16 weeks) individual psychotherapy with strong research efficacy.¹⁵ Using four problem areas associated with depression — grief, interpersonal disputes, role transitions and interpersonal deficits⁹ — IPT treatment focuses on difficulties in interpersonal relationships.

For people affected by dysthymia, the interpersonal emphasis of IPT makes it particularly well suited to treating decreased social facility and social withdrawal associated with this disorder.⁹ Specifically, IPT encourages people to try novel interpersonal approaches in their work and home environments. Imagine, for example, a dentist with dysthymia who, through years of isolated private practice, has not discussed his thoughts, feelings and conflicts with others for fear of compromising his high professional standards and personal integrity. Using communication analysis, role playing and other techniques, IPT will teach him the skills to overcome his fears and to foster a psychologically nurturing interpersonal network that alleviates the symptoms of dysthymia.

Regardless of the type of intervention individuals receive for dysthymia, it is essential that they seek effective treatment. Longitudinal studies have found that nearly 80% of people diagnosed with untreated dysthymia develop a history of comorbid major depression,¹⁶ and nearly 50% develop a severe personality disorder¹⁷ and are at elevated risk for substance abuse.¹⁸ Thus it is important for dentists who find themselves under significant stress to recognize when they are at risk for crossing the threshold from professional burnout syndrome into the world of dysthymia.

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Dr. Frey is a private practitioner and consultant who specializes in interpersonal and cognitive therapy.

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References
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14. Elkin I, Shea MT, Watkins JT, Imber, IM, Stotsky SM, Collins JF and others. National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments. Arch Gen Psychiatry 1989; 46:971-82.

15. Weissman MM, Markowitz JC. Interpersonal psychotherapy: current status. Arch Gen Psychiatry 1994; 51:599-606.

16. McCullough JP, Klein DN, Shea MT, and others. DSM-IV field trial for major depression, dysthymia, and minor depression. Abstracts of the American Psychological Association Annual Meeting. Washington, DC; 1992.

17. Klein DN, Taylor EB, Harding K, Dickstein S. Double depression and episodic major depression: demographic, clinical, familial, personality, and socioenvironmental characteristics and short-term outcome. Am J Psychiatry 1988; 41:229-37.