Special Article
Clinically Significant Non-Major Depression: Old Concepts, New Insights

https://doi.org/10.1097/00019442-200205000-00003Get rights and content

Clinically significant non-major depression has been underinvestigated despite its high prevalence and public health impact. Although there is an increasing recognition of the importance of non-major forms of depression, their nosological boundaries and neurobiological mechanisms remain largely unknown. The authors discuss the literature pertaining to the current concepts, phenomenology, neurobiology, and treatment approaches to geriatric non-major clinically significant depression. They examine the similarities and differences between various subtypes of depressive disorders and compare non-major, clinically significant depression in elderly patients with non-geriatric adult populations. They draw conclusions from the published literature and propose clinical criteria for the diagnosis of clinically significant non-major depression in elderly persons.

Section snippets

Nosological and Diagnostic Complexities

In current psychiatric practice and research in both elderly patients and younger adult populations, two principal approaches define depression: 1) depressive symptoms; and 2) more specific depressive illnesses or disorders defined in terms of duration, number, and type of depressive symptoms. Most nonpsychiatrists typically regard depression in terms of the first construct, whereas psychiatrists apply the second.8 Most studies demonstrate that patients with depressive symptoms, even in the

Minor Depression

Minor Depressive Disorder is now included in the DSM-IV as a “potential category,” with a set of diagnostic research criteria proposed for further studies.10 The essential feature of minor depression is one or more periods of depressive symptoms that are identical to major depressive episodes in duration (2 weeks or longer), but which involve fewer symptoms and less impairment. An episode involves either a depressed mood or loss of interest or pleasure in nearly all activities. In total, at

DOES GERIATRIC “NON-MAJOR DEPRESSION” DIFFER FROM DEPRESSION IN YOUNGER ADULTS?

Some similarities and differences exist in phenomenology and disease course of depression in elderly patients and in younger adults.49, 50, 51 Unlike major depression, with its preponderance of biological and melancholic features, the clinical presentation of minor depression is variable.52 Blazer and colleagues9 identified a symptom cluster profile unique to people over 60 years old, characterized by depressed mood, psychomotor retardation, poor concentration, constipation, and poor

TREATMENT

To date, studies of treatment of non-major depressive disorders are limited in number. Very little is known about treatment strategies in clinically significant non-major depression. Most existing studies focus on dysthymia and minor depression in primary care.39, 46, 106, 107

Descriptive studies have established that in treating depression, primary care providers use one or more of three modalities: watchful waiting, medication, and referral to the specialty sector.108 Used most commonly,

CONCLUSIONS

There are similarities and differences in the manifestations of clinically significant depressive disorders. There is an emerging consensus from epidemiological, longitudinal, and genetic studies supporting the idea of a continuum of depressive disorders, ranging from the very mild “subthreshold” to major unipolar and bipolar disorders. Evidence from neuroimaging and neuropsychological studies lends additional support to this thesis. All forms of clinically significant depression are associated

References (123)

  • AJ Rush et al.

    Depression-spectrum disease with and without depression in first-degree relatives

    J Affect Disord

    (1995)
  • AD Roses et al.

    APOE is a major susceptibility gene for Alzheimer's disease

    Curr Opin Biotechnol

    (1994)
  • GS Zubenko et al.

    Association of the APOE epsilon-4 allele with clinical subtypes of late-life depression

    Biol Psychiatry

    (1996)
  • H Lavretsky et al.

    Apolipoprotein-E and white-matter hyperintensities in late-life depression

    Am J Geriatr Psychiatry

    (2000)
  • ML Levy et al.

    Apolipoprotein-E genotype and noncognitive symptoms in Alzheimer's disease

    Biol Psychiatry

    (1999)
  • M Mauricio et al.

    A longitudinal study of apolipoprotein-E genotype and depressive symptoms in community-dwelling older adults

    Am J Geriatr Psychiatry

    (2000)
  • BD Lebowitz et al.

    Diagnosis and treatment of depression in late life: consensus statement update

    JAMA

    (1997)
  • AT Beekman et al.

    Consequences of major and minor depression in later life: a study of disability, well-being, and service utilization

    Psychol Med

    (1997)
  • DA Beck et al.

    Minor depression: a review of the literature

    Int J Psychiatry Med

    (1996)
  • HG Koenig

    Differences in psychosocial and health correlates of major and minor depression in medically ill older adults

    J Am Geriatr Soc

    (1997)
  • LL Judd et al.

    Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population

    Am J Psychiatry

    (1996)
  • C Tannock et al.

    Minor depression in the aged: concepts, prevalence, and optimal management

    Drugs Aging

    (1995)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (1994)
  • WE Broadhead et al.

    Depression, disability days, and days from work in a prospective epidemiological survey

    JAMA

    (1990)
  • KB Wells et al.

    The functioning and well-being of depressed patients: results from the Medical Outcomes Study

    JAMA

    (1989)
  • RE Kendell

    Clinical validity

    Psychol Med

    (1989)
  • RE Kendell

    What is a case?

    Arch Gen Psychiatry

    (1988)
  • ED Caine et al.

    Clinical and etiological heterogeneity of mood disorders in elderly patients

  • OP Wiggings et al.

    The limits of psychiatric knowledge and the problem of classification

  • SB Guze

    Why Psychiatry Is A Branch of Medicine

    (1992)
  • HM Van Praag

    The DSM-IV (Depression) classification: to be or not to be?

    J Nerv Ment Dis

    (1990)
  • HM Van Praag

    Inflationary tendencies in judging the yield of depression research

    Biol Psychiatry

    (1998)
  • HM Van Praag

    Diagnosis, the rate-limiting factor of biological depression research

    Biol Psychiatry

    (1993)
  • E Robins et al.

    Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia

    Am J Psychiatry

    (1970)
  • D Goldberg et al.

    Common Mental Disorders: A Bio-Social Model

    (1992)
  • DA Grayson et al.

    The relationship between symptoms and diagnoses of minor psychiatric disorder in general practice

    Psychol Med

    (1987)
  • DA Grayson et al.

    Diagnosis of dementia and depression: a latent trait analysis of their performance

    Psychol Med

    (1987)
  • JJ Gallo et al.

    Age differences in the symptoms of depression: a latent trait analysis

    J Gerontol Psychol Sci

    (1994)
  • J Gallo

    The epidemiology of mental disorders in middle-age and late-life: conceptual issues

    Epidemiol Rev

    (1995)
  • JJ Gallo et al.

    Sadness in older persons: 13-year follow-up of a community sample in Baltimore, Maryland

    Psychol Med

    (1999)
  • AY Tien et al.

    Clinical diagnosis: a marker for disease?

    J Nerv Ment Dis

    (1997)
  • G Parker et al.

    Subtyping depression, I: is psychomotor disturbance necessary and sufficient to the definition of melancholia?

    Psychol Med

    (1995)
  • G Parker et al.

    Subtyping depression, II: clinical distinction of psychotic depression and non-psychotic melancholia

    Psychol Med

    (1995)
  • G Parker et al.

    Subtyping depression, III: development of a clinical algorithm for melancholia and comparison with other diagnostic measures

    Psychol Med

    (1995)
  • WAM Volleberg et al.

    The structure and stability of common mental disorders

    Arch Gen Psychiatry

    (2001)
  • LL Judd et al.

    A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders

    Arch Gen Psychiatry

    (1998)
  • BL Rollman et al.

    Minor and subsyndromal depression: functional disability worth treating (editorial; comment)

    J Am Geriatr Soc

    (1999)
  • HG Koenig et al.

    Depression in medically ill hospitalized older adults: prevalence, characteristics, and course of symptoms according to six diagnostic schemes

    Am J Psychiatry

    (1997)
  • Cited by (128)

    • Depression among older adults with diabetes mellitus

      2015, Clinics in Geriatric Medicine
    View all citing articles on Scopus

    Dr. Kumar is at the UCLA Department of Psychiatry and Biobehavioral Sciences.

    This work was supported in part by the NARSAD Young Investigator Award and K23-MH 01948 to Dr. Lavretsky, and grants MH55115, MH 61567, and KO2-MH02043 (to Dr. Kumar).

    View full text