Articles4 April 2006
    Author, Article, and Disclosure Information



    Although depressive conditions in later life are a major public health problem, the outcomes of minor and subsyndromal depression are largely unknown.


    To compare outcomes among patients with minor and subsyndromal depression, major depression, and no depression, and to examine putative outcome predictors.


    Cohort study.


    Patients from primary care practices in greater New York City, and Philadelphia and Pittsburgh, Pennsylvania.


    622 patients who were at least 60 years of age and presented for treatment in primary care practices that provided usual care in a randomized, controlled trial of suicide prevention. Of the 441 (70.9%) patients who completed 1 year of follow-up, 122 had major depression, 205 had minor or subsyndromal depression, and 114 did not have depression at baseline.


    One year after a baseline evaluation, data were collected by using the following tools: Hamilton Depression Rating Scale, the depressive disorders section of the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition), Charlson Comorbidity Index, Multilevel Assessment Instrument for measuring instrumental activities of daily living, Physical Component Summary of the Medical Outcomes Study Short Form-36, and Duke Social Support Index.


    Patients with minor or subsyndromal depression had intermediate depressive and functional outcomes. Mean adjusted 1-year Hamilton depression score was 10.9 (95% CI, 9.6 to 12.2) for those with initial major depression, 7.0 (CI, 5.9 to 8.1) for those with minor or subsyndromal depression, and 2.9 (CI, 1.6 to 4.2) for those without depression (P < 0.001 for each paired comparison). Compared with patients who were not depressed, those who had minor or subsyndromal depression had a 5.5-fold risk (CI, 3.1-fold to 10.0-fold) for major depression at 1 year after controlling for demographic characteristics (P < 0.001). Cerebrovascular risk factors were not associated with a diagnosis of depression at 1 year after controlling for overall medical burden. Initial medical burden, self-rated health, and subjective social support were significant independent predictors of depression outcome.


    Participants received care at practices that had personnel who had been given enhanced education about depression treatment; 29.1% of participants withdrew from the study before completing 1 year of follow-up.


    The intermediate outcomes of minor and subsyndromal depression demonstrate the clinical significance of these conditions and suggest that they are part of a spectrum of depressive illness. Greater medical burden, poor subjective health status, and poorer subjective social support confer a higher risk for poor outcome.

    *Additional information regarding the authors' roles as study coordinators is available in the Appendix.


    • 1. Charney DSReynolds CFLewis LLebowitz BDSunderland TAlexopoulos GSet alDepression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life. Arch Gen Psychiatry2003;60:664-72. [PMID: 12860770] CrossrefMedlineGoogle Scholar
    • 2. Lebowitz BDPearson JLSchneider LSReynolds CFAlexopoulos GSBruce MLet alDiagnosis and treatment of depression in late life. Consensus statement update. JAMA1997;278:1186-90. [PMID: 9326481] CrossrefMedlineGoogle Scholar
    • 3. Alexopoulos GSVrontou CKakuma TMeyers BSYoung RCKlausner Eet alDisability in geriatric depression. Am J Psychiatry1996;153:877-85. [PMID: 8659609] CrossrefMedlineGoogle Scholar
    • 4. Lyness JMKing DACox CYoediono ZCaine EDThe importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability. J Am Geriatr Soc1999;47:647-52. [PMID: 10366161] CrossrefMedlineGoogle Scholar
    • 5. Beekman ATDeeg DJBraam AWSmit JHVan Tilburg WConsequences of major and minor depression in later life: a study of disability, well-being and service utilization. Psychol Med1997;27:1397-409. [PMID: 9403911] CrossrefMedlineGoogle Scholar
    • 6. Bruce MLSeeman TEMerrill SSBlazer DGThe impact of depressive symptomatology on physical disability: MacArthur Studies of Successful Aging. Am J Public Health1994;84:1796-9. [PMID: 7977920] CrossrefMedlineGoogle Scholar
    • 7. Rollman BLReynolds CFMinor and subsyndromal depression: functional disability worth treating [Editorial]. J Am Geriatr Soc1999;47:757-8. [PMID: 10366181] CrossrefMedlineGoogle Scholar
    • 8. Steffens DCHays JCKrishnan KRDisability in geriatric depression. Am J Geriatr Psychiatry1999;7:34-40. [PMID: 9919318] CrossrefMedlineGoogle Scholar
    • 9. Mueller TIKohn RLeventhal NLeon ACSolomon DCoryell Wet alThe course of depression in elderly patients. Am J Geriatr Psychiatry2004;12:22-9. [PMID: 14729555] CrossrefMedlineGoogle Scholar
    • 10. Conwell YDuberstein PRCaine EDRisk factors for suicide in later life. Biol Psychiatry2002;52:193-204. [PMID: 12182926] CrossrefMedlineGoogle Scholar
    • 11. Lavretsky HKumar AClinically significant non-major depression: old concepts, new insights. Am J Geriatr Psychiatry2002;10:239-55. [PMID: 11994211] CrossrefMedlineGoogle Scholar
    • 12. Judd LLPaulus MPWells KBRapaport MHSocioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. Am J Psychiatry1996;153:1411-7. [PMID: 8890673] CrossrefMedlineGoogle Scholar
    • 13. Judd LLSchettler PJAkiskal HSThe prevalence, clinical relevance, and public health significance of subthreshold depressions. Psychiatr Clin North Am2002;25:685-98. [PMID: 12462855] CrossrefMedlineGoogle Scholar
    • 14. Kumar AJin ZBilker WUdupa JGottlieb GLate-onset minor and major depression: early evidence for common neuroanatomical substrates detected by using MRI. Proc Natl Acad Sci U S A1998;95:7654-8. [PMID: 9636205] CrossrefMedlineGoogle Scholar
    • 15. Pasternak REPrigerson HHall MMiller MDFasiczka AMazumdar Set alThe posttreatment illness course of depression in bereaved elders. High relapse/recurrence rates. Am J Geriatr Psychiatry1997;5:54-9. [PMID: 9169245] CrossrefMedlineGoogle Scholar
    • 16. Hybels CFBlazer DGPieper CFToward a threshold for subthreshold depression: an analysis of correlates of depression by severity of symptoms using data from an elderly community sample. Gerontologist2001;41:357-65. [PMID: 11405433] CrossrefMedlineGoogle Scholar
    • 17. Parmelee PAKatz IRLawton MPDepression among institutionalized aged: assessment and prevalence estimation. J Gerontol1989;44:M22-9. [PMID: 2783434] CrossrefMedlineGoogle Scholar
    • 18. Oxman TEDietrich AJSchulberg HCThe depression care manager and mental health specialist as collaborators within primary care. Am J Geriatr Psychiatry2003;11:507-16. [PMID: 14506084] CrossrefMedlineGoogle Scholar
    • 19. Oxman TESengupta ATreatment of minor depression. Am J Geriatr Psychiatry2002;10:256-64. [PMID: 11994212] CrossrefMedlineGoogle Scholar
    • 20. Lyness JMTreatment of depressive conditions in later life: real-world light for dark (or dim) tunnels [Editorial]. JAMA2004;291:1626-8. [PMID: 15069051] CrossrefMedlineGoogle Scholar
    • 21. Schulberg HCMulsant BSchulz RRollman BLHouck PRReynolds CFCharacteristics and course of major depression in older primary care patients. Int J Psychiatry Med1998;28:421-36. [PMID: 10207741] CrossrefMedlineGoogle Scholar
    • 22. Kivela SLViramo PPahkala KFactors predicting chronicity of depression in elderly primary care patients. Int Psychogeriatr2000;12:183-94. [PMID: 10937539] CrossrefMedlineGoogle Scholar
    • 23. Kukull WAKoepsell TDInui TSBorson SOkimoto JRaskind MAet alDepression and physical illness among elderly general medical clinic patients. J Affect Disord1986;10:153-62. [PMID: 2941471] CrossrefMedlineGoogle Scholar
    • 24. Callahan CMHui SLNienaber NAMusick BSTierney WMLongitudinal study of depression and health services use among elderly primary care patients. J Am Geriatr Soc1994;42:833-8. [PMID: 8046192] CrossrefMedlineGoogle Scholar
    • 25. Lyness JMCaine EDKing DAConwell YDuberstein PRCox CDepressive disorders and symptoms in older primary care patients: one-year outcomes. Am J Geriatr Psychiatry2002;10:275-82. [PMID: 11994214] CrossrefMedlineGoogle Scholar
    • 26. Lyness JMBruce MLKoenig HGParmelee PASchulz RLawton MPet alDepression and medical illness in late life: report of a symposium. J Am Geriatr Soc1996;44:198-203. [PMID: 8576513] CrossrefMedlineGoogle Scholar
    • 27. Sinclair PALyness JMKing DACox CCaine EDDepression and self-reported functional status in older primary care patients. Am J Psychiatry2001;158:416-9. [PMID: 11229982] CrossrefMedlineGoogle Scholar
    • 28. Alexopoulos GSMeyers BSYoung RCCampbell SSilbersweig DCharlson M“Vascular depression” hypothesis. Arch Gen Psychiatry1997;54:915-22. [PMID: 9337771] CrossrefMedlineGoogle Scholar
    • 29. Lyness JMThe cerebrovascular model of depression in late life. CNS Spectr2002;7:712-5. [PMID: 15034496] CrossrefMedlineGoogle Scholar
    • 30. Krishnan KRHays JCBlazer DGMRI-defined vascular depression. Am J Psychiatry1997;154:497-501. [PMID: 9090336] CrossrefMedlineGoogle Scholar
    • 31. Steffens DCHelms MJKrishnan KRBurke GLCerebrovascular disease and depression symptoms in the cardiovascular health study. Stroke1999;30:2159-66. [PMID: 10512922] CrossrefMedlineGoogle Scholar
    • 32. Mast BTNeufeld SMacNeill SELichtenberg PALongitudinal support for the relationship between vascular risk factors and late-life depressive symptoms. Am J Geriatr Psychiatry2004;12:93-101. [PMID: 14729564] CrossrefMedlineGoogle Scholar
    • 33. Alexopoulos GSKiosses DNMurphy CHeo MExecutive dysfunction, heart disease burden, and remission of geriatric depression. Neuropsychopharmacology2004;29:2278-84. [PMID: 15340393] CrossrefMedlineGoogle Scholar
    • 34. Steffens DCKrishnan KRCrump CBurke GLCerebrovascular disease and evolution of depressive symptoms in the cardiovascular health study. Stroke2002;33:1636-44. [PMID: 12053004] CrossrefMedlineGoogle Scholar
    • 35. Lyness JMKing DAConwell YCox CCaine EDCerebrovascular risk factors and 1-year depression outcome in older primary care patients. Am J Psychiatry2000;157:1499-501. [PMID: 10964868] CrossrefMedlineGoogle Scholar
    • 36. Lyness JMCaine EDKing DAConwell YCox CDuberstein PRCerebrovascular risk factors and depression in older primary care patients: testing a vascular brain disease model of depression. Am J Geriatr Psychiatry1999;7:252-8. [PMID: 10438697] CrossrefMedlineGoogle Scholar
    • 37. Caine EDLyness JMKing DAReconsidering depression in the elderly. Am J Geriatr Psychiatry1993;1:4-20. CrossrefMedlineGoogle Scholar
    • 38. Bruce MLTen Have TRReynolds CFKatz IISchulberg HCMulsant BHet alReducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized, controlled trial. JAMA2004;291:1081-91. [PMID: 14996777] CrossrefMedlineGoogle Scholar
    • 39. Depression Guideline PanelClinical Practice Guideline Number 5: Depression in Primary Care, 2: Treatment of Major Depression. Rockville, MD: U.S. Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993. Google Scholar
    • 40. Reynolds CFDegenholtz HParker LSSchulberg HCMulsant BHPost Eet alTreatment as usual (TAU) control practices in the PROSPECT Study: managing the interaction and tension between research design and ethics. Int J Geriatr Psychiatry2001;16:602-8. [PMID: 11424169] CrossrefMedlineGoogle Scholar
    • 41. Folstein MFFolstein SEMcHugh PR“Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res1975;12:189-98. [PMID: 1202204] CrossrefMedlineGoogle Scholar
    • 42. Radloff LSThe CES-D Scale. A self-report depression scale for research in the general population. Applied Psychological Measurement1992;7:343-51. Google Scholar
    • 43. Lyness JMNoel TKCox CKing DAConwell YCaine EDScreening for depression in elderly primary care patients. A comparison of the Center for Epidemiologic Studies-Depression Scale and the Geriatric Depression Scale. Arch Intern Med1997;157:449-54. [PMID: 9046897] CrossrefMedlineGoogle Scholar
    • 44. Williams JBA structured interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry1988;45:742-7. [PMID: 3395203] CrossrefMedlineGoogle Scholar
    • 45. Spitzer RLWilliams JBWGibbon MStructured Clinical Interview for DSM-III-R (SCID). New York: New York Psychiatric Institute, Biometrics Research; 1986. Google Scholar
    • 46. American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994. Google Scholar
    • 47. American Heart AssociationStroke Risk-Factor Prediction Chart. Dallas, TX: American Heart Association; 1990. Google Scholar
    • 48. Charlson MEPompei PAles KLMacKenzie CRA new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis1987;40:373-83. [PMID: 3558716] CrossrefMedlineGoogle Scholar
    • 49. Lawton MPMoss MFulcomer MKleban MHA research and service oriented multilevel assessment instrument. J Gerontol1982;37:91-9. [PMID: 7053405] CrossrefMedlineGoogle Scholar
    • 50. Ware JESherbourne CDThe MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care1992;30:473-83. [PMID: 1593914] CrossrefMedlineGoogle Scholar
    • 51. Murrell SANorris FHHutchins GMDistribution and desirability of life events in older adults: population and policy implications. Journal of Community Psychology1984;12:301-11. CrossrefGoogle Scholar
    • 52. Landerman RGeorge LKCampbell RTBlazer DGAlternative models of the stress buffering hypothesis. Am J Community Psychol1989;17:625-42. [PMID: 2627025] CrossrefMedlineGoogle Scholar
    • 53. Hedeker DGibbons RDA random-effects ordinal regression model for multilevel analysis. Biometrics1994;50:933-44. [PMID: 7787006] CrossrefMedlineGoogle Scholar
    • 54. Neter JKutner MHNachtsheim CJWasserman WApplied Linear Statistical Models, 4th ed. New York: McGraw-Hill; 1996. Google Scholar
    • 55. Tanner MATools for Statistical Inference: Methods for the Exploration of Posterior Distributions and Likelihood Functions, 2nd ed. New York: Springer-Verlag; 1993. Google Scholar
    • 56. Horwath EJohnson JKlerman GLWeissman MMDepressive symptoms as relative and attributable risk factors for first-onset major depression. Arch Gen Psychiatry1992;49:817-23. [PMID: 1417435] CrossrefMedlineGoogle Scholar
    • 57. Dietrich AJOxman TEWilliams JWSchulberg HCBruce MLLee PWet alRe-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial. BMJ2004;329:602. [PMID: 15345600] CrossrefMedlineGoogle Scholar
    • 58. Wells KSherbourne CDuan NUnutzer JMiranda JSchoenbaum Met alQuality improvement for depression in primary care: do patients with subthreshold depression benefit in the long run? Am J Psychiatry2005;162:1149-57. [PMID: 15930064] CrossrefMedlineGoogle Scholar
    • 59. Alexopoulos GSKatz IRBruce MLHeo MTen Have TRaue Pet alRemission in depressed geriatric primary care patients: a report from the PROSPECT study. Am J Psychiatry2005;162:718-24. [PMID: 15800144] CrossrefMedlineGoogle Scholar
    • 60. Williams JWBarrett JOxman TFrank EKaton WSullivan Met alTreatment of dysthymia and minor depression in primary care: a randomized, controlled trial in older adults. JAMA2000;284:1519-26. [PMID: 11000645] CrossrefMedlineGoogle Scholar
    • 61. Unutzer JKaton WCallahan CMWilliams JWHunkeler EHarpole Let alCollaborative care management of late-life depression in the primary care setting: a randomized, controlled trial. JAMA2002;288:2836-45. [PMID: 12472325] CrossrefMedlineGoogle Scholar
    • 62. Pinquart M, Duberstein PR, Lyness JM. Treatments for later life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. Am J Psychiatry [In press]. Google Scholar
    • 63. Ciechanowski PWagner ESchmaling KSchwartz SWilliams BDiehr Pet alCommunity-integrated home-based depression treatment in older adults: a randomized, controlled trial. JAMA2004;291:1569-77. [PMID: 15069044] CrossrefMedlineGoogle Scholar