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.
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.
Charney DS, Reynolds CF, Lewis L, Lebowitz BD, Sunderland T, Alexopoulos GS, et al. Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life. Arch Gen Psychiatry. 2003;60:664-72. [PMID: 12860770] CrossrefMedlineGoogle Scholar
Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce ML, et al. Diagnosis and treatment of depression in late life. Consensus statement update. JAMA. 1997;278:1186-90. [PMID: 9326481] CrossrefMedlineGoogle Scholar
Alexopoulos GS, Vrontou C, Kakuma T, Meyers BS, Young RC, Klausner E, et al. Disability in geriatric depression. Am J Psychiatry. 1996;153:877-85. [PMID: 8659609] CrossrefMedlineGoogle Scholar
Lyness JM, King DA, Cox C, Yoediono Z, Caine ED. The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability. J Am Geriatr Soc. 1999;47:647-52. [PMID: 10366161] CrossrefMedlineGoogle Scholar
Beekman AT, Deeg DJ, Braam AW, Smit JH, Van Tilburg W. Consequences of major and minor depression in later life: a study of disability, well-being and service utilization. Psychol Med. 1997;27:1397-409. [PMID: 9403911] CrossrefMedlineGoogle Scholar
Bruce ML, Seeman TE, Merrill SS, Blazer DG. The impact of depressive symptomatology on physical disability: MacArthur Studies of Successful Aging. Am J Public Health. 1994;84:1796-9. [PMID: 7977920] CrossrefMedlineGoogle Scholar
Rollman BL, Reynolds CF. Minor and subsyndromal depression: functional disability worth treating [Editorial]. J Am Geriatr Soc. 1999;47:757-8. [PMID: 10366181] CrossrefMedlineGoogle Scholar
Steffens DC, Hays JC, Krishnan KR. Disability in geriatric depression. Am J Geriatr Psychiatry. 1999;7:34-40. [PMID: 9919318] CrossrefMedlineGoogle Scholar
Mueller TI, Kohn R, Leventhal N, Leon AC, Solomon D, Coryell W, et al. The course of depression in elderly patients. Am J Geriatr Psychiatry. 2004;12:22-9. [PMID: 14729555] CrossrefMedlineGoogle Scholar
Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later life. Biol Psychiatry. 2002;52:193-204. [PMID: 12182926] CrossrefMedlineGoogle Scholar
Lavretsky H, Kumar A. Clinically significant non-major depression: old concepts, new insights. Am J Geriatr Psychiatry. 2002;10:239-55. [PMID: 11994211] CrossrefMedlineGoogle Scholar
Judd LL, Paulus MP, Wells KB, Rapaport MH. Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. Am J Psychiatry. 1996;153:1411-7. [PMID: 8890673] CrossrefMedlineGoogle Scholar
Judd LL, Schettler PJ, Akiskal HS. The prevalence, clinical relevance, and public health significance of subthreshold depressions. Psychiatr Clin North Am. 2002;25:685-98. [PMID: 12462855] CrossrefMedlineGoogle Scholar
Kumar A, Jin Z, Bilker W, Udupa J, Gottlieb G. Late-onset minor and major depression: early evidence for common neuroanatomical substrates detected by using MRI. Proc Natl Acad Sci U S A. 1998;95:7654-8. [PMID: 9636205] CrossrefMedlineGoogle Scholar
Pasternak RE, Prigerson H, Hall M, Miller MD, Fasiczka A, Mazumdar S, et al. The posttreatment illness course of depression in bereaved elders. High relapse/recurrence rates. Am J Geriatr Psychiatry. 1997;5:54-9. [PMID: 9169245] CrossrefMedlineGoogle Scholar
Hybels CF, Blazer DG, Pieper CF. Toward a threshold for subthreshold depression: an analysis of correlates of depression by severity of symptoms using data from an elderly community sample. Gerontologist. 2001;41:357-65. [PMID: 11405433] CrossrefMedlineGoogle Scholar
Parmelee PA, Katz IR, Lawton MP. Depression among institutionalized aged: assessment and prevalence estimation. J Gerontol. 1989;44:M22-9. [PMID: 2783434] CrossrefMedlineGoogle Scholar
Oxman TE, Dietrich AJ, Schulberg HC. The depression care manager and mental health specialist as collaborators within primary care. Am J Geriatr Psychiatry. 2003;11:507-16. [PMID: 14506084] CrossrefMedlineGoogle Scholar
Oxman TE, Sengupta A. Treatment of minor depression. Am J Geriatr Psychiatry. 2002;10:256-64. [PMID: 11994212] CrossrefMedlineGoogle Scholar
Lyness JM. Treatment of depressive conditions in later life: real-world light for dark (or dim) tunnels [Editorial]. JAMA. 2004;291:1626-8. [PMID: 15069051] CrossrefMedlineGoogle Scholar
Schulberg HC, Mulsant B, Schulz R, Rollman BL, Houck PR, Reynolds CF. Characteristics and course of major depression in older primary care patients. Int J Psychiatry Med. 1998;28:421-36. [PMID: 10207741] CrossrefMedlineGoogle Scholar
Kivela SL, Viramo P, Pahkala K. Factors predicting chronicity of depression in elderly primary care patients. Int Psychogeriatr. 2000;12:183-94. [PMID: 10937539] CrossrefMedlineGoogle Scholar
Kukull WA, Koepsell TD, Inui TS, Borson S, Okimoto J, Raskind MA, et al. Depression and physical illness among elderly general medical clinic patients. J Affect Disord. 1986;10:153-62. [PMID: 2941471] CrossrefMedlineGoogle Scholar
Callahan CM, Hui SL, Nienaber NA, Musick BS, Tierney WM. Longitudinal study of depression and health services use among elderly primary care patients. J Am Geriatr Soc. 1994;42:833-8. [PMID: 8046192] CrossrefMedlineGoogle Scholar
Lyness JM, Caine ED, King DA, Conwell Y, Duberstein PR, Cox C. Depressive disorders and symptoms in older primary care patients: one-year outcomes. Am J Geriatr Psychiatry. 2002;10:275-82. [PMID: 11994214] CrossrefMedlineGoogle Scholar
Lyness JM, Bruce ML, Koenig HG, Parmelee PA, Schulz R, Lawton MP, et al. Depression and medical illness in late life: report of a symposium. J Am Geriatr Soc. 1996;44:198-203. [PMID: 8576513] CrossrefMedlineGoogle Scholar
Sinclair PA, Lyness JM, King DA, Cox C, Caine ED. Depression and self-reported functional status in older primary care patients. Am J Psychiatry. 2001;158:416-9. [PMID: 11229982] CrossrefMedlineGoogle Scholar
Alexopoulos GS, Meyers BS, Young RC, Campbell S, Silbersweig D, Charlson M. “Vascular depression” hypothesis. Arch Gen Psychiatry. 1997;54:915-22. [PMID: 9337771] CrossrefMedlineGoogle Scholar
Lyness JM. The cerebrovascular model of depression in late life. CNS Spectr. 2002;7:712-5. [PMID: 15034496] CrossrefMedlineGoogle Scholar
Krishnan KR, Hays JC, Blazer DG. MRI-defined vascular depression. Am J Psychiatry. 1997;154:497-501. [PMID: 9090336] CrossrefMedlineGoogle Scholar
Steffens DC, Helms MJ, Krishnan KR, Burke GL. Cerebrovascular disease and depression symptoms in the cardiovascular health study. Stroke. 1999;30:2159-66. [PMID: 10512922] CrossrefMedlineGoogle Scholar
Mast BT, Neufeld S, MacNeill SE, Lichtenberg PA. Longitudinal support for the relationship between vascular risk factors and late-life depressive symptoms. Am J Geriatr Psychiatry. 2004;12:93-101. [PMID: 14729564] CrossrefMedlineGoogle Scholar
Alexopoulos GS, Kiosses DN, Murphy C, Heo M. Executive dysfunction, heart disease burden, and remission of geriatric depression. Neuropsychopharmacology. 2004;29:2278-84. [PMID: 15340393] CrossrefMedlineGoogle Scholar
Steffens DC, Krishnan KR, Crump C, Burke GL. Cerebrovascular disease and evolution of depressive symptoms in the cardiovascular health study. Stroke. 2002;33:1636-44. [PMID: 12053004] CrossrefMedlineGoogle Scholar
Lyness JM, King DA, Conwell Y, Cox C, Caine ED. Cerebrovascular risk factors and 1-year depression outcome in older primary care patients. Am J Psychiatry. 2000;157:1499-501. [PMID: 10964868] CrossrefMedlineGoogle Scholar
Lyness JM, Caine ED, King DA, Conwell Y, Cox C, Duberstein PR. Cerebrovascular risk factors and depression in older primary care patients: testing a vascular brain disease model of depression. Am J Geriatr Psychiatry. 1999;7:252-8. [PMID: 10438697] CrossrefMedlineGoogle Scholar
Caine ED, Lyness JM, King DA. Reconsidering depression in the elderly. Am J Geriatr Psychiatry. 1993;1:4-20. CrossrefMedlineGoogle Scholar
Bruce ML, Ten Have TR, Reynolds CF, Katz II, Schulberg HC, Mulsant BH, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized, controlled trial. JAMA. 2004;291:1081-91. [PMID: 14996777] CrossrefMedlineGoogle Scholar
Depression Guideline Panel. Clinical 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
Reynolds CF, Degenholtz H, Parker LS, Schulberg HC, Mulsant BH, Post E, et al. Treatment as usual (TAU) control practices in the PROSPECT Study: managing the interaction and tension between research design and ethics. Int J Geriatr Psychiatry. 2001;16:602-8. [PMID: 11424169] CrossrefMedlineGoogle Scholar
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-98. [PMID: 1202204] CrossrefMedlineGoogle Scholar
Radloff LS. The CES-D Scale. A self-report depression scale for research in the general population. Applied Psychological Measurement. 1992;7:343-51. Google Scholar
Lyness JM, Noel TK, Cox C, King DA, Conwell Y, Caine ED. Screening for depression in elderly primary care patients. A comparison of the Center for Epidemiologic Studies-Depression Scale and the Geriatric Depression Scale. Arch Intern Med. 1997;157:449-54. [PMID: 9046897] CrossrefMedlineGoogle Scholar
Williams JB. A structured interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry. 1988;45:742-7. [PMID: 3395203] CrossrefMedlineGoogle Scholar
Spitzer RL, Williams JBW, Gibbon M. Structured Clinical Interview for DSM-III-R (SCID). New York: New York Psychiatric Institute, Biometrics Research; 1986. Google Scholar
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994. Google Scholar
American Heart Association. Stroke Risk-Factor Prediction Chart. Dallas, TX: American Heart Association; 1990. Google Scholar
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373-83. [PMID: 3558716] CrossrefMedlineGoogle Scholar
Lawton MP, Moss M, Fulcomer M, Kleban MH. A research and service oriented multilevel assessment instrument. J Gerontol. 1982;37:91-9. [PMID: 7053405] CrossrefMedlineGoogle Scholar
Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473-83. [PMID: 1593914] CrossrefMedlineGoogle Scholar
Murrell SA, Norris FH, Hutchins GM. Distribution and desirability of life events in older adults: population and policy implications. Journal of Community Psychology. 1984;12:301-11. CrossrefGoogle Scholar
Landerman R, George LK, Campbell RT, Blazer DG. Alternative models of the stress buffering hypothesis. Am J Community Psychol. 1989;17:625-42. [PMID: 2627025] CrossrefMedlineGoogle Scholar
Hedeker D, Gibbons RD. A random-effects ordinal regression model for multilevel analysis. Biometrics. 1994;50:933-44. [PMID: 7787006] CrossrefMedlineGoogle Scholar
Neter J, Kutner MH, Nachtsheim CJ, Wasserman W. Applied Linear Statistical Models, 4th ed. New York: McGraw-Hill; 1996. Google Scholar
Tanner MA. Tools for Statistical Inference: Methods for the Exploration of Posterior Distributions and Likelihood Functions, 2nd ed. New York: Springer-Verlag; 1993. Google Scholar
Horwath E, Johnson J, Klerman GL, Weissman MM. Depressive symptoms as relative and attributable risk factors for first-onset major depression. Arch Gen Psychiatry. 1992;49:817-23. [PMID: 1417435] CrossrefMedlineGoogle Scholar
Dietrich AJ, Oxman TE, Williams JW, Schulberg HC, Bruce ML, Lee PW, et al. Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial. BMJ. 2004;329:602. [PMID: 15345600] CrossrefMedlineGoogle Scholar
Wells K, Sherbourne C, Duan N, Unutzer J, Miranda J, Schoenbaum M, et al. Quality improvement for depression in primary care: do patients with subthreshold depression benefit in the long run? Am J Psychiatry. 2005;162:1149-57. [PMID: 15930064] CrossrefMedlineGoogle Scholar
Alexopoulos GS, Katz IR, Bruce ML, Heo M, Ten Have T, Raue P, et al. Remission in depressed geriatric primary care patients: a report from the PROSPECT study. Am J Psychiatry. 2005;162:718-24. [PMID: 15800144] CrossrefMedlineGoogle Scholar
Williams JW, Barrett J, Oxman T, Frank E, Katon W, Sullivan M, et al. Treatment of dysthymia and minor depression in primary care: a randomized, controlled trial in older adults. JAMA. 2000;284:1519-26. [PMID: 11000645] CrossrefMedlineGoogle Scholar
Unutzer J, Katon W, Callahan CM, Williams JW, Hunkeler E, Harpole L, et al. Collaborative care management of late-life depression in the primary care setting: a randomized, controlled trial. JAMA. 2002;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
Ciechanowski P, Wagner E, Schmaling K, Schwartz S, Williams B, Diehr P, et al. Community-integrated home-based depression treatment in older adults: a randomized, controlled trial. JAMA. 2004;291:1569-77. [PMID: 15069044] CrossrefMedlineGoogle Scholar
Author, Article and Disclosure Information
From University of Rochester Medical Center, Rochester, New York; Weill Medical College of Cornell University, White Plains, New York; University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Grant Support: PROSPECT is a collaborative research study funded by the National Institute of Mental Health. The 3 collaborative sites include the Advanced Centers for Intervention and Services Research of Cornell University (R01 MH59366, P30 MH68638), the University of Pennsylvania (R01 MH59380, P30 MH52129), and the University of Pittsburgh (R01 MH59381, P30 MH52247, P30 MH71944). Additional small grants came from Forest Laboratories and the John D. Hartford Foundation. Dr. Bruce is a recipient of National Institute of Mental Health grant NIMH K02 MH01634, and Dr. Lyness is supported by NIMH R01 MH61429 and K24 MH71509 from the Institute.
Disclosures: Consultancies: G.S. Alexopoulos (Forest Pharmaceuticals); Honoraria: G.S. Alexopoulos (Forest Pharmaceuticals, Janssen, Cephalon, Pfizer Inc., Bristol-Myers Squibb, Eli Lilly Inc., Glaxo Wellcome); Grants received: G.S. Alexopoulos (Forest Pharmaceuticals, Cephalon); Other (tablets and placebos): C.F. Reynolds III (Forest Pharmaceuticals, GlaxoSmithKline, Pfizer Inc., Eli Lilly Inc.).
Corresponding Author: Jeffrey M. Lyness, MD, Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Boulevard, Rochester, NY 14642; e-mail, [email protected]
Current Author Addresses: Dr. Lyness: Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Boulevard, Rochester, NY 14642.
Drs. Heo, Alexopoulos, and Bruce: New York Hospital Cornell Medical Center, 21 Bloomingdale Road, White Plains, NY 10605.
Drs. Datto, Ten Have, and Katz: University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104.
Drs. Drayer and Reynolds: Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15213.
Author Contributions: Conception and design: J.M. Lyness, T.R.Ten Have, I.R. Katz, C.F. Reynolds III, G.S. Alexopoulos, M.L. Bruce.
Analysis and interpretation of the data: J.M. Lyness, M. Heo, C.J. Datto, R. Drayer, I.R. Katz, M.L. Bruce.
Drafting of the article: J.M. Lyness, C.J. Datto, C.F. Reynolds III, G.S. Alexopoulos, M.L. Bruce.
Critical revision of the article for important intellectual content: J.M. Lyness, M. Heo, T.R.Ten Have, C.J. Datto, R. Drayer, C.F. Reynolds III, G.S. Alexopoulos, I.R. Katz, M.L. Bruce.
Final approval of the article: J.M. Lyness, M. Heo, T.R.Ten Have, C.J. Datto, C.F. Reynolds III, G.S. Alexopoulos, I.R. Katz, M.L. Bruce.
Provision of study materials or patients: C.F. Reynolds III, G.S. Alexopoulos, I.R. Katz, M.L. Bruce.
Statistical expertise: T.R.Ten Have, M. Heo.
Obtaining of funding: T.R.Ten Have, C.F. Reynolds III, G.S. Alexopoulos, I.R. Katz, M.L. Bruce.
Administrative, technical, or logistic support: I.R. Katz, M.L. Bruce.
Collection and assembly of data: C.J. Datto, G.S. Alexopoulos, I.R. Katz, M.L. Bruce.