In this column we focus on clinically significant geriatric depression that does not meet established criteria for major depressive disorder. This category encompasses several clinical subtypes with subtle distinctions. We highlight the phenomenologic and therapeutic evidence in support of this category of disorders.
Studies of treatment of nonmajor depressive disorders are limited (
+14,
+15). Little is known about treatment strategies for clinically significant nonmajor depression. Most studies have focused on dysthymia and minor depression in primary care settings.
Descriptive studies have established that primary care providers use one or more of three modalities in treating depression: watchful waiting, medication, and referral to the specialty sector. In the case of watchful waiting, the most commonly used modality, it has been shown that return visits involve sympathetic listening and a show of interest, and in some cases brief "common sense" counseling.
The use of medication is virtually the only active treatment delivered by primary care providers, but the evidence of efficacy of psychopharmacologic interventions for persons with nonmajor depression is lacking. Oxman and Sengupta (
+14) reviewed treatment of minor depression and concluded that older persons were as responsive to treatment as younger persons. The limited evidence from randomized trials that have included a control condition suggests that antidepressants and counseling have some benefit and should be attempted. However, the placebo responses were high in the few controlled studies that have been conducted, and such nonspecific therapeutic factors as an attentive physician may be particularly beneficial.
Both similarities and differences exist in the clinical manifestations of clinically significant depressive disorders. There is an emerging consensus from epidemiologic and longitudinal studies that supports the idea of a continuum of depressive disorders, ranging from the very mild "subthreshold" depression to major unipolar and bipolar disorders. All forms of clinically significant depression are associated with considerable economic and psychosocial consequences. Current approaches to studying affective illness that adhere to traditional nosologic categories may not be adequate for the next generation of research into the biologic and psychosocial correlates of this group of disorders. We propose clinical criteria for the diagnosis of clinically significant nonmajor depression among elderly persons (see box). These criteria are consistent with operational definitions of minor depression used in other clinical studies but are broader in clinical and methodologic scope.
Proposed diagnostic criteria for clinically significant nonmajor depression
1. Presence of low mood or loss of interest in all activities most of the day, nearly every day
2. At least two additional symptoms from the DSM checklist:
• Significant weight loss when not dieting or weight gain (a change of more than 5 percent in body weight in a month) or a decrease or increase in appetite nearly every day
• Insomnia or hypersomnia nearly every day
• Pychomotor retardation or agitation nearly every day (observable by others, not merely subjective feelings of restlessness or slowness
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
• Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
3. The symptoms cause clinically significant distress or impairment in social and occupational functioning
4. A score of at least 10 on the 17-item Hamilton Depression Scale or at least 12 on the Geriatric Depression Scale (GDS) (or a GDS score of at least 5 on the 15-item scale)
5. Duration of at least one month; duration subtypes: one to six months, six to 24 months, and more than 24 months
6. The symptoms may be associated with precipitating events, such as the loss of a significant other
7. Organic criteria based on comorbid conditions:
• Objective evidence from physical and neurologic examination and laboratory tests or history of cerebral disease, damage, or dysfunction or of systemic physical disorder known to cause cerebral dysfunction, including hormonal disturbances and drug effects
• A presumed relationship between the development or exacerbation of the underlying disease and clinically significant depression
• The disturbance is confined to the direct psychological effect of alcohol or drug use
• Recovery or significant improvement in the depressive symptoms after removal of or improvement in the underlying presumed cause
8. Exclusion criteria: no lifetime history of an episode of mania or hypomania, or a chronic psychotic disorder, such as schizophrenia or delusional disorder. History of major depressive episode is not an exclusion criterion
This work was supported in part by a Young Investigator Award from the National Alliance for Research on Schizophrenia and Depression and by grant K23-MH-01948 to Dr. Lavretsky and grants MH-55115, MH-61567, and KO2-MH-02043 to Dr. Kumar from the National Institutes of Health.