Regular Research Articles
Outcomes of Subsyndromal Depression in Older Primary Care Patients

https://doi.org/10.1097/JGP.0b013e3181cb87d6Get rights and content

Objectives

Most older persons in primary care suffering clinically significant depressive symptoms do not meet criteria for major or minor depression. The authors tested the hypothesis that patients with subsyndromal depression (SSD) would have poorer psychiatric, medical, and functional outcomes at follow-up than nondepressed patients but not as poor as those with minor or major depression. The authors also explored the relative outcomes of three definitions of SSD to determine their relative prognostic value.

Design

Prospective observational cohort study.

Setting

Primary care practices in Monroe County, NY.

Participants

Four hundred eighty-one primary care patients aged 65 years and older who completed research assessments at intake and at least 1 year of follow-up evaluation.

Measurements

Depression diagnoses and three definitions of SSD were determined by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the 24-item Hamilton Depression Rating Scale. Other validated measures assessed anxiety, cognition, medical burden, and functional status.

Results

Patients with SSD had poorer 1-year lagged outcomes than nondepressed subjects in terms of psychiatric symptoms and functional status, often not significantly different than major or minor depression. Two of the SSD definitions identified subjects with poorer psychiatric and functional outcomes than the third SSD definition.

Conclusions

Clinicians should be vigilant in caring for patients with SSD, monitoring for persistent, or worsening depressive symptoms including suicidality, anxiety, cognitive impairment, and functional decline. Researchers may use particular SSD definitions to identify individuals at higher risk of poor outcomes, to better understand the relationships of SSD to functional disability, and to test innovative preventive and therapeutic interventions.

Section snippets

Procedures and Subjects

The methods of this study have been described previously.18 Briefly, we attempted to enroll all patients aged 65 years or older who presented for care at primary care offices on select days. Sites for enrollment included internal medicine and family medicine private practices and hospital-based clinic settings. Patients gave written consent to participate in the study, using procedures approved by the University of Rochester Research Subjects Review Board. Consenting subjects underwent

RESULTS

Of the 745 subjects initially enrolled, 472 were women (63.3%), 684 were whites (91.8%), 44 African Americans (5.9%), and 17 from other racial or ethnic groups (2.3%). Of the whole group, 41 (5.5%) had major depression, 52 (6.9%) minor depression, and 146 (19.6%) had SSD-A. Using the alternative SSD definitions, 113 (15.2%) had SSD-B and 206 (27.7%) had SSD-C. Overall, 280 (37.6%) met criteria for at least one SSD diagnosis, leaving 372 (49.9%) who were nondepressed by all SSD definitions.

CONCLUSIONS

Our findings confirmed a key aspect of our hypothesis: Patients with SSD had poorer outcomes than nondepressed subjects in terms of psychiatric symptoms and functional status. In many cases, the SSD outcomes were not significantly different from the outcomes of minor and even major depression, e.g., with respect to 1-year lagged overall depressive symptom severity, suicidal ideation, psychic anxiety, cognition, and medical burden. These results build on prior work regarding the clinical

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  • Cited by (0)

    Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.AJGPonline.org).

    The authors thank the patients, staff, and providers of the following primary care practices: University of Rochester Medical Center, Department of Medicine; Pulsifer Medical; East Ridge Family Medicine; Highland Family Medicine; Olsan Medical; Clinton Crossings Medical; Panorama Internal Medicine; Highland Geriatric Medicine; and Culver Medical. The authors thank the following members for technical assistance: Karen Gibson, M.S.Ed.; Constance Bowen, M.A.; James Evinger, M.Div.; Cameron Gardner, M.D.; Iwona Juskiewicz, M.D., Ayesha Khan, M.D., Michael New; Andra Niculescu, M.D.; Jean Sauvain, B.S.; Jill Scheltz, B.A., L.M.T.; and Judy Woodhams, M.F.A.

    This work was supported by NIMH grants R01 MH061429 and K24 MH071509.

    Presented in part at the American Association for Geriatric Psychiatry, Orlando, FL, March 16, 2008.

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