How can we help depressed but not (majorly) depressed patients?

Eric is a 60 year old man presenting with a depressed mood, low energy, and low appetite for the past 2 months. He notes increasing conflict with his partner, but no anhedonia, insomnia, difficulty concentrating, or thoughts of worthlessness or suicide. A year ago, he experienced a depressed mood and low energy for 2 months that resolved on their own. He is hoping to discuss treatment options today.

What diagnosis would you give Eric? 

A. Subthreshold depressive disorder 

B. Major depressive disorder (MDD)

C. Dysthymia

D. Persistent major depressive disorder 


Answer: A


These diagnoses are differentiated by the number of symptoms and the length of illness. 

Eric has subthreshold (also referred to as minor) depression, which is characterized by at least 2 weeks of depressed mood and 1-3 other major depression symptoms. In addition to the suffering caused by the depressive symptoms, adults with subthreshold depression are 5x more likely to experience an episode of major depression in the next year compared to those who do not have any depressive symptoms (Lyness, 2006). If subthreshold depression persists for 2 years, then the diagnosis of persistent depressive disorder (which includes dysthymia) is most applicable. Patients with dysthymia are never without symptoms for more than 2 months at a time. Major depressive disorder requires 5 or more depressive symptoms for at least 2 weeks. The diagnosis becomes persistent major depressive disorder when those 5 or more depressive symptoms last for at least 2 years.

Now that you’ve clarified the diagnosis of subthreshold depressive disorder, what treatment do you recommend for Eric?

A. None – it should resolve on its own

B. Antidepressant

C. Psychotherapy

D. Both an antidepressant & psychotherapy


Answer: C

Psychotherapy is the first line treatment for subthreshold depression.  It has a moderate effect on the depressive symptoms, and significantly reduces the incidence of major depression in the next 6 months (RR 0.61) (Cuipers, 2014). Importantly, the authors of this meta-analysis note that these results should be taken with caution, as the quality of these studies was deemed suboptimal, and the positive results are based on patient self-assessment only (not clinician rated outcomes). In contrast, antidepressants should not be offered as first line treatment to patients with subthreshold depression, as a 2011 meta-analysis found no significant difference between antidepressant and placebo treatment (Barbui, 2011). You can consider medication treatment for patients with subthreshold depression if their symptoms last for 2 years (at which point their diagnosis would actually be persistent depressive disorder). Patients with persistent depressive disorder respond better to antidepressant medications than placebo (RR 1.75) (Levkovitz, 2011). 

You can reassure Eric that he does not have a diagnosis of major depressive disorder, but is at higher risk of experiencing a major depressive episode in the future.  Offer him psychotherapy for now, and continue to monitor his symptoms.

References:

Barbui C, Cipriani A, Patel V, Ayuso-Mateos JL, van Ommeren M. Efficacy of antidepressants and benzodiazepines in minor depression: systematic review and meta-analysis. Br J Psychiatry. 2011;198(1):11-16. doi:10.1192/bjp.bp.109.076448

Cuijpers P, Koole SL, van Dijke A, Roca M, Li J, Reynolds CF. Psychotherapy for subclinical depression: meta-analysis. Br J Psychiatry. 2014;205(4):268-274. doi:10.1192/bjp.bp.113.138784

Levkovitz Y, Tedeschini E, Papakostas GI. Efficacy of Antidepressants for Dysthymia: A Meta-Analysis of Placebo-Controlled Randomized Trials. J Clin Psychiatry. 2011;72(04):509-514. doi:10.4088/JCP.09m05949blu

Lyness JM, Heo M, Datto CJ, et al. Outcomes of Minor and Subsyndromal Depression among Elderly Patients in Primary Care Settings. Ann Intern Med. 2006;144(7):496. doi:10.7326/0003-4819-144-7-200604040-00008

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