WHAT IS SUBCLINICAL DEPRESSION?

Subclinical depression is depression that is not extensive enough in symptoms to merit a diagnosis of major depression or dysthymia according to DSM-IV, which categorizes various mental and emotional diseases and lists required symptoms for each major diagnostic category.

However, a patient diagnosed with a given disorder doesn’t necessarily display every one of those listed characteristic symptoms. Of the nine symptoms listed for major depression, any five permit the diagnosis. Dysthymia also has a list of nine symptoms; only three are required for the diagnosis. A diagnosis of mania or hypomania also requires a specific number of symptoms, but mild hypomania, unlike mania, may cause little or no impairment of functioning and may be, in fact, desirable.

But what about patients who have only two of the traits needed for diagnosis of major depression? Or only one? Feelings of despair, hopelessness, and pessimism alone aren’t enough to diagnose major depression or dysthymia. Merely feeling depressed, sad, empty, timid, or withdrawn most of the time does not qualify as major depression or dysthymia, although these are certainly a few of the symptoms included in these syndromes. Some patients, normal in all other respects, may only exhibit sleep disruption or a severe drop in self-esteem or a fear of new social situations. Other patients may come in with a myriad of physical complaints, none of which can be explained by physical causes, and alone these complaints do not allow the physician to diagnose depression.

Because these patients fall short of the totality of the required DSM-IV symptoms for diagnosing major depression or dysthymia, manifesting only a single, or a few isolated symptoms of the illness (depression) they, therefore, do not qualify for one of the DSM-IV diagnoses. Instead, they are counted among the subclinically depressed and are often exclusively treated in psychotherapy, either sitting or lying on the couch, by the psychoanalyst, psychologist, psychiatrist, or social work-therapist.

People who fall into this category often remain incompletely diagnosed and untreated because they may continue to function fairly well and don’t feel enough pain to go to a psychiatrist. They may instead go to their internist or psychologist and be diagnosed with “irritable bowel syndrome” or “personality disorder”. They’re just miserable most of the time, and misery is not a formal psychiatric diagnosis.

Often considered ideal candidates for psychoanalysis, these patients have been called the “worried well”. They tend to seek psychotherapy, feeling that their timidity, lack of interest, difficulty competing with their peers, and low self-confidence are psychological problems, which will be “cured” on the couch. When the subclinical depressive symptoms have been chronic, therapy alone usually fails. But I have seen many patients with subclinical depressions who have responded very well to Prozac, in combination with personal short-term psychotherapy.

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