Minor Depression:
Diagnosis and Management
in Primary Care

Case presentation
A 68-year-old divorced Caucasian man (Mr. N) was referred by his family physician for mental health treatment. Ten months earlier, he suffered the traumatic loss of his 32-year-old daughter, who was murdered by her boyfriend after a domestic dispute. On examination, Mr. N exhibited a lack of pleasure in activities, depressed mood, and loss of energy. His medical history included visual impairment from macular degeneration. In the months following his daughter’s death, Mr. N’s family physician suggested counseling, but the patient refused, saying he wasn’t “crazy.” Mr. N became more isolated from friends and family as his depressive symptoms became more evident. He expressed growing frustration with impatient customers whom he encountered while working the night shift at a local gas station. The presence of macular degeneration contributed to Mr. N’s difficulty interacting with others because he could not see their faces clearly during interpersonal or business conversations. Mr.N eventually realized that stress was adversely affecting his health and allowed an on-site geropsychologist to join him for a primary care visit at the university-affiliated family medicine center.The psychologist was available through a university fellowship in collaborative mental health care. During Mr.N’s joint visit with his physician and the geropsychologist, all three agreed that strategies to manage work stress would be useful for Mr.N.They also agreed that the family physician should regularly attend Mr. N’s sessions with the geropsychologist. For the first few sessions, Mr. N’s physician and the psychologist decided not to focus on the loss of his daughter because Mr. N had initially refused this conventional form of grief counseling. Mr.N’s female partner of 10 years participated in all of his biweekly sessions. She helped him reconnect with friends and re-establish his participation in activities. Other stress management strategies included limiting Mr.N’s excessive self-imposed work hours, teaching him how to cope with visual impairment, and working with him to develop new ways to manage frustrated customers. After five psychotherapy sessions, Mr.N’s family physician stopped attending and suggested that Mr.N talk more with the geropsychologist about his daughter.A geriatric psychiatrist was consulted and offered Mr.N antidepressanttreatment, which he refused. In psychotherapy,Mr. N began to discuss and grieve the loss of his daughter, and treatment focused on maintaining active relationships with family and friends. Sessions continued twice a month for 8 months and decreased to once a month for another 5 months. Mr. N ended treatment with significant improvements in work functioning and resolution of his depressive symptoms.

This case illustrates an example of minor depression, which is common in a primary care setting. The prevalence of minor depression among older primary care patients is approximately 5%, which is comparable to that of major depression.1 As with other late-life mood disorders, medical comorbidity is common with minor depression and often plays a role in the patient’s symptoms, as illustrated by the impact of Mr. N’s visual impairment on his work functioning.Minor depression is associated with increased functional impairment2,3 and increased mortality rates in older men.3 The course of minor depression is variable. At 1 year, although one half of patients will be improved, the remaining one-half will exhibit persistent minor depression or a worsening of symptoms that meet criteria for major depression.4

The appendix to the Diagnostic and Statistical Manual ofMental Disorders Fourth Edition (DSM-IV)5 lists minor depression as a diagnostic category that requires further research.

The table includes a list of diagnostic criteria for minor depression and a comparison with the longer- established criteria for major depression
and dysthymic disorder.

The empiric literature evaluating treatments for minor depression is nascent, unlike the extensive evidence base for major depression.2 There is modest evidence for the efficacy of the selective serotonin reuptake inhibitor paroxetine in treating minor depression.6 Many experts support the use of antidepressants in patients with minor depression, although making such recommendations must be couched more judiciously than to patients with major depression because there is a relative lack of clear or strong evidence for pharmacologic treatment of minor depression. Unlike dysthymic disorder, a chronic condition that is often unresponsive to psychosocial treatments alone, minor depression may respond to psychotherapy. 2,6 Based on evidence that interpersonal counseling (a type of interpersonal psychotherapy adapted to medical settings) can effectively decrease depressive symptoms in medically ill older patients, interpersonal psychotherapy was used to address Mr.N’s losses and draw upon the support of his partner.7 This interpersonal approach to treatment assumes that relationships—with family, friends, and others—are effective for addressing the social and interpersonal aspects of depression. If a patient does not have a network of family and friends, other individuals such as physicians or close neighbors might be included. Indeed, Mr. N’s family physician functioned in an important psychosocial capacity within his social network. As with many patients, Mr.N’s initial negative attitudes toward psychiatric referral did not prevent him from ultimately working well in and obtaining benefit from therapy.

Table DSM-IV diagnostic criteria* for minor depression, major depression, and dysthymic disorder

Minor depression Major depression Dysthymic disorder

Symptoms Must have 2-4 symptoms, Must have ≥5 symptoms,
Must have depressed mood AND OR loss of interest/pleasure OR

Two or more of the following:

Duration Two weeks, most of the day, Two years, most of the day, nearly every day more days than not

Impairment Symptoms cause clinically Symptoms cause clinically Symptoms cause clinically significant distress or significant distress or significant distress or impairment in social, impairment in social, impairment in social, occupational, or other occupational, or other occupational, or other important areas of important areas of important areas of functioning.