Depressive symptoms in absence of diagnostic criteria: Symptoms, triggers, and additional details
Subsyndromal depression (SSD), a subthreshold form of depression, is a common yet often overlooked condition. As classified by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), SSD involves depressive symptoms that are distressing but do not meet the full criteria for major depressive disorder.
The brain-derived neurotrophic factor (BDNF), a protein crucial for neuron survival, growth, memory, and learning, and linked to depression, plays a role in the development of SSD. Similarly, the major histocompatibility complex (MHC), a group of genes that help the immune system recognize foreign substances, has links to depression.
Research suggests that SSD is associated with an increased risk of psychosocial disability, major depression, dysthymia, social phobia, and generalized anxiety disorder (GAD). A physical health condition can also increase the risk of depression. Psychological factors such as negative self-concept, sensitivity to rejection, neuroticism, rumination, and negative emotionality contribute to the development of SSD.
Sociodemographics, social support, and adverse childhood experiences are significant social determinants that influence the development of depression. Unhealthy habits like poor diet, little or infrequent exercise, alcohol consumption, and smoking can also be associated with depression.
The kynurenine pathway, which plays a role in generating cellular energy within the body, and the tryptophan catabolites pathway, which interacts with proteins and acids within the body, have been linked to depression. Single nucleotide polymorphisms (SNPs), the most common genetic variations found in people, have been associated with depression, particularly SNPs of genes involved in the tryptophan catabolites pathway.
Genetic factors, such as family history, BDNF protein, MHC region genes, and SNPs of genes involved in the tryptophan catabolites pathway, have been linked to depression. The HPA axis becomes chronically over-activated due to long-term stress, which can contribute to the development of SSD.
Treatment selection for SSD should be individualized based on symptom severity, functional impairment, patient preference, age, and coexisting conditions. Early intervention is key in preventing long-term challenges and having success with treatment options for SSD.
Psychological therapies form a significant part of the treatment for SSD. Cognitive-behavioral therapy (CBT) is the most evidence-based approach, with other effective therapies including interpersonal psychotherapy (IPT), mindfulness-based interventions, and family- or caregiver-inclusive therapies. These approaches have shown small-to-moderate benefits in reducing depressive symptoms and improving functioning, often comparable to medication, especially in youth and young adults.
Antidepressant medications, while evidence specific to SSD is limited, may be considered, especially if symptoms are persistent or cause significant impairment. Selection often considers prior responses and side effect profiles.
Brain stimulation therapies, such as electroconvulsive therapy (ECT) and other neurostimulation techniques, are generally reserved for more severe or treatment-resistant depression but may be explored if symptoms worsen or do not respond to other treatments.
Lifestyle modifications like frequent exercise, a balanced diet, and optimal sleep duration can also aid in managing SSD symptoms.
Researchers argue that SSD should stand apart as a category, and a doctor should treat it similarly to major depression. A person with SSD has (but fewer than five) symptoms of depression that have been present most of the time for at least two weeks and have impaired social functioning. A diagnosis of subsyndromal depression means a person is experiencing two to five of the symptoms most of the time during a two-week period, and the symptoms do not meet the severity of major depression.
Getting a formal diagnosis of SSD can be difficult due to the DSM-5-TR not explicitly identifying subthreshold categories of depression. However, recognising and addressing SSD is crucial in preventing its progression to major depression and ensuring timely, effective treatment.
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