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a JP Gibbons Professor of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
MINICUCI and colleagues (1), in this issue of the Journal of Gerontology: Medical Sciences, report a high prevalence of depressive symptoms among elderly men and women in the Veneto region of northeastern Italy. More than one half the sample of women (58%) and over one third the sample of men (34%) score in the range of clinically significant depressive symptoms as assessed by the Center for Epidemiologic Studies–Depression scale (CES-D) (2). As found in most studies of community-dwelling elders, women were at higher risk for depression than men, and depression was more frequent among unmarried men, among persons with little or no education, among those with few contacts by phone with relatives and friends, among persons with more cognitive impairment, among persons with physical illness and fair to poor self-rated health, and among persons with disabilities (3)(4).
These prevalence estimates are much higher than those found among community-dwelling elders in the United States, which range from about 8% to 16% (3)(4). The most obvious questions that arise from these data (questions addressed by Minicuci and colleagues) (1) are, "Why is the prevalence of depressive symptoms so high in this Italian community?" and "Can the variance in prevalence between this sample and comparable United States samples be explained by cultural differences?" These are most important questions, yet questions that have been raised time and again when data derived from instruments developed in one culture are applied to another culture. I would pose a different question: "Why are depressive symptoms so frequent among elders across all cultures?"
We have reified the diagnosis of depression. This reification occurred in psychiatry with the introduction of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (5). This manual and its successors, DSM-III-R and DSM-IV (6)(7), adopted an operational definition of depression, namely major depression. When these operational criteria were applied to older adults, however, the prevalence of depression was found to be very low, between 1% and 3% (8). Yet clinicians knew that depression was much more frequent. The gap between the frequency of depressive symptoms and the diagnosis of major depression led to the emergence of minor depression or subsyndromal depression as a construct to fill in the gap (9). Yet where clinicians draw the line between reactions to the slings and arrows of life and clinical depression remains unclear (10).
I would propose that clinicians not focus exclusively upon where to draw the line, an inquiry that spawns additional inquiries about the cultural sensitivity and specificity of instruments such as the CES-D. Rather, I suggest clinicians consider a phenomenon that is clearly expressed in all of these surveys. The burden of emotional suffering among community-dwelling elders is significant. Whatever the language barriers, I have no doubt that the CES-D is tapping considerable emotional discomfort and disquiet in Veneto. I also have little doubt that the etiology of much (perhaps most) of the emotional suffering is sociocultural. The significant association of depressive symptoms with social resources in Veneto, for example, is perhaps a key to interpreting these data.
If I am correct in my interpretation regarding the etiology of these symptoms (and what I have proposed is an interpretation and nothing more), then how might these symptoms best be understood? First, I doubt that these symptoms can be explained primarily as the result of a biological predisposition to depression. Certainly a biological predisposition is critical to understanding depression in late life. Yet not in one's wildest imagination can a frequency of over 50% among these Veneto women be attributed to a biological predisposition. I suspect the most entrenched biological psychiatrist would attribute these symptoms primarily to the "worried well" among elders. In fact, these symptoms may not so much reflect depression as a general reaction to physical, psychological, and social stressors in the environment. Yet attributing the symptoms to something other than a biological predisposition should not separate the clinician from concern about these symptoms.
Broadhead (11), in a study over a decade ago, introduced the concept of minor depression. In this study of community-dwelling adults, he found considerable disability among what he labeled as minor depression without mood disorder, or depression without sadness. There is little doubt that he and others who have followed him tapped in both community and clinical samples a group of elders who suffer emotional distress and whose distress has interfered with their ability to function. But can clinicians rightly consider these persons depressed? These persons certainly experience symptoms of depression, such as sleep difficulties, problems with concentration, and even lethargy. Yet just as perhaps many persons in the Veneto study, they may not have endorsed "sadness" or being "down in the dumps" as symptoms. Even if persons do endorse these symptoms, what is the clinician's rationale for labeling these persons as depressed?
Labeling these persons depressed is not an action without consequences. If they are depressed in the early 21st century, then the treatment of choice is antidepressant medications. One study reports that more than 10% of all elders over the age of 75 are taking prescribed antidepressant medications (12). Perhaps these persons can benefit from the medication, yet if clinicians reify the construct of depression for these persons in the United States and Veneto, they may close their inquiries into other areas; for, depression in U.S. society usually means chemical imbalance, and clinicians treat a chemical imbalance with medications.
I would close by reminding the reader that nonspecific psychiatric symptoms have been recognized as prevalent in community samples as long as surveys have been fielded (13). In addition, these symptoms have at times variously been labeled Da Costra's syndrome, neurasthenia, demoralization, and perhaps even Gulf War Syndrome. They reflect a general level of stress response in the persons sampled and in turn reflect an environment that is stressful. The environment is not uniformly stressful across all persons, so some carry the burden of this physical and sociocultural environment more than others. I would propose that clinicians consider the Veneto data as an alert that many elders in that region of Italy (as noted by Minicuci and colleagues) (1) experience a quality of life that is not good. Labeling these persons as depressed probably does little to focus this alert and may mask the source of the problem. Prime suspects for the source, I propose, lie outside the elders themselves and cannot necessarily be addressed solely by individualized interventions. If clinicians are concerned about the burden of emotional distress in the community, then clinicians must pay attention to the context within which this emotional distress emerges.
Received October 22, 2001
Accepted October 23, 2001
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