Article

A Descriptive Analysis of Minor Depression

Mark Hyman Rapaport, M.D. Objective: The authors provide a de- tive signs and symptoms of depression.
tailed clinical description of minor de- Approximately one-third of the subjects
pression: its symptoms, level of disability, with minor depression had a past history
Lewis L. Judd, M.D.
stability, and relationship to patient and of major depressive disorder, and nearly
family history of major depressive disor- half had a family history of unipolar de-
Pamela J. Schettler, Ph.D. der. pressive disorder; however, neither factor
Method: Rigorous criteria for minor de- affected the severity or quality of minor
Kimberly Ann Yonkers, M.D. depressive symptoms.
pression, including functional disability,
were used to identify 226 individuals for a
Michael E. Thase, M.D. three-phase treatment study. This report
Conclusions: These data suggest that
1) minor depression is not evanescent;
presents data obtained on that study 2) minor depression is characterized by
David J. Kupfer, M.D. group during the first study phase, a 4- mood and cognitive symptoms rather
week placebo lead-in period. than neurovegetative symptoms; 3) mi-
Ellen Frank, Ph.D. nor depression may occur either indepen-
Results: One hundred sixty-two subjects
(72% of the initial study group) remained dently of a lifetime history of major de-
John M. Plewes, M.D. in the study for 4 weeks and continued to pressive disorder or as a stage of illness in
meet criteria for minor depression. Minor the course of recurrent unipolar depres-
Gary D. Tollefson, M.D., Ph.D. depression in these subjects was prima- sive disorder; and 4) depressive disorders
rily characterized by mood and cognitive should be conceptualized as a continuum
A. John Rush, M.D. symptoms, not the classical neurovegeta- of severity.

(Am J Psychiatry 2002; 159:637–643)

T he term “minor depression” has been used to de-

scribe depressive conditions that are not of sufficient se-
pressive disorder. 5) The greater the number of symptoms
of depression, the greater the number of episodes, length
verity and duration to meet criteria for a major depressive of longest episode, degree of impairment, and likelihood of
episode (1–6). DSM-III included a chronic form of minor having a comorbid diagnosis and family history of psychi-
depression as a diagnostic category (dysthymia), but mi- atric disorders. 6) Individuals with a history of major de-
nor depression lasting less than 2 years was folded in with pressive disorder freely traverse between major depressive
atypical depression, identified as depressive disorder not disorder, minor depression, and subsyndromal depressive
otherwise specified in DSM-III-R. In DSM-IV, minor de- symptoms (3–5, 8–14).
pressive disorder was identified as a potential diagnostic The most common symptoms reported for individuals
category that requires empirical validation. The proposed with minor depression in the ECA data set are recurrent
diagnostic criteria for minor depressive disorder required thoughts of death, insomnia, feeling tired all the time,
the presence of two to four symptoms of depression last- trouble concentrating, poor appetite, and feelings of
ing for at least 2 weeks and excluded individuals with a worthlessness (4).
previous history of major depressive disorder. These data, as well as analyses of other large data sets
Epidemiologic studies, primarily based on the Epidemi- (15, 16), suggest that we need to broaden our conceptual-
ologic Catchment Area (ECA) and National Comorbidity ization of depressive disorders. Kendler and Gardner’s
Survey databases, document the prevalence, societal costs, 1998 longitudinal analysis of the Virginia Twin Registry
functional disability, and long-term consequences of mi- (16) demonstrated that the presence of five or more symp-
nor depression (3–9). Although investigators have used a toms of depression was not a more accurate harbinger of
variety of definitions and analytic strategies, the overarch- depression at 1-year follow-up than the presence of three
ing findings from these studies are as follows: 1) Minor de- or four symptoms. Data from the NIMH Collaborative
pression has a point prevalence rate of 2%–5%. 2) Minor Study on Depression (15) demonstrated that, following an
depression is associated with functional impairment and entry episode of major depressive disorder, patients spent
greater service utilization. 3) Minor depression is associ- an average of 58% of the weeks during the next 9 years ex-
ated with a greater risk of developing major depressive dis- periencing major depressive disorder (15% of the weeks),
order. 4) The presence of depressed mood or anhedonia minor depression (27% of the weeks), or subsyndromal
(the “A criterion”) is associated with even greater dysfunc- depressive symptoms (16% of the weeks). The confluence
tion and risk of developing a future episode of major de- of these findings suggests that there may be value in con-

Am J Psychiatry 159:4, April 2002 637

MINOR DEPRESSION

sidering depression as a spectrum of disorders rather than pression module of the National Institute of Mental Health Diag-
a single categorical disorder. nostic Interview Schedule (DIS) (18); the Medical Outcomes
Study 36-item Short-Form Health Survey (19); the 28-item version
Despite considerable evidence of the prevalence and of the Hamilton Depression Rating Scale, which was also scored
disability associated with minor depression, many ques- for the 17-item and 21-item versions (20–22); the Hamilton Anxi-
tions remain. Is minor depression an evanescent phenom- ety Rating Scale (23); the 30-item version of the clinician-rated In-
enon or an enduring and disabling condition? What is the ventory for Depressive Symptomatology (24); the Beck Depres-
sion Inventory (25); the HSCL (26); and the Clinical Global
nature of the relationship between minor depression and
Impression (CGI) severity scale (27). The extensive demographic
an individual’s personal or family history of major depres- evaluation of the subjects included determination of Research
sive disorder? Do these factors influence the qualitative Diagnostic Criteria family history diagnoses. Subjects had to have
presentation of minor depression? In this article we ad- normal physical examination and laboratory results, including a
dress the following hypotheses: 1) Minor depression is not complete blood count, urine toxicology screen, urine analysis,
and serum chemistries for hepatic and renal function.
evanescent. 2) There is a strong family history of unipolar
Subjects were reevaluated weekly for the 4 weeks after study
disorder associated with minor depression. 3) A substan-
entry with the DIS depression section, Hamilton depression scale,
tial number of individuals with minor depression pre- Inventory for Depressive Symptomatology, Short-Form Health
viously have had episodes of major depressive disorder. Survey, Global Assessment of Functioning Scale (DSM-III, p. 122),
4) Minor depression shares mood and cognitive symp- CGI severity scale, and CGI improvement scale.
toms with major depressive disorder but not the neuro-
Diagnostic Criteria for Minor Depression
vegetative and reverse neurovegetative symptoms of de-
pression. 5) One cannot differentiate individuals with In defining minor depression for this study, we made several
methodological and conceptual decisions. First, at the inception
minor depression from one another on the basis of past
of this study in 1992, the majority of available data regarding mi-
history of major depression or family history of depression. nor depression resulted from ECA analyses, which used the de-
pression section of the DIS; therefore, we adopted the DIS as our
primary diagnostic tool for defining minor depression. Second,
Method anticipating concerns that minor depression might be perceived
Overview of the Study as trivial, we required that functional disability be evident accord-
ing to scores on both the Global Assessment of Functioning Scale
Data for this report are derived from a comprehensive study of and at least one of two Short-Form Health Survey subscales.
the diagnosis and treatment of minor depression. The study had Third, we included subjects with a past history of major depres-
three distinct phases: 1) an initial diagnostic evaluation followed sive disorder or dysthymia so that our study group would be more
by a 4-week single-blind placebo lead-in period; 2) a 12-week representative of the larger group of patients with minor depres-
double-blind, placebo-controlled treatment phase; and 3) a 24- sive symptoms. However, to eliminate the possibility that the mi-
week randomized crossover continuation phase. In-depth dis- nor depression was a residual phase of another type of depressive
cussion of the acute and continuation treatment study design episode, we did not include subjects who had experienced major
and results will be presented elsewhere. depression or dysthymia within the last 2 years. Fourth, because
This descriptive report of minor depression is based on data the antidepressants used in treatment phases of this trial (seroto-
from the placebo lead-in phase of the study. Demographic and nin reuptake inhibitors) are effective treatments for a variety of
clinical ratings presented here were obtained at the initial study psychiatric disorders, we excluded individuals with any current
visit. Data pertaining to the stability of symptoms and overall cri- axis I disorder.
teria for minor depression were obtained during the subsequent To qualify as having “confirmed” minor depression, subjects in
four weekly visits constituting the placebo lead-in period. this study had to meet the following three criteria at the initial di-
agnostic visit and at least three of the four subsequent visits, in-
Subject Recruitment cluding those during the last 2 weeks of the single-blind study pe-
The subjects were recruited at three sites (University of Califor- riod:
nia, San Diego; University of Pittsburgh; and University of Texas, 1. At least 2 weeks of depressed mood/dysphoria/sadness (DIS
Southwestern Medical Center) primarily by means of advertise- item 1) and pervasive loss of interest/pleasure in all or almost all
ments in local newspapers. Some subjects were referred to the activities (DIS item 2) and at least one additional depressive
study by psychiatrists and family practitioners in the local commu- symptom group from the DIS or at least 2 weeks of depressed
nity. A few subjects entered the study through referral from sub- mood/dysphoria/sadness (DIS item 1) or pervasive loss of inter-
jects already involved in research at the institution. After telephone est/pleasure in all or almost all activities (DIS item 2), but not
screening, subjects were invited in for a diagnostic evaluation. both of these, and at least two additional depressive symptom
Subjects who were invited in for a diagnostic interview partici- groups from the DIS.
pated in the process of informed consent before this interview. 2. A Global Assessment of Functioning Scale score of 70 or less
Informed consent involved the subject’s reviewing a written doc- for the last month. (The time frame was decreased to the last
ument describing the study with the principal investigator’s staff, week during the 4 weeks of single-blind evaluation.)
who answered any questions before the subject signed the con- 3. A score of 75 or less on the social role function scale or a score
sent form. of 67 or less on the emotional role function scale of the Short-
All subjects were at least 18 years of age, conversant in English, Form Health Survey for a time period including the last month.
and willing to be available for participation in the 40-week study. Subjects who had developed five or more symptoms of major
depressive disorder when they were interviewed with the DIS de-
Evaluation of Subjects
pression section were interviewed with the depression module of
Measures used for the initial evaluation of subjects included the SCID to determine whether their minor depression had pro-
the Structured Clinical Interview for DSM-IV (SCID) (17); the de- gressed to major depressive disorder.

638 Am J Psychiatry 159:4, April 2002

 RAPAPORT, JUDD, SCHETTLER, ET AL.

TABLE 1. Characteristics of 226 Subjects Whose Screening Diagnosis of Minor Depression Was or Was Not Confirmed
Characteristic Confirmed (N=162) Not Confirmed (N=64)a Comparison
N % N % Fisher’s Exact p

Sexb 0.18
Female 96 59.3 31 49.2
Male 66 40.7 32 50.8
Race 0.36
Caucasian 146 90.1 55 85.9
Other 16 9.9 9 14.1
Past major depressive disorder 0.05
Yes 52 32.1 12 18.8
No 110 67.9 52 81.3
Family history 0.06d
Unipolar depressionc 74 45.7 23 35.9
Bipolar disorder 10 6.2 1 1.6
No affective disorder 78 48.1 40 62.5

Mean SD Range Mean SD Range t df p

Age (years) 43.5 11.7 18–72 40.7 12.1 21–70 1.58 223 0.12
Visit 1 scores
Inventory for Depressive Symptomatology 23.0 5.8 9–40 21.9 8.3 3–43 0.92 81.4e 0.36
17-item Hamilton Depression Rating Scale 12.0 3.1 6–21 12.2 4.6 1–21 –0.27 80.1e 0.79
Clinical Global Impression severity of depression 3.4 0.6 3–5 3.5 0.7 1–5 0.96f 0.34
Global Assessment of Functioning Scale 65.0 4.6 52–70 64.3 5.7 52–80 0.90 94.6e 0.67
a Reasons for not being confirmed as having minor depression include the following occurrences during the 4-week single-blind placebo lead-
in period: developed major depressive disorder (N=5); spontaneously recovered from minor depression (N=14); had a contraindicating med-
ical condition (N=10); had another protocol violation (N=3); experienced adverse effects while taking placebo that caused subject to drop
out (N=4); subject dropped out because of lack of efficacy of placebo (N=5); subject dropped out of the study for another personal reason,
such as difficulty with scheduling of visits (N=17); or subject dropped out and could not be contacted (N=6).
b N=63 for nonconfirmed subjects; the sex of one subject was not noted.
c History of major depressive disorder or dysthymia, without bipolar disorder.
d Fisher’s exact test of any affective history (unipolar or bipolar) versus no affective history. Family history of unipolar major depressive disor-
der occurred for 70 (43.2%) of the subjects with confirmed minor depression, compared with 22 (34.4%) of the subjects not confirmed as hav-
ing minor depression.
e Degrees of freedom adjusted for unequal variances.
f z computed by Wilcoxon rank sum test.

Exclusion Criteria positive versus negative family history of depression) were con-
sidered sufficiently large to detect group differences. Since this is
Exclusion criteria for the study were current major depressive
a descriptive report, statistics and resulting probability values are
disorder or dysthymia; major depressive disorder or dysthymia
to be taken as descriptive indicators, not inferential ones.
within the last 2 years; major depressive disorder in partial remis-
sion; loss of a loved one or significant other within the past year;
serious suicidal risk; substance or alcohol abuse or dependence Results
within the last year; a current diagnosis of any axis I disorder; a
lifetime diagnosis of bipolar disorder (type I), borderline person- Of the 226 subjects who met criteria for minor depres-
ality disorder, antisocial personality disorder, psychotic disorder,
sion at initial screening, 64 did not complete the 4-week
organic mood disorder, organic psychotic disorder, or schizo-
phrenia; use of any psychotropic drug except chloral hydrate lead-in phase of the study for the following reasons: ad-
within 7 days or a monoamine oxidase inhibitor within 14 days of verse effects (N=4), lack of efficacy (N=5), withdrew con-
starting active treatment; the presence of a serious medical con- sent or declined further participation (N=17), had con-
dition that was not currently stabilized; seizure disorder within traindicated medical conditions (N=10), other protocol
the last year; a history of severe allergies or multiple adverse drug
violations (N=3), were lost to follow-up (N=6), developed
reactions; previous nonresponse or adverse reaction to fluoxe-
tine; or previous participation in a fluoxetine study. major depressive disorder (N=5), or no longer met criteria
for minor depression (N=14). The 162 individuals (72% of
Statistical Analyses the initial sample) who remained in the study for 4 weeks
Descriptive statistics are presented for key demographic and and continued to meet criteria for minor depression con-
clinical characteristics of the study group. After evaluating con- stitute the study group of subjects with confirmed and
tinuous data for homogeneity of variance and normal distribu-
tion, we compared different study subgroups using t tests. Chi-
nontransient minor depression who are the focus of this
square tests or Fisher’s exact tests were used to compare groups report.
on categorical variables, and Wilcoxon rank sum tests were used As shown in Table 1, 59% of subjects with confirmed mi-
for measures with ordinal values such as CGI and Short-Form nor depression were women, 90% were Caucasian, and
Health Survey scales. A probability level of p=0.05 (two-tailed)
was used to determine statistical significance of group differ-
their mean age was 43.5 years. Overall, the 64 subjects ex-
ences. Group sizes for the two comparisons of interest (positive cluded from the analyses did not differ significantly from
versus negative patient history of major depressive disorder and the 162 patients with confirmed minor depression with re-

Am J Psychiatry 159:4, April 2002 639

MINOR DEPRESSION

TABLE 2. Clinical Rating Scale Scores at Visit 1 for 162 Subjects With Confirmed Minor Depression
Score
Clinical Rating Scale Mean SD Median Lowest Quartile Highest Quartile
Inventory for Depressive Symptomatology (N=161) 23.0 5.8 22.0 9–18 28–40
Hamilton Depression Rating Scale total
17-item (N=162) 12.0 3.1 12.0 6–10 15–21
28-item (N=162) 14.2 4.1 14.0 6–11 18–28
Beck Depression Inventory (N=162) 18.3 7.1 18.0 4–13 23–43
Clinical Global Impression severity of depression (N=162) 3.4 0.6 3.0 —a —a
Hamilton Anxiety Rating Scale total (N=161) 12.0 4.6 12.0 3–8 16–24
a Restricted scale values with the following frequencies at visit 1: for a score of 3 (mild), N=95 (58.6%); for a score of 4 (moderate), N=62 (38.3%);
for a score of 5 (marked), N=5 (3.1%).

TABLE 3. Psychosocial Functioning at Visit 1 for 162 Subjects With Confirmed Minor Depression, 502 Subjects With Major
Depressive Disorder, and 2,474 Normal Subjects
Score by Subject Group Comparison of
Medical Outcomes Minor Depression Comparison of
Study 36-Item Short- Major Depressive and Major Minor Depression
Form Health Survey Minor Depression Disorder Normal Depressive Disorder and Normal
Scale Mean SD Median Mean SD Median Mean SD Median t (df=656) p t (df=2,628) p
Social function 53.2 21.7 50.0 57.2 27.7 62.5 83.3 22.7 100.0 –1.65 0.10 –16.12 <0.001
Emotional role function 24.6 28.1 33.3 38.9 39.8 33.3 81.3 33.0 100.0 –4.17 <0.001 –21.00 <0.001
Physical role function 68.6 38.1 100.0 44.4 40.3 50.0 81.0 34.0 100.0 6.63 <0.001 –4.39 <0.001
Physical function 86.8 14.6 90.0 71.6 27.2 80.0 84.2 23.3 90.0 6.68 <0.001 1.38 0.17
Bodily pain 71.3 22.5 74.0 58.8 26.7 61.0 75.2 23.7 74.0 5.29 <0.001 –2.00 0.05
Mental health 44.1 14.4 44.0 46.3 20.8 44.0 74.4 18.1 80.0 –1.23 0.22 –20.52 <0.001
Vitality 31.8 16.2 30.0 40.1 21.1 40.0 60.9 21.0 65.0 –4.51 <0.001 –17.00 <0.001
General health 66.7 21.1 72.0 52.9 23.0 52.0 72.0 20.3 72.0 6.66 <0.001 –3.16 <0.01

spect to sex, race, age, family history of affective disorders, Table 2 demonstrates that baseline clinical ratings for
or initial symptom rating scale scores; however, they were the subjects with confirmed minor depression encompass
significantly less likely to have a past history of major de- a broad range of depressive severity, from mild symptoms
pressive disorder (Table 1). The subgroups of subjects who to moderately severe symptoms, which overlap with scores
withdrew, were excluded, or changed diagnostic status observed in outpatients with major depressive disorder.
were fairly heterogeneous and too small for meaningful Table 3 presents the scores on the Short-Form Health
statistical comparison. The 14 subjects who spontane- Survey subscales for our subjects with minor depression,
ously recovered from minor depression during the 4-week compared with data reported in previous studies of pa-
placebo lead-in phase tended to be the least severely ill on tients with major depressive disorder and normal subjects
all clinical measures. The five subjects who developed ma- (14). Our subjects with minor depression were more im-
jor depressive disorder had clinical ratings similar to the paired than normal subjects on most measures and were
top third of patients with confirmed minor depression. Pa- at least as impaired as patients with major depressive dis-
tients who dropped out (N=17) or were lost to follow-up order on many measures.
(N=6) constituted heterogeneous groups encompassing a Seven DIS symptoms were frequently endorsed at the
wide range of depressive severity. initial evaluation of our study group: feeling sad or de-
pressed nearly every day (an inclusion criterion) (N=179
Thirty-two percent of the subjects with minor depres-
[79%]), fatigue (N=163 [72%]), trouble thinking or concen-
sion had a past history of major depressive disorder (Table
trating (N=145 [64%]), sleep disturbance (N=140 [62%]),
1). They did not differ from the subjects without a past his-
feelings of worthlessness (N=118 [52%]), loss of interest in
tory of major depressive disorder on any demographic
things usually enjoyed (N=108 [48%]), and loss of interest
characteristic, family history variable, or clinical rating of
in sex and/or other people (N=99 [44%]). Between 60%
severity or dysfunction. and 71% of the subjects endorsing those symptoms at en-
Forty-six percent of the subjects with minor depression try into the study continued to report them at all of the
had a first-degree relative who had suffered from unipolar next four visits, while they were taking placebo (single-
depression (major depressive disorder or dysthymia), and blind). By contrast, those symptoms with low rates of ini-
6% had a first-degree relative with bipolar disorder (Table tial endorsement—appetite disturbance (16% [N=36]),
1). A positive family history of depression was associated slow or restless/fidgety (9% [N=20]), and thoughts of
with a higher total 17-item Hamilton depression scale score death/suicide (9% [N=20])—were highly unstable over the
(mean=12.5, SD=3.0, versus mean=11.4, SD=3.1) (t=2.16, next four visits.
df=150, p=0.03). (A difference of 1.1 on the 17-item Hamil- Table 4 reports the frequency of endorsements of indi-
ton depression scale usually is not clinically significant.) vidual items of the clinician-rated Inventory for Depres-

640 Am J Psychiatry 159:4, April 2002

 RAPAPORT, JUDD, SCHETTLER, ET AL.

sive Symptomatology in our study group. The 11 most fre- TABLE 4. Scores of 162 Subjects With Confirmed Minor De-
quently endorsed items at the initial visit were sad mood pression on the Clinician-Rated Inventory for Depressive
Symptomatology at Baseline and Over a 4-Week Placebo
(93%), lack of involvement (91%), quality of mood dis- Lead-In Period
tinctly different from bereavement (85%), irritable mood Subjects
(85%), lack of pleasure and enjoyment (an inclusion crite- Maintaining
rion) (83%), problems concentrating and making deci- Subjects With Symptom
Symptom Item for 3 or
sions (83%), having a pessimistic outlook for the future Item at 4 of the 4
(83%), fatigue (82%), anxious mood (80%), increased in- Inventory for Depressive Baselinea Weeksa
terpersonal sensitivity (71%), and increased mood reactiv- Symptomatology Symptom Item N % N %
ity (70%). Table 4 also shows the persistence of symptoms 1. Sleep onset insomnia 58 36 39 24
during weekly evaluations, again demonstrating consider- 2. Midnocturnal insomnia 100 62 70 43
3. Early morning insomnia 66 41 41 25
able stability among the frequently endorsed symptoms. 4. Hypersomnia 23 14 3 2
5. Sad mood 151 93 134 83
6. Irritable mood 138 85 110 68
Discussion 7. Anxious mood 130 80 99 61
8. Increased mood reactivity 113 70 79 49
We believe that the data from this study support four 9. Mood variation 70 43 31 19
conclusions, each with important implications for the 10. Quality of mood distinctly
different from bereavement 138 85 122 75
conceptualization and clinical management of minor 11. Appetite decrease 15 9 2 1
depression. 12. Appetite increase 28 17 11 7
First, minor depression with functional disability is not 13. Weight decrease 8 5 0 0
14. Weight increase 26 16 3 2
evanescent. The majority of individuals initially meeting 15. Problems with concentration
our rigorous criteria for minor depression had persistent and decision making 134 83 109 67
depressive symptoms and disability throughout a subse- 16. Pessimistic outlook—self 109 67 83 51
17. Pessimistic outlook—future 134 83 113 70
quent 4-week period. Of the 226 individuals who met cri- 18. Suicidal ideation 19 12 6 4
teria at intake, only five (2.2%) developed major depres- 19. Involvement 147 91 117 72
sive disorder and 14 (6.2%) spontaneously recovered 20. Fatigue 133 82 105 65
21. Lack of pleasure/enjoyment
during the 4-week placebo period. (other than sexual) 134 83 97 60
Our second conclusion is that minor depression is char- 22. Lack of sexual interest 100 62 78 48
23. Psychomotor slowing 49 30 19 12
acterized by affective and cognitive symptoms: sadness, 24. Psychomotor agitation 45 28 21 13
loss of pleasure/enjoyment, irritable mood, anxious mood, 25. Somatic complaints 99 61 65 40
pessimism, difficulty concentrating, lack of involvement, 26. Sympathetic arousal 45 28 8 5
27. Panic/phobic symptoms 18 11 2 1
and fatigue. It is distinguished from more severe forms of 28. Gastrointestinal symptoms 18 11 3 2
depression by the infrequent occurrence of the classical 29. Increased interpersonal
neurovegetative and reverse neurovegetative signs and sensitivity 115 71 79 49
30. Leaden paralysis/physical
symptoms of depression. In contrast, individuals with mi- energy 86 53 44 27
nor depression in the ECA database endorsed more of the a Percentage reporting any degree of symptom is based on response
classic neurovegetative signs of depression. (The ECA is an values 1–3, representing increasing levels of frequency;
epidemiological survey and may have included subjects 0=none.
with mild major depressive disorder in the minor depres-
sion group.) An additional important finding is that highly gues against the conceptualization of minor depression
endorsed symptoms of depression at the initial interview as simply a stage in the lifetime emergence of major de-
continued to be endorsed consistently throughout 4 weeks pressive disorder. Patients with and without past major
of observation. depressive disorder also did not differ in clinical mea-
Our third conclusion from this study is that minor de- sures of depressive severity or functional disability. Only
pression may occur either 1) independently of a history of 2.2% of subjects initially meeting criteria for minor de-
major depressive disorder, 2) as a less severe but stable pression in this study went on to develop episodes of ma-
episode of major depressive disorder for individuals who jor depressive disorder during the next 4 weeks, suggest-
have experienced past episodes, or 3) as a transitional ing that minor depression may be a transitional state for a
state for individuals traversing between euthymia and minority of individuals.
more severe forms of depression. In our study group of The fourth and broadest conclusion from our study is
162 subjects with stable minor depression, 52 (32%) had a that minor depression and major depressive disorder
history of past major depression, which suggests that it should be considered part of a spectrum of severity rather
may not be appropriate to use a past history of major de- than as two discrete disorders. Several lines of evidence
pressive disorder as an exclusion criterion for minor de- support this conceptualization. First, subjects meeting
pression. In our study, individuals with and without past our rigorous criteria for minor depression over a 4-week
major depression were nearly identical in age, which ar- period had scores on clinical rating scales for depression

Am J Psychiatry 159:4, April 2002 641

MINOR DEPRESSION

indicating a broad spectrum of severity from a mild level

to a level approaching the threshold for major depressive Received Nov. 15, 2000; revisions received April 27 and Sept. 18,
2001; accepted Nov. 15, 2001. From the Psychopharmacology Re-
disorder. Second, individuals with and without a previous search Program, Department of Psychiatry, University of California,
history of major depressive disorder had similar rates of San Diego, School of Medicine; the Psychiatric Service, VA Healthcare
System, San Diego; Eli Lilly and Co., Indianapolis; Western Psychiatric
family history of mood disorders, suggesting that minor Institute and Clinic, Department of Psychiatry, University of Pitts-
depression, in some instances, may be part of a spectrum burgh; and the Department of Psychiatry, University of Texas, South-
western Medical Center, Dallas. Address reprint requests to Dr. Rapa-
of mood disorders inherited within a family. In our clinical
port, University of California, San Diego, Psychopharmacology
study group, 47 (43%) of the 110 subjects with minor de- Research Program, Department of Psychiatry, 8950 Villa La Jolla Dr.,
pression who did not have a previous history of major de- Suite 2243, La Jolla, CA 92037; [email protected] (e-mail).
Supported by an unrestricted research grant from Eli Lilly and Com-
pressive disorder and 27 (52%) of the 52 subjects who did pany; by the National Alliance for Research on Schizophrenia and
have such a history had a first-degree relative with unipo- Depression (Dr. Rapaport); and by NIMH grants MH-30914, MH-
49746, MH-80001 (Dr. Rapaport), MH-01908 (Dr. Yonkers), MH-30915
lar mood disorder. This is consistent with findings from (Dr. Kupfer), MH-49115 and MH-30915 (Dr. Frank), and MH-53799 (Dr.
epidemiologic studies indicating that the presence of mi- Rush). Dr. Schettler is a statistical consultant to Eli Lilly and Company.
nor depression carries a greater vulnerability for depres- The authors thank Lara X. Williams and Arnold Hieter for adminis-
trative work and Patricia Rodgers for project coordination in San
sion in family members, similar to that seen in major de- Diego.
pressive disorder (2, 4, 8, 16). Further support for the
spectrum concept of depressive disorders comes from our
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