Skip to main content
    • Aa
    • Aa

The complex relationship between depressive symptoms and functional limitations in community-dwelling older adults: the impact of subthreshold depression

  • C. F. Hybels (a1), C. F. Pieper (a2) and D. G. Blazer (a1)

Depressive symptoms above screening thresholds have been shown to predict functional decline in older adults. Less is known about the impact of subthreshold depression, and whether more symptoms confer significantly greater risk compared to fewer symptoms.


Using data from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE) collected over 10 years, we used repeated-measures mixed models to predict functional change by depression status at the prior (index) in-person interview. Depressive symptoms were measured using a modified version of the Center for Epidemiologic Studies Depression Scale (CES-D). Subthreshold depression was operationalized as 6–8 symptoms and CES-D-defined depression as 9–20 symptoms in the previous week. Three domains of functional status were assessed at the subsequent in-person interview: limitations in basic activities of daily living (ADL), instrumental ADL (IADL) and mobility.


Controlling for race, sex, age, education, marital status, cognitive status, health status, self-perceived health, perceived social support and functional status at the index interview, having ⩾6 depressive symptoms predicted an increase of 0.12 IADL limitations 3–4 years later (p=0.03). The incremental effect of CES-D-defined depression (⩾9 symptoms compared to 6–8 symptoms) was not significant, suggesting that the effect of more symptomatic depression did not add to that of subthreshold depression. CES-D score modeled as a continuous variable predicted functional change for all domains, but the relationship was not linear, supporting a possible threshold effect.


The relationship between depressive symptoms and functional change is complex, not necessarily linear, and may vary by tasks assessed.

Corresponding author
*Address for correspondence: C. F. Hybels, Ph.D., Duke University Medical Center, Box 3003, Durham, NC 27710, USA. (Email:
Hide All
ATF Beekman , DJH Deeg , AW Braam , JH Smit , W van Tilberg (1997). Consequences of major and minor depression in later life: a study of disability, well-being, and service utilization. Psychological Medicine 27, 13971409.

ATF Beekman , DJH Deeg , T van Tilberg , JH Smit , C Hooijer , W van Tilberg (1995). Major and minor depression in later life: a study of prevalence and risk factors. Journal of Affective Disorders 36, 6575.

DG Blazer (2003). Depression in late life: review and commentary. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 58, 249265.

ML Bruce (2001). Depression and disability in late life: directions for future research. American Journal of Geriatric Psychiatry 9, 102112.

ML Bruce , TE Seeman , SS Merrill , DG Blazer (1994). The impact of depressive symptomatology on physical disability: MacArthur Studies of Successful Aging. American Journal of Public Health 84, 17961799.

LD Carbonare , S Maggi , M Noale , S Giannini , R Rozzini , VL Cascio , G Crepaldi ; ILSA Working Group (2009). Physical disability and depressive symptomatology in an elderly population: a complex relationship. The Italian Longitudinal Study on Aging (ILSA). American Journal of Geriatric Psychiatry 17, 144154.

D Cronin-Stubbs , CF Mendes de Leon , LA Beckett , TS Field , RJ Glynn , DA Evans (2000). Six-year effect of depressive symptoms on the course of physical disability in community-living older adults. Archives of Internal Medicine 160, 30743080.

HH Dodge , Y Du , JA Saxton , M Ganguli (2006). Cognitive domains and trajectories of functional independence in nondemented elderly persons. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 61, 13301337.

DD Dunlop , LM Manheim , M Sohn , X Liu , RW Chang (2002). Incidence of functional limitation in older adults: the impact of gender, race, and chronic conditions. Archives of Physical Medicine and Rehabilitation 83, 964971.

DD Dunlop , P Semanik , J Song , LM Manheim , V Shih , RW Chang (2005). Risk factors for functional decline in older adults with arthritis. Arthritis and Rheumatism 52, 12741282.

SA Everson-Rose , KA Skarupski , JL Bienias , RS Wilson , DA Evans , CF Mendes de Leon (2005). Do depressive symptoms predict declines in physical performance in an elderly, biracial population? Psychosomatic Medicine 67, 609615.

JJ Gallo , PV Rabins , CG Lyketsos , AY Tien , JC Anthony (1997). Depression without sadness: functional outcomes of nondysphoric depression in later life. Journal of the American Geriatrics Society 45, 570578.

JJ Gallo , GW Rebok , S Tennsted , VG Wadley , A Horgas ; Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Study Investigators (2003). Linking depressive symptoms and functional disability in late life. Aging and Mental Health 7, 469480.

TM Gill , HG Allore , SE Hardy , Z Guo (2006). The dynamic nature of mobility disability in older persons. Journal of the American Geriatrics Society 54, 248254.

R Hebert , C Brayne , D Spiegelhalter (1999). Factors associated with functional decline and improvement in a very elderly community-dwelling population. American Journal of Epidemiology 150, 501510.

CF Hybels , DG Blazer , CF Pieper (2001). Toward a threshold for subthreshold depression: an analysis of correlates of depression by severity of symptoms using data from an elderly community sample. The Gerontologist 41, 357365.

T Ishizaki , S Watanabe , T Suzuki , H Shibata , H Haga (2000). Predictors for functional decline among nondisabled older Japanese living in a community during a 3-year follow-up. Journal of the American Geriatrics Society 48, 14241429.

LL Judd , HS Akiskal (2002). The clinical and public health relevance of current research on subthreshold depressive symptoms in elderly patients. American Journal of Geriatric Psychiatry 10, 233238.

S Katz , TD Downs , HR Cash , RC Grotz (1970). Progress in development of the index of ADL. The Gerontologist 10, 2030.

GIJM Kempen , AV Ranchor , E van Sonderen , CHM van Jaarsveld , R Sanderman (2006). Risk and protective factors of different functional trajectories in older persons: are these the same? Journals of Gerontology. Series B, Psychological Sciences and Social Sciences 61, P95–P101.

GIJM Kempen , R Sanderman , W Scaf-Klomp , J Ormel (2003). The role of depressive symptoms in recovery from injuries to the extremities in older persons: a prospective study. International Journal of Geriatric Psychiatry 18, 1422.

S-L Kivela , K Pahkala (2001). Depressive disorder as a predictor of physical disability in old age. Journal of the American Geriatrics Society 49, 290296.

E Korn , B Graubard (1991). Epidemiologic studies utilizing surveys: accounting for sampling design. American Journal of Public Health 81, 11661173.

LR Landerman , GG Fillenbaum (1997). Differential relationships of risk factors to alternative measures of disability. Journal of Aging and Health 9, 266279.

EJ Lenze , JC Rogers , LM Martire , BH Mulsant , BL Rollman , MA Dew , R Schulz , CF Reynolds (2001). The association of late-life depression and anxiety with physical disability: a review of the literature and prospectus for future research. American Journal of Geriatric Psychiatry 9, 113135.

EJ Lenze , R Schulz , L Martire , B Zdaniuk , T Glass , WJ Kop , SA Jackson , CF Reynolds (2005). The course of functional decline in older people with persistently elevated depressive symptoms: longitudinal findings from the Cardiovascular Health Study. Journal of the American Geriatrics Society 53, 569575.

JM Lyness , M Heo , CJ Datto , TR Ten Have , IR Katz , R Drayer , CF Reynolds , GS Alexopoulos , ML Bruce (2006). Outcomes of minor and subsyndromal depression among elderly patients in primary care settings. Annals of Internal Medicine 144, 496504.

JM Lyness , DA King , C Cox , Z Yoediono , EC Caine (1999). The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability. Journal of the American Geriatrics Society 47, 647652.

ES McConnell , CF Pieper , RJ Sloane , LG Branch (2002). Effects of cognitive performance on change in physical function in long-stay nursing home residents. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 57, M778M784.

KM Mehta , K Yaffe , KE Covinsky (2002). Cognitive impairment, depressive symptoms, and functional decline in older people. Journal of the American Geriatrics Society 50, 10451050.

CF Mendes de Leon , LA Beckett , GG Fillenbaum , DB Brock , LG Branch , DA Evans , LF Berkman (1997). Black–white differences in risk of becoming disabled and recovering from disability in old age: a longitudinal analysis of two EPESE populations. American Journal of Epidemiology 145, 488497.

J Ormel , FV Rijsdijk , M Sullivan , E von Sonderen , GIJM Kempen (2002). Temporal and reciprocal relationship between IADL/ADL disability and depressive symptoms in late life. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences 57, P338P347.

BWJH Penninx , DJH Deeg , JT van Eijk , ATF Beekman , JM Guralnik (2000). Changes in depression and physical decline in older adults: a longitudinal perspective. Journal of Affective Disorders 61, 112.

BWJH Penninx , JM Guralnik , L Ferrucci , EM Simonsick , DJH Deeg , RB Wallace (1998). Depressive symptoms and physical decline in community-dwelling older persons. Journal of the American Medical Association 279, 17201726.

BWJH Penninx , S Leveille , L Ferrucci , JTM van Eijk , JM Guralnik (1999). Exploring the effect of depression on physical disability: longitudinal evidence from the established populations for epidemiologic studies of the elderly. American Journal of Public Health 89, 13461352.

E Pfeiffer (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society 23, 433441.

HA Pincus , WW Davis , LE McQueen (1999). ‘Subthreshold’ mental disorders: a review and synthesis of studies on minor depression and other ‘brand names’. British Journal of Psychiatry 174, 288296.

LS Radloff (1977). The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement 1, 385401.

I Rosow , N Breslau (1966). A Guttman health scale for the aged. Journal of Gerontology 21, 556559.

PA Sinclair , JM Lyness , DA King , C Cox , ED Caine (2001). Depression and self-reported functional status in older primary care patients. American Journal of Psychiatry 158, 416419.

AE Stuck , JM Walthert , T Nikolaus , CJ Bula , C Hohmann , JC Beck (1999). Risk factors for functional status decline in community-living elderly people: a systematic literature review. Social Science and Medicine 48, 445469.

CH van Gool , GIJM Kempen , BWJH Penninx , DJH Deeg , ATF Beekman , JTM van Eijk (2005). Impact of depression on disablement in late middle aged and older persons: results from the Longitudinal Aging Study Amsterdam. Social Science and Medicine 60, 2536.

L Wang , G van Belle , WB Kukull , EB Larson (2002). Predictors of functional change: a longitudinal study of nondemented people aged 65 and older. Journal of the American Geriatrics Society 50, 15251534.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 4
Total number of PDF views: 50 *
Loading metrics...

Abstract views

Total abstract views: 223 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 17th October 2017. This data will be updated every 24 hours.