Skip to main content
    • Aa
    • Aa
  • Get access
    Check if you have access via personal or institutional login
  • Cited by 32
  • Cited by
    This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

    Chen, Szu-Wei and Chippendale, Tracy 2016. Factors associated with IADL independence: implications for OT practice. Scandinavian Journal of Occupational Therapy, p. 1.

    Hajek, André Luck, T. Brettschneider, C. Posselt, T. Lange, C. Wiese, B. Steinmann, S. Weyerer, S. Werle, J. Pentzek, M. Fuchs, A. Stein, J. Bickel, H. Mösch, E. Wagner, M. Heser, K. Maier, W. Scherer, M. Riedel-Heller, S. G. and König, H.-H. 2016. Factors affecting functional impairment among elderly Germans — Results of a longitudinal study. The journal of nutrition, health & aging,

    Ludvigsson, Mikael Marcusson, Jan Wressle, Ewa and Milberg, Anna 2016. Markers of subsyndromal depression in very old persons. International Journal of Geriatric Psychiatry, Vol. 31, Issue. 6, p. 619.

    Ylli, Alban Miszkurka, Malgorzata Phillips, Susan P. Guralnik, Jack Deshpande, Nandini and Zunzunegui, Maria Victoria 2016. Clinically relevant depression in old age: An international study with populations from Canada, Latin America and Eastern Europe. Psychiatry Research, Vol. 241, p. 236.

    Yohannes, Abebaw M. Müllerová, Hana Hanania, Nicola A. Lavoie, Kim Tal-Singer, Ruth Vestbo, Jorgen Rennard, Steven I. and Wouters, Emil F.M. 2016. Long-term Course of Depression Trajectories in Patients With COPD. Chest, Vol. 149, Issue. 4, p. 916.

    Anton, Stephen D. Woods, Adam J. Ashizawa, Tetso Barb, Diana Buford, Thomas W. Carter, Christy S. Clark, David J. Cohen, Ronald A. Corbett, Duane B. Cruz-Almeida, Yenisel Dotson, Vonetta Ebner, Natalie Efron, Philip A. Fillingim, Roger B. Foster, Thomas C. Gundermann, David M. Joseph, Anna-Maria Karabetian, Christy Leeuwenburgh, Christiaan Manini, Todd M. Marsiske, Michael Mankowski, Robert T. Mutchie, Heather L. Perri, Michael G. Ranka, Sanjay Rashidi, Parisa Sandesara, Bhanuprasad Scarpace, Philip J. Sibille, Kimberly T. Solberg, Laurence M. Someya, Shinichi Uphold, Connie Wohlgemuth, Stephanie Wu, Samuel Shangwu and Pahor, Marco 2015. Successful aging: Advancing the science of physical independence in older adults. Ageing Research Reviews, Vol. 24, p. 304.

    Bernard, P. Ninot, G. Bernard, P.L. Picot, M.C. Jaussent, A. Tallon, G. and Blain, H. 2015. Effects of a six-month walking intervention on depression in inactive post-menopausal women: a randomized controlled trial. Aging & Mental Health, Vol. 19, Issue. 6, p. 485.

    de Guzman, Allan B. Lacampuenga, Prince Edward U. and Lagunsad, Algem Paul V. 2015. Examining the Structural Relationship of Physical Activity, Cognition, Fear of Falling, and Mobility Limitation of Filipino in Nursing Homes. Educational Gerontology, Vol. 41, Issue. 7, p. 527.

    Gómez-Gallego, María Gómez-García, Juan and Ato-Lozano, Ester 2015. The mediating role of depression in the association between disability and quality of life in Alzheimer's disease. Aging & Mental Health, p. 1.

    Ludvigsson, Mikael Milberg, Anna Marcusson, Jan and Wressle, Ewa 2015. Normal Aging or Depression? A Qualitative Study on the Differences Between Subsyndromal Depression and Depression in Very Old People. The Gerontologist, Vol. 55, Issue. 5, p. 760.

    Makizako, Hyuma Shimada, Hiroyuki Doi, Takehiko Tsutsumimoto, Kota Lee, Sangyoon Hotta, Ryo Nakakubo, Sho Harada, Kazuhiro Lee, Sungchul Bae, Seongryu Harada, Kenji and Suzuki, Takao 2015. Cognitive Functioning and Walking Speed in Older Adults as Predictors of Limitations in Self-Reported Instrumental Activity of Daily Living: Prospective Findings from the Obu Study of Health Promotion for the Elderly. International Journal of Environmental Research and Public Health, Vol. 12, Issue. 3, p. 3002.

    Overcash, Janine 2015. Assessing the Functional Status of Older Cancer Patients in an Ambulatory Care Visit. Healthcare, Vol. 3, Issue. 3, p. 846.

    Riddle, Daniel L. Perera, Robert A. Nay, William T. and Dumenci, Levent 2015. What Is the Relationship Between Depressive Symptoms and Pain During Functional Tasks in Persons Undergoing TKA? A 6-year Perioperative Cohort Study. Clinical Orthopaedics and Related Research®, Vol. 473, Issue. 11, p. 3527.

    Riddle, Meghan McQuoid, Douglas R. Potter, Guy G. Steffens, David C. and Taylor, Warren D. 2015. Disability but not social support predicts cognitive deterioration in late-life depression. International Psychogeriatrics, Vol. 27, Issue. 05, p. 707.

    Yao, Hiroshi Takashima, Yuki Araki, Yuko Uchino, Akira Yuzuriha, Takefumi and Hashimoto, Manabu 2015. Leisure-Time Physical Inactivity Associated with Vascular Depression or Apathy in Community-Dwelling Elderly Subjects: The Sefuri Study. Journal of Stroke and Cerebrovascular Diseases, Vol. 24, Issue. 11, p. 2625.

    Covinsky, Kenneth E. Cenzer, Irena Stijacic Yaffe, Kristine O'Brien, Sarah and Blazer, Dan G. 2014. Dysphoria and Anhedonia as Risk Factors for Disability or Death in Older Persons: Implications for the Assessment of Geriatric Depression. The American Journal of Geriatric Psychiatry, Vol. 22, Issue. 6, p. 606.

    Hirsch, Jameson K. Walker, Kristin L. Wilkinson, Ross B. and Lyness, Jeffrey M. 2014. Family Criticism and Depressive Symptoms in Older Adult Primary Care Patients: Optimism and Pessimism as Moderators. The American Journal of Geriatric Psychiatry, Vol. 22, Issue. 6, p. 632.

    Kulmala, Jenni Hinrichs, Timo Törmäkangas, Timo von Bonsdorff, Mikaela B. von Bonsdorff, Monika E. Nygård, Clas-Håkan Klockars, Matti Seitsamo, Jorma Ilmarinen, Juhani and Rantanen, Taina 2014. Work-related stress in midlife is associated with higher number of mobility limitation in older age—results from the FLAME study. AGE, Vol. 36, Issue. 6,

    Song, Hee-Jung Meade, K. Akobundu, U. and Sahyoun, N. R. 2014. Depression as a correlate of functional status of community-dwelling older adults: Utilizing a short-version of 5-item Geriatric Depression Scale as a screening tool. The journal of nutrition, health & aging, Vol. 18, Issue. 8, p. 765.

    Song, Hee-Jung Meade, K. Akobundu, U. and Sahyoun, N. R. 2014. Depression as a correlate of functional status of community-dwelling older adults: Utilizing a short-version of 5-item geriatric depression scale as a screening tool. The journal of nutrition, health & aging,


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)
  • DOI:
  • Published online: 09 April 2009

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:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

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? *