Subthreshold Depression in Children & Adolescents
Alex Navarrete
Do you think you are normal? How would you distinguish between what is normal and what isn't? The subject matter of these questions is also a point of debate in the field of psychology. Currently, there is no definitive consensus on how to best define or differentiate normal and abnormal functioning in children and adolescents. Despite the evolving debate, the Manual of Mental Disorders (DSM-5) has settled on implementing criteria for the diagnosis of most disorders. The use of categories and criteria in the DSM-5 gave rise to the subthreshold label. The subthreshold label is applied to someone when they have a large number of symptoms for a disorder, but do not meet the clinical criteria for a meaningful diagnosis. Children and adolescents with subthreshold symptoms of depression face a plethora of issues, some of which could be helped if they were granted a diagnosis (Cartwright et al., 2017).
Although the problems faced by youths with subthreshold depression have been known for a while, new research suggests that these struggles were exacerbated by the COVID-19 pandemic (Liao et al., 2021). Although the full extent of COVID-19’s impact on mental health is currently unknown, Phelps and Sperry (2020) expect the adverse mental health effects of the pandemic to become clearer in the coming years. Therefore, it is crucial to address subthreshold depression in children and adolescents now.
The threshold between normality and disorder is ambiguous and, consequently, arbitrary. These arbitrary distinctions have consequences which are exemplified by the struggles of children and adolescents with subthreshold depression. There are a significant percentage of children and adolescents who exhibit subthreshold symptoms for depression (Carrellas et al., 2017; Cartwright et al., 2017). In fact, one study reported that subthreshold depression was present in adolescents almost three times more than major depressive disorder (MDD) (Balázs et al., 2013). According to Balázs and colleagues, subthreshold depression presents psychological harm and functional impairment to those with the condition despite its perceived lack of severity. Specifically, children and adolescents with subthreshold depression are likely to experience troubles with emotional regulation and social problem solving (Crockett et al., 2020). Although MDD presents a higher risk of mortality, the rates of suicide do not largely differ between those with major depression and those with subthreshold depression (Cuijpers et al., 2013). The research on the topic shows that youths with subthreshold symptoms of depression often do not greatly differ from those who fully meet the diagnostic criteria.
In comparison to youths who do not show any symptoms of depression, children and adolescents with subthreshold depression differ greatly in terms of their level of impairment and distress. Yet, according to Helzer and colleagues (2006), individuals with subthreshold depression are often left with the same insurance coverage as those without any symptoms at all. This discrepancy is a result of the limitations of the current DSM. Clinicians have to work within the confines of the DSM-5 and a clinician’s diagnosis, or lack thereof, is shared with one's insurance provider. Thus, those with subthreshold depression may not have the same access to treatment as those who are diagnosed with MDD. According to Cartwright et al. (2017), the confining nature of the current diagnostic system is exemplified through children and adolescents with subthreshold symptoms because diagnoses are made while rapid physical, cognitive and emotional development is still in progress. Therefore, the categorical nature of the current DSM often does not sufficiently account for the psychopathological development of children and adolescents.
Research suggests that cognitive-behavioral therapy (CBT) works best for adolescents with subthreshold depressive symptoms. CBT is a form of psychotherapy that has been demonstrated to be effective for a range of problems, including depression (APA, 2017). A recent meta-analysis found that CBT reduced the likelihood of adolescents developing MDD. However, researchers could not find sufficient evidence to support the same claim in children (Cuijpers et al., 2021). More research needs to be conducted to test the efficacy of CBT in regards to treating children and adolescents with subthreshold depression. Nevertheless, CBT can be relatively expensive and may not be accessible to all without insurance to cover the cost.
Emerging research challenges the overreliance of the current categorical approach to mental illness and instead proposes a new, inclusive model. This model proposes that disorders should be conceptualized on a continuum with no distinct lines between mental illness and normality. This approach would provide an accurate reflection of the complexity and ever-changing nature of mental illness (Helzer et al., 2006). If mental illness lies on a spectrum as emerging studies suggest, then the current categorical approach to diagnosing disorders cannot justly serve all clients. Therefore, the DSM-5 should ideally include conceptualizations of disorders, such as depression, on a spectrum. Redefining common mood disorders such as depression and anxiety as belonging to a spectrum of symptoms rather than an exclusive criteria can open the door for many youths to start receiving accurate and accessible treatment. It is a challenge easier said than done given that insurance providers would most likely side against it, but if we want to aid as many people as possible in the coming years, research and reform needs to begin now.
References
American Psychiatric Association. (2017). What is Cognitive Behavioral Therapy? https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
Balázs, J., Miklósi, M., Keresztény, Á., Hoven, C.W., Carli, V., Wasserman, C., Apter, A., Bobes, J., Brunner, R., Cosman, D., Cotter, P., Haring, C., Iosue, M., Kaess, M., Kahn, J. P., Keeley, H., Marusic, D., Postuvan, V., Resch, F., Saiz, P .A., Sisask, M., Snir, A., Tubiana, A., Varnik, A., Sarchiapone, M. & Wasserman, D. (2013), Adolescent subthreshold-depression and anxiety: psychopathology, functional impairment and increased suicide risk. Journal of Child Psychology and Psychiatry, 54: 670-677. https://doi-org.proxy.wexler.hunter.cuny.edu/10.1111/ jcpp.12016
Carrellas, N. W., Biederman, J., & Uchida, M. (2017). How prevalent and morbid are subthreshold manifestations of major depression in adolescents? A literature review. Journal of Affective Disorders, 210, 166–173. https://doi-org.proxy. wexler.hunter.cuny.edu/10.1016/j.jad.2016.12.037
Cartwright, J., Lasser, J., & Gottlieb, M. C. (2017). To code or not to code: Some ethical conflicts in diagnosing children. Practice Innovations, 2(4), 195–206. https:// doi.apa.org/doiLanding?doi=10.1037%2Fpri0000053
Crockett, M. A., Martínez, V., & Jiménez-Molina, Á. (2020). Subthreshold depression in adolescence: Gender differences in prevalence, clinical features, and associated factors. Journal of Affective Disorders, 272, 269–276. https://doi-org.proxy. wexler.hunter.cuny.edu/10.1016/j.jad.2020.03.111
Cuijpers, P., Vogelzangs, N., Twisk, J., Kleiboer, A., Li, J., & Penninx, B. (2013). Differential mortality rates in major and subthreshold depression: Meta-analysis of studies that measured both. British Journal of Psychiatry, 202(1), 22-27. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/differential-mortality-rates-in-major-and-subthreshold-depression-metaanalysis-of-studies-that-measured-both/B07AF3C2D278707468561F6E0F78F44C
Cuijpers, P., Pineda, B. S., Ng, M. Y., Weisz, J. R., Muñoz, R. F. Gentili, C., Quero, S., & Karyotaki, E. (2021). A Meta-analytic Review: Psychological Treatment of Subthreshold Depression in Children and Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 60(9), 1072. https://www.jaacap. org/article/S0890-8567(21)00074-5/fulltext#relatedArticles
Helzer, J. E., Kraemer, H. C., & Krueger, R. F. (2006). The feasibility and need for dimensional psychiatric diagnoses. Psychological Medicine, 36, 1671–1680. http://dx.doi.org/10.1017/S003329170600821X
Liao, Y., Fan, B., Zhang, H., Guo, L., Lee, Y., Wang, W. X., Li, W. Y., Gong, M. Q., Lui, L. M. W., Li, L. J., Lu, C. Y., & McIntyre, R. (2021). The impact of COVID-19 on subthreshold depressive symptoms: A longitudinal study. Epidemiology and Psychiatric Sciences, 30(20). https://www.cambridge.org/core/journals/epidem iology-and-psychiatric-sciences/article/impact-of-covid19-on-subthreshold-depressive-symptoms-a-longitudinal-study/A5699387CE6A1F49D43DECBE5B9CAEA1
Phelps, C., & Sperry, L. L. (2020). Children and the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(1), S73–S75. https://doi.org /10.1037/tra0000861