Asian Journal of Psychiatry 102 (2024) 104253

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Prevalence of subthreshold depression in older adults: A systematic review

and meta-analysis
Xiaoyan Zhao a,1,2, Li Zhang b,1 , Ariadna Albajara Sáenz c,1, Xinyue Zhang b, Jia Sun b,
Qiqing Zhong a,3 , Yuanjuan Cheng b,*, Yong Jia a,c,**,4,5
a
School of Nursing, Jilin University, Changchun 130012, China
b
Department of Nursing, Second Hospital, Jilin University, Changchun 130022, China
c
Department of Psychiatry, University of Cambridge, Cambridge CB2 0AH, United Kingdom

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The prevalence of subthreshold depression (StD) in older adults shows considerable variation across
Subthreshold depression studies. This study aimed to determine the prevalence of subthreshold depression in elderly people.
Old adults Methods: We conducted a thorough literature search across multiple databases, including PubMed, Web of Sci­
Meta-analysis
ence, Medline, Cochrane Library, SinoMed, Wan Fang Data, CNKI, and VIP. Statistical analyses were carried out
Prevalence
using STATA version 16.0. Our study was prospectively registered with PROSPERO (CRD42023494210).
Results: Seventy-seven studies involving 225,232 individuals were included in this meta-analysis. The overall
prevalence of subthreshold depression was 18.6 % (95 % CI: 16.0 %-21.2 %, I2 =99.8 %, p<0.001. Subgroup
analyses showed the prevalence of StD in older adults varied depending on the screening tools used and the
continent of the study. Funnel plots and Egger’s test did not reveal any significant publication bias (Egger’s test: p
= 0.057).
Conclusion: The prevalence of subthreshold depression in older adults is high, suggesting attention needs to be
paid to the mental health of the elderly. To prevent a larger public health issue, it is imperative to implement
timely and effective preventive measures and interventions, focusing on early detection and intervention.

1. Introduction developing MDD. Additionally, several cross-sectional studies have

found that StD is associated with more pronounced neuropsychiatric
Subthreshold depression (StD) refers to clinically relevant depressive symptoms and accelerated cognitive and functional decline (Verdaguer
symptoms that do not meet the criteria for a major depressive disorder et al., 2020; Zhu et al., 2022). In the elderly population, StD is also
(MDD) according to the DSM (Diagnostic and Statistical Manual of associated with frailty (Borges et al., 2021), impaired physiological
Mental Disorders), or for a depressive episode according to the ICD functioning, reduced quality of life (Pietrzak et al., 2013), and poorer
(International Classification of Diseases) (Takagaki et al., 2014). self-rated health (Vahia et al., 2010). Furthermore, StD increases the risk
Numerous studies have shown that StD in older adults is associated with of cardiovascular disease (Harshfield et al., 2020), and, compared to
an increased risk of MDD, Alzheimer’s disease, and chronic illnesses. A MDD, is linked to cumulative dysfunction over time (Lyness et al.,
systematic review and meta-analysis of longitudinal cohort studies (Lee 1999). One of the central features of StD is cognitive-emotional symp­
et al., 2019) demonstrated that StD is linked to a heightened risk of toms (Liao et al., 2022), which differ from those of MDD only in degree

* Corresponding author at: Department of Nursing, Second Hospital, Jilin University, No. 4026 Yatai Street, Changchun, Jilin 130022, China.
** Corresponding author at: School of Nursing, Jilin University, No. 965 Xinjiang Street, Changchun, Jilin 130012, China.
E-mail addresses: 1342008202@qq.com (X. Zhao), zhangli01@jlu.edu.cn (L. Zhang), aa2354@cam.ac.uk (A.A. Sáenz), 2622595881@qq.com (X. Zhang),
17824910614@163.com (J. Sun), 229478355@qq.com (Q. Zhong), chengyj@jlu.edu.cn (Y. Cheng), jiayong@jlu.edu.cn (Y. Jia).
1
These authors contributed equally to this work.
2
ORCID: 0009–0001-7586–5354
3
ORCID: 0009–0003-0129–9665
4
ORCID: 0000–0002-4201–6591
5
ORCID: 0000–0002-4201–6591.

https://doi.org/10.1016/j.ajp.2024.104253
Received 6 July 2024; Received in revised form 17 September 2024; Accepted 25 September 2024
Available online 1 October 2024
1876-2018/© 2024 Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
X. Zhao et al. Asian Journal of Psychiatry 102 (2024) 104253

(Solomon et al., 2001). While different StD symptoms may influence PHQ-9, DSM, Mini International Neuropsychiatric Interview (MINI),
disease progression to varying extents (Howland et al., 2008), enhancing and CIDI, along with clear criteria for using these tools to assess StD;
effective prophylaxis for StD can provide sustained benefits by pre­ Study design (S): original observational and/or epidemiological studies
venting first episodes of depression and reducing the risk of recurrence examining the definition, prevalence, and associated characteristics of
(Allen et al., 2007). Overall, StD treatment not only alleviates depressive minor/subthreshold depression in older adults.
symptoms but also helps prevent the onset of major depression (Cuijpers By contrast, studies were excluded if they fulfilled any of the
et al., 2019). following criteria: 1) written in a language other than Chinese or En­
Currently, the diagnostic criteria for StD are highly heterogeneous, glish; 2) the data was incomplete; 3) unavailable full text; and 4) cate­
yet the condition can typically be established using validated measures, gorized as reviews, case reports, comments, letters, or editorials.
such as the Centre for Epidemiological Studies Depression Scale-Revised
(CES-D), the Patient Health Questionnaire (PHQ-9), or the Beck 2.3. Data extraction and quality assessment
Depression Inventory-II (BDI-II). These tools allow the identification of
depressive symptoms, while a diagnosis of MDD based on DSM-IV The two principal investigators independently extracted data from
criteria can be excluded using the Composite International Diagnostic each article using a standardized form with predefined categories:
Interview (CIDI), or the Structured Clinical Interview for DSM Disorders author details, geographical location, sample size, participant de­
(SCID). The most commonly used screening tool for depression is the mographics (including age and gender distribution), screening tools
CES-D, followed by the PHQ-9 (Volz et al., 2023). In older adults, the utilized, specific outcomes (including screening criteria and prevalence
Geriatric Depression Scale (GDS), a self-report measure of depression in of StD), and reported prevalence rates. Any discrepancies between the
older adults, was reported as the most commonly used measure in this investigators were resolved through discussion, facilitated by the cor­
population. As the population ages, the psychological well-being of responding author.
older adults becomes increasingly important, with significant implica­ Furthermore, both investigators independently used the Joanna
tions for the healthcare system and the socio-economy (Curran et al., Briggs Institute (JBI) quality assessment tool, developed by Munn et al.
2020). Without proper diagnosis, subthreshold symptoms may go un­ (2014), (2015), to evaluate the quality of the included studies. This tool
recognized, leaving older adults without adequate support or treatment comprises nine criteria covering aspects such as sampling methods,
(Vink et al., 2008). However, there is still no instrument specifically study population characteristics, data collection processes, and result
designed to measure StD in older adults. categorization (Munn et al., 2014, 2015). Each criterion was evaluated
In terms of prevalence, a study by Zhang et al. pooled data from 113 with responses categorized as "yes," "no," "unclear," or "not applicable,"
studies and reported a prevalence of StD of 11.02 % in the general reflecting whether the study met specified criteria. A higher count of
population (Zhang et al., 2023). Similarly, Wesselhoeft et al. found that "yes" responses indicates higher study quality and lower risk of bias. Any
the prevalence estimates of StD in adolescents ranged from 5.3 % unresolved discrepancies were adjudicated by a third researcher tasked
~12.0 % (Wesselhoeft et al., 2013). In older adults, StD prevalence with making the final decision based on a comprehensive review of the
seems to be largely dependent on national data and screening tools, with literature.
rates ranging from 1.38 % to 58.18 % (Bijl et al., 2009; Cohen et al.,
2009), highlighting significant variability. However, there have been no 2.4. Statistical analysis
rigorous systematic analyses of StD prevalence in this population.
Therefore, the aim of this systematic review and meta-analysis was to Statistical analyses were performed using Stata 15.1 software. The
determine prevalence estimates of StD in older adults and identify prevalence of depression was estimated using a random-effects model to
associated influencing factors. Reliable estimates of StD prevalence in account for between-study heterogeneity (Borenstein et al., 2010). The
older adults are necessary to understand its etiology, promote early significance of heterogeneity was assessed using standard χ2 tests and I2
detection, and develop effective prevention and treatment strategies. statistics, where I2 values ≥75 % indicate substantial heterogeneity
(Higgins et al., 2003).
2. Methods Sensitivity analyses were performed to assess the impact of indi­
vidual studies on overall prevalence estimates by systematically
This study was registered in advance with the International Pro­ excluding each study. Meta-analyses were stratified based on predefined
spective Register of Systematic Reviews (PROSPERO: study-level characteristics. Publication bias was evaluated by visual
CRD42023494210). Given its nature as a secondary synthesis of pub­ inspection of funnel plots, and Egger’s tests (Egger et al., 1997; Stuck
lished studies, ethical approval and participant consent were deemed et al., 1998). If the distribution of studies in the funnel plot is roughly
unnecessary. symmetrical, it indicates that there is no publication bias in these
studies. A p < 0.05 was considered as statistically significant (two-sided)
2.1. Search strategy and study identification in Egger’s tests.

We systematically searched four English databases (PubMed, Web of 3. Result

Science, Medline, Cochrane Library) and four Chinese databases
(SinoMed, Wan Fang Data, CNKI, VIP) for studies published until April 3.1. Study selection
2024. Our search strategy included both free and subject terms, utilizing
Boolean operators (OR and AND) to combine search criteria. Details of Fig. 1 presents the PRISMA flowchart illustrating the study selection
the search strategies are reported in Appendix 1. process. Initially, 6895 articles were retrieved from 8 electronic data­
bases. After removing duplicates, 5132 articles remained. Following title
2.2. Inclusion and exclusion criteria and abstract screening, 178 articles were selected for full text screening.
Subsequently, 101 studies were excluded, resulting in 77 studies being
Following the PICOS framework, the inclusion criteria were estab­ included in the systematic review.
lished as follows: Participants (P): individuals aged 55 years and older;
Intervention (I) and Comparison (C): not applicable; Outcomes (O): 3.2. Study characteristics
prevalence of StD measured using globally recognized depression
screening tools with demonstrated validity and reliability for older The characteristics of the included studies are reported in Table 1. A
adults, such as the GDS, CES-D, the Hamilton Depression Scale (HAMD), total of 77 studies met the inclusion criteria and were included in the

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X. Zhao et al. Asian Journal of Psychiatry 102 (2024) 104253

Fig. 1. Flow diagram of literature search.

meta-analysis. Among them, 22 studies were from Asia, 25 from Europe, 1.38–26.7 % in Europe, 2.3–58.18 % in the Americas, 4.1–14.5 % in
25 from the Americas, four from Oceania and one was global (176 Oceania, and was 44.9 % globally. Specific details are reported in
countries included). The sample sizes of the included studies ranged Table 1.
from 92 to 15,326, with a total of 225,232 participants aged ≥55 years.
Of the 77 studies, 16 studies reported the prevalence of StD using the 3.3. Methodological quality
DSM, 15 studies the CES-D, 15 studies the GDS, 15 studies the PHQ, 4
studies the HAMD, 4 studies the Geriatric Mental State Schedule (GMS), The minimum number of "yes" responses was 6, and the maximum
3 studies the ICD-10, 2 studies the EURO-Depression (Euro-D) scale, 1 was 9. Among the 68 studies, "yes" responses ranged from 7 to 9. Nine
study used the Impairment Scale (IS) and 1 study used the Diagnostic studies had exactly 6 "yes" responses. On average, the 77 included
Interview Schedule (DSQ). In our systematic review, the prevalence of studies had 7.5 "yes" responses. Detailed information of quality assess­
StD in older adults varied from 1.38 % to 58.18 %. Specifically, the ment is reported in Appendix 2.
prevalence of StD in older adults ranged from 3.5 % to 56.89 % in Asia,

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X. Zhao et al. Asian Journal of Psychiatry 102 (2024) 104253

Table 1
Characteristics of the 77 studies included in the meta-analysis.
Authors Country Sample Gender (n Age(y) Screening Symptom or score specification Prevalence
size (n) males) tools （%）

Albertorio-Diaz et al. (2017) USA 2951 Unavailable ≥60 PHQ− 9 (DSM- 2–4 depressive symptoms present in the previous 6.4
IV-TR) two weeks, but do not meet the criteria for either
MDE or MDD
Alexandrino-Silva et al. (2011) Brazil 367 129 ≥60 ICD− 10 2 or 3 depressive symptoms 8.7
Allgaier et al. (2013) Germany 92 13 65–97 DSM-IV 2–4 depressive symptoms present for a minimum of 14.1
2 weeks
Almeida et al. (2011) Australia 20,677 8706 ≥60 PHQ− 9 2 depressive symptoms have been present most 4.1
days, and 3 depressive symptoms have been present
for more than half of the days during the previous
two weeks
Almeida et al. (2015) Australia 1649 1649 ≥80 PHQ− 9 PHQ− 9 total scores between 5 and 9 14.5
An et al. (2020) Korea 733 Unavailable ≥65 GDS GDS scores of 10 points or higher, but no diagnosis 27.96
of major or minor depressive disorders
Liu et al. (2023) China 234 77 ≥60 HAMD− 17 HAMD− 17 total scores between 7 and 17 44.02
Yao et al. (2018) China 368 122 ≥60 HAMD− 17 HAMD− 17 total scores between 7 and 20 17.93
Shu et al. (2019) China 546 292 ≥60 GDS− 15 GDS− 15 total scores between 5 and 9 40.3
Angermann et al. (2011) Germany 702 501 67±12 PHQ− 9 PHQ− 9 total scores between 9 and 11 15
Aranda et al. (2001) USA 149 44 69.3 PHQ− 9 Fewer symptoms than those required for any 20.1
±10.1 specific DSM-IV diagnoses (e.g., major pression in
partial remission, dysthymia, other depressive
disorder).
Areán & Alvidrez (2001) USA 95 69 ≥55 GDS (DSM-III- GDS scores of ≥ 14, but without meeting criteria for 14
R) a current Axis I disorder
Barry et al. (2009) USA 754 268 ≥70 CES-D CES-D total scores between 0 and 9 57.2
Beekman et al. (1995) Netherlands 3056 1478 55–85 CES-D CES-D total scores ≥ 16, but without meeting 12.9
rigorous diagnostic criteria for major depression
Bijl et al. (2009) Netherlands 6804 2849 ≥55 CES-D CES-D total scores ≥ 16, but without meeting 1.38
rigorous diagnostic criteria for major depression
Blank et al. (2004) USA 360 133 ≥60 GDS, CES-D DIS-diagnosed dysthymia and "symptoms 7
(DIS) falling short of major depression"
Borges et al. (2021) Brazil 315 100 ≥60 PHQ− 9 PHQ− 9 total scores between 5 and 9 27.3
(DSM− 5),
GDS− 15
Boyle et al. (2010) USA 470 173 ≥60 DSM-IV DSM-IV appendix B criteria 7.02
(SCID)
Braam et al. (2014) Unavailable 14,200 Unavailable ≥65 GMS-AGECAT Respondents who have level 1 or 2 within the 15.2
syndrome clusters of depression and anxiety,
pertaining to the month preceding the examination
Bremmer et al. (2008) Netherlands 1285 629 ≥65 CES-D (DSM- CES-D total scores ≥16, but without meeting 12
III) rigorous diagnostic criteria for major depression
Bremmer et al. (2006) Netherlands 2403 1099 ≥55 CES-D (DIS) CES-D total scores ≥16, but without meeting 11.7
rigorous diagnostic criteria for major depression
Brooks et al. (2019) USA 709 Unavailable ≥60 PHQ− 9 PHQ− 9 total scores between 5 and 9 23.98
Brown et al. (2003) USA 403 135 ≥65 DSM-IV DSM-IV diagnosis of minor 8.18
(SCID) depression regardless of medical etiology
Bruce et al. (2006) Australia 207 106 ≥70 GHS (DSM-IV) DSM-IV criteria for minor 4.8
depression
Burns et al. (2020) Australia 2551 1317 60–64 PHQ− 9 PHQ− 9 total scores between 5 and 9 12.19
van Varsseveld et al. (2015) Netherlands 1188 590 ≥65 CES-D CES-D total scores≥16, but without meeting 13.6
diagnostic criteria for major depression
Chang et al. (2015) Korea 51,602 48,420 55–64 PHQ− 9 (DSM- A positive response to at least one of the two items, 29.83
IV) but a total of less than five positive responses to the
total of nine items
Chang et al. (2017) China 2673 1456 ≥65 CES-D CES-D total scores between 0 and 9 24.2
Chao et al. (2020) USA 3138 1298 ≥60 PHQ− 9 PHQ− 9 total scores between 1 and 4 34.3
Chen et al. (2014) China 351 195 ≥65 GDS− 15 GDS− 15 total scores between 5 and 9 26.8
Chuan et al. (2008) Singapore 1092 495 ≥60 GMS-AGECAT Respondents with diagnostic confidence levels of 9.6
(DSM-IV) 1–2 for depression are categorized as subsyndromal
depression, which exhibit some depressive
symptoms but do not meet the criteria for a
syndromal diagnosis (levels 3–5)
Lv et al. (2013) China 4502 Unavailable ≥60 GDS− 15 GDS− 15 total scores between 5 and 8 40.9
Cohen et al. (2009) USA 110 50 ≥55 CES-D CES-D total scores between 8 and 16 58.18
Cole et al. (2006) Canada 380 139 ≥65 DSM-IV 2–4 depressive symptoms present for a minimum of 23.4
2 weeks
Cao et al. (2019) China 615 267 ≥60 GDS GDS total scores between 11 and 20 21.95
Demakakos et al. (2013) England 4300 1928 ≥60 CES-D CES-D total scores between 2 and 3 18.56
Dirmaier et al. (2010) Germany 866 443 ≥60 DSQ (ICD− 10) DSQ total scores between 5 and 7 20.7
Egbert et al. (2023) Global (176 15,326 6774 ≥55 PHQ− 8 PHQ− 8 total scores between 1 and 4 44.9
countries)
Forlani et al. (2014) Italy 359 182 ≥74 ICD− 10 Symptoms not severe enough for a 5.6
diagnosis of depression
(continued on next page)

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Table 1 (continued )
Authors Country Sample Gender (n Age(y) Screening Symptom or score specification Prevalence
size (n) males) tools （%）

Friedman et al. (2009) USA 539 188 ≥65 DSM-IV 2–4 depressive symptoms present for a minimum of 10.8
(SCID) 2 weeks
Gabryelewicz et al. (2004) Poland 102 30 70 DSM-IV 2–4 depressive symptoms present for a minimum of 26.5
±7.5 2 weeks
Gallo et al. (2007) USA 1226 369 ≥60 HAMD (DSM- 4 depression symptoms and HAMD score of 16.56
IV) 10 or higher, during 4 weeks or more
Gellis (2010) USA 289 86 ≥65 DSM-IV 2–4 depressive symptoms present for a minimum of 16.4
(SCID) 2 weeks
Glaesmer et al. (2011) Germany 1659 771 ≥60 PHQ− 9 PHQ− 9 total scores between 5 and 9 3.8
Gonçalves-Pereira et al. (2019) Portugal 1405 626 ≥65 EURO-D Cases of EURO-D depression that do not 13.5
(ICD− 10) meet full criteria for an ICD− 10 depressive
episode (specifically, individuals scoring below the
validated cut-off point of 4 on the EURO-D scale are
considered as having subsyndromal depression.)
Grabovich et al. (2010) USA 481 273 ≥65 HAMD, SCID According to three definitions of SSD: HAMD total 19.6
scores ≥ 10; any two depressive symptoms at the
SCID threshold level; two symptoms of depression
at either SCID threshold or subthreshold levels,
with at least one symptom being depressed mood or
decreased interests/pleasure
Han et al. (2020) China 1002 180 ≥100 GDS− 15 GDS− 15 total scores between 6 and 9 38.12
Heesterbeek et al. (2017) Netherlands 540 239 74.8 CES-D CES-D cut-off scores: ≥ 16 21.3
±11.5
Ho et al. (2016) Singapore 1070 467 ≥60 GMS (DSM-IV) Diagnostic confidence levels between 1–2 9.9
according to GMS, where individuals do not meet
the criteria for major depression as defined by DSM-
IV
Lan & Thuy (2020) Vietnam 110 44 ≥60 GDS GDS total scores between 11 and 19 25.5
Hoogendijk et al. (2008) Netherlands 1282 623 ≥65 CES-D CES-D scores ≥16 but Diagnostic Interview 13.18
Schedule negative for MDD
Hybels et al. (2001) USA 3674 2270 ≥65 CES-D CES-D total scores between 6 and 8 9.1
Johansson et al. (2019) Latin America 11,472 4131 ≥65 EURO-D ≥4 symptoms in the EURO-D scale but without 20.6
(4 countries) (ICD− 10) meeting ICD− 10 criteria
Jongenelis et al. (2004) Netherlands 350 109 ≥55 GDS (DSM-IV) GDS total scores >10, without meeting DSM-IV 24
criteria for major or minor depression
Karlsson et al. (2016) Sweden 3084 1132 ≥60 DSM-IV-TR A minimum of 2 and no more than 4 5.1
depression symptoms present
Kramer et al. (2009) Germany 97 24 ≥65 DSM-IV 2–4 depressive symptoms are present for a 14.4
minimum of 2 weeks
Laborde-Lahoz et al. (2015) USA 10,409 3860 ≥55 DSM-IV At least one core symptom of MDD (i.e., depressed 13.8
mood or anhedonia) and up to four or five
additional depressive symptoms that were not
clinically significant or caused functional
impairment
Liao et al. (2023) China 3885 Unavailable ≥65 PHQ− 9 PHQ− 9 scores ≥ 5 but no 6.08
MDD diagnosis during the last 12 months
Lyness et al. (1999) USA 224 85 ≥60 HAMD (DSM- Not eligible for either major or minor depression, 10.3
III-R) and HAMD scores greater than 10
Ludvigsson et al. (2019) Sweden 371 153 85 GDS− 15 GDS− 15 total scores between 3 and 5 26.7
Morrow-Howell et al. (2008) USA 1170 272 ≥60 CES-D CES-D total scores ≥9 19.06
Nakamura et al. (2022) Brazil 3356 1234 ≥60 PHQ− 9 PHQ− 9 total scores ≥ 5 14
Oh et al. (2020) Korea 6640 2837 ≥60 DSM-IV Operational diagnostic criteria 9.24
Pietrzak et al. (2013) USA 5862 Unavailable ≥65 DSM-IV At least 5 depression symptoms present, but 11.6
without meeting the distress or impairment
criterion for major depression
Préville et al. (2008) Canada 2798 1148 ≥65 DSM-IV Essential features of depression 5.7
and between 2 and 4 of the 7
associated symptoms of depression present
Schneider et al. (2000) Germany 262 Unavailable ≥60 IS (ICD− 10) IS scores of 3–4, indicating subclinical syndromes, 17.6
and fulfilling criteria for one or more ICD− 10
diagnoses from chapter F
Sigström et al. (2018) Sweden 563 224 ≥70 DSM− 5 At least 2 of the 9 depressive symptoms listed in 8.2
DSM− 5 present, but without meeting the diagnostic
criteria for either MD or MIND
Cui et al. (2021) China 430 189 ≥60 GDS− 15 GDS− 15 total scores ≥6 22.3
Zhang et al. (2022) China 1146 370 ≥60 CES-D CES-D total scores ≥10 56.89
Tiong et al. (2013) Singapore 375 173 ≥55 DSM-IV 2–4 depressive symptoms present for a minimum of 14.4
2 weeks
Topuzoğlu et al. (2015) Turkey 521 Unavailable 55–64 SCID (DSM- Less than five symptoms/ having symptoms for less 2.3
IV-TR) than two weeks/ having non-interfering
impairment due to symptoms
Vaccaro et al. (2017) Italian 1254 582 70–75 CES-D, GDS− 15 total scores ≥6 15.71
GDS− 15
Vahia et al. (2010) USA 1979 0 ≥60 CES-D CES-D total scores between 8 and 15 20.3
(continued on next page)

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Table 1 (continued )
Authors Country Sample Gender (n Age(y) Screening Symptom or score specification Prevalence
size (n) males) tools （%）

Wyman et al. (2020) USA 411 0 ≥65 CES-D CES-D total scores ≥16, but without meeting the 15.82
criteria for depressive diagnosis
Wu et al. (2017) China 5664 2664 ≥55 CES-D CES-D total scores ≥16, but without meeting the 3.5
criteria for depressive diagnosis
Xiang et al. (2018) USA 811 250 ≥60 CES-D (CIDI- CES-D scores ≥3 but reported fewer than 5 38.7
SF) symptoms on the CIDI-SF
Yohannes et al. (2003) UK 137 69 ≥60 GMS-AGECAT GMS-AGECAT scores of 1–2 25

Abbreviations: GDS, Geriatric Depression Scale; CES-D, the Center for Epidemiological Studies Depression Scale; HAMD, the Hamilton Depression Scale; PHQ, Patient
Health Questionnaires; DSM, Diagnostic and Statistical Manual of Mental Disorders; MINI, Mini International Neuropsychiatric Interview; CIDI, Composite interna­
tional Diagnostic interview; IS, Impairment Scale; GMS-AGECAT, Geriatric Mental State Schedule-Automated Geriatric Examination for Computer Assisted Taxonomy;
SCID, Structured Clinical Interview for DSM Disorders; ICD, The International Statistical Classification of Diseases and Related Health Problems; EURO-D, Europe
Depression scale; DIS, Diagnostic Interview Schedule.

3.4. Meta-analysis findings of 12.95 % among older adults, highlighting variations potentially
attributable to differences in StD criteria (Licht-Strunk et al., 2005) and
3.4.1. Prevalence of StD in older adults methodological factors such as sample sizes, sampling techniques, and
From the 77 studies reporting a prevalence of StD in older adults, the StD assessment tools.
overall prevalence of depression was 18.6 % (95 %CI:16.0 %–21.2 %, The present study found that the prevalence of StD in older adults
I2=99.8 %, p<0.001) (Fig. 2). varied depending on the screening tools used. Studies using diagnostic
manuals reported the lowest prevalence of StD (11.1 %; 95 % CI: 8.9 %-
3.4.2. Sensitivity analysis and publication bias 13.3 %), while studies using scales reported the highest prevalence of
Sensitivity analysis using random-effects models assessed the impact StD (22.6 %; 95 % CI: 19.0 %-26.2 %). The prevalence of StD in studies
of individual studies on the pooled estimate. No single study was found using a combination of both methods was 15.8 % (95 % CI: 10.7 %-
to significantly alter the primary results, indicating the robustness of our 20.9 %). Although self-administered scales are prone to misinterpreta­
meta-analysis (Fig. 3). Additionally, the funnel plot and Egger test did tion and response bias, self-report tools often show higher rates of
not indicate any significant publication bias (Egger’s test: p= 0.057＞ depression due to greater symptom disclosure (Levis et al., 2019; Vilagut
0.05) (Fig. 4). et al., 2016). In addition, when using structured interviews, the reported
incidence may be lower than the actual incidence if the interviewer’s
3.4.3. Subgroup analyses skills are inadequate, potentially leading to underdiagnosis (Mitchell
Subgroup analyses were stratified by screening tool, continent, and et al., 2011; Pilevarzadeh et al., 2019). Our findings are consistent with
scale, to explore potential sources of heterogeneity. Table 2 illustrates recent research suggesting that using a single mode of assessment may
the prevalence of StD in old adults among each subgroup. over- or underpredict depression, and for this reason, a combination of
assessment approaches has been recommended for diagnosis (Balsamo
3.4.3.1. Screening tools. Among the 77 studies included, the most used et al., 2018; Levin-Aspenson and Watson, 2018).
screening tool was scales, followed by diagnostic manuals, and finally a Our study identified continent-based variations in StD prevalence.
combination of the two. Studies using screening scales reported the Australia and Europe had lower prevalence rates compared to the
highest prevalence of StD in older adults at 22.6 % (95 % CI: 19.0 %- Americas and Asia. One possible explanation is that depression preva­
26.2 %), followed by studies using a combination of scales and diag­ lence is influenced by a region’s socioeconomic conditions (Hu et al.,
nostic manuals, with a prevalence of 15.8 % (95 % CI: 10.7 %-20.9 %). 2021). For instance, according to the UN World Population Prospects
Finally, studies using only a diagnostic manual reported the lowest 2022 report (United Nations, 2022), population density is the highest in
prevalence at 11.1 % (95 % CI: 8.9 %-13.3 %). Asia and the lowest in Oceania. The impact of population density on
mental health is complex. A study showed that older populations living
3.4.3.2. Continent. The study covered four continents, and the preva­ in areas with the highest and low-to-medium population densities are
lence estimates for each continent, in descending order, were: 23.5 % more likely to experience depression than those in areas with the lowest
(95 % CI: 17.5 %-29.6 %) in Asia, 19.0 % (95 % CI: 15.6 %-22.4 %) in population densities (Walters et al., 2004). Additionally, European
the Americas, 14.1 % (95 % CI:11.2 %-17.1 %) in Europe, and 8.9 % governments benefit from more supportive public health policies
(95 % CI: 3.0 %-14.8 %) in Oceania. (Schnittker, 2020), making individuals more likely to seek mental health
support. Conversely, North American governments have lower expen­
3.4.3.3. Scale. Of the 54 studies that used scales, the most frequently ditures on mental health (Errazuriz et al., 2023), which may hinder
used were, in descending order: CES-D, PHQ, GDS, HAMD, GMS, and timely and effective prevention and treatment efforts. Furthermore,
EURO-D. Studies using the GDS reported the highest prevalence of StD at self-reporting tools typically use different thresholds in different regions,
27.1 % (95 % CI: 20.6 %-33.6 %), while those using the GMS reported which may introduce methodological differences, leading to variations
the lowest prevalence at 12.7 % (95 % CI: 8.4 %-16.9 %). Studies using in estimates (Krishnamoorthy et al., 2020). Finally, stigmatization of
the PHQ reported a prevalence closest to the overall prevalence at people with mental illness leads to patients hiding their symptoms
18.3 % (95 % CI: 10.0 %-26.6 %). (Patten et al., 2012). In Europe, there is lower stigma attached to mental
illness compared to other regions, and people are more willing to
4. Discussion confront depressive symptoms and seek help and treatment (Yang et al.,
2020).
This systematic review and meta-analysis represent the first In studies screening for StD in older adults using scales alone, there
comprehensive assessment of global subthreshold depression (StD) were also large variations in prevalence estimates. This may be
prevalence among older adults. Our meta-analysis found a prevalence of explained by methodological differences, such as the use of different
18.6 % (95 % CI: 16.0 %-21.2 %) in this population. In contrast, a recent screening tools and cut-off points (Krishnamoorthy et al., 2020). While
study by R. Zhang et al. (Zhang et al., 2023) reported a lower prevalence depression scales are useful in clinical practice, these instruments do not

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X. Zhao et al. Asian Journal of Psychiatry 102 (2024) 104253

Fig. 2. The prevalence of StD in older adults.

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X. Zhao et al. Asian Journal of Psychiatry 102 (2024) 104253

Fig. 3. Sensitivity analysis for StD in the meta-analysis.

have an established cut-off for diagnosing StD, which can vary by high-income countries, possibly due to fewer years of schooling, limited
country, population, and setting (Biella et al., 2019). For example, few resources for health services, and other factors (Pan et al., 2022; Pilania
studies have reported a specific cutoff point for StD using the GDS-15 (C. et al., 2019).
Shin et al., 2019). Moreover, the lack of a clear, universally accepted Studies that deviated from robust results in sensitivity analyses are
definition of StD may also contribute to differences in its reported also discussed. First, establishing a cut-off of a CES-D scale score of ≥10
prevalence (Volz et al., 2023). (Zhang et al., 2022) and ≥8 (Cohen et al., 2009) to define StD, without
Meanwhile, this study could not examine whether factors such as considering scores below these thresholds, expands the range of sub­
gender, education, and economic status affect StD in older adults due to threshold depressive symptoms to encompass other depressive cate­
insufficient data. Some studies have shown that the prevalence of StD is gories. This might have led to an overestimation of StD prevalence.
significantly higher in women than in men (Crockett et al., 2020; Curran Secondly, during the time when Egbert et al. conducted their study, the
et al., 2020), which may be related to women’s dual responsibility for WHO officially declared the COVID-19 outbreak a pandemic on
work and family. Additionally, older adults in low- and middle-income November 3, 2020 (Egbert et al., 2023). Their data, therefore, reflect
countries have a higher prevalence of depression compared to those in global public attitudes during the early and accelerated phases of the

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structured interviews, which raises the risk of underdiagnosing and

misdiagnosing StD in clinical practice (Crockett et al., 2020; Jiang et al.,
2020). Zhang et al. (2022) emphasized the importance of identifying
reliable biomarkers for diagnosing and making treatment decisions
regarding StD. They suggested that advanced neuroimaging techniques
could provide valuable biomarkers for clinical use (Zhang et al., 2022).
Their results illustrated that utilizing a radiomics approach centered on
functional measures achieved a robust ability to differentiate between
StD and MDD, exhibiting high classification accuracy. This capability
enhances the feasibility of making objective and dependable individual
diagnoses in clinical settings, but no definite biomarker has yet been
found. Finally, Tuithof et al. found that chronic physical illnesses, which
may cause a variety of somatic symptoms, constitute a risk factor for
developing MDD in individuals with StD (Tuithof et al., 2018). Addi­
tionally, Li et al. (2023) showed that somatic symptoms have good
predictive potential for identifying StD (Li et al., 2023). This suggests
that general practitioners need to consider somatic symptoms for the
Fig. 4. Funnel plot for StD estimates used in the meta-analysis. early identification and management of depression in their practice.
Overall, further research is necessary to refine the assessment of StD in
COVID-19 pandemic, as well as before, during, and after challenging and the elderly population.
significant policy decisions made by many governments. A global The strengths of this meta-analysis lie in its substantial sample size,
pandemic can significantly impact mental health, with a general trend wide geographic scope, inclusion of multiple instruments for diagnosing
toward increased rates of depression (Santomauro et al., 2021). Finally, StD in older adults, and sensitivity and subgroup analyses exploring
the population in Barry et al.’s study included older adults with varying possible reasons for heterogeneity and reporting prediction intervals.
levels of disability, and the association between StD and disability However, there are some limitations that need to be emphasized. Meta-
among older adults is well established. A broad spectrum of depressive analyses of observational studies typically encounter heterogeneity,
symptoms, including those that do not meet the criteria for sub­ which does not necessarily undermine their findings (Ofori-Asenso et al.,
syndromal depression, is linked to impaired functioning, leading to 2019). Similarly, our study exhibited some heterogeneity, thus requiring
higher rates of StD occurrence (Barry et al., 2009). cautious interpretation of our results. On the one hand, the diversity of
StD is considered to be underdiagnosed in older adults (VanItallie, diagnostic tools increased the heterogeneity of the findings, although
2005), leading researchers to actively explore new tools and indicators this also improved the validity of the diagnosis of StD in older adults.
for screening StD. In addition to existing screening scales for depressive This suggests that future research could develop an instrument specif­
symptoms, many studies have investigated new screening methods. For ically designed to assess StD in the elderly population, which would
instance, Shin et al. (2021) discovered distinct vocal differences during improve detection rates, and accurately identify subthreshold depres­
depressive episodes and proposed that machine learning could effec­ sive symptoms in this population. On the other hand, factors associated
tively distinguish between non-depressed individuals and those with with StD, such as economic status and social support, which are
minor or major depression (D. Shin et al., 2021). Hansen et al. (2022) particularly relevant in old adults, were not analyzed in subgroups due
investigated a speech emotion recognition model capable of precisely to insufficient data. In the future, further analyses should address these
distinguishing between healthy individuals and patients with depression factors and focus on the psychological conditions of the elderly to pre­
(Hansen et al., 2022). While these studies have some limitations, vent further development and deterioration of depressive symptoms.
voice-based systems seem to reduce self-report and manual scoring In conclusion, the prevalence of StD in older adults is high, indicating
biases, and can be employed remotely, affordably, and non-intrusively. the need for increased attention to the mental health of the elderly.
Effectively implementing voice-based depression screening could pro­ Timely and effective preventive measures and interventions are neces­
vide an additional tool for early diagnosis. Additionally, Ghiasi et al. sary to detect and intervene early, preventing it from becoming a larger
(2021) proposed an automatic classification pipeline for detecting StD public health issue. Research has shown that somatic symptoms,
using electroencephalography (Ghiasi et al., 2021). Currently, the particularly energy-related symptoms, show good predictive potential
recognition of StD relies solely on subjective clinical scores and for identifying StD (Li et al., 2023). Non-pharmacological interventions

Table 2
Subgroup analyses by screening tools, continent, scale.
Subgroups No. of studies Prevalence (%) 95 %CI (%) I2 (%) P-value within subgroup P-values across subgroups

Screening tools ​ ​ ​ ​ ​ ＜0.001

Scale 41 22.6 19.0–26.2 99.8 ＜0.001 ​
Diagnostic manual 20 11.1 8.9–13.3 97.4 ＜0.001 ​
Scale and Diagnostic manual 16 15.8 10.7–20.9 99.6 ＜0.001 ​
Continent ​ ​ ​ ​ ​ ＜0.001
America 25 19.0 15.6–22.4 99.1 ＜0.001 ​
Asia 22 23.5 17.5–29.6 99.8 ＜0.001 ​
Europe 25 14.1 11.2–17.1 99.3 ＜0.001 ​
Oceania 4 8.9 3.0–14.8 98.9 ＜0.001 ​
Scale ​ ​ ​ ​ ​ ​
CES-D 19 21.4 26.9–25.9 99.7 ＜0.001 ​
GDS 12 27.1 20.6–33.6 97.9 ＜0.001 0.008
PHQ 14 18.3 10.0–26.6 99.9 ＜0.001 ​
HAMD 4 21.8 12.2–31.4 96.3 ＜0.001 ​
GMS 3 12.7 8.4–16.9 87.9 ＜0.001 ​
EURO-D 2 17.1 10.1–24.1 98.1 ＜0.001 ​

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(NPIs) have been demonstrated to be effective in preventing the pro­ Risk and to Guide Risk Reduction Strategies in Later Life. Int. Psychogeriatr. 23 (2),
280–291. https://doi.org/10.1017/S1041610210001870.
gression of StD to MDD and improving depressive symptoms (Huang
Almeida, O.P., Yeap, B.B., Hankey, G.J., Golledge, J., Flicker, L., 2015. Association of
et al., 2023). Mental health promotion and prevention strategies for Depression with Sexual and Daily Activities: A Community Study of Octogenarian
older adults focus on supporting healthy aging and enhancing social Men. Am. J. Geriatr. Psychiatry 23 (3), 234–242. https://doi.org/10.1016/j.
support to avoid loneliness, which is strongly associated with StD in the jagp.2013.09.007.
An, H., Han, J.W., Jeong, H.-G., Kim, T.H., Lee, J.J., Lee, S.B., Park, J.H., Kim, K.W.,
elderly (WHO, 2023). At the same time, further research is needed to 2020. Parasympathetic Predominance Is a Risk Factor for Future Depression: A
develop and evaluate assessment tools for StD in older adults to improve Prospective Cohort Study. J. Affect. Disord. 260, 232–237. https://doi.org/10.1016/
screening. j.jad.2019.09.015.
Angermann, C.E., Gelbrich, G., Störk, S., Schowalter, M., Deckert, J., Ertl, G., Faller, H.,
2011. Somatic Correlates of Comorbid Major Depression in Patients with Systolic
Registration Heart Failure. Int. J. Cardiol. 147 (1), 66–73. https://doi.org/10.1016/j.
ijcard.2009.07.044.
Aranda, M.P., Lee, P.-J., Wilson, S., 2001. Correlates of Depression in Older Latinos.
This meta-analysis was registered in PROSPERO (number: Home Health Care Serv. Q. 20 (1), 1–20. https://doi.org/10.1300/J027v20n01_01.
CRD42023494210). Areán, P.A., Alvidrez, J., 2001. The Prevalence of Psychiatric Disorders and
Subsyndromal Mental Illness in Low-Income, Medically Ill Elderly. Int J Psychiatry
Med. 31 (1), 9–24. https://doi.org/10.2190/YGL6-N54R-08RW-1BF4.
Financial disclosure Balsamo, M., Cataldi, F., Carlucci, L., Padulo, C., Fairfield, B., 2018. Assessment of late-
life depression via self-report measures: a review. Clin. Interv. Aging 13, 2021–2044.
https://doi.org/10.2147/CIA.S178943.
None.
Barry, L.C., Allore, H.G., Bruce, M.L., Gill, T.M., 2009. Longitudinal association between
depressive symptoms and disability burden among older persons. J. Gerontol. Ser. A
Source of funding Biol. Sci. Med. Sci. 64 (12), 1325–1332. https://doi.org/10.1093/gerona/glp135.
Beekman, A.T.F., Deeg, D.J.H., Van Tilburg, T., Smit, J.H., Hooijer, C., Van Tilburg, W.,
1995. Major and Minor Depression in Later Life: A Study of Prevalence and Risk
This research supported by Jilin Province Healthcare Talent Special Factors. J. Affect. Disord. 36 (1–2), 65–75. https://doi.org/10.1016/0165-0327(95)
Project (2019SCZT082). 00061-5.
Biella, M.M., Borges, M.K., Strauss, J., Mauer, S., Martinelli, J.E., & Aprahamian, I.
(2019). Subthreshold Depression Needs A Prime Time In Old Age Psychiatry? A
CRediT authorship contribution statement Narrative Review Of Current Evidence. Neuropsychiatric Disease and Treatment, 15
((Biella M.M.; Borges M.K.; Aprahamian I., ivan.aprahamian@gmail.com)
Department and Institute of Psychiatry, Faculty of Medicine, University of São Paulo,
Li Zhang: Writing – original draft, Project administration, Data São Paulo, Brazil), 2763–2772. Embase. https://doi.org/10.2147/NDT.S223640.
curation. Ariadna Albajara Sáenz: Writing – review & editing, Super­ Bijl, M.J., Luijendijk, H.J., van den Berg, J.F., Visser, L.E., van Schaik, R.H.N.,
vision. Xiaoyan Zhao: Writing – original draft, Project administration, Hofman, A., Vulto, A.G., van Gelder, T., Tiemeier, H., Stricker, B.H.C., 2009.
Association between the CYP2D6*4 polymorphism and depression or anxiety in the
Data curation. Yuanjuan Cheng: Writing – review & editing, Resources, elderly (Embase). Pharmacogenomics 10 (4), 541–547. https://doi.org/10.2217/
Methodology, Funding acquisition. Yong Jia: Writing – review & edit­ pgs.09.9.
ing, Resources, Methodology, Funding acquisition. Jia Sun: Writing – Blank, K., Gruman, C., Robison, J.T., 2004. Case-Finding for Depression in Elderly
People: Balancing Ease of Administration With Validity in Varied Treatment
review & editing. Qiqing Zhong: Writing – review & editing. Xinyue
Settings. J. Gerontol. A 59 (4), M378–M384. https://doi.org/10.1093/gerona/59.4.
Zhang: Writing – review & editing. M378.
Borenstein, M., Hedges, L.V., Higgins, J.P.T., Rothstein, H.R., 2010. A basic introduction
to fixed-effect and random-effects models for meta-analysis. Res. Synth. Methods 1
Declaration of Competing Interest (2), 97–111. https://doi.org/10.1002/jrsm.12.
Borges, M.K., Aprahamian, I., Romanini, C.V., Oliveira, F.M., Mingardi, S.V.B., Lima, N.
A., Cecato, J.F., Petrella, M., Oude Voshaar, R.C., 2021. Depression as a determinant
The authors declare that they have no known competing financial of frailty in late life. Aging Ment. Health 25 (12), 2279–2285. https://doi.org/
interests or personal relationships that could have appeared to influence 10.1080/13607863.2020.1857689.
the work reported in this paper. Boyle, L.L., Porsteinsson, A.P., Cui, X., King, D.A., Lyness, J.M., 2010. Depression
Predicts Cognitive Disorders in Older Primary Care Patients. J Clin Psychiatry 71
(01), 74–79. https://doi.org/10.4088/JCP.08m04724gry.
Acknowledgement Braam, A.W., Copeland, J.R.M., Delespaul, P.A.E.G., Beekman, A.T.F., Como, A.,
Dewey, M., Fichter, M., Holwerda, T.J., Lawlor, B.A., Lobo, A., Magnússon, H.,
Prince, M.J., Reischies, F., Wilson, K.C., Skoog, I., 2014. Depression, Subthreshold
None. Depression and Comorbid Anxiety Symptoms in Older Europeans: Results from the
EURODEP Concerted Action. J. Affect. Disord. 155, 266–272. https://doi.org/
10.1016/j.jad.2013.11.011.
Appendix A. Supporting information Bremmer, M.A., Beekman, A.T.F., Deeg, D.J.H., Penninx, B.W.J.H., Dik, M.G., Hack, C.E.,
Hoogendijk, W.J.G., 2008. Inflammatory Markers in Late-Life Depression: Results
Supplementary data associated with this article can be found in the from a Population-Based Study. J. Affect. Disord. 106 (3), 249–255. https://doi.org/
10.1016/j.jad.2007.07.002.
online version at doi:10.1016/j.ajp.2024.104253.
Bremmer, M.A., Hoogendijk, W.J.G., Deeg, D.J.H., Schoevers, R.A., Schalk, B.W.M.,
Beekman, A.T.F., 2006. Depression in Older Age Is a Risk Factor for First Ischemic
References Cardiac Events. Am J Geriatr Psychiatry 14 (6), 523–530. https://doi.org/10.1097/
01.JGP.0000216172.31735.d5.
Brooks, J.M., Petersen, C., Kelly, S.M., Reid, M.C., 2019. Likelihood of Depressive
Albertorio-Diaz, J.R., Eberhardt, M.S., Oquendo, M., Mesa-Frias, M., He, Y., Jonas, B.,
Symptoms in US Older Adults by Prescribed Opioid Potency: National Health and
Kang, K., 2017. Depressive States among Adults with Diabetes: Findings from the
Nutrition Examination Survey 2005-2013. Am J Geriatr Psychiatry 34 (10),
National Health and Nutrition Examination Survey, 2007–2012. Diabetes Res Clin
1481–1489. https://doi.org/10.1002/gps.5157.
Pract 127, 80–88. https://doi.org/10.1016/j.diabres.2017.02.031.
Brown, E.L., McAvay, G., Raue, P.J., Moses, S., Bruce, M.L., 2003. Recognition of
Alexandrino-Silva, C., Alves, T.F., Tófoli, L.F., Wang, Y.-P., Andrade, L.H., 2011.
Depression Among Elderly Recipients of Home Care Services. Psychiatr Serv. 54 (2),
Psychiatry - Life Events and Social Support in Late Life Depression. Clinics 66 (2),
208–213. https://doi.org/10.1176/appi.ps.54.2.208.
233–238. https://doi.org/10.1590/S1807-59322011000200009.
Bruce, D.G., Casey, G., Davis, W.A., Starkstein, S.E., Clarnette, R.C., Foster, J.K., Ives, F.
Allen, N.B., Hetrick, S.E., Simmons, J.G., Hickie, I.B., 2007. Early intervention for
J., Almeida, O.P., Davis, T.M.E., 2006. Vascular Depression in Older People with
depressive disorders in young people: the opportunity and the (lack of) evidence.
Diabetes. Diabetologia 49 (12), 2828–2836. https://doi.org/10.1007/s00125-006-
Med. J. Aust. 187 (S7), S15–S17. https://doi.org/10.5694/j.1326-5377.2007.
0478-y.
tb01329.x.
Burns, R.A., Shea Andrews, N.C., Anstey, K.J., 2020. ‘Role of Apolipoprotein E Epsilon 4
Allgaier, A.-K., Kramer, D., Saravo, B., Mergl, R., Fejtkova, S., Hegerl, U., 2013. Beside
(APOE*ε4) as an Independent Risk Factor for Incident Depression over a 12-Year
the Geriatric Depression Scale: The WHO-Five Well-Being Index as a Valid Screening
Period in Cognitively Intact Adults across the Lifespan’. BJPsych Open 6 (3), e47.
Tool for Depression in Nursing Homes. Int. J. Geriatr. Psychiatry 28 (11),
https://doi.org/10.1192/bjo.2020.29.
1197–1204. https://doi.org/10.1002/gps.3944.
Cao, Y., Yijun, W., Lixia, L., Yu, G., Qingyue, H., Ming, G., 2019. ‘Analysis of the current
Almeida, O.P., Alfonso, H., Pirkis, J., Kerse, N., Sim, M., Flicker, L., Snowdon, J.,
status of geriatric depression and related factors in Chengdu (in Chinese)’. Chinese
Draper, B., Byrne, G., Goldney, R., Lautenschlager, N.T., Stocks, N., Scazufca, M.,
Huisman, M., Araya, R., Pfaff, J., 2011. A Practical Approach to Assess Depression

10
X. Zhao et al. Asian Journal of Psychiatry 102 (2024) 104253

Journal of Geriatric Cardiovascular and Cerebrovascular Disease 21 (11), A Population-Based Study. Int. Psychogeriatr. 23 (8), 1294–1300. https://doi.org/
1182–1187. 10.1017/S1041610211000780.
Chang, H.Y., Keyes, K.M., Mok, Y., Jung, K.Ji, Shin, Y.-J., Jee, S.H., 2015. Depression as a Gonçalves-Pereira, M., Prina, A.M., Cardoso, A.M., da Silva, J.A., Prince, M., Xavier, M.,
Risk Factor for Overall and Hormone-Related Cancer: The Korean Cancer Prevention 2019. The Prevalence of Late-Life Depression in a Portuguese Community Sample: A
Study. J. Affect. Disord. 173, 1–8. https://doi.org/10.1016/j.jad.2014.10.064. 10/66 Dementia Research Group Study. J. Affect. Disord. 246, 674–681. https://doi.
Chang, Y.-C., Lu, M.C., Hu, I.-H., Wu, W.-C.I., Hu, S.C., 2017. Effects of Different org/10.1016/j.jad.2018.12.067.
Amounts of Exercise on Preventing Depressive Symptoms in Community-Dwelling Grabovich, A., Lu, N., Tang, W., Tu, X., Lyness, J.M., 2010. Outcomes of Subsyndromal
Older Adults: A Prospective Cohort Study in Taiwan. BMJ Open 7 (4), e014256. Depression in Older Primary Care Patients. Am J Geriatr Psychiatry 18 (3), 227–235.
https://doi.org/10.1136/bmjopen-2016-014256. https://doi.org/10.1097/JGP.0b013e3181cb87d6.
Chao, Y.-Y., You, E., Chang, Y.-P., Dong, X., 2020. Anxiety Symptoms, Depressive Han, K., Yang, S., Jia, W., Wang, S., Song, Y., Cao, W., Wang, J., Liu, M., He, Y., 2020.
Symptoms, and Traditional Chinese Medicine Use in U.S. Chinese Older Adults. Health-Related Quality of Life and Its Correlation With Depression Among Chinese
J. Immigr. Minor. Health 22 (4), 746–753. https://doi.org/10.1007/s10903-019- Centenarians. Public Health Front. 8. https://doi.org/10.3389/fpubh.2020.580757.
00935-0. Hansen, L., Zhang, Y.-P., Wolf, D., Sechidis, K., Ladegaard, N., Fusaroli, R., 2022.
Chen, C.-M., Huang, G.-H., Chen, C.C.-H., 2014. Older Patients’ Depressive Symptoms 6 A generalizable speech emotion recognition model reveals depression and remission.
Months after Prolonged Hospitalization: Course and Interrelationships with Major Acta Psychiatr. Scand. 145 (2), 186–199. https://doi.org/10.1111/acps.13388.
Associated Factors. Arch Gerontol Geriatr 58 (3), 339–343. https://doi.org/ Harshfield, E.L., Pennells, L., Schwartz, J.E., Willeit, P., Kaptoge, S., Bell, S., Shaffer, J.A.,
10.1016/j.archger.2013.12.007. Bolton, T., Spackman, S., Wassertheil-Smoller, S., Kee, F., Amouyel, P., Shea, S.J.,
Chuan, S.K., Kumar, R., Matthew, N., Heok, K.E., Pin, N.T., 2008. Subsyndromal Kuller, L.H., Kauhanen, J., van Zutphen, E.M., Blazer, D.G., Krumholz, H., Nietert, P.
Depression in Old Age: Clinical Significance and Impact in a Multi-Ethnic J., Emerging Risk Factors Collaboration, 2020. Association between depressive
Community Sample of Elderly Singaporeans. Int. Psychogeriatr. 20 (1), 188–200. symptoms and incident cardiovascular diseases. JAMA 324 (23), 2396–2405.
https://doi.org/10.1017/S1041610207006187. https://doi.org/10.1001/jama.2020.23068.
Cohen, C.I., Goh, K.H., Yaffee, R.A., 2009. Depression outcome among a biracial sample Heesterbeek, T.J., van der Aa, H.P.A., van Rens, G.H.M.B., Twisk, J.W.R., van Nispen, R.
of depressed urban elders (Embase). Am. J. Geriatr. Psychiatry: Off. J. Am. Assoc. M.A., 2017. The Incidence and Predictors of Depressive and Anxiety Symptoms in
Geriatr. Psychiatry 17 (11), 943–952. https://doi.org/10.1097/ Older Adults with Vision Impairment: A Longitudinal Prospective Cohort Study.
JGP.0b013e3181b970c7. Ophthalmic Physiol. Opt. 37 (4), 385–398. https://doi.org/10.1111/opo.12388.
Cole, M.G., McCusker, J., Ciampi, A., Windholz, S., Latimer, E., Belzile, E., 2006. The Higgins, J.P.T., Thompson, S.G., Deeks, J.J., Altman, D.G., 2003. Measuring
Prognosis of Major and Minor Depression in Older Medical Inpatients. Am J Geriatr inconsistency in meta-analyses. BMJ: Br. Med. J. 327 (7414), 557–560.
Psychiatry 14 (11), 966–975. https://doi.org/10.1097/01. Ho, C., Jin, A., Nyunt, M.S.Z., Feng, L., Ng, T.P., 2016. Mortality Rates in Major and
JGP.0000224327.16963.9f. Subthreshold Depression: 10-Year Follow-up of a Singaporean Population Cohort of
Crockett, M.A., Martínez, V., Jiménez-Molina, Á., 2020. Subthreshold depression in Older Adults. Postgrad. Med. 128 (7), 642–647. https://doi.org/10.1080/
adolescence: gender differences in prevalence, clinical features, and associated 00325481.2016.1221319.
factors. J. Affect. Disord. 272, 269–276. https://doi.org/10.1016/j.jad.2020.03.111. Hoogendijk, W.J.G., Lips, P., Dik, M.G., Deeg, D.J.H., Beekman, A.T.F., Penninx, B.W.J.
Cui, X., Fengqin, L., Jinhua, Z., Miaomiao, S., He, Z., Wenjing, Z., 2021. Analysis of the H., 2008. Depression Is Associated With Decreased 25-Hydroxyvitamin D and
current status and correlation between dyskinesia syndrome and subthreshold Increased Parathyroid Hormone Levels in Older Adults. Arch. Gen. Psychiatry 65 (5),
depression in rural older adults (in Chinese)’. Nurs. Res. 35 (12), 2106–2110. 508. https://doi.org/10.1001/archpsyc.65.5.508.
Cuijpers, P., Quero, S., Dowrick, C., Arroll, B., 2019. Psychological treatment of Howland, R.H., Schettler, P.J., Rapaport, M.H., Mischoulon, D., Schneider, T.,
depression in primary care: recent developments. Curr. Psychiatry Rep. 21 (12), 129. Fasiczka, A., Delrahiem, K., Maddux, R., Lightfoot, M., Nierenberg, A.A., 2008.
https://doi.org/10.1007/s11920-019-1117-x. Clinical features and functioning of patients with minor depression. Psychother.
Curran, E., Rosato, M., Ferry, F., & Leavey, G. (2020). Prevalence and factors associated Psychosom. 77 (6), 384–389. https://doi.org/10.1159/000151519.
with anxiety and depression in older adults: Gender differences in psychosocial Hu, S.C., Tsai, Y.-H., Li, D.-C., Hsu, W.-C., Huang, N.-C., 2021. Social-economic
indicators. Journal of Affective Disorders, 267((Curran E., e.curran@ulster.ac.uk; environments and depressive symptoms in community-dwelling adults: a multi-level
Rosato M.; Ferry F.; Leavey G.) Bamford Centre for Mental Health and Wellbeing, analysis for two nationwide datasets in Taiwan. Article 14. Int. J. Environ. Res.
Ulster University, Northern Ireland, United Kingdom), 114–122. Embase. https:// Public Health 18 (14). https://doi.org/10.3390/ijerph18147487.
doi.org/10.1016/j.jad.2020.02.018. Huang, K., You, S., Yue, X., Yan, S., Bai, L., He, R., Jiao, Y., Han, B., Momin, K., Wu, J.,
Demakakos, P., Cooper, R., Hamer, M., de Oliveira, C., Hardy, R., Breeze, E., 2013. The Jia, Y., Chen, L., 2023. Effects of non-pharmacological interventions on depressive
Bidirectional Association between Depressive Symptoms and Gait Speed: Evidence symptoms and risk of major depressive disorder in adults with subthreshold
from the English Longitudinal Study of Ageing (ELSA). PLOS ONE 8 (7), e68632. depression: a systematic review and meta-analysis. Psychiatry Res. 326, 115333.
https://doi.org/10.1371/journal.pone.0068632. https://doi.org/10.1016/j.psychres.2023.115333.
Dirmaier, J., Watzke, B., Koch, U., Schulz, H., Lehnert, H., Pieper, L., Wittchen, H.-U., Hybels, Celia F., Blazer, Dan G., Pieper, Carl F., 2001. Toward a Threshold for
2010. Diabetes in Primary Care: Prospective Associations between Depression, Subthreshold Depression. Gerontol. 41 (3), 357–365. https://doi.org/10.1093/
Nonadherence and Glycemic Control. Psychother Psychosom 79 (3), 172–178. geront/41.3.357.
https://doi.org/10.1159/000296135. Jiang, L., Zhang, S., Wang, Y., So, K.-F., Ren, C., Tao, Q., 2020. Efficacy of light therapy
Egbert, A.R., Karpiak, S., Havlik, R., Cankurtaran, S., 2023. Global occurrence of for a college student sample with non-seasonal subthreshold depression: an RCT
depressive symptoms during the COVID-19 pandemic. J. Psychosom. Res. 166, study. J. Affect. Disord. 277, 443–449. https://doi.org/10.1016/j.jad.2020.08.055.
111145. https://doi.org/10.1016/j.jpsychores.2022.111145. Johansson, L., Guerra, M., Prince, M., Hörder, H., Falk, H., Stubbs, B., Matthew Prina, A.,
Egger, M., Davey Smith, G., Schneider, M., Minder, C., 1997. Bias in meta-analysis 2019. Associations between Depression, Depressive Symptoms, and Incidence of
detected by a simple, graphical test. BMJ (Clin. Res. Ed.) 315 (7109), 629–634. Dementia in Latin America: A 10/66 Dementia Research Group Study. J. Alzheimer’s
https://doi.org/10.1136/bmj.315.7109.629. Dis. 69 (2), 433–441. https://doi.org/10.3233/JAD-190148.
Errazuriz, A., Avello-Vega, D., Ramirez-Mahaluf, J.P., Torres, R., Crossley, N.A., Jongenelis, K., Pot, A.M., Eisses, A.M.H., Beekman, A.T.F., Kluiter, H., Ribbe, M.W.,
Undurraga, E.A., Jones, P.B., 2023. Prevalence of depressive disorder in the adult 2004. Prevalence and Risk Indicators of Depression in Elderly Nursing Home
population of Latin America: a systematic review and meta-analysis. Lancet Reg. Patients: The AGED Study. J. Affect. Disord. 83 (2), 135–142. https://doi.org/
Health - Am. 26, 100587. https://doi.org/10.1016/j.lana.2023.100587. 10.1016/j.jad.2004.06.001.
Forlani, C., Morri, M., Ferrari, B., Dalmonte, E., Menchetti, M., De Ronchi, D., Atti, A.R., Karlsson, B., Johnell, K., Sigström, R., Sjöberg, L., Fratiglioni, L., 2016. Depression and
2014. Prevalence and Gender Differences in Late-Life Depression: A Population- Depression Treatment in a Population-Based Study of Individuals Over 60 Years Old
Based Study. Am J Geriatr Psychiatry 22 (4), 370–380. https://doi.org/10.1016/j. Without Dementia. Am J Geriatr Psychiatry 24 (8), 615–623. https://doi.org/
jagp.2012.08.015. 10.1016/j.jagp.2016.03.009.
Friedman, B., Delavan, R.L., Sheeran, T.H., Bruce, M.L., 2009. ‘The Effect of Major and Kramer, D., Allgaier, A.-K., Fejtkova, S., Mergl, R., Hegerl, U., 2009. Depression in
Minor Depression on Medicare Home Healthcare Services Use’. J Am Geriatr Soc 57 Nursing Homes: Prevalence, Recognition, and Treatment. Int J Psychiatry Med. 39
(4), 669–675. https://doi.org/10.1111/j.1532-5415.2009.02186.x. (4), 345–358. https://doi.org/10.2190/PM.39.4.a.
Gabryelewicz, T., Styczynska, M., Pfeffer, A., Wasiak, B., Barczak, A., Luczywek, E., Krishnamoorthy, Y., Rajaa, S., Rehman, T., 2020. Diagnostic accuracy of various forms of
Androsiuk, W., Barcikowska, M., 2004. Prevalence of Major and Minor Depression in geriatric depression scale for screening of depression among older adults: systematic
Elderly Persons with Mild Cognitive Impairment—MADRS Factor Analysis. Int. J. review and meta-analysis. Arch. Gerontol. Geriatr. 87, 104002. https://doi.org/
Geriatr. Psychiatry 19 (12), 1168–1172. https://doi.org/10.1002/gps.1235. 10.1016/j.archger.2019.104002.
Gallo, J.J., Bogner, H.R., Morales, K.H., Post, E.P., Lin, J.Y., Bruce, M.L., 2007. The Effect Laborde-Lahoz, P., El-Gabalawy, R., Kinley, J., Kirwin, P.D., Sareen, J., Pietrzak, R.H.,
of a Primary Care Practice–Based Depression Intervention on Mortality in Older 2015. Subsyndromal Depression among Older Adults in the USA: Prevalence,
Adults. Ann. Intern. Med. 146 (10), 689–698. Comorbidity, and Risk for New-onset Psychiatric Disorders in Late Life. Int. J.
Gellis, Z.D., 2010. Depression Screening in Medically Ill Homecare Elderly’. Best Geriatr. Psychiatry 30 (7), 677–685. https://doi.org/10.1002/gps.4204.
Practices in Mental Health 6 (1), 1–16. Lan, N.H., Thi Thu Thuy, N., 2020. Depression among Ethnic Minority Elderly in the
Ghiasi, S., Dell’Acqua, C., Benvenuti, S.M., Scilingo, E., Gentili, C., Valenza, G., & Greco, Central Highlands, Vietnam, 205510292096723 Health Psychol. Open. 7 (2).
A. (2021). Classifying subclinical depression using EEG spectral and connectivity https://doi.org/10.1177/2055102920967236.
measures. 2021 43rd Annual International Conference of the IEEE Engineering in Lee, Y.Y., Stockings, E.A., Harris, M.G., Doi, S.A.R., Page, I.S., Davidson, S.K.,
Medicine & Biology Society (EMBC), 2050–2053. https://doi.org/10.1109/ Barendregt, J.J., 2019. The risk of developing major depression among individuals
EMBC46164.2021.9630044. with subthreshold depression: a systematic review and meta-analysis of longitudinal
Glaesmer, H., Riedel-Heller, S., Braehler, E., Spangenberg, L., Luppa, M., 2011. Age- and cohort studies. Psychol. Med. 49 (1), 92–102. https://doi.org/10.1017/
Gender-Specific Prevalence and Risk Factors for Depressive Symptoms in the Elderly: S0033291718000557.

11
X. Zhao et al. Asian Journal of Psychiatry 102 (2024) 104253

Levin-Aspenson, H.F., Watson, D., 2018. Mode of administration effects in Pilania, M., Yadav, V., Bairwa, M., Behera, P., Gupta, S.D., Khurana, H., Mohan, V.,
psychopathology assessment: analyses of gender, age, and education differences in Baniya, G., Poongothai, S., 2019. Prevalence of depression among the elderly
self-rated versus interview-based depression. Psychol. Assess. 30 (3), 287–295. (60 years and above) population in India, 1997-2016: a systematic review and meta-
https://doi.org/10.1037/pas0000474. analysis. BMC Public Health 19 (1), 832. https://doi.org/10.1186/s12889-019-
Levis, B., Benedetti, A., Thombs, B.D., 2019. Accuracy of Patient Health Questionnaire-9 7136-z.
(PHQ-9) for screening to detect major depression: Individual participant data meta- Pilevarzadeh, M., Amirshahi, M., Afsargharehbagh, R., Rafiemanesh, H., Hashemi, S.-M.,
analysis. BMJ 365, l1476. https://doi.org/10.1136/bmj.l1476. Balouchi, A., 2019. Global prevalence of depression among breast cancer patients: a
Li, X., Zhang, H., Han, X., Guo, L., Ceban, F., Liao, Y., Shi, J., Wang, W., Liu, Y., Song, W., systematic review and meta-analysis. Breast Cancer Res. Treat. 176 (3), 519–533.
Zhu, D., Wang, H., Li, L., Fan, B., Lu, C., McIntyre, R.S., 2023. Predictive potential of https://doi.org/10.1007/s10549-019-05271-3.
somatic symptoms for the identification of subthreshold depression and major Préville, M., Boyer, R., Grenier, S., Dubé, M, Voyer, P., Punti, R., Baril, M.-C., Streiner, D.
depressive disorder in primary care settings. Front. Psychiatry 14. https://doi.org/ L., Cairney, J., Brassard, J., Scientific Committee of the ESA Study, 2008. The
10.3389/fpsyt.2023.999047. Epidemiology of Psychiatric Disorders in Quebec’s Older Adult Population. Can. J.
Liao, D.-D., Dong, M., Ding, K.-R., Hou, C.-L., Tan, W.-Y., Ke, Y.-F., Jia, F.-J., Wang, S.-B., Psychiatry. 53 (12), 822–832. https://doi.org/10.1177/070674370805301208.
2023. Prevalence and Patterns of Major Depressive Disorder and Subthreshold Santomauro, D.F., Herrera, A.M.M., Shadid, J., Zheng, P., Ashbaugh, C., Pigott, D.M.,
Depressive Symptoms in South China. J. Affect. Disord. 329, 131–140. https://doi. Abbafati, C., Adolph, C., Amlag, J.O., Aravkin, A.Y., Bang-Jensen, B.L., Bertolacci, G.
org/10.1016/j.jad.2023.02.069. J., Bloom, S.S., Castellano, R., Castro, E., Chakrabarti, S., Chattopadhyay, J.,
Liao, Y., Zhang, H., Guo, L., Fan, B., Wang, W., Teopiz, K.M., Lui, L.M.W., Lee, Y., Li, L., Cogen, R.M., Collins, J.K., Ferrari, A.J., 2021. Global prevalence and burden of
Han, X., Lu, C., McIntyre, R.S., 2022. Impact of cognitive-affective and somatic depressive and anxiety disorders in 204 countries and territories in 2020 due to the
symptoms in subthreshold depression transition in adults: evidence from Depression COVID-19 pandemic. Lancet 398 (10312), 1700–1712. https://doi.org/10.1016/
Cohort in China (DCC). J. Affect. Disord. 315, 274–281. https://doi.org/10.1016/j. S0140-6736(21)02143-7.
jad.2022.08.009. Schneider, G., Kruse, A., Nehen, H.-G., Senf, W., Heuft, G., 2000. The Prevalence and
Licht-Strunk, E., van der Kooij, K.G., van Schaik, D.J.F., van Marwijk, H.W.J., van Differential Diagnosis of Subclinical Depressive Syndromes in Inpatients 60 Years
Hout, H.P.J., de Haan, M., Beekman, A.T.F., 2005. Prevalence of depression in older and Older. Psychother Psychosom 69 (5), 251–260. https://doi.org/10.1159/
patients consulting their general practitioner in The Netherlands (Embase). Int. J. 000012404.
Geriatr. Psychiatry 20 (11), 1013–1019. https://doi.org/10.1002/gps.1391. Schnittker, J., 2020. Religion, social integration, and depression in Europe: evidence
Liu, S.F., GuiFang, N., JianPing, S., HongXia, W., PingPing, W., JinRong, G., XiongBo, L., from the European Social Survey. Soc. Sci. Med. 267, 112376. https://doi.org/
Hui, G., 2023. Analysis of the current situation of subthreshold depression and 10.1016/j.socscimed.2019.112376.
influencing factors among elderly people in nursing institutions (in Chinese)’. Shin, D., Cho, W.I., Park, C.H.K., Rhee, S.J., Kim, M.J., Lee, H., Kim, N.S., Ahn, Y.M.,
Medical Information 36 (16), 93–97, 103. 2021. Detection of minor and major depression through voice as a biomarker using
Ludvigsson, M., Marcusson, J., Wressle, E., Milberg, A., 2019. Morbidity and Mortality in machine learning. J. Clin. Med. 10 (14). https://doi.org/10.3390/jcm10143046.
Very Old Individuals with Subsyndromal Depression: An 8-Year Prospective Study. Shin, C., Park, M.H., Lee, S.-H., Ko, Y.-H., Kim, Y.-K., Han, K.-M., Jeong, H.-G., Han, C.,
Int. Psychogeriatr. 31 (11), 1569–1579. https://doi.org/10.1017/ 2019. Usefulness of the 15-item geriatric depression scale (GDS-15) for classifying
S1041610219001480. minor and major depressive disorders among community-dwelling elders. J. Affect.
Lv, Q.J., Feng, Y.L., Gu, W., Fang, F.F., 2013. Investigation of the correlation between Disord. 259, 370–375. https://doi.org/10.1016/j.jad.2019.08.053.
depressive symptoms and physical fitness in an elderly military population (in Shu, J., Yanyan, Z., Baimaiti, P., 2019. Analysis of the current situation of depression and
Chinese)’. Journal of Hospital Management of the People’s Liberation Army 20 (5), its influencing factors among bedridden elderly in nursing institutions in Urumqi (in
476–478. https://doi.org/10.16770/j.cnki.1008-9985.2013.05.024. Chinese)’. Chin. Med. Herald 16 (11), 42–45.
Lyness, J.M., King, D.A., Cox, C., Yoediono, Z., Caine, E.D., 1999. The importance of Sigström, R., Waern, M., Gudmundsson, P., Skoog, I., Östling, S., 2018. Depressive
subsyndromal depression in older primary care patients: prevalence and associated Spectrum States in a Population-Based Cohort of 70-Year Olds Followed over 9
functional disability. J. Am. Geriatr. Soc. 47 (6), 647–652. https://doi.org/10.1111/ Years. Int. J. Geriatr. Psychiatry 33 (8), 1028–1037. https://doi.org/10.1002/
j.1532-5415.1999.tb01584.x. gps.4888.
Mitchell, A.J., Chan, M., Bhatti, H., Halton, M., Grassi, L., Johansen, C., Meader, N., Solomon, A., Haaga, D. a F., Arnow, B.A., 2001. Is clinical depression distinct from
2011. Prevalence of depression, anxiety, and adjustment disorder in oncological, subthreshold depressive symptoms? A review of the continuity issue in depression
haematological, and palliative-care settings: a meta-analysis of 94 interview-based research. J. Nerv. Ment. Dis. 189 (8), 498.
studies. Lancet Oncol. 12 (2), 160–174. https://doi.org/10.1016/S1470-2045(11) Stuck, A.E., Rubenstein, L.Z., Wieland, D., 1998. Bias in meta-analysis detected by a
70002-X. simple, graphical test. BMJ 316 (7129), 469. https://doi.org/10.1136/
Morrow-Howell, N., Proctor, E., Choi, S., Lawrence, L., Brooks, A., Hasche, L., Dore, P., bmj.316.7129.469.
Blinne, W., 2008. Depression in Public Community Long-Term Care: Implications for Takagaki, K., Okamoto, Y., Jinnin, R., Mori, A., Nishiyama, Y., Yamamura, T.,
Intervention Development. J Behav Health Serv Res 35 (1), 37–51. https://doi.org/ Takebayashi, Y., Ogata, A., Okamoto, Y., Miyake, Y., Shimoda, H., Kawakami, N.,
10.1007/s11414-007-9098-7. Yamawaki, S., 2014. Behavioral characteristics of subthreshold depression. J. Affect.
Munn, Z., Moola, S., Lisy, K., Riitano, D., Tufanaru, C., 2015. Methodological guidance Disord. 168, 472–475. https://doi.org/10.1016/j.jad.2014.07.018.
for systematic reviews of observational epidemiological studies reporting prevalence Tiong, W.W., Yap, P., Huat Koh, G.C., Phoon Fong, N., Luo, N., 2013. Prevalence and
and cumulative incidence data. JBI Evid. Implement. 13 (3), 147. https://doi.org/ Risk Factors of Depression in the Elderly Nursing Home Residents in Singapore.
10.1097/XEB.0000000000000054. Aging & Mental Health 17 (6), 724–731. https://doi.org/10.1080/
Munn, Z., Moola, S., Riitano, D., Lisy, K., 2014. The development of a critical appraisal 13607863.2013.775638.
tool for use in systematic reviews addressing questions of prevalence. Int. J. Health Topuzoğlu, A., Binbay, T., Ulaş, H., Elbi, H., Aksu Tanık, F., Zağlı, N., Alptekin, K., 2015.
Policy Manag. 3 (3), 123–128. https://doi.org/10.15171/ijhpm.2014.71. The Epidemiology of Major Depressive Disorder and Subthreshold Depression in
Nakamura, C.A., Scazufca, M., Peters, T.J., Fajersztajn, L., Van De Ven, P., Izmir, Turkey: Prevalence, Socioeconomic Differences, Impairment and Help-
Hollingworth, W., Araya, R., Moreno-Agostino, D., 2022. Depressive and Seeking. J. Affect. Disord. 181, 78–86. https://doi.org/10.1016/j.jad.2015.04.017.
Subthreshold Depressive Symptomatology among Older Adults in a Tuithof, M., ten Have, M., van Dorsselaer, S., Kleinjan, M., Beekman, A., de Graaf, R.,
Socioeconomically Deprived Area in Brazil. Int. J. Geriatr. Psychiatry 37 (2). https:// 2018. Course of subthreshold depression into a depressive disorder and its risk
doi.org/10.1002/gps.5665. factors. J. Affect. Disord. 241, 206–215. https://doi.org/10.1016/j.jad.2018.08.010.
Ofori-Asenso, R., Chin, K.L., Mazidi, M., Zomer, E., Ilomaki, J., Zullo, A.R., Gasevic, D., United Nations. (2022). World Population Prospects 2022: Summary of Results | Population
Ademi, Z., Korhonen, M.J., LoGiudice, D., Bell, J.S., Liew, D., 2019. Global incidence Division. https://www.un.org/development/desa/pd/content/World-Population-
of frailty and prefrailty among community-dwelling older adults: a systematic Prospects-2022.
review and meta-analysis. JAMA Netw. Open 2 (8), e198398. https://doi.org/ Vaccaro, R., Borrelli, P., Abbondanza, S., Davin, A., Polito, L., Colombo, M., Francesca
10.1001/jamanetworkopen.2019.8398. Vitali, S., Villani, S., Guaita, A., 2017. Subthreshold Depression and Clinically
Oh, D.J., Han, J.W., Kim, T.H., Kwak, K.P., Kim, B.J., Kim, S.G., Kim, J.L., Moon, S.W., Significant Depression in an Italian Population of 70–74-Year-Olds: Prevalence and
Park, J.H., Ryu, S.H., Youn, J.C., Lee, D.Y., Lee, D.W., Lee, S.B., Lee, J.J., Jhoo, J.H., Association with Perceptions of Self. Biomed Res. Int. 2017, 3592359. https://doi.
Kim, K.W., 2020. Epidemiological Characteristics of Subsyndromal Depression in org/10.1155/2017/3592359.
Late Life. Aust. N. Z. J. Psychiatry 54 (2), 150–158. https://doi.org/10.1177/ Vahia, I.V., Meeks, T.W., Thompson, W.K., Depp, C.A., Zisook, S., Allison, M., Judd, L.L.,
0004867419879242. Jeste, D.V., 2010. Subthreshold depression and successful aging in older women
Pan, X., Xiao, Y., Ren, D., Xu, Z.-M., Zhang, Q., Yang, L.-Y., Liu, F., Hao, Y.-S., Zhao, F., (Embase). Am. J. Geriatr. Psychiatry: Off. J. Am. Assoc. Geriatr. Psychiatry 18 (3),
Bai, Y.-H., 2022. Prevalence of mental health problems and associated risk factors 212–220. https://doi.org/10.1097/JGP.0b013e3181b7f10e.
among military healthcare workers in specialized COVID-19 hospitals in Wuhan, van Varsseveld, N.C., van Bunderen, C.C., Sohl, E., Comijs, H.C., Penninx, B.W.J.H.,
China: a cross-sectional survey (Scopus). Asia-Pac. Psychiatry 14 (1). https://doi. Lips, P., Drent, M.L., 2015. Serum Insulin-like Growth Factor 1 and Late-Life
org/10.1111/appy.12427. Depression: A Population-Based Study. Psychoneuroendocrinology 54, 31–40.
Patten, S.B., Williams, J.V.A., Lavorato, D.H., Bulloch, A.G.M., D’Arcy, C., Streiner, D.L., https://doi.org/10.1016/j.psyneuen.2015.01.014.
2012. Recall of recent and more remote depressive episodes in a prospective cohort VanItallie, T.B., 2005. Subsyndromal depression in the elderly: underdiagnosed and
study (Scopus). Soc. Psychiatry Psychiatr. Epidemiol. 47 (5), 691–696. https://doi. undertreated. Metabolism 54 (5, Supplement), 39–44. https://doi.org/10.1016/j.
org/10.1007/s00127-011-0385-5. metabol.2005.01.012.
Pietrzak, R.H., Kinley, J., Afifi, T.O., Enns, M.W., Fawcett, J., Sareen, J., 2013. Verdaguer, E.S., Stafford, J., Tuijt, R., Orgeta, V., 2020. Minor and subthreshold
Subsyndromal depression in the United States: prevalence, course, and risk for depressive disorders in Alzheimer’s disease: a systematic review and meta-analysis
incident psychiatric outcomes. Psychol. Med. 43 (7), 1401–1414. https://doi.org/ of prevalence studies. J. Affect. Disord. 263, 728–734. https://doi.org/10.1016/j.
10.1017/S0033291712002309. jad.2019.11.053.

12
X. Zhao et al. Asian Journal of Psychiatry 102 (2024) 104253

Vilagut, G., Forero, C.G., Barbaglia, G., Alonso, J., 2016. Screening for depression in the Xiang, X., Leggett, A., Himle, J.A., Kales, H.C., 2018. Major Depression and Subthreshold
general population with the center for epidemiologic studies depression (CES-D): a Depression among Older Adults Receiving Home Care. Am J Geriatr Psychiatry 26
systematic review with meta-analysis. PLoS ONE 11 (5), e0155431. https://doi.org/ (9), 939–949. https://doi.org/10.1016/j.jagp.2018.05.001.
10.1371/journal.pone.0155431. Yang, Y., Li, Y., Wu, Z.-H., 2020. Survey of State-of-the-art Distributed Tracing
Vink, D., Aartsen, M.J., Schoevers, R.A., 2008. Risk factors for anxiety and depression in Technology (Scopus). Ruan Jian Xue Bao/J. Softw. 31 (7), 2019–2039. https://doi.
the elderly: a review. J. Affect. Disord. 106 (1), 29–44. https://doi.org/10.1016/j. org/10.13328/j.cnki.jos.006047.
jad.2007.06.005. Yao, Q., Hui, H., Ling, W., Yating, A., Kaili, S., Mengying, L., Yu, Z., 2018. Analysis of the
Volz, H.-P., Stirnweiß, J., Kasper, S., Möller, H.-J., Seifritz, E., 2023. Subthreshold current status and influencing factors of subthreshold depression among community-
depression – concept, operationalisation and epidemiological data. A scoping dwelling older adults in Wuhan (in Chinese)’. Nurs. Res. 32 (15), 2435–2437.
review. Int. J. Psychiatry Clin. Pract. 27 (1), 92–106. https://doi.org/10.1080/ Yohannes, A.M., Baldwin, R.C., Connolly, M.J., 2003. Prevalence of Sub-Threshold
13651501.2022.2087530. Depression in Elderly Patients with Chronic Obstructive Pulmonary Disease. Int. J.
Walters, K., Breeze, E., Wilkinson, P., Price, G.M., Bulpitt, C.J., Fletcher, A., 2004. Local Geriatr. Psychiatry 18 (5), 412–416. https://doi.org/10.1002/gps.851.
area deprivation and urban-rural differences in anxiety and depression among Zhang, B., Liu, S., Liu, X., Chen, S., Ke, Y., Qi, S., Wei, X., Ming, D., 2022. Discriminating
people older than 75 years in Britain. Am. J. Public Health 94 (10), 1768–1774. subclinical depression from major depression using multi-scale brain functional
https://doi.org/10.2105/ajph.94.10.1768. features: a radiomics analysis. J. Affect. Disord. 297, 542–552. https://doi.org/
Wesselhoeft, R., Sørensen, M.J., Heiervang, E.R., Bilenberg, N., 2013. Subthreshold 10.1016/j.jad.2021.10.122.
depression in children and adolescents – a systematic review. J. Affect. Disord. 151 Zhang, R., Peng, X., Song, X., Long, J., Wang, C., Zhang, C., Huang, R., Lee, T.M.C., 2023.
(1), 7–22. https://doi.org/10.1016/j.jad.2013.06.010. The prevalence and risk of developing major depression among individuals with
WHO. (2023). Mental health of older adults. https://www.who.int/news-room/fact- subthreshold depression in the general population (Medline). Psychol. Med. 53 (8),
sheets/detail/mental-health-of-older-adults. 3611–3620. https://doi.org/10.1017/S0033291722000241.
Wu, C.S., Yu, S.-H., Lee, C.-Y., Tseng, H.-Y., Chiu, Y.F., Hsiung, C.A., 2017. Prevalence of Zhang, Y., Zhang, X., Cao, B., Wang, H., Liu, Y., Guo, Q., Liu, S., Zhang, W., 2022. Study
and Risk Factors for Minor and Major Depression among Community-Dwelling Older on the status quo and influencing factors of subthreshold depression in the elderly
Adults in Taiwan. Int. Psychogeriatr. 29 (7), 1113–1121. https://doi.org/10.1017/ living alone in China based on CLHLS (in Chinese). Evid. Based Nurs. 8 (8),
S1041610217000199. 1068–1071.
Wyman, M.F., Jonaitis, E.M., Ward, E.C., Zuelsdorff, M., Gleason, C.E., 2020. Depressive Zhu, Y., Li, C., Xie, W., Zhong, B., Wu, Y., Blumenthal, J.A., 2022. Trajectories of
Role Impairment and Subthreshold Depression in Older Black and White Women: depressive symptoms and subsequent cognitive decline in older adults: a pooled
Race Differences in the Clinical Significance Criterion. Int. Psychogeriatr. 32 (3), analysis of two longitudinal cohorts (Embase). Age Ageing 51 (1), afab191. https://
393–405. https://doi.org/10.1017/S1041610219001133. doi.org/10.1093/ageing/afab191.

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