Journal of Affective Disorders 168 (2014) 472–475
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Brief report
Behavioral characteristics of subthreshold depression Koki Takagaki a,n, Yasumasa Okamoto a, Ran Jinnin a,b, Asako Mori a, Yoshiko Nishiyama a, Takanao Yamamura a, Yoshitake Takebayashi c, Akiko Ogata d, Yuri Okamoto b, Yoshie Miyake b, Haruki Shimoda e, Norito Kawakami e, Shigeto Yamawaki a a
Department of Psychiatry and Neurosciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan Health Service Center, Hiroshima University, Japan c Graduate school of Integrated Arts and Sciences, Hiroshima University, Japan d Department of Psychology, Hiroshima University, Japan e Department of Mental Health, The University of Tokyo, Japan b
art ic l e i nf o
a b s t r a c t
Article history: Received 27 June 2014 Accepted 8 July 2014 Available online 23 July 2014
Background: This study examines differences in behavioral characteristics among individuals who are not depressed and individuals with subthreshold depression, and depression. Methods: We conducted structured interviews with 111 undergraduate students, who also completed self-report scales. The participants were divided into a non-depression group, a subthreshold depression group, and a depression group based on results of the structured interview and the BDI-II. Results: There were significant differences in avoidance between depression group and other two groups. Also, for the environmental rewards, there were significant difference between the nondepressed group and the other two groups. Limitations: The sample of depressed participants was small. The overall sample consisted only undergraduate students. Conclusions: This study reported that there are different behavioral characteristics among non-depression, subthreshold depression, and depression groups. Whereas depression group is characterized by high frequency of avoidance and low environmental rewards, subthreshold depression group is characterized by only low environmental rewards. & 2014 Elsevier B.V. All rights reserved.
Keywords: Depression Subthreshold depression Behavioral characteristics
1. Introduction It has been reported that the 12-month prevalence of depression in Japan was 2.9% (Kawakami et al., 2005). Moreover, in recent years, subthreshold depression has received considerable attention (Bertha and Balazs, 2013). Subthreshold depression is defined as clinically significant depressive symptoms that do not meet diagnostic criteria for Major Depressive Disorder (MDD: Pincus et al., 1999). Subthreshold depression is known to be a risk factor for depression (Bertha and Balazs, 2013). The incidence of MDD in people with subthreshold depression is higher than in people without subthreshold depression (Cuijpers and Smit, 2004). Therefore, there is a need to investigate subthreshood depression, in addition to investigating depression. Ferster (1973) suggested that many activities of depressed individuals are characterized by avoidance of aversive life experiences,
n
Corresponding author. Tel.: þ 81 82 257 5208; fax: þ 81 82 257 5209. E-mail address: [email protected] (K. Takagaki).
http://dx.doi.org/10.1016/j.jad.2014.07.018 0165-0327/& 2014 Elsevier B.V. All rights reserved.
and a concomitant reduced frequency of positively reinforced behaviors. It has been demonstrated that clients react to depressed feelings with avoidance behaviors (Kanter et al., 2010). Moreover, several studies have reported that depressive people responded poorly to reward conditions (Henriques and Davidson, 2000). It has been suggested that depression is characterized by impairments in reinforcements processing, and that depressed patients are less able to modulate their behavior in response to reinforcements (Eshel and Roiser, 2010). As a result, depressed individuals have an increased frequency of avoidance, as well as a decrease in the degree of positive reinforcements compared to healthy people. However, no study to date has investigated the behavioral characteristics related to subthreshold depression. The possibility of significant differences in the degrees of avoidance and positive reinforcement between subthreshold depression and depression, suggest the need to use difference behavioral interventions for depression and subthreshold depression. Therefore, the purpose of this study was to compare differences in behavioral characteristics between individuals with subthreshold depression and nondepressed, and depressed individuals.
K. Takagaki et al. / Journal of Affective Disorders 168 (2014) 472–475
2. Methods 2.1. Participants We screened 2308 freshmen BDI-II before entered Hiroshima University. Recruitment took place through email on a public information sharing center. We contacted students who had BDI-II scores greater than or equal to 10 by email. After providing informed consent, the participants were 111 (48 women, 63 men) Japanese undergraduate students. Their mean age was 18.76 yr. (SD¼ .66).
473
diagnostic criteria for BD in this study. Individuals who did not meet criteria for MDD in their lifetime history and who had BDI-II scores lower than 13 were allocated to the non-depressed group. Individuals who did not meet criteria for MDD in their lifetime history and who had BDI-II scores greater than or equal to 14 were allocated to the subthreshold depression group. Individuals who met diagnostic criteria for MDD in their lifetime history and who had BDI-II scores greater than or equal to 14 were allocated to the depression group. Also, we excluded individuals who met diagnostic criteria for MDD in their lifetime history and who had BDI-II scores lower than 13.
2.2. Measures 2.4. Statistical analysis 2.2.1. The Japanese version of the behavioral activation for depression scale (BADS; Takagaki et al., 2013) The original BADS was developed by Kanter et al. (2007), and consisted of 25 items that are rated on a 7-point scale (0: Not at all to 6: Completely). The BADS consists of four subscales. The Activation subscale (BADS-AC) measures goal-directed activation and the completion of scheduled activities. The Avoidance/Rumination subscale (BADS-AR) measures the avoidance of a negative aversive state, and engaging in rumination, rather than active problem solving. The Work/School Impairment subscale (BADSWS) measures the consequences of inactivity and passivity on work and school responsibilities. The Social Impairment (BADS-SI) subscale measures similar social consequences and social isolation. Takagaki et al. (2013) developed and demonstrated the reliability and validity of the Japanese version of the BADS. 2.2.2. The Japanese version of the environmental reward observation scale (EROS; Kunisato et al., 2011) The original EROS was developed by Armento and Hopko (2007). The EROS consists of 10 items that are scored on a 4point scale (1: Strongly disagree to 4: Strongly agree), and is used to measure the exposure to environmental rewards deemed essential for increasing response-contingent positive reinforcement. Kunisato et al. (2011) developed the Japanese version the EROS, and reported the reliability and validity of this scale. 2.2.3. The Japanese version of the beck depression inventory, 2nd version (BDI-II; Kojima and Furukawa, 2003) The original BDI-II was developed by Beck et al. (1996). This scale consists of 21 self-report items that are scored on a 4-point scale, and is used to measure depressive symptoms. Kojima and Furukawa (2003) developed the Japanese version of the BDI-II and demonstrated the reliability and validity of the BDI-II. 2.2.4. Composite international diagnostic interview (CIDI; Kessler and Ustun, 2004) The CIDI is a widely used structured interview for assessing mental disorders. We used the computerized version (Kessler and Ustun, 2004). Also each participant was assessed for their lifetime history of MDD and Bipolar Disorder (BD). We used the Japanese version of the CIDI (Kawakami et al., 2005). 2.3. Procedure Approval for the study was obtained from the ethics committee of Hiroshima University. Recruitment took place through email on a public information sharing center. After obtaining informed consent, a trained interviewer conducted a telephone structured interview (CIDI) with each participant. We sent self-report scales to 113 participants through the Internet. The 111 participants completed self-report scales through the Internet. The collection rate of self-report scales was 98.23% in this study. Nobody met
First, we reported the descriptive data. Second, ANOVAs were conducted for the behavioral characteristics data to examine differences among the three groups.
3. Results 3.1. Descriptive data for the non-depressed group, subthreshold depression group, and depression group Based upon the telephone structured interview and the BDI-II, the participants were classified into groups: 50 participants in the non-depressed group (BDI-II ¼7.48); 41 in the subthreshold depression group (BDI-II ¼17.98); 11 in the depression group (BDI-II¼ 21.18); 9 in the exclusion criteria (BDI-II ¼7.56). The mean scores on the measures are shown in Table 1. We examined whether there are significant differences of age and gender balance among three groups. The reported that there were no significant difference of age and gender balance among three groups. 3.2. Differences of behavioral factors among the three groups Table 1 shows the mean scores and significant differences between the groups. One-way ANOVAs yielded significant differences among the non-depressed group, the subthreshold depression group, and the depression group for scores on the BADS-Total [F (2, 99) ¼12.64, po .01],BADS-AR [F (2, 99) ¼10.69, p o.01], Table 1 Descriptive data among three groups. Non-depression Group
Female/male Mean Age BDI-II BADS-Total BADS-AC BADS-AR BADS-SI BADS-WS EROS
Depression Group
N = 50
Subthreshold Depression Group N = 41
N = 11
19/31 18.80 (.67) 7.48 (3.29) 99.54 (16.33) a 15.30 (8.78) 13.18 (7.68) a 3.86 (4.54) a 6.72 (4.42) a 25.88 (4.40) a
16/25 18.71 (.64) 17.98 (4.97) 88.85 (18.56) b 13.34 (8.90) 17.20 (7.99) a 5.59 (4.99) a 9.71 (5.34) b 22.00 (4.71) b
8/3 18.82 (.87) 21.18 (7.67) 71.46 (20.11) c 11.46 (6.64) 25.00 (8.91) b 10.73 (7.25) b 12.27 (5.43) b 20.46 (5.08) b
Note. Values in parentheses represent standard deviation. There are significant difference between different shoulder alphabet(a, b, c) (p o .05). BDI-II: Beck Depression Inventory –II, BADS-Total: Behavioral Activation for Depression Scale-Total scores, BADS-AC: Behavioral Activation for Depression Scale-Activation, BADS-AR: Behavioral Activation for Depression Scale-Avoidance/ Rumination, BADS-SI: Behavioral Activation for Depression Scale-Social Impairment, BADS-WS : Behavioral Activation for Depression Scale-Work/School Impairment, EROS: Environmental Reward Observation Scale.
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K. Takagaki et al. / Journal of Affective Disorders 168 (2014) 472–475
BADS-SI[F (2, 99) ¼8.42, p o.01], BADS-WS [F (2, 99) ¼7.76, p o.01], and EROS [F (2, 99) ¼10.97, p o.01]. We next conducted multiple comparisons for each scales. The results yielded significant differences among the three groups for BADS-Total. There were significant differences between the depression group and the other two groups in BADS-AR and BADS-SI. There were significant differences between the non-depressed group and the other two groups in the BADS-WS and the EROS. A one-way ANOVA yielded no significant difference among the three groups for the BADS-AC [F (2, 99) ¼1.15, p ¼.32].
4. Discussion The current study investigated the behavioral characteristics of people with subthreshold depression. The higher scores of the BADS-Total represented increased activation (Kanter et al., 2007). Based upon these findings for the BADS-Total, BADS-AR, BADS-AC, and EROS, the behavioral characteristics of the subthreshold depression group in this study were more active compared to the depression group. Also, the subthreshold depression group was also characterized by receiving less rewards from the environment, they had dysfunctions in their college life. Decreased response-contingent positive reinforcement can provide a sufficient explanation of depression (Dimidjian et al., 2011). Adolescent with a current depressive disorder were less reward seeking than adolescents without a psychopathology (Rawal et al., 2013). Therefore, the subthreshold depression group was characterized by hyposensitivity to rewards. Moreover, Behavioral characteristics of subthreshold depression group became of less avoidant behaviors compared with depression group. Findings of this study indicated that behavioral characteristics of the depression group were characterized by a lack of increased activation. Moreover, the depression group was characterized by a high frequency of avoidance and obtaining fewer rewards from the environment. Furthermore, the results of BADS-SI and BADS-WS indicated that the depression group had dysfunctions in social situations and college life. Avoidance contributes to the onset and maintenance of depression (Manos et al., 2010; Trew, 2011) and it is a risk factor for depression (Ottenbreit and Dobson, 2008). The highest avoidance score of the depression group in this study was similar to that of a previous study (Ottenbreit and Dobson, 2008). The low level of environmental rewards experienced by depressed students indicated that these students were not exposed to environmental rewards. Behavioral activation is an empirically supported intervention for depression (Sturmey, 2009). The goal of behavioral activation is to increase activated behaviors while decreasing avoidant behaviors, as well as restoring an environment characterized by diverse and stable sources of positive reinforcement (Manos et al., 2010). Because depressed people have a high frequency of avoidance and low environmental rewards, it is necessary to increase their activated behavior, while decreasing avoidance, and thereby increase their access to positively reinforcing events. On the other hand, the results of this study indicated that the main behavioral characteristic of subthreshold depression group is the low frequency of environmental rewards. Therefore, primary target in interventions for subthreshold depression is increasing access to positively reinforcing events and activities, which is similar to initial behavioral activation (Lewinsohn et al., 1978). It is important to point out two limitations of the present study. The number of participants in the depression group was small. Next, the participants consisted of only undergraduate students. In order to generalize the results to the general population, it would be important to replicate this study using a larger and a more diverse sample of participants. Despite the above limitations
however, the results of this study are important in that they identified differences in behavioral characteristics between individuals suffering from depression and subthreshold depression. People with subthreshold depression have different behavioral characteristics from non-depressed and depression people. People with depression are characterized by a high frequency of avoidance and low access to environmental rewards, whereas those with subthreshold depression are characterized only by low accesses to environmental rewards. We hypothesized that increasing access to positively reinforcing events and activities, similar to initial behavioral activation (Lewinsohn et al., 1978), would be the primary aim of interventions for people with subthreshold depression. However, the effectiveness of such interventions for individuals with subthreshold depression was not examined in this study. It is suggested that future studies should investigate whether interventions aimed at increasing access to positively reinforcing events and activities would be an effective intervention for people with subthreshold depression.
Role of funding source This research was supported by the Grant-in-Aid for Scientific Research on Innovative Areas by the Ministry of Education, Culture, Sports, Science and Technology of Japan and the Strategic Research Program for Brain Sciences by the Ministry of Education, Culture, Sports, Science and Technology of Japan.
Conflict of interest All authors report no potential conflicts of interest.
Acknowledgments None.
References Armento, M.E., Hopko, D.R., 2007. The Environmental Reward Observation Scale (EROS): development, validity, and reliability. Behav. Ther. 38, 107–119. Beck, A.T., Steer, R.A., Brown, G.K., 1996. Beck Depression Inventory: Manual, 2nd ed. The Psychological Corp, San Antonio, Texas. Bertha, E.A., Balazs, J., 2013. Subthreshold depression in adolescence: a systematic review. Eur. Child Adolesc. Psychiatry 22, 589–603. Cuijpers, P., Smit, F., 2004. Subthreshold depression as a risk indicator for major depressive disorder: a systematic review of prospective studies. Acta Psychiatr. Scand. 109, 325–331. Dimidjian, S., Barrera Jr., M, Martell, C., Munoz, R.F., Lewinsohn, P.M., 2011. The origins and current status of behavioral activation treatment for depression. Annu. Rev. Clin. Psychol. 7, 1–38. Eshel, N, Roiser, J.P., 2010. Reward and punishment processing in depression. Biol. Psychiatry 68, 118–124. Ferster, C.B., 1973. A functional analysis of depression. Am. Psychol. 28, 857–870. Henriques, J.B., Davidson, R.J., 2000. Decreased responsiveness to reward in depression. Cognit. Emot. 14, 711–724. Kanter, J.W., Mulick, P.S., Busch, A.M., Berlin, K.S., Martell, C.R., 2007. The Behavioral Activation for Depression Scale (BADS): psychometric properties and factor structure. J. Psychopathol. Behav. Assess. 29, 191–202. Kanter, J.W., Manos, R.C., Bowe, W.M., Baruch, D.E., Busch, A.M., Rusch, L.C., 2010. What is behavioral activation? A review of the empirical literature. Clin. Psychol. Rev. 30, 608–620. Kawakami, N., Takeshima, T., Ono, Y., Uda, H., Hata, Y., Nakane, Y., Nakane, H., Iwata, N., Furukawa, T.A., Kikkawa, T., 2005. Twelve-month prevalence, severity, and treatment of common mental disorders in communities in Japan: preliminary finding from the World Mental Health Japan Survey 2002–2003. Psychiatry Clin. Neurosci. 59, 441–452. Kessler, R.G., Ustun, T.B., 2004. The World Mental Health (WMH) survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int. J. Methods Psychiatr. Res. 13, 93–121. Kojima, M., Furukawa, T., 2003. Japanese Version of the Beck Depression Inventory, 2nd ed. Nippon-Hyoron-sha Co, Tokyo. Kunisato, Y., Takagaki, K., Okajima, I., Nakajima, S., Ishikawa, S., Kanai, Y., Okamoto, Y., Sakano, Y., Yamawaki, S., 2011. Development of Japanese version of Environmental Reward Observation Scale (EROS). Jpn. J. Behav. Ther. 37, 21–31. Lewinsohn, P.M., Muñoz, R.F., Youngren, M.A., Zeiss, A.M., 1978. Control Your Depression. Prentice Hall Press, New York. Manos, R.C., Kanter, J.W., Busch, A.M., 2010. A critical review of assessment strategies to measure the behavioral activation model of depression. Clin. Psychol. Rev. 30, 547–561.
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Ottenbreit, N.D., Dobson, K.S., 2008. Avoidance. In: Dobson, K.S., Dozois, D.J.A. (Eds.), Risk Factors in Depression. Academic Press, London, pp. 447–470. Pincus, H.A., Davis, W.W., McQueen, L.E., 1999. Subthreshold mental disorders. a review and synthesis of studies on minor depression and other brand names. Br. J. Psychiatry 174, 288–296. Rawal, A., Collishaw, S., Thapar, A., Rice, F., 2013. The risk of playing it safe: a prospective longitudinal study of response to reward in the adolescent offspring of depressed parents. Psychol. Med. 43, 27–38.
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Sturmey, P., 2009. Behavioral activation is an evidence-based treatment for depression. Behav. Modif. 33, 818–829. Takagaki, K., Okajima, I., Kunisato, Y., Nakajima, S., Kanai, Y., Ishikawa, S., Sakano, Y., 2013. Development and validation of the Japanese version of the Behavioral Activation for Depression Scale (BADS). Arch. Psychiatr. Diagn. Clin. Eval. 6, 76–85. Trew, J.L., 2011. Exploring the roles of approach and avoidance in depression: an integrative model. Clin. Psychol. Rev. 31, 1156–1168.
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Brief report
Behavioral characteristics of subthreshold depression Koki Takagaki a,n, Yasumasa Okamoto a, Ran Jinnin a,b, Asako Mori a, Yoshiko Nishiyama a, Takanao Yamamura a, Yoshitake Takebayashi c, Akiko Ogata d, Yuri Okamoto b, Yoshie Miyake b, Haruki Shimoda e, Norito Kawakami e, Shigeto Yamawaki a a
Department of Psychiatry and Neurosciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan Health Service Center, Hiroshima University, Japan c Graduate school of Integrated Arts and Sciences, Hiroshima University, Japan d Department of Psychology, Hiroshima University, Japan e Department of Mental Health, The University of Tokyo, Japan b
art ic l e i nf o
a b s t r a c t
Article history: Received 27 June 2014 Accepted 8 July 2014 Available online 23 July 2014
Background: This study examines differences in behavioral characteristics among individuals who are not depressed and individuals with subthreshold depression, and depression. Methods: We conducted structured interviews with 111 undergraduate students, who also completed self-report scales. The participants were divided into a non-depression group, a subthreshold depression group, and a depression group based on results of the structured interview and the BDI-II. Results: There were significant differences in avoidance between depression group and other two groups. Also, for the environmental rewards, there were significant difference between the nondepressed group and the other two groups. Limitations: The sample of depressed participants was small. The overall sample consisted only undergraduate students. Conclusions: This study reported that there are different behavioral characteristics among non-depression, subthreshold depression, and depression groups. Whereas depression group is characterized by high frequency of avoidance and low environmental rewards, subthreshold depression group is characterized by only low environmental rewards. & 2014 Elsevier B.V. All rights reserved.
Keywords: Depression Subthreshold depression Behavioral characteristics
1. Introduction It has been reported that the 12-month prevalence of depression in Japan was 2.9% (Kawakami et al., 2005). Moreover, in recent years, subthreshold depression has received considerable attention (Bertha and Balazs, 2013). Subthreshold depression is defined as clinically significant depressive symptoms that do not meet diagnostic criteria for Major Depressive Disorder (MDD: Pincus et al., 1999). Subthreshold depression is known to be a risk factor for depression (Bertha and Balazs, 2013). The incidence of MDD in people with subthreshold depression is higher than in people without subthreshold depression (Cuijpers and Smit, 2004). Therefore, there is a need to investigate subthreshood depression, in addition to investigating depression. Ferster (1973) suggested that many activities of depressed individuals are characterized by avoidance of aversive life experiences,
n
Corresponding author. Tel.: þ 81 82 257 5208; fax: þ 81 82 257 5209. E-mail address: [email protected] (K. Takagaki).
http://dx.doi.org/10.1016/j.jad.2014.07.018 0165-0327/& 2014 Elsevier B.V. All rights reserved.
and a concomitant reduced frequency of positively reinforced behaviors. It has been demonstrated that clients react to depressed feelings with avoidance behaviors (Kanter et al., 2010). Moreover, several studies have reported that depressive people responded poorly to reward conditions (Henriques and Davidson, 2000). It has been suggested that depression is characterized by impairments in reinforcements processing, and that depressed patients are less able to modulate their behavior in response to reinforcements (Eshel and Roiser, 2010). As a result, depressed individuals have an increased frequency of avoidance, as well as a decrease in the degree of positive reinforcements compared to healthy people. However, no study to date has investigated the behavioral characteristics related to subthreshold depression. The possibility of significant differences in the degrees of avoidance and positive reinforcement between subthreshold depression and depression, suggest the need to use difference behavioral interventions for depression and subthreshold depression. Therefore, the purpose of this study was to compare differences in behavioral characteristics between individuals with subthreshold depression and nondepressed, and depressed individuals.
K. Takagaki et al. / Journal of Affective Disorders 168 (2014) 472–475
2. Methods 2.1. Participants We screened 2308 freshmen BDI-II before entered Hiroshima University. Recruitment took place through email on a public information sharing center. We contacted students who had BDI-II scores greater than or equal to 10 by email. After providing informed consent, the participants were 111 (48 women, 63 men) Japanese undergraduate students. Their mean age was 18.76 yr. (SD¼ .66).
473
diagnostic criteria for BD in this study. Individuals who did not meet criteria for MDD in their lifetime history and who had BDI-II scores lower than 13 were allocated to the non-depressed group. Individuals who did not meet criteria for MDD in their lifetime history and who had BDI-II scores greater than or equal to 14 were allocated to the subthreshold depression group. Individuals who met diagnostic criteria for MDD in their lifetime history and who had BDI-II scores greater than or equal to 14 were allocated to the depression group. Also, we excluded individuals who met diagnostic criteria for MDD in their lifetime history and who had BDI-II scores lower than 13.
2.2. Measures 2.4. Statistical analysis 2.2.1. The Japanese version of the behavioral activation for depression scale (BADS; Takagaki et al., 2013) The original BADS was developed by Kanter et al. (2007), and consisted of 25 items that are rated on a 7-point scale (0: Not at all to 6: Completely). The BADS consists of four subscales. The Activation subscale (BADS-AC) measures goal-directed activation and the completion of scheduled activities. The Avoidance/Rumination subscale (BADS-AR) measures the avoidance of a negative aversive state, and engaging in rumination, rather than active problem solving. The Work/School Impairment subscale (BADSWS) measures the consequences of inactivity and passivity on work and school responsibilities. The Social Impairment (BADS-SI) subscale measures similar social consequences and social isolation. Takagaki et al. (2013) developed and demonstrated the reliability and validity of the Japanese version of the BADS. 2.2.2. The Japanese version of the environmental reward observation scale (EROS; Kunisato et al., 2011) The original EROS was developed by Armento and Hopko (2007). The EROS consists of 10 items that are scored on a 4point scale (1: Strongly disagree to 4: Strongly agree), and is used to measure the exposure to environmental rewards deemed essential for increasing response-contingent positive reinforcement. Kunisato et al. (2011) developed the Japanese version the EROS, and reported the reliability and validity of this scale. 2.2.3. The Japanese version of the beck depression inventory, 2nd version (BDI-II; Kojima and Furukawa, 2003) The original BDI-II was developed by Beck et al. (1996). This scale consists of 21 self-report items that are scored on a 4-point scale, and is used to measure depressive symptoms. Kojima and Furukawa (2003) developed the Japanese version of the BDI-II and demonstrated the reliability and validity of the BDI-II. 2.2.4. Composite international diagnostic interview (CIDI; Kessler and Ustun, 2004) The CIDI is a widely used structured interview for assessing mental disorders. We used the computerized version (Kessler and Ustun, 2004). Also each participant was assessed for their lifetime history of MDD and Bipolar Disorder (BD). We used the Japanese version of the CIDI (Kawakami et al., 2005). 2.3. Procedure Approval for the study was obtained from the ethics committee of Hiroshima University. Recruitment took place through email on a public information sharing center. After obtaining informed consent, a trained interviewer conducted a telephone structured interview (CIDI) with each participant. We sent self-report scales to 113 participants through the Internet. The 111 participants completed self-report scales through the Internet. The collection rate of self-report scales was 98.23% in this study. Nobody met
First, we reported the descriptive data. Second, ANOVAs were conducted for the behavioral characteristics data to examine differences among the three groups.
3. Results 3.1. Descriptive data for the non-depressed group, subthreshold depression group, and depression group Based upon the telephone structured interview and the BDI-II, the participants were classified into groups: 50 participants in the non-depressed group (BDI-II ¼7.48); 41 in the subthreshold depression group (BDI-II ¼17.98); 11 in the depression group (BDI-II¼ 21.18); 9 in the exclusion criteria (BDI-II ¼7.56). The mean scores on the measures are shown in Table 1. We examined whether there are significant differences of age and gender balance among three groups. The reported that there were no significant difference of age and gender balance among three groups. 3.2. Differences of behavioral factors among the three groups Table 1 shows the mean scores and significant differences between the groups. One-way ANOVAs yielded significant differences among the non-depressed group, the subthreshold depression group, and the depression group for scores on the BADS-Total [F (2, 99) ¼12.64, po .01],BADS-AR [F (2, 99) ¼10.69, p o.01], Table 1 Descriptive data among three groups. Non-depression Group
Female/male Mean Age BDI-II BADS-Total BADS-AC BADS-AR BADS-SI BADS-WS EROS
Depression Group
N = 50
Subthreshold Depression Group N = 41
N = 11
19/31 18.80 (.67) 7.48 (3.29) 99.54 (16.33) a 15.30 (8.78) 13.18 (7.68) a 3.86 (4.54) a 6.72 (4.42) a 25.88 (4.40) a
16/25 18.71 (.64) 17.98 (4.97) 88.85 (18.56) b 13.34 (8.90) 17.20 (7.99) a 5.59 (4.99) a 9.71 (5.34) b 22.00 (4.71) b
8/3 18.82 (.87) 21.18 (7.67) 71.46 (20.11) c 11.46 (6.64) 25.00 (8.91) b 10.73 (7.25) b 12.27 (5.43) b 20.46 (5.08) b
Note. Values in parentheses represent standard deviation. There are significant difference between different shoulder alphabet(a, b, c) (p o .05). BDI-II: Beck Depression Inventory –II, BADS-Total: Behavioral Activation for Depression Scale-Total scores, BADS-AC: Behavioral Activation for Depression Scale-Activation, BADS-AR: Behavioral Activation for Depression Scale-Avoidance/ Rumination, BADS-SI: Behavioral Activation for Depression Scale-Social Impairment, BADS-WS : Behavioral Activation for Depression Scale-Work/School Impairment, EROS: Environmental Reward Observation Scale.
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K. Takagaki et al. / Journal of Affective Disorders 168 (2014) 472–475
BADS-SI[F (2, 99) ¼8.42, p o.01], BADS-WS [F (2, 99) ¼7.76, p o.01], and EROS [F (2, 99) ¼10.97, p o.01]. We next conducted multiple comparisons for each scales. The results yielded significant differences among the three groups for BADS-Total. There were significant differences between the depression group and the other two groups in BADS-AR and BADS-SI. There were significant differences between the non-depressed group and the other two groups in the BADS-WS and the EROS. A one-way ANOVA yielded no significant difference among the three groups for the BADS-AC [F (2, 99) ¼1.15, p ¼.32].
4. Discussion The current study investigated the behavioral characteristics of people with subthreshold depression. The higher scores of the BADS-Total represented increased activation (Kanter et al., 2007). Based upon these findings for the BADS-Total, BADS-AR, BADS-AC, and EROS, the behavioral characteristics of the subthreshold depression group in this study were more active compared to the depression group. Also, the subthreshold depression group was also characterized by receiving less rewards from the environment, they had dysfunctions in their college life. Decreased response-contingent positive reinforcement can provide a sufficient explanation of depression (Dimidjian et al., 2011). Adolescent with a current depressive disorder were less reward seeking than adolescents without a psychopathology (Rawal et al., 2013). Therefore, the subthreshold depression group was characterized by hyposensitivity to rewards. Moreover, Behavioral characteristics of subthreshold depression group became of less avoidant behaviors compared with depression group. Findings of this study indicated that behavioral characteristics of the depression group were characterized by a lack of increased activation. Moreover, the depression group was characterized by a high frequency of avoidance and obtaining fewer rewards from the environment. Furthermore, the results of BADS-SI and BADS-WS indicated that the depression group had dysfunctions in social situations and college life. Avoidance contributes to the onset and maintenance of depression (Manos et al., 2010; Trew, 2011) and it is a risk factor for depression (Ottenbreit and Dobson, 2008). The highest avoidance score of the depression group in this study was similar to that of a previous study (Ottenbreit and Dobson, 2008). The low level of environmental rewards experienced by depressed students indicated that these students were not exposed to environmental rewards. Behavioral activation is an empirically supported intervention for depression (Sturmey, 2009). The goal of behavioral activation is to increase activated behaviors while decreasing avoidant behaviors, as well as restoring an environment characterized by diverse and stable sources of positive reinforcement (Manos et al., 2010). Because depressed people have a high frequency of avoidance and low environmental rewards, it is necessary to increase their activated behavior, while decreasing avoidance, and thereby increase their access to positively reinforcing events. On the other hand, the results of this study indicated that the main behavioral characteristic of subthreshold depression group is the low frequency of environmental rewards. Therefore, primary target in interventions for subthreshold depression is increasing access to positively reinforcing events and activities, which is similar to initial behavioral activation (Lewinsohn et al., 1978). It is important to point out two limitations of the present study. The number of participants in the depression group was small. Next, the participants consisted of only undergraduate students. In order to generalize the results to the general population, it would be important to replicate this study using a larger and a more diverse sample of participants. Despite the above limitations
however, the results of this study are important in that they identified differences in behavioral characteristics between individuals suffering from depression and subthreshold depression. People with subthreshold depression have different behavioral characteristics from non-depressed and depression people. People with depression are characterized by a high frequency of avoidance and low access to environmental rewards, whereas those with subthreshold depression are characterized only by low accesses to environmental rewards. We hypothesized that increasing access to positively reinforcing events and activities, similar to initial behavioral activation (Lewinsohn et al., 1978), would be the primary aim of interventions for people with subthreshold depression. However, the effectiveness of such interventions for individuals with subthreshold depression was not examined in this study. It is suggested that future studies should investigate whether interventions aimed at increasing access to positively reinforcing events and activities would be an effective intervention for people with subthreshold depression.
Role of funding source This research was supported by the Grant-in-Aid for Scientific Research on Innovative Areas by the Ministry of Education, Culture, Sports, Science and Technology of Japan and the Strategic Research Program for Brain Sciences by the Ministry of Education, Culture, Sports, Science and Technology of Japan.
Conflict of interest All authors report no potential conflicts of interest.
Acknowledgments None.
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