INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY Int J Geriatr Psychiatry 2008; 23: 1175–1181. Published online 10 June 2008 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/gps.2051
Development and validation of the Cognitive Inventory of Subjective Distress Pascal Antoine 1*, Christine Antoine 2 and Jean-Louis Nandrino 1 1
University Lille North of France—UPRES URECA EA 1059—’Family, Health and Emotion’ Group, Villeneuve d’Ascq, France 2 Centre Hospitalier Intercommunal, Wasquehal, France
SUMMARY Objectives Objectives This study was aimed at exploring some of the facets of psychological distress during aging, and at validating an inventory, the Cognitive Inventory of Subjective Distress (CISD) for assessing this kind of distress. Methods An inventory of thoughts representing distress schemas was administered to 298 elderly subjects living at home or in a center. Results Factor analyses suggested retaining 29 items. They explained 62% of the total variance and corresponded to seven distinct facets: abandonment, dependency, disengagement, fear of losing control, loss of individuality, refusal of help, and vulnerability. These dimensions turned out to be relatively independent of each other and moderately correlated with measures of depression and anxiety. The internal consistency and temporal reliability of the seven scales are good. Conclusion The CISD is an original tool for assessing psychological distress. It is geared to old and very old individuals living in a center for the elderly, and its design takes the fatiguability and cognitive heterogeneity of this population into account. This inventory can also be used for psychopathological assessment and can serve as a baseline for following patients over time or in the course of therapy. Copyright # 2008 John Wiley & Sons, Ltd. key words — distress; depression; anxiety; assessment; elderly
INTRODUCTION Psychological distress can be defined as a reaction to internal and external demands characterized by a heterogeneous set of psychological symptoms such as low self-esteem, hopelessness, helplessness, sadness, and fear (Dohrenwend et al., 1980). A long-neglected subjective phenomenon, psychological distress can only be accessed through self-observation by the patient, in opposition to evaluations by a clinician (Ritsner et al., 2002). Negative cognitions are at the heart of this kind of distress (Barlow and Durand, 1999). Most research on elderly distress has dealt with well-identified problems such as major depression and *Correspondence to: P. Antoine, Universite´ de Lille 3, UPRES URECA EA 1059—’Family, Health and Emotion’ Group, BP 60149, 59653 Villeneuve d’Ascq Cedex, France. E-mail:
[email protected] Copyright # 2008 John Wiley & Sons, Ltd.
anxiety disorders. Clinically, these disorders have been fully described for young adults, but they are less clear-cut for the elderly (Alexopoulos et al., 2002). Subthreshold depressive states are common (Gurland et al., 1996) and sometimes long-lasting (Berger et al., 1999), and they may precede a bout of major depression (Lyness et al., 1999). It is highly important, then, to rapidly detect these states and start treatment. Some authors have distinguished various subthreshold depressive states (Geiselmann and Bauer, 2000) based partially on differences in the subjective experiences and cognitions reported by patients. The concept of a maladaptive schema, which emerged and expanded considerably during the 1980s, is particularly useful in this approach. Maladaptive schemas are pervasive knowledge structures about the self and one’s relationships with others (Schmidt and Joiner, 2004). They develop during childhood, evolve throughout the lifespan, and are inflexible, Received 6 January 2008 Accepted 10 April 2008
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unconditional, and irrefutable, which is what makes them maladaptive. Their utility in therapy first became apparent for patients with a personality disorder. Schema-based therapies are designed for complex clinical cases, i.e. complex in terms of the disorders themselves, the rigidity of the underlying cognitive structures, and the patient’s capacity to follow through with therapy (McGinn and Young, 1996; McGinn et al., 1995). Elderly subjects undergoing therapy often exhibit all three of these characteristics. Furthermore, comorbidity between depression and avoidance or dependency personality disorders is great in this population (Devanand et al., 2000). Research has pointed out the existence of certain maladaptive thoughts among the elderly (Zeiss and Steffen, 1996; Geiselmann and Bauer, 2000) linked to physical ill-being or loneliness, or related to concerns about mental or somatic health (Baltes and Smith, 1997). The range of cognitions taken into account must therefore be extended. The primary goal of this study was to explore the facets of psychological distress in aging. The second goal was to examine the psychometric properties of an inventory of subjective distress. Emphasis is placed on determining whether and to what extent subjective items can be used to test elderly individuals with a varying degree of cognitive deterioration. This tool could be used to assess different dimensions of cognitive distress, and to help in the functional analysis of patients with subthreshold depressive states who are in need of psychotherapy or psychological support. MATERIALS AND METHOD The CISD The details of a pilot study are described in an earlier publication (Antoine et al., 2007). The first phase of that study involved generating 60 questionnaire items in reference to past research on schemas and cognitions during aging. The resulting questionnaire was tested on a sample of 198 elderly subjects. Response-distribution analyses and factor analyses allowed us to eliminate 16 ineffective items, leaving 44 test items for the validation phase reported in the present article. For the validation phase, the items were presented in random order to the subjects. The instructions were short and simple and referred explicitly to cognitions: ‘Here is a series of statements corresponding to inner thoughts or reflections that one might have at any time of the day, in various situations. You should indicate whether these thoughts are the kind you might have, or Copyright # 2008 John Wiley & Sons, Ltd.
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have already had in the past’. The subjects had to choose among four responses ranging from ‘totally false for me’ to ‘totally true for me’. The testing was conducted by research assistants who had an undergraduate degree in psychology and were specifically trained for this study. For each of the 44 items, the assistants had to note any difficulties the participants had, such as requests for explanations, needing to be prompted, or answering without seeming to understand the question. The extent of cognitive deterioration was assessed on the Mini-Mental State Examination (MMSE) (Folstein et al., 1975). This quick test screens for cognitive disorders by exploring temporal and spatial orientation, immediate and long-term memory, attention, and praxic abilities. Persons suffering from dementia generally obtain a score below 24, with variations according to age and sociocultural level. Autonomy was evaluated on the Activities of Daily Living Scale (ADLS) (Lawton and Brody, 1969). This measure was obtained by questioning a caretaker. The basic activities assessed were bathing, eating, dressing, self-care, walking, and toiletting. Scoring of each activity was simplified, with 1 point for full autonomy and 0 if any help was necessary. Depression was assessed on the Geriatric Depression Scale or GDS (Yesavage et al., 1983), which is a ‘yes–no’ self-evaluation scale for the elderly that requires little time and effort. This scale does not include the somatic items that are often part of depression measures, because these items can generate a bias in an elderly population. The version used was the reduced 15-item version (Sheikh and Yesavage, 1986). Anxiety was measured on the State-Trait Anxiety Inventory (STAI) (Spielberger, 1983). Only trait anxiety was assessed, i.e. the general tendency to feel anxiety. The inventory is composed of 20 selfevaluation items. Description of the sample All participants were at least 60 years old. The exclusion criteria were: severe dementia (MMSE score below 10) and sensory or mental disorders that prevented testing via a questionnaire. The presence of a mood disorder was not an exclusion criterion. There were 296 participants in all (228 women and 68 men) ranging in age between 61 and 103 (mean age 82.7 7.3 years). Their MMSE score fell between 11 and 30 (mean 23.2 4.8). They reported their marital status as single (n ¼ 55), divorced (n ¼ 10), living maritally (n ¼ 27), or widowed (n ¼ 204). Int J Geriatr Psychiatry 2008; 23: 1175–1181. DOI: 10.1002/gps
development and validation of the cisd To recruit the participants living in a center (n ¼ 252), 16 centers located in urban and rural areas in the north of France were contacted. The types of centers included ones that take in relatively autonomous elderly individuals (daytime centers, elderly residencies, nonmedical retirement homes) as well centers for dependent persons (medical-care homes). The persons living at home were contacted through lists obtained from various city halls (n ¼ 44). A subgroup of 71 participants also filled out concurrent validity questionnaires. The scores of these subjects ranged from 11–30 on the MMSE, 0–6 on the ADLS, 21–64 on the STAI, and 0–14 on the reduced GDS. Among these participants, 21 had a score greater than or equal to the depression cutoff point on the GDS (Schreiner et al., 2003). To verify the questionnaire’s reliability, the distress items were administered to a second subgroup of 49 participants 15 days after the first test. Statistical analyses were run in Statistica 6. The topic and procedure of the study were presented to the participants orally and in writing. Only those participants who gave their written consent were included in the study. RESULTS Analysis of testing difficulties For each item, a difficulty rating equal to the proportion of participants who had trouble with that item was calculated. This coefficient fell between 0.7% (n ¼ 2) and 7.1% (n ¼ 21). The total number of difficult items for each participant was also calculated. The correlation between this score and the MMSE score was r ¼ 0.18, p < 0.001. This correlation is nonnegligible, but low nonetheless. Preliminary item analyses As a second step, the item distributions were examined (Gorsuch, 1997). The skewness and kurtosis indexes were 1.5 or less (in absolute value). The item correlation matrix was studied to detect potential redundancies and to avoid producing artificial clusters (Lyne and Roger, 2000). Only five pairs of items had a correlation coefficient slightly above r ¼ 0.60. A semantic analysis of these pairs did not reveal any redundancy. Multidimensional analyses Schema structures were studied using principal component analyses. Three methods were employed Copyright # 2008 John Wiley & Sons, Ltd.
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to estimate the optimal number of components to retain: the scree test (Cattell, 1966), Kaiser-Guttman’s criterion (Kaiser, 1961), and component representativeness. The Kaiser criterion generally leads to overestimation of the number of dimensions (Tzeng, 1992). The scree test is a rather subjective evaluation that also slightly overestimates the number of factors (Zwick and Velicer, 1986). The representativeness of each component after rotation gives the number of nonnegligible loadings. In line with Kline’s (1994) recommendations, orthogonal rotations were applied to make the factorial structure as intelligible as possible for relatively independent constructs. Nine components had an eigenvalue above 1 (Kaiser criterion). The shape of the eigenvalue curve suggested retaining seven components (scree test). Moreover, examination of the nine-, eight-, and seven-component solutions consistently indicated that only seven components had at least three loadings above 0.40. For this reason, a seven-dimensional structure was retained. In order to end up with an understandable, parsimonious, and stable structure, selection criteria were defined to determine which items should be included in each factor. To increase the chances of obtaining a stable structure, the effect of double loading was minimized by only accepting those where: the highest loading was greater than 0.40 and the secondary loadings less than 0.35. The difference between the highest loading and the others was greater than 0.20. After analysis of the factor weights, and iterative elimination of items that did not meet the selection criteria, 29 items were left (Table 1). They are organized into seven components (i.e. schemas) that explain 62% of the total variance. The first schema, abandonment, corresponds to the fear of being abandoned by family and friends and the fear of ending up isolated, with no social contacts. The four items that load onto this component explain 10.4% of the variance. The dependency schema is associated with four items that explain 10.5% of the variance. This schema corresponds to a perceived need for continuous and extensive assistance in handling everyday affairs and coping with one’s own needs. The third schema (7.3% of the variance) includes five items related to disengagement, i.e. loss of interest in activities. The fourth schema corresponds to fear of losing control and has four items with high loadings. These items, which explain 8.4% of the total variance, concern the tendency to display hostility, whether verbally or physically, and to be aggressive when angry. The fifth schema explains 8.6% of the total variance and includes four items related to loss of Int J Geriatr Psychiatry 2008; 23: 1175–1181. DOI: 10.1002/gps
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Table 1. Loadings of the 29 Items in the Seven-Component Solution* ABAN DEPE DISE FOLC LIND RHEL VULN From now on, I’m afraid that people will brush me aside and forget me 0.78 Lately, I get the impression that I’m being neglected 0.78 I’m afraid my family or friends will abandon me or leave me 0.77 I feel like I’m being left out or abandoned 0.76 I’m completely dependent on others I absolutely have to have someone available to help me at all times If I didn’t have help every minute, I’d feel lost I feel I need help with every little thing I do For me, thinking about tomorrow isn’t useful anymore 0.24 At my age, there’s no point struggling anymore I no longer feel like trying to do things in my life 0.20 I tell myself that at my age, I’m not going to change anymore No matter what I do, my health and situation will never improve When I get emotional, I tend to get carried away and act mean I lose my composure whenever I feel I’ve been offended When I’m angry, I can no longer control myself I can’t stand people’s remarks or criticism these days, and I quickly get aggressive I’m no longer in charge of my own life I’m no longer free to make my own choices I feel like I’m not a whole person anymore I have the impression that my life is beyond my control 0.36 It appalls me when I can’t do things by myself I get angry when someone has to do things for me I hate feeling indebted to or dependent on others It’s humiliating to have to ask for help I’m constantly afraid that something serious will happen to me I’m constantly afraid I’ll be in an accident I feel distressed about the idea of suffering for the rest of my life I’m constantly thinking about terrible things that might happen to me 0.21 Explained variance 3.03 Percentage of explained variance 10.4
0.21 0.21 0.21
0.79 0.78 0.76 0.75 0.33 0.28
0.22 0.71 0.66 0.58 0.56 0.51
0.26 0.26 0.32 0.82 0.72 0.69 0.69
0.29
0.21
0.22 0.23 0.75 0.72 0.66 0.65 0.24
0.23
0.26 0.20 3.03 10.5
2.11 2.45 7.3 8.4
0.25
2.48 8.6
0.20 0.72 0.72 0.72 0.64
2.29 7.9
0.85 0.75 0.66 0.64 2.59 8.9
*Structure obtained by principal component analysis followed by varimax rotation. Loadings above 0.30 are shown in bold. For the sake of readability, loadings below 0.20 are not shown. ABAN ¼ abandonment; DEPE ¼ dependency; DISE ¼ disengagement; FOLC ¼ fear of losing control; LIND ¼ loss of individuality; RHEL ¼ refusal of help; VULN ¼ vulnerability.
individuality during aging: feeling trapped, loneliness, and loss of control over one’s life. The refusal-of-help schema corresponds to actual refusals of help, or behavioral and emotional reactions generated by the need for help. Four items contribute to this component (7.9% of the variance). Finally, the seventh schema, vulnerability, accounts for 8.9% of the variance and includes four items pertaining to generalized fear about various concerns commonly found in the
elderly. Scores on the seven distress scales were calculated by adding the item responses. Correlations between the distress scales The correlation matrix of the seven schema scores showed that none of the scores were totally independent of the other six (Table 2). All correlations were significant ( p < 0.001), but were less than 0.52.
Table 2. Correlations Between the Distress Scales* Dependency Disengagement Fear Of Losing Control Loss Of Individuality Refusal Of Help Vulnerability
0.40 0.36 0.33 0.47 0.29 0.40 Abandonment
0.50 0.21 0.48 0.29 0.39 Dependency
0.20 0.51 0.35 0.37 Disengagement
0.32 0.32 0.35 0.26 0.37 0.27 Fear Of Losing Control Loss Of Individuality Refusal Of Help
*Bravais-Pearson’s r (n ¼ 296). All coefficients are significant at p < 0.001. Copyright # 2008 John Wiley & Sons, Ltd.
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development and validation of the cisd Table 3. Properties of the Distress Scales
Abandonment Dependency Disengagement Fear Of Losing Control Loss Of Individuality Refusal Of Help Vulnerability
Mean
Standard Deviation
Number of items
Internal Consistency
Reliability*
6.51 7.88 12.72 6.60 8.05 8.73 8.51
3.18 3.48 3.67 2.78 3.45 3.28 3.53
4 4 5 4 4 4 4
0.85 0.85 0.73 0.76 0.79 0.72 0.80
0.85 0.90 0.79 0.87 0.83 0.80 0.84
*Bravais-Pearson’s r (n ¼ 49). The coefficients are significant at p < 0.001.
The internal consistency of the seven schemas fell between 0.72 and 0.85. Reliability over time (15 days) was between 0.79 and 0.90 ( p < 0.001). These characteristics are satisfactory (e.g. Guilford and Fruchter, 1978) (Table 3).
of the schemas were significantly and positively correlated with the GDS and STAI scores. The highest correlations were with the abandonment and lossof-individuality schemas. DISCUSSION
Role of sociodemographic variables and health A comparison of the schema scores of women and men indicated no significant sex differences (t-test < 1.25, df ¼ 294, p > 0.20). All of the correlations between age and the schema scores were low and nonsignificant (Table 4). Four schemas were significantly correlated with cognitive deterioration or decreased autonomy. The abandonment schema was linked to autonomy level, and the disengagement and loss-of-individuality schemas were linked to the MMSE and ADLS scores. Most of these correlations were relatively low (less than 0.30): only the dependency-schema score was strongly correlated with ADL (r ¼ 0.56, p < 0.001). The anxiety and depression scores were significantly correlated with each other (r ¼ 0.67, p < 0.001). Correlations of the schema scores with the depression and anxiety indexes were higher. Except for the loss-of-control schema, all
Table 4. Correlations between the measures* Age MMSE
ADLS
GDS
STAI
Abandonment 0.13 0.12 S0.29 0.60*** 0.58*** Dependency 0.09 S0.27 S0.56*** 0.41*** 0.29 Disengagement 0.16 S0.29 S0.27 0.46*** 0.33** Fear Of Losing Control S0.22 S0.06 0.05 0.21 0.33** Loss Of Individuality 0.22 S0.35* S0.29 0.61*** 0.57*** Refusal Of Help 0.04 0.00 S0.12 0.48*** 0.37** Vulnerability S0.02 S0.03 0.05 0.40*** 0.38** *Bravais-Pearson’s r (n ¼ 71). Significant coefficients at p < 0.05 are shown in bold. **p < 0.01; ***p < 0.001. ADLS ¼ (Activities of Daily Living Scale; GDS ¼ Geriatric Depression Scale; STAI ¼ State-Trait Anxiety Inventory. Copyright # 2008 John Wiley & Sons, Ltd.
On the conceptual level, the aim was to study the factorial organization of aging-specific schemas in relation to general schemas. On the psychometric level, the aim was to examine whether this instrument has satisfactory measurement properties. Structure of psychological distress in elderly subjects The questionnaire items can be organized into a simple factorial structure with seven dimensions. Four of the dimensions, fear of losing control, dependency, vulnerability, and abandonment, were derived from earlier research on schemas. However, for reasons related to face validity and content validity, the items––and as a result, the constructs themselves––were worded in a simple and direct way and took the specificities of aging into account. These constructs can be regarded as maladaptive schemas, as early schemas that have aged, or as new entities specific to aging itself. Arguments that would allow us to choose among these alternatives are currently lacking, due in particular to insufficient empirical knowledge about the conditions under which maladaptive schemas emerge and are sustained or evolve during the lifespan. The other three dimensions, disengagement, loss of individuality, and refusal of help, seem to be specific to the elderly. They were deduced from research on distress and subthreshold depressive states in aging. All seven thought structures showed up clearly in our multidimensional analyses. They are not confounded, nor do they form separate blocks that are distinct from the other factors. It is improbable that Int J Geriatr Psychiatry 2008; 23: 1175–1181. DOI: 10.1002/gps
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such schemas could appear suddenly. It is more likely that they are rooted in personal beliefs about aging and the situations encountered during aging, and probably evolve considerably when the individual reaches this stage of life.
correlated with the MMSE score. This means that for the degree of deterioration under consideration here, this criterion is not relevant. Moreover, the internal consistency and temporal reliability of the schema scales were good.
Relationships between distress and the anxiety and depression indexes
Limitations of the study and future perspectives
The observed correlation between anxiety and depression was higher than the correlations with the various schema measures. Thus, evaluating these cognitive schemas seems to be good way to obtain complementary information to supplement the measures classically used to diagnose depression and anxiety. This type of construct affords a broader view of distress that is not only quantitative but also qualitative. In a schema-based approach, suffering can be grasped in a more finely-tuned manner, and in several different domains, thereby supporting both a functional analysis and a psychopathological analysis of patients. Schema assessment can constitute the first step toward patient servicing, for it can help in determining the best therapy or treatment and the best way to apply it. Understanding patients’ distress requires understanding their self-appraisal, thoughts, and beliefs about their life. As we develop an understanding of patients’ experience by considering their appraisal and thoughts, we can then help them evaluate these cognitions and construct alternative thoughts that will better serve them. It can also serve as a baseline for evaluating a patient’s progress in the middle term. At a more fundamental level, these results raise the question of the nature of psychological distress in comparison to anxiety and depression, which, from the statistical standpoint, appear to be intricately linked to each other. These two disorders may be subcategories of one and the same disorder (Devanand, 2002). It can be hypothesized that distress factors may be facets of a cognitive nucleus of vulnerability shared by all elderly subjects suffering from anxiety, depression, or subthreshold depressive states. Psychometric properties From the psychometric standpoint, two critical issues were raised here: the feasibility of testing the elderly given their degree of cognitive deterioration, and the properties of the scales in comparison to standard ones currently in use. The eligibility criterion for the study was an MMSE score above 10, which allowed us to examine the optimal testing conditions. The results indicated a low difficulty rating that was only weakly Copyright # 2008 John Wiley & Sons, Ltd.
This elderly sample was quite old, on average, and was made up of a high proportion of women and widowed individuals. It follows that the factorial structure we identified might pertain primarily to this type of population. Future research should be conducted to find out whether this structure is stable in other elderly samples, and also to determine whether it is applicable to non-French-speaking individuals. It would also be worthwhile to compare the distress levels of elderly persons living in a center to those of elderly persons living at home, and to define norms for these two groups. Although this study took the degree of cognitive deterioration into account in deciding whether testing was feasible, the relevance of the participants responses was not assessed. To do so, the Cornell Scale for Depression in Dementia could be introduced as an external indicator of response validity (Alexopoulos et al., 1988). When cognitive deterioration is great, the correlation between self-evaluations of depression and clinicians’ evaluations drops sharply (Ott and Fogel, 1992), which poses the problem of the patient’s ability to grasp his/her own difficulties. A deeper understanding of the links between disorder awareness, self-awareness, and measures of subjective distress is needed. Fundamental research should be undertaken to study the time course of distress and its fluctuations with life events (such as placement in a center). Finally, determining the prevalence of the schemas identified in this study, both among young adults and across various age groups, could tell us whether these schemas are rooted in beliefs or representations of aging already present at a younger age. More generally, it seems crucial to test the merits of this type of tool in predicting declining health among these patients, especially given their high risk of falling into a major depressive state or resorting to suicide. CONCLUSION The CISD appears to be a reliable tool that uses less than 30 items to grasp seven facets of subjective distress. It is an original instrument for assessing psychological distress that is geared to old and very old Int J Geriatr Psychiatry 2008; 23: 1175–1181. DOI: 10.1002/gps
development and validation of the cisd individuals living in a home or center for the elderly. Its design takes the fatiguability and cognitive heterogeneity of this population into account. The CISD can be used to evaluate several facets of distress, as a supplement to traditional tools for diagnosing affective disorders. Without being dependent on psychiatric classifications, it contributes to psychopathological assessment and helps in the functional analysis of persons who are in need of psychological support or are suffering from a diagnosed affective disorder. It can serve as a baseline for following a patient over time and in the course of therapy. CONFLICT OF INTEREST None known. REFERENCES Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. 1988. Cornell scale for depression in dementia. Biol Psychiatry 23: 271–284. Alexopoulos GS, Borson S, Cuthbert BN, et al. 2002. Assessment of Late Life Depression. Biol Psychiatry 52: 164–174. Antoine P, Antoine C, Poinsot R. 2007. Elderly distress: cognitive schema identification. Psychol NeuroPsychiatr Vieil 5: 305–314 (in French). Baltes PB, Smith J. 1997. A systemic-wholistic view of psychological functioning in very old age: Introduction to a collection of articles from the Berlin Aging Study. Psychol Aging 12: 395–409. Barlow DH, Durand VM. 1999. Abnormal Psychology: an Integrative Approach. Brooks/Cole: Pacific Grove, CA. Berger AK, Small BJ, Forsell Y, et al. 1999. Preclinical symptoms of major depression in the very old age: A prospective longitudinal study. Am J Psychiatry 156: 1239–1241. Cattell RB. 1966. The scree test for the number of factors. Multivar Behav Res 1: 245–276. Devanand DP, Turret N, Moody BJ, et al. 2000. Personality disorders in elderly patients with dysthymic disorder. Am J Geriatr Psychiatry 8: 188–195. Devanand DP. 2002. Comorbid psychiatric disorders in late life depression. Biol Psychiatry 51: 236–242. Dohrenwend BP, Shrout PE, Egri G, Mendelsohn FS. 1980. Nonspecific psychological distress and other dimensions of psychopathology. Measures for use in the general population. Arch Gen Psychiatry 37: 1229–1236. Folstein MF, Folstein SE, McHugh PR. 1975. ‘Mini-Mental State’: a practical method for grading the state of patients for the clinician. J. Psychiatric Res 12: 189–198. Geiselmann B, Bauer M. 2000. Subthreshold depression in the elderly: qualitative or quantitative distinction? Compr Psychiatry 41: 32–38.
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