A. A. Gadit ( Hamdard University, Karachi. )
According to world health report (2001), 25% of the population, at sometime during their life are affected by mental and behavioral disorders. These disorders have great economic impact on societies and the quality of life of individuals and families. These problems are present at any point in time in about 10% of the adult population. Twenty percent of all patients seen by primary health care providers have one or more mental disorders. The common disorders causing severe disability include depressive disorders, substance use disorders, schizophrenia, epilepsy, Alzheimer’s disease, mental retardation and disorders of childhood and adolescents.1
The lCD (International Classification of Diseases) and DSM (Diagnostic and Statistical Manual) classification have categorized mental disorders on certain criteria that include the time duration, symptomatology and disturbance in social and occupational functioning. If the criteria for respective illnesses are met, then the diagnosis is made and the patient becomes eligible for treatment. There are numerous instances where the diagnostic criteria is not fulfilled fully but there is a gross disturbance in personal, social and occupational functioning along with distressing symptoms of diseases for example anxiety and depression.
World over there is a talk about these incomplete disorders which are called subthreshold disorders. These are characterized by a variety of symptoms that do not conform to a formal diagnosis of mental disorder according to standard psychiatric classification. Information about the characteristics, development and outcome of these disorders is of considerable ifnportance since they are frequent and cause distress and disability.2
Subthreshold psychiatric disorders are mild, masked, atypical, or intense but brief psychopathological syndromes below the threshold of standardized diagnosis. They indicate beginning, intermittent, or residual states of well known psychiatric disorders associated with other psychiatric and somatic disorders.3
Goldberg mentions about individuals with subthreshold disorders containing a small proportions of “true cases” which falls in the categorically disturbed population of patients while the dimensional category have the same basic disorder but in insufficient degree to warrant a diagnostic label.4
Depression is a serious but treatable disorder which is characterized by symptoms like: low mood, disturbed appetite, insomnia, loss of interest and energy, weeping tendencies and death wishes etc. with a duration of at least two weeks affecting social, personal and occupational life. There are many cases, which do not fulfill the duration and symptoms criteria but pose lot of distress in life. As mentioned in this context that frank mental disorders such as depression and panic disorders are prevalent in primary care and cause substantial suffering and interference in daily functions. Even subthreshold or subsyndromal conditions with fewer symptoms cause substantial morbidity.4
Nearly 50% of individuals in the community meet threshold and subthreshold diagnostic criteria for depression and anxiety, with depression being far more common, co-occurrence of anxiety and depression is common as the majority of individuals who experience anxiety also manifest threshold or subthreshold depression.6
In the outpatients, subthreshold depression appeared to be a variant of affective disorder and was treated as such in the mental health specialty sector but not in general medical sector.7 The findings emphasize the importance of treatment outcome studies of patients with subthreshold depression. It is described by the researchers that subthreshold depression does not carry mortality risk for men8 and less serious 12-month outcome than the threshold cases.9
Major depression is a serious diagnostic category but recent epidemiological research in general population and primary care demonstrated that a substantial proportion of disabling depressive syndromes do not meet the diagnostic criteria for major depression.10
Researchers have pointed out certain facts about other conditions for example; the presence of subthreshold anxiety disorders is influenced by age, gender and previous professional level.11 Adjustment disorder is one of the subthreshold disorders that is less well defined and shares characteristics of other diagnostic groups. Higher number of subthreshold PTSD (Post Traumatic Stress Disorder) symptoms were associated with greater impairment, comorbidity and suicidal ideation.12
Subthreshold symptoms in schizophrenia can be prodromal signs of a psychotic relapse. In people without schizophrenia, similar symptoms may indicate the presence of disorders termed as schizophrenia spectrum disorders’. Subthreshold schizophrenia-like symptoms may indicate a genetically transmitted higher proneness to schizophrenia.13
In the local context since its independence, Pakistan
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16.Gadit A. Shamanic concept and treatment of mental illness in Pakistan. J CoIl Phys Surg Pakistan 1998:8:33-5.
17.Pincus HA, Davis W. McQueen. Subthreshold mental disorders: a review and synthesis of studies on minor depression and other brand names. Br J Psychiatry 1999:174:288-96.