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Screening for depression and its risk factors in geriatric population: A rural community based study
Asian Journal of Psychiatry 4 (2011) 284–287
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Screening for depression and its risk factors in geriatric population: A rural community based study Sharmishtha S. Deshpande a,*, Mithila Gadkari a, Swati S. Raje b a b
Dept. of Psychiatry, MIMER Medical College, Talegaon Dabhade, Tal. Maval Dist., Pune 410507, Maharashtra, India Dept. of Community Medicine, MIMER Medical College, Talegaon Dabhade, Tal. Maval Dist., Pune 410507, Maharashtra, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 November 2010 Received in revised form 9 May 2011 Accepted 7 August 2011
This is a rural community-based study for screening depression and its risk factors in a geriatric population. A proportionate random sample was collected from six villages in Maval Taluka through house-to-house surveys conducted by the authors. A short (15 item) form of the geriatric depression scale was used, along with a semi-structured questionnaire specially designed for the study. On this 15-item scale, 41.1% scored 5 or higher, which suggests likely depression, and 18.9% scored higher than ten, which suggests definite depression. Depression was significantly more prevalent in those who had faced a stressful event in the past two years, in those lacking emotional support from a close confidant and in those suffering some systemic illness or sensory deprivation. The commonest stressor faced was the death of their spouse or child. This was statistically the most significant finding in those depressed (P = 0.0007). The need for treatment was perceived by these old people, but often not by their relatives. They could not seek treatment on their own due to restrictions on mobility due to old age, and being in rural areas, where psychiatric treatment facilities are not easily accessible. ß 2011 Elsevier B.V. All rights reserved.
Keywords: Geriatric depression Risk factors in old age depression
1. Introduction Old age is the last and the most difficult developmental stage in life. The daunting tasks of this stage along with the physical and cognitive decline make these senior citizens prone to sadness. As per definition of the World Health Organization, a person beyond 65 is considered to be of old age. It is the age at which a person retires from active employment and mostly becomes dependent on others in various ways. According to the 2001 census, 6.1% of Indian populations belong to this age group and it is estimated that by 2025 this number will increase to 12% (Namboodiri, 2005). Prevalence of depression in Indian studies of old age has been found to be 30–40%. Data from one of the first specialty geriatric clinics in India showed prevalence of depression as 39.9% (Agarwal, 2006; Nandi et al., 1975; Venkoba Rao and Mahadevan, 1982). Lifetime risk for depression in males is 8–12% and for females is 20–26% (Ahuja, 2006). Point prevalence of major depression in the elderly is reported as approximately 4.4% in women and 2.7% in men (Steffens et al., 2000). Geriatric depression has been identified as a major public health problem due to its serious consequences such as functional
* Corresponding author. Present address: Dept. of Psychiatry, Smt. Kashibai Navale Medical College & General Hospital, Narhe, Ambegaon, Pune 411041, Maharashtra, India. E-mail addresses: [email protected] (S.S. Deshpande), [email protected] (M. Gadkari), [email protected] (S.S. Raje). 1876-2018/$ – see front matter ß 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2011.08.001
decline, diminished quality of life, demands on caregivers and increased health service utilization apart from mortality due to associated physical illness or suicide (Spar and La Rue, 2009). Symptoms for patients at this age and in this social situation are often considered normal or expectable. Somatization of emotional symptoms is found to be more common in Indian settings (Amin et al., 1998). Physical ill health imposes severe restrictions in all walks of existence, including work, social relations and independence. Seniors also have momentary or lasting preoccupations with death and dying. Dependency on caregivers is highly distressing for some people, whereas some suffer sadness due to loss of near and dear ones. Close interpersonal relationships are known to be one of the protective factors for depression (Amin et al., 1998). With the fall of the joint family system and decline of traditional values, the social position of the aged in India has started to become comparable to that in western countries. Thus, the prevalence of geriatric depression is likely to increase in the future. Research to find risk factors, develop useful tools to identify depression at a primary care level and provision for treatment would all be necessary in the future to reduce the morbidity and mortality arising from depression. Mental health problems are rarely discussed by health professionals during routine health visits. They often cause significant disability and also interpersonal conflicts. This increases the burden of caregivers and may pose various practical problems in taking care of the elderly.
S.S. Deshpande et al. / Asian Journal of Psychiatry 4 (2011) 284–287
2. Method This was an observational cross-sectional descriptive study. The aim of this study was to screen the geriatric population for depression in a rural community in Maval Taluka of Maharashtra. Permission of the Institutional Ethical Committee was obtained prior to this study. Informed verbal consent of participants was taken before interviewing. The relatives were asked to allow reasonable privacy during the interview. The elderly subjects themselves answered all the questions. Gross cognitive impairment, if any, was screened clinically during initial conversation while developing rapport with them. The study was conducted across six villages adopted by the rural health centre of this hospital. This population included 4798 males and 4511 females. Number of seniors expected was considered 7% of this population, of which 25% were included in this study by systematic proportionate random sampling technique. Thus, the number of males and females to be interviewed from each village were calculated based on population of that village. A proportionate sample was then collected by randomization. Out of these, those who consented were included in the study. Very few declined to participate due to personal reasons and medical problems. They were no different from the study population. As this area was routinely surveyed and provided health care by the department of community medicine of this institute, overall cooperation obtained was excellent. The social worker, who frequently visited the area, introduced the interviewer to the family. House to house surveying using a semi-structured questionnaire and GDS (geriatric depression scale, short form) (Yesavage et al., 1983) was carried out by the authors. Semi-structured format for the study documented sociodemographic factors and some risk factors for depression including recent stressors, social support, and presence of physical ailments. Stressors and other information were documented verbatim. Marathi translation of GDS was then administered. GDS is a self rating scale, including 30 items about cognitive complaints and social behavior. The 15 item short form has been developed which includes all key items for dysphoria but not cognitive items, which may be confused due to memory changes with aging (Brown and Schinka, 2005). It has been translated in 24 languages and its validity is well established. This scale is not sufficient to diagnose depression but identifies individuals whose depressive symptoms exceed the norm. A score of higher than 5 is suggestive of depression and a score of higher than 10 is almost always definite depression. 3. Results Data obtained was entered into an Excel spreadsheet and analyzed using SPSS 15. Out of 180 patients screened in this study, 74 (41.1%) scored 5 or higher, which is a score suggestive of depressive disorder, while 18.9% of total scored higher than 10 which suggests definite depression. The Table 1 shows frequency of various sociodemographic variables among those depressed, defined as a cut off of scores of 5 and 10 as per GDS. The percentage of depressed people is steadily increasing with age if we consider more depressed people (GDS score > 10, P = 0.08). Equal numbers of males and females screened positive for depression as is expected in old age. The number who screened positive is significantly higher in those widowed or divorced. Marriage continues to be a protective factor at this age as also revealed from the results about the availability of a close confidant. Remaining occupied in work also seems to be associated with less depressive symptoms (P = 0.11). Undergoing considerable stress in the past two years was
285
Table 1 Various socio-demographic factors in depressed and non-depressed population considering GDS cut off of 5 and 10. Criteria
N (%)
D (5 as cut off) (% d)
D (10 as cut off) (% d)
Age group 65–69 70–74 75–79 80
112 34 17 17
(62.2) (18.8) (9.4) (9.4)
39 (34.8) 16 (47.1) 9 (52.9) 10 (58.8) x2 = 3.24 P < 0.34
16 (14.3) 6 (17.6) 5 (29.4) 7 (41.2) x2 = 6.75 P < 0.08
92 (52.1) 88 (48.9)
37 (40.2) 37 (42.0) x2 = 0.03 P < 0.86
21 (22.8) 13 (14.8) x2 = 1.54 P < 0.215
Sex Male Female
Marital status Married Widowed Unmarried Remarried
124 54 1 1
(68.5) (30) (0.6) (0.6)
42 (33.9) 30 (55.5) 1 (100) 1 (100) x2 = 6.02 P < 0.11
27 (21.7) 5 (9.25) 1 (100) 1 (100) x2 10.01 P < 0.011
Past occupation Housewife Farmer Service Self employed No work
18 117 35 9 1
(9.9) (64.9) (19.6) (5) (0.6)
6 (33.3) 49 (41.9) 17 (48.6) 1 (11.1) 0 x2 = 3.55 P < 0.46
3 (16.13) 22 (18.8) 7 (20.0) 2 (20.2) 0 x2 = 1.23 P < 0.87
Present occupation Home Farm work Other shop/job
124 (68.9) 45 (24.9) 11 (6.2)
59 (47.6) 13 (28.9) 2 (18.2) x2 = 4.3 P < 0.11
20 (16.13) 12 (26.7) 2 (18.2) x2 = 1.9 P < 0.38
Recent stressors Yes No
49 (27.2) 131 (72.8)
33 (67.4) 41 (31.3) x2 = 11.3 P < 0.0007
21 (42.9) 13 (9.9) x2 = 20.3 P < 0.000001
Other/past stressors Yes No
55 (30.4) 125 (69.6)
28 (50.9) 46 (36.8) x2 = 1.85 P < 0.17
16 (29.1) 18 (14.4) x2 4.3 P < 0.03
Close confident None Spouse Other relative Friend
Education Illiterate Up to 4th Up to 10th College Graduate and above
63 58 33 26
(35.0) (32.2) (18.3) (14.4)
35 (55.6) 17 (29.3) 14 (42.4) 8 (30.8) x2 = 6.02 P < 0.11
21 (33.33) 3 (5.17) 9 (27.7) 1 (3.85) x2 = 16.97 P < 0.0007
106 39 29 4 2
(58.9) (21.7) (16.1) (2.2) (1.1)
49 (46.2) 14 (35.9) 9 (31.0) 1 (25) 1 (50) x2 = 6.02 P < 0.11
22 (20.75) 11 (28.21) 1 (3.33) 0 0 x2 = 6.7 P < 0.15
Table 2 Various physical illnesses and depressed population considering cut off score of 5 or more. Total
N
Number depressed
Percentage
Total Any illness Systemic illness Cataract Orthopedic problems
180 116 55 31 47
74 53 29 17 21
41.11 45.69 52.73 54.84 44.68
x2 = 2.0004, P < 0.26 (difference not statistically significant).
S.S. Deshpande et al. / Asian Journal of Psychiatry 4 (2011) 284–287
286
Table 3 Responses of depressed and non-depressed study population to various questions in GDS – 15 (Yesavage et al., 1983) (cut off > 5). Serial no.
Question
Answer Affirming Depression (N = 180) (n, %total)
Number depressed as GDS > 5 (d, %n)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Are you basically satisfied with your life?a Have you dropped many of your activities and interests? Do you feel your life is empty? Do you often get bored? Are you in good spirits most of the time?a Are you afraid that something bad is going to happen to you? Do you feel happy most of the time?a Do you often feel helpless? Do you prefer to stay home, rather than going out and doing new things? Do you think you have more memory problems than most? Do you think it is wonderful to be alive?a Do you feel pretty worthless the way you are now? Do you feel full of energy?a Do you feel that your situation is hopeless? Do you feel most people are better off than you are?
43 89 74 84 65 32 61 62 75 71 51 54 68 43 48
42 62 61 65 58 26 54 50 51 40 49 46 52 30 39
a
(23.89) (49.44) (41.11) (46.67) (36.11) (17.78) (33.89) (34.44) (41.67) (39.44) (28.33) (30) (37.78) (23.89) (26.67)
(97.67) (69.67) (82.43) (77.38) (89.23) (81.25) (88.52) (80.65) (68) (56.34) (96.08) (85.19) (76.47) (69.76) (81.25)
Reverse scoring.
significantly associated with depression (P = 0.0007). Common stressors faced included death of spouse or child (38%) or any other close relative or friend (24%), physical limitations due to medical illness or accidents limiting their functional abilities (18%), physical abuse or neglect by their children and other financial or social problems (18%). In those having more severe depressive symptoms (considering a cutoff of 10/15), the difference in those who had faced such stressors was far more statistically significant (P = 0.0000001). Many patients suffer various physical ailments at this age. In this study 64.4% of patients had some chronic physical illness. The presence of any illness is more frequently associated with depressive symptoms as seen in Table 2. Those suffering from systemic illnesses such as Diabetes Mellitus or hypertension are more frequent among those with depression. Those suffering from visual or hearing impairments also often have depressive symptoms. But the difference between the numbers of elderly depressed in those both with and without physical ailments is not statistically significant (Chi square 2.0004, P = 0.26). It is possible that there are also significant undiagnosed medical problems in this population. Remoteness of area and lack of healthcare facilities could be contributory to this under-diagnosis. We tried to identify the specific symptoms of depression in this population, which can be used for case identification at primary health care centre levels. These are summarised in Table 3. All those who screened positive for depression reported feeling bored, not in good spirits, not experiencing happiness, had given up on their activities and interests and were not happy about being alive. So these questions can become a part of routine screening for depression by general physicians for elderly people. These questions mainly describe low mood and loss of interest which are cardinal symptoms of major depressive disorder. Questions about feelings of emptiness and hopelessness have high specificity. Affirmative answers to these are given only by those depressed. 4. Discussion and conclusion Late life depression has varied manifestations. Depression symptom checklists specifically designed for the geriatric population are useful in determining the degree of depression. Phenomenological presentation of this depression may not be homogeneous. Disturbances in functioning are important in diagnosing as well as the important concern of family members. Older adults are more likely to experience impairments in daily activities and mobility restrictions.
Up to 70% respond well to treatment with antidepressant drugs and interpersonal therapy, making this a rewarding exercise in detecting and treating depression. The results of a number of studies suggest a relation between social support and outcome of depressive episodes. Good outcome of late life depression has been reported to be associated with female gender, current or recent employment, less severe depressive symptomatology, absence of major life events and serious medical illnesses (Blazer et al., 2010). Community based mental health studies have revealed that point prevalence of depressive disorders in the geriatric population is approximately 27%. In India, prevalence reported is between 13 and 25% (Amin et al., 1998; Sharma et al., 1985; Agrawal and Jhingan, 2002; Barua and Kar, 2010). In this study, 41.5% screened positive for minor depression (cutoff of 5 on geriatric depression scale) and 18.9% screened positive for the possibility of significant depression (cutoff of 10). Many of these elderly people had reduced their activities and reported fewer interests. They were feeling bored and empty and preferred to stay at home (40–45% of total). However, those with significant scores for depression reported poor life satisfaction, not feeling happy or in good spirits and were not feeling good being alive (around 90% of depressed people) (Table 3). These are simple questions that may be asked by a general practitioner during a routine health visit. The questions in this questionnaire could be answered readily by less educated rural people. Minor depressive conditions are more common in the elderly than full syndrome major depression. Of these, only a small number receive treatment (Steffens et al., 2000). None of these were receiving any psychiatric treatment. They expressed the wish to overcome their sadness, but had no access to mental health services due to being in a remote area, having limited mobility due to age and also many relatives perceived their sadness as ‘‘normal’’ for their age. Those staying single or divorced, as well as those lacking a close confidant for sharing and support, were significantly higher among those with depressive features as seen in Table 1. Severely depressed elderly people who had previous suicide attempts and had poor social support are more likely to have suicidal ideation and require more attention for treatment (Alexopoulos et al., 1999). Facing various stressors in the last two years such as loss of a close relative, loss of functioning, or psychological or physical abuse, was the single statistically most significant risk factor for depressive features. Recent stressors like financial problems and widowhood along with a higher number of stressful life events on
S.S. Deshpande et al. / Asian Journal of Psychiatry 4 (2011) 284–287
the basis of various sociodemographic, psychological and clinical variables increased depression (Sharma et al., 1985; Agrawal and Jhingan, 2002). Significant stressors encountered more than two years back had relatively less impact as denoted by Table 1 (P = 0.03). The subjects scoring high on the scale had more occurrences of systemic illness (54.8%) for a cutoff of 5 (Table 2). Patients with cardiovascular morbidities are known to have a higher prevalence of anxiety-depressive disorders (Severus et al., 2001); however, this was not endorsed in this study. The need for community based treatment has been stressed by researchers for quite some time. General physicians should be trained to identify depression, identify the psychosomatic symptoms and provide primary care (Amin et al., 1998). Assessment of elderly people in a simple culture should be done in a sensitive way by the primary care physician. This can lead the way to management of depression in the elderly in India. From this study, we have tried to identify the frequencies of various symptoms of depression as detected using questions asked in this scale (Table 3). Questions with high sensitivity and specificity could have been identified if diagnostic assessment with structured interviews of these patients was completed. Structured diagnostic assessment was not possible in this study due to remoteness of area and inability of the subjects to visit a distant hospital. This study was not conducted with the aim of discovering anything new. We want to draw the attention of the health sector towards this problem of public health significance. The solution to this has to be practical and located in the vicinity. Thus, culturally sensitive appropriate measures of diagnosis and treatment need to be researched. This study is a small first step towards this goal. Psycho-education of relatives and the attitude towards the problems of the elderly need modification. Many of the subjects could not work, were often irritable and found it difficult to adjust in the family. These morbidities need to be assessed further in detail. Community based programs to improve emotional support seems to be the need of the hour to help the elderly cope with loneliness and sad mood. Special attention to mental health is needed at the time when they undergo stressors, mainly relationship losses. There is a scarcity of Indian rural community based studies on mental health. Acceptance of mental health problems and help seeking these services is proportionately negligible in India. We need to talk more openly about these distressing problems. Geriatric depression has recently been more in focus due to the increasing population of the elderly. Mental health services have been made available to those living in remote places by using the GRACE model (geriatric resources for assessment and care of elders) (Counsell et al., 2006). Similar models need to be developed for the Indian setting. Conflict of interest None.
287
Contributors Dr S. Deshpande – Planning research study, preparing protocol and method of study, assistance and guidance in data collection, preparing manuscript. Dr M. Gadkari – Writing protocol, data collection, data entry, writing literature review. Mrs. S. Raje – Assistance in determining method, data analysis and statistical interpretations, manuscript review. Ethical approval We have obtained approval of Institutional Ethical Committee of MIMER Medical College, Talegaon Dabhade, Pune, India for conducting this study. Acknowledgements We sincerely acknowledge support of Department of Community Medicine and Mrs Archana Raje, Clinical Psychologist, MIMER Medical College, Talegaon Dabhade in data collection. References Agarwal, S.P., 2006. Mental Health: An Indian perspective 1946–2003. Elsevier Publication, New Delhi, Director at General Health Services Ministry of Health and Family Welfare New Delhi, name of chapter - the graying of India, pp. 240–248. Agrawal, N., Jhingan, H.P., 2002. life events and depression in elderly. Indian J. Psychiatry 44 (1), 34–40. Ahuja, N., 2006. A Short Textbook of Psychiatry. . Alexopoulos, G.S., Bruce, M.L., Hull, J., Sirey, J.A., Kakuma, T., 1999. Clinical Determinants of suicidal ideation and behavior in geriatric depression. Arch. Gen. Psychiatry 56, 1048–1053. Amin, G., Shah, S., Vankar, G.K., 1998. The prevalence and recognition of depression in primary care. Indian J. Psychiatry 40 (4), 364–369. A. Barua, N. Kar, screening for depression in elderly Indian population, Indian J Psychiatry 2010. Blazer, D.G., Steffens, D.C., Koenig, H.G., 2010. Textbook of Geriatric Psychiatry, Indian Edition, Chapter 15, Mood Disorders. The American Psychiatric Publishing, pp. 275–299. Brown, L.M., Schinka, J.A., 2005. Development and initial validation of a 15 item informant version of the Geriatric depression scale Int. J. Geriatr. Psychiatry 20, 911–918. Counsell, S.R., Callahan, C.M., Buttar, A.B., Clark, D.O., et al., 2006. Geriatric resources for assessment and care of elders (GRACE): a new model of primary care for low income seniors. J. Am. Geriatr. Soc. 54 (7), 1136–1141. Namboodiri, V.M.D., 2005. Concise textbook of psychiatry, 2nd edition, name of chapter - psychiatry of old age chapter 24. Elsevier Publication, New Delhi, pp. 376–384. Nandi, D.N., Ajmanis, Ganguli, A., et al., 1975. Psychiatric disorders in a rural community in West Bengal: an epidemiological study. Indian J. Psychiatry 38, 307. Severus, W.E., Littman, A.B., Stoll, A.L., 2001. Omega-3 fatty acids, homocysteine, and the increased risk of cardiovascular mortality in major depressive disorder. Harv. Rev. Psychiatry 9, 280–293. Sharma, D.K., Satija, D.C., Nathawat, S.S., 1985. Psychological determinants of depression in old age. Indian J. Psychiatry 27 (1), 83–90. Spar, J.E., La Rue, A., 2009. Normal Aging, Clinical Manual of Geriatric Psychiatry, Indian Edition. American Psychiatric Publishing, Inc., Washington, DC, London, UK. Steffens, D.C., Skoog, I., Norton, M.C., Hart, A.D., Tschanz, J.T., et al., 2000. Prevalence of depression and its treatment in an elderly population. The Cache County study. Arch. Gen. Psychiatry June, 601–607. Venkoba Rao, A., Mahadevan, T., 1982. Geropsychiatric morbidity, survey in a semi urban population near Madurai. Indian J. Psychiatry 24 (3), 258–267. Yesavage, J.A., Brink, T.L., Rose, T.L., et al., 1983. Development and validation of a geriatric depression screening scale: a preliminary report. J. Psychiatr. Res. 17, 37–49.
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Screening for depression and its risk factors in geriatric population: A rural community based study Sharmishtha S. Deshpande a,*, Mithila Gadkari a, Swati S. Raje b a b
Dept. of Psychiatry, MIMER Medical College, Talegaon Dabhade, Tal. Maval Dist., Pune 410507, Maharashtra, India Dept. of Community Medicine, MIMER Medical College, Talegaon Dabhade, Tal. Maval Dist., Pune 410507, Maharashtra, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 November 2010 Received in revised form 9 May 2011 Accepted 7 August 2011
This is a rural community-based study for screening depression and its risk factors in a geriatric population. A proportionate random sample was collected from six villages in Maval Taluka through house-to-house surveys conducted by the authors. A short (15 item) form of the geriatric depression scale was used, along with a semi-structured questionnaire specially designed for the study. On this 15-item scale, 41.1% scored 5 or higher, which suggests likely depression, and 18.9% scored higher than ten, which suggests definite depression. Depression was significantly more prevalent in those who had faced a stressful event in the past two years, in those lacking emotional support from a close confidant and in those suffering some systemic illness or sensory deprivation. The commonest stressor faced was the death of their spouse or child. This was statistically the most significant finding in those depressed (P = 0.0007). The need for treatment was perceived by these old people, but often not by their relatives. They could not seek treatment on their own due to restrictions on mobility due to old age, and being in rural areas, where psychiatric treatment facilities are not easily accessible. ß 2011 Elsevier B.V. All rights reserved.
Keywords: Geriatric depression Risk factors in old age depression
1. Introduction Old age is the last and the most difficult developmental stage in life. The daunting tasks of this stage along with the physical and cognitive decline make these senior citizens prone to sadness. As per definition of the World Health Organization, a person beyond 65 is considered to be of old age. It is the age at which a person retires from active employment and mostly becomes dependent on others in various ways. According to the 2001 census, 6.1% of Indian populations belong to this age group and it is estimated that by 2025 this number will increase to 12% (Namboodiri, 2005). Prevalence of depression in Indian studies of old age has been found to be 30–40%. Data from one of the first specialty geriatric clinics in India showed prevalence of depression as 39.9% (Agarwal, 2006; Nandi et al., 1975; Venkoba Rao and Mahadevan, 1982). Lifetime risk for depression in males is 8–12% and for females is 20–26% (Ahuja, 2006). Point prevalence of major depression in the elderly is reported as approximately 4.4% in women and 2.7% in men (Steffens et al., 2000). Geriatric depression has been identified as a major public health problem due to its serious consequences such as functional
* Corresponding author. Present address: Dept. of Psychiatry, Smt. Kashibai Navale Medical College & General Hospital, Narhe, Ambegaon, Pune 411041, Maharashtra, India. E-mail addresses: [email protected] (S.S. Deshpande), [email protected] (M. Gadkari), [email protected] (S.S. Raje). 1876-2018/$ – see front matter ß 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2011.08.001
decline, diminished quality of life, demands on caregivers and increased health service utilization apart from mortality due to associated physical illness or suicide (Spar and La Rue, 2009). Symptoms for patients at this age and in this social situation are often considered normal or expectable. Somatization of emotional symptoms is found to be more common in Indian settings (Amin et al., 1998). Physical ill health imposes severe restrictions in all walks of existence, including work, social relations and independence. Seniors also have momentary or lasting preoccupations with death and dying. Dependency on caregivers is highly distressing for some people, whereas some suffer sadness due to loss of near and dear ones. Close interpersonal relationships are known to be one of the protective factors for depression (Amin et al., 1998). With the fall of the joint family system and decline of traditional values, the social position of the aged in India has started to become comparable to that in western countries. Thus, the prevalence of geriatric depression is likely to increase in the future. Research to find risk factors, develop useful tools to identify depression at a primary care level and provision for treatment would all be necessary in the future to reduce the morbidity and mortality arising from depression. Mental health problems are rarely discussed by health professionals during routine health visits. They often cause significant disability and also interpersonal conflicts. This increases the burden of caregivers and may pose various practical problems in taking care of the elderly.
S.S. Deshpande et al. / Asian Journal of Psychiatry 4 (2011) 284–287
2. Method This was an observational cross-sectional descriptive study. The aim of this study was to screen the geriatric population for depression in a rural community in Maval Taluka of Maharashtra. Permission of the Institutional Ethical Committee was obtained prior to this study. Informed verbal consent of participants was taken before interviewing. The relatives were asked to allow reasonable privacy during the interview. The elderly subjects themselves answered all the questions. Gross cognitive impairment, if any, was screened clinically during initial conversation while developing rapport with them. The study was conducted across six villages adopted by the rural health centre of this hospital. This population included 4798 males and 4511 females. Number of seniors expected was considered 7% of this population, of which 25% were included in this study by systematic proportionate random sampling technique. Thus, the number of males and females to be interviewed from each village were calculated based on population of that village. A proportionate sample was then collected by randomization. Out of these, those who consented were included in the study. Very few declined to participate due to personal reasons and medical problems. They were no different from the study population. As this area was routinely surveyed and provided health care by the department of community medicine of this institute, overall cooperation obtained was excellent. The social worker, who frequently visited the area, introduced the interviewer to the family. House to house surveying using a semi-structured questionnaire and GDS (geriatric depression scale, short form) (Yesavage et al., 1983) was carried out by the authors. Semi-structured format for the study documented sociodemographic factors and some risk factors for depression including recent stressors, social support, and presence of physical ailments. Stressors and other information were documented verbatim. Marathi translation of GDS was then administered. GDS is a self rating scale, including 30 items about cognitive complaints and social behavior. The 15 item short form has been developed which includes all key items for dysphoria but not cognitive items, which may be confused due to memory changes with aging (Brown and Schinka, 2005). It has been translated in 24 languages and its validity is well established. This scale is not sufficient to diagnose depression but identifies individuals whose depressive symptoms exceed the norm. A score of higher than 5 is suggestive of depression and a score of higher than 10 is almost always definite depression. 3. Results Data obtained was entered into an Excel spreadsheet and analyzed using SPSS 15. Out of 180 patients screened in this study, 74 (41.1%) scored 5 or higher, which is a score suggestive of depressive disorder, while 18.9% of total scored higher than 10 which suggests definite depression. The Table 1 shows frequency of various sociodemographic variables among those depressed, defined as a cut off of scores of 5 and 10 as per GDS. The percentage of depressed people is steadily increasing with age if we consider more depressed people (GDS score > 10, P = 0.08). Equal numbers of males and females screened positive for depression as is expected in old age. The number who screened positive is significantly higher in those widowed or divorced. Marriage continues to be a protective factor at this age as also revealed from the results about the availability of a close confidant. Remaining occupied in work also seems to be associated with less depressive symptoms (P = 0.11). Undergoing considerable stress in the past two years was
285
Table 1 Various socio-demographic factors in depressed and non-depressed population considering GDS cut off of 5 and 10. Criteria
N (%)
D (5 as cut off) (% d)
D (10 as cut off) (% d)
Age group 65–69 70–74 75–79 80
112 34 17 17
(62.2) (18.8) (9.4) (9.4)
39 (34.8) 16 (47.1) 9 (52.9) 10 (58.8) x2 = 3.24 P < 0.34
16 (14.3) 6 (17.6) 5 (29.4) 7 (41.2) x2 = 6.75 P < 0.08
92 (52.1) 88 (48.9)
37 (40.2) 37 (42.0) x2 = 0.03 P < 0.86
21 (22.8) 13 (14.8) x2 = 1.54 P < 0.215
Sex Male Female
Marital status Married Widowed Unmarried Remarried
124 54 1 1
(68.5) (30) (0.6) (0.6)
42 (33.9) 30 (55.5) 1 (100) 1 (100) x2 = 6.02 P < 0.11
27 (21.7) 5 (9.25) 1 (100) 1 (100) x2 10.01 P < 0.011
Past occupation Housewife Farmer Service Self employed No work
18 117 35 9 1
(9.9) (64.9) (19.6) (5) (0.6)
6 (33.3) 49 (41.9) 17 (48.6) 1 (11.1) 0 x2 = 3.55 P < 0.46
3 (16.13) 22 (18.8) 7 (20.0) 2 (20.2) 0 x2 = 1.23 P < 0.87
Present occupation Home Farm work Other shop/job
124 (68.9) 45 (24.9) 11 (6.2)
59 (47.6) 13 (28.9) 2 (18.2) x2 = 4.3 P < 0.11
20 (16.13) 12 (26.7) 2 (18.2) x2 = 1.9 P < 0.38
Recent stressors Yes No
49 (27.2) 131 (72.8)
33 (67.4) 41 (31.3) x2 = 11.3 P < 0.0007
21 (42.9) 13 (9.9) x2 = 20.3 P < 0.000001
Other/past stressors Yes No
55 (30.4) 125 (69.6)
28 (50.9) 46 (36.8) x2 = 1.85 P < 0.17
16 (29.1) 18 (14.4) x2 4.3 P < 0.03
Close confident None Spouse Other relative Friend
Education Illiterate Up to 4th Up to 10th College Graduate and above
63 58 33 26
(35.0) (32.2) (18.3) (14.4)
35 (55.6) 17 (29.3) 14 (42.4) 8 (30.8) x2 = 6.02 P < 0.11
21 (33.33) 3 (5.17) 9 (27.7) 1 (3.85) x2 = 16.97 P < 0.0007
106 39 29 4 2
(58.9) (21.7) (16.1) (2.2) (1.1)
49 (46.2) 14 (35.9) 9 (31.0) 1 (25) 1 (50) x2 = 6.02 P < 0.11
22 (20.75) 11 (28.21) 1 (3.33) 0 0 x2 = 6.7 P < 0.15
Table 2 Various physical illnesses and depressed population considering cut off score of 5 or more. Total
N
Number depressed
Percentage
Total Any illness Systemic illness Cataract Orthopedic problems
180 116 55 31 47
74 53 29 17 21
41.11 45.69 52.73 54.84 44.68
x2 = 2.0004, P < 0.26 (difference not statistically significant).
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Table 3 Responses of depressed and non-depressed study population to various questions in GDS – 15 (Yesavage et al., 1983) (cut off > 5). Serial no.
Question
Answer Affirming Depression (N = 180) (n, %total)
Number depressed as GDS > 5 (d, %n)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Are you basically satisfied with your life?a Have you dropped many of your activities and interests? Do you feel your life is empty? Do you often get bored? Are you in good spirits most of the time?a Are you afraid that something bad is going to happen to you? Do you feel happy most of the time?a Do you often feel helpless? Do you prefer to stay home, rather than going out and doing new things? Do you think you have more memory problems than most? Do you think it is wonderful to be alive?a Do you feel pretty worthless the way you are now? Do you feel full of energy?a Do you feel that your situation is hopeless? Do you feel most people are better off than you are?
43 89 74 84 65 32 61 62 75 71 51 54 68 43 48
42 62 61 65 58 26 54 50 51 40 49 46 52 30 39
a
(23.89) (49.44) (41.11) (46.67) (36.11) (17.78) (33.89) (34.44) (41.67) (39.44) (28.33) (30) (37.78) (23.89) (26.67)
(97.67) (69.67) (82.43) (77.38) (89.23) (81.25) (88.52) (80.65) (68) (56.34) (96.08) (85.19) (76.47) (69.76) (81.25)
Reverse scoring.
significantly associated with depression (P = 0.0007). Common stressors faced included death of spouse or child (38%) or any other close relative or friend (24%), physical limitations due to medical illness or accidents limiting their functional abilities (18%), physical abuse or neglect by their children and other financial or social problems (18%). In those having more severe depressive symptoms (considering a cutoff of 10/15), the difference in those who had faced such stressors was far more statistically significant (P = 0.0000001). Many patients suffer various physical ailments at this age. In this study 64.4% of patients had some chronic physical illness. The presence of any illness is more frequently associated with depressive symptoms as seen in Table 2. Those suffering from systemic illnesses such as Diabetes Mellitus or hypertension are more frequent among those with depression. Those suffering from visual or hearing impairments also often have depressive symptoms. But the difference between the numbers of elderly depressed in those both with and without physical ailments is not statistically significant (Chi square 2.0004, P = 0.26). It is possible that there are also significant undiagnosed medical problems in this population. Remoteness of area and lack of healthcare facilities could be contributory to this under-diagnosis. We tried to identify the specific symptoms of depression in this population, which can be used for case identification at primary health care centre levels. These are summarised in Table 3. All those who screened positive for depression reported feeling bored, not in good spirits, not experiencing happiness, had given up on their activities and interests and were not happy about being alive. So these questions can become a part of routine screening for depression by general physicians for elderly people. These questions mainly describe low mood and loss of interest which are cardinal symptoms of major depressive disorder. Questions about feelings of emptiness and hopelessness have high specificity. Affirmative answers to these are given only by those depressed. 4. Discussion and conclusion Late life depression has varied manifestations. Depression symptom checklists specifically designed for the geriatric population are useful in determining the degree of depression. Phenomenological presentation of this depression may not be homogeneous. Disturbances in functioning are important in diagnosing as well as the important concern of family members. Older adults are more likely to experience impairments in daily activities and mobility restrictions.
Up to 70% respond well to treatment with antidepressant drugs and interpersonal therapy, making this a rewarding exercise in detecting and treating depression. The results of a number of studies suggest a relation between social support and outcome of depressive episodes. Good outcome of late life depression has been reported to be associated with female gender, current or recent employment, less severe depressive symptomatology, absence of major life events and serious medical illnesses (Blazer et al., 2010). Community based mental health studies have revealed that point prevalence of depressive disorders in the geriatric population is approximately 27%. In India, prevalence reported is between 13 and 25% (Amin et al., 1998; Sharma et al., 1985; Agrawal and Jhingan, 2002; Barua and Kar, 2010). In this study, 41.5% screened positive for minor depression (cutoff of 5 on geriatric depression scale) and 18.9% screened positive for the possibility of significant depression (cutoff of 10). Many of these elderly people had reduced their activities and reported fewer interests. They were feeling bored and empty and preferred to stay at home (40–45% of total). However, those with significant scores for depression reported poor life satisfaction, not feeling happy or in good spirits and were not feeling good being alive (around 90% of depressed people) (Table 3). These are simple questions that may be asked by a general practitioner during a routine health visit. The questions in this questionnaire could be answered readily by less educated rural people. Minor depressive conditions are more common in the elderly than full syndrome major depression. Of these, only a small number receive treatment (Steffens et al., 2000). None of these were receiving any psychiatric treatment. They expressed the wish to overcome their sadness, but had no access to mental health services due to being in a remote area, having limited mobility due to age and also many relatives perceived their sadness as ‘‘normal’’ for their age. Those staying single or divorced, as well as those lacking a close confidant for sharing and support, were significantly higher among those with depressive features as seen in Table 1. Severely depressed elderly people who had previous suicide attempts and had poor social support are more likely to have suicidal ideation and require more attention for treatment (Alexopoulos et al., 1999). Facing various stressors in the last two years such as loss of a close relative, loss of functioning, or psychological or physical abuse, was the single statistically most significant risk factor for depressive features. Recent stressors like financial problems and widowhood along with a higher number of stressful life events on
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the basis of various sociodemographic, psychological and clinical variables increased depression (Sharma et al., 1985; Agrawal and Jhingan, 2002). Significant stressors encountered more than two years back had relatively less impact as denoted by Table 1 (P = 0.03). The subjects scoring high on the scale had more occurrences of systemic illness (54.8%) for a cutoff of 5 (Table 2). Patients with cardiovascular morbidities are known to have a higher prevalence of anxiety-depressive disorders (Severus et al., 2001); however, this was not endorsed in this study. The need for community based treatment has been stressed by researchers for quite some time. General physicians should be trained to identify depression, identify the psychosomatic symptoms and provide primary care (Amin et al., 1998). Assessment of elderly people in a simple culture should be done in a sensitive way by the primary care physician. This can lead the way to management of depression in the elderly in India. From this study, we have tried to identify the frequencies of various symptoms of depression as detected using questions asked in this scale (Table 3). Questions with high sensitivity and specificity could have been identified if diagnostic assessment with structured interviews of these patients was completed. Structured diagnostic assessment was not possible in this study due to remoteness of area and inability of the subjects to visit a distant hospital. This study was not conducted with the aim of discovering anything new. We want to draw the attention of the health sector towards this problem of public health significance. The solution to this has to be practical and located in the vicinity. Thus, culturally sensitive appropriate measures of diagnosis and treatment need to be researched. This study is a small first step towards this goal. Psycho-education of relatives and the attitude towards the problems of the elderly need modification. Many of the subjects could not work, were often irritable and found it difficult to adjust in the family. These morbidities need to be assessed further in detail. Community based programs to improve emotional support seems to be the need of the hour to help the elderly cope with loneliness and sad mood. Special attention to mental health is needed at the time when they undergo stressors, mainly relationship losses. There is a scarcity of Indian rural community based studies on mental health. Acceptance of mental health problems and help seeking these services is proportionately negligible in India. We need to talk more openly about these distressing problems. Geriatric depression has recently been more in focus due to the increasing population of the elderly. Mental health services have been made available to those living in remote places by using the GRACE model (geriatric resources for assessment and care of elders) (Counsell et al., 2006). Similar models need to be developed for the Indian setting. Conflict of interest None.
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Contributors Dr S. Deshpande – Planning research study, preparing protocol and method of study, assistance and guidance in data collection, preparing manuscript. Dr M. Gadkari – Writing protocol, data collection, data entry, writing literature review. Mrs. S. Raje – Assistance in determining method, data analysis and statistical interpretations, manuscript review. Ethical approval We have obtained approval of Institutional Ethical Committee of MIMER Medical College, Talegaon Dabhade, Pune, India for conducting this study. Acknowledgements We sincerely acknowledge support of Department of Community Medicine and Mrs Archana Raje, Clinical Psychologist, MIMER Medical College, Talegaon Dabhade in data collection. References Agarwal, S.P., 2006. Mental Health: An Indian perspective 1946–2003. Elsevier Publication, New Delhi, Director at General Health Services Ministry of Health and Family Welfare New Delhi, name of chapter - the graying of India, pp. 240–248. Agrawal, N., Jhingan, H.P., 2002. life events and depression in elderly. Indian J. Psychiatry 44 (1), 34–40. Ahuja, N., 2006. A Short Textbook of Psychiatry. . Alexopoulos, G.S., Bruce, M.L., Hull, J., Sirey, J.A., Kakuma, T., 1999. Clinical Determinants of suicidal ideation and behavior in geriatric depression. Arch. Gen. Psychiatry 56, 1048–1053. Amin, G., Shah, S., Vankar, G.K., 1998. The prevalence and recognition of depression in primary care. Indian J. Psychiatry 40 (4), 364–369. A. Barua, N. Kar, screening for depression in elderly Indian population, Indian J Psychiatry 2010. Blazer, D.G., Steffens, D.C., Koenig, H.G., 2010. Textbook of Geriatric Psychiatry, Indian Edition, Chapter 15, Mood Disorders. The American Psychiatric Publishing, pp. 275–299. Brown, L.M., Schinka, J.A., 2005. Development and initial validation of a 15 item informant version of the Geriatric depression scale Int. J. Geriatr. Psychiatry 20, 911–918. Counsell, S.R., Callahan, C.M., Buttar, A.B., Clark, D.O., et al., 2006. Geriatric resources for assessment and care of elders (GRACE): a new model of primary care for low income seniors. J. Am. Geriatr. Soc. 54 (7), 1136–1141. Namboodiri, V.M.D., 2005. Concise textbook of psychiatry, 2nd edition, name of chapter - psychiatry of old age chapter 24. Elsevier Publication, New Delhi, pp. 376–384. Nandi, D.N., Ajmanis, Ganguli, A., et al., 1975. Psychiatric disorders in a rural community in West Bengal: an epidemiological study. Indian J. Psychiatry 38, 307. Severus, W.E., Littman, A.B., Stoll, A.L., 2001. Omega-3 fatty acids, homocysteine, and the increased risk of cardiovascular mortality in major depressive disorder. Harv. Rev. Psychiatry 9, 280–293. Sharma, D.K., Satija, D.C., Nathawat, S.S., 1985. Psychological determinants of depression in old age. Indian J. Psychiatry 27 (1), 83–90. Spar, J.E., La Rue, A., 2009. Normal Aging, Clinical Manual of Geriatric Psychiatry, Indian Edition. American Psychiatric Publishing, Inc., Washington, DC, London, UK. Steffens, D.C., Skoog, I., Norton, M.C., Hart, A.D., Tschanz, J.T., et al., 2000. Prevalence of depression and its treatment in an elderly population. The Cache County study. Arch. Gen. Psychiatry June, 601–607. Venkoba Rao, A., Mahadevan, T., 1982. Geropsychiatric morbidity, survey in a semi urban population near Madurai. Indian J. Psychiatry 24 (3), 258–267. Yesavage, J.A., Brink, T.L., Rose, T.L., et al., 1983. Development and validation of a geriatric depression screening scale: a preliminary report. J. Psychiatr. Res. 17, 37–49.