J Ctta Epkmbl Vol. 43, No. 11, pp. 1131-1141, 1990 Printcd in Great Brit& All rights rcservcd
0895-4356/90 $3.00 + 0.00 Copyright Q 1990 Pcrgamon Pres8 pk
CHRONIC ILLNESS AND DEPRESSIVE SYMPTOMS IN THE ELDERLY: A POPULATION-BASED STUDY LAWRENCEA. PALINICAS,‘~* DEBORAHL. WINGARD~and ELIZABETHBARRETT-CONNOR~ Divisions of ‘Family Medicine (T-007) and *Epidemiology, Department of Community and Family Medicine and Medicine, School of Medicine, University of Califomia San Diego, La Jolla, CA 92093, U.S.A. (Received in revised form 26 April 1990)
Abstract-A cross-sectional study of the distribution of depressive symptoms and association between depressed mood and chronic illness was conducted in a geographically defined population in southem Califomia of 1617 men and women aged 65 years and older. The prevalente of depressed mood for the total population was 5.2%. Women exhibited a significantly higher mean depressive symptom score and a prevalente rate almost twice that of men. Depressive symptoms were associated with several risk factors in both sexes, including age, self-perception of current health status, number of reported chronic diseases and medications and amount of exercise. However, the relationship between physical illness and depressive symptoms appeared to differ by sex with respect to the nature of the disease or disability and the type of medication currently used. These findings indicate that the risk of depression does not diminish with age among the elderly as other studies have suggested. Depressive symptoms Sex differentiation
Geriatrics
Aged
INTRODUCTION Individuals with one or more chronic illnesses often experience a number of psychological disturbances, ranging from depressive symptoms to major psychiatrie disorders [l-51. Several clinical conditions, such as cancer [6,7J, stroke and other neurological disorders [8,9], thyroid disorders [lol, diabetes [l 1, 121 and arthritis [1] have been found to increase the risk of depressive symptoms either because of their direct hormonal or neuroendocrine effects or as a side effect of drug treatment. The fear, uncertainty, negative body image, loss of selfesteem and sense of identity, and effects on employment status and interpersonal relationships associated with chronic illness in genera1 *Author for correspondence.
Chronic disease
Health surveys
may also contribute to an increased risk of depressive symptoms [2]. Although the association between chronic illness and depressive symptoms has been welldocumented among medical inpatients [ 13-151, relatively few attempts have been made to examine this relationship in the genera1 population [ 161. An understanding of the risk of depressive symptoms associated with chronic illness in noninstitutionalized adults is important for three reasons. First, the clinical assessment of patients with psychiatrie disorders and patients with chronic medical conditions is complicated by the presence of depressive symptoms in both sets of conditions. Consequently, psychiatrie disorders such as major depression and dysthymia in patients with other medical diseases frequently go undetected and untreated [4]. Wond, depressive symptoms increase the risk
1131
LAWRENCE A. PALINKAS et al.
1132
of treatment noncompliance, making effective treatment of chronic illness in an outpatient setting problematic [ 171. Third, depressive symptoms may further weaken the immune system, making persons with chronic illness susceptible to disease complications and increased clinical severity [18, 191. Many chronic illnesses are known to increase with age, making older adults a potential risk group for depression [20,21]. However, results of the NIMH Epidemiologic Catchment Area (ECA) surveys of psychiatrie disorders indicate that current and lifetime rates of major depressive disorders in adults 65 years of age and older are significantly lower than for any other age group [22,23]. Older adults were treated as a single age group in these studies, however, and the possibility of age-related differences within this segment of the population was not examined. Moreover, while the prevalente of clinical depression appears to decrease with age, a number of studies have noted an increase in the prevalente of depressive symptoms in the elderly [24,25]. Transient depressions may occur in as many as 30% of the elderly [26]. This paper describes a cross-sectional study of the relationship between chronic illness and depressive symptoms in a noninstitutionalized community of older adults who have been followed for 15 years. Three specific components of chronic illness are examined: (1) specific clinical condition or diagnosis; (2) medications currently used; and (3) health behaviors related to the risk of chronic illness. MATERIALS AND METHODS
Between 1972 and 1974, 82% of al1 adult residents of Rancho Bernardo, Calif. participated in a survey of risk factors for heart disease as part of a Lipid Research Clinic Prevalente Study [27]. Since the time of this visit, al1 original study participants have been contacted annually. In 1984, al1 surviving participants who were 40 years of age or older at the first visit were invited to participate in a follow-up visit designed primarily to screen for diabetes and other chronic diseases. Over 79% of the men and 74% of the women attended a clinic visit between January 1984 and June 1987. Subjects were administered questionnaires during this visit which obtained information on personal medical history, current drug and vitamin usage, exercise, alcohol, smoking and depressive symptoms. Depressed mood was
assessed on the basis of responses to 18 of 21 items of the Beek Depression Inventory (BDI) [28]. Three of the original21 items (guilt, expectation of punishment, self-hate) were excluded from the questionnaire. However, because the scale does not weigh any particular item as being more important to measuring depression than any other item, the use of the 18-item scale should not have compromised the scale’s validity. This was supported by studies of similar self-reported symptom scales which suggest that as many as three-fourths of the items from highly reliable measures can be dropped without much loss in sensitivity or specificity [29]. Total scores were proportionally adjusted to correspond to scores and cut-points established for the full 21-item scale. Only subjects who answered each of these items were included in the study. Of the 1721 adults 65 years of age and older who were eligible for the study, 104 individuals were excluded from further analysis because of incomplete or missing answers. Because many of these individuals may indeed have been depressed, prevalente figures may be underestimated. Scale reliability (Cronbach’s tl) for the Rancho Bernardo elderly population was 0.72. Although higher reliability coefficients have been reported for this scale, it compares favorably with coefficients based on samples of elderly community volunteers (a = 0.76) and depressed outpatients (tl = 0.73) [30]. A cutpoint of 13 was used to define cases of mild or severe depression among study subjects based on its use as a reliable indicator of mild to severe depressive symptoms in populations at risk for chronic disease and disability [31, 321. Nielsen and Williams [32] found a score between 12 and 13 to have 0.79 sensitivity and 0.77 specificity in an outpatient medical population. As defined by Beek and Beek [33], scores of 21-30 indicate moderate depression, and 31 and over indicate severe depression. The relationship between depressive symptoms and health status of subjects was evaluated in terms of physical health and certain healthrelated behaviors. Physical health status was assessed by means of self-reported health status compared with health status of others their own age. Subjects were also asked to report history of chronic conditions and number of current medications. These indicators were then regrouped into four categories ranging from no conditions or medications to three or more. Health behaviors selected for examination
Chronic Illness and Depressive Symptoms in the
Elderly
1133
Table 1. Mean BDI score and prevalente of BDI score 2 13 by age and sex; Rancho Bemardo, Calif., 1984-1987 Mean BDI score n Total Men 65-74 yrs 75+ yrs Women 65-74 yrs 75+ yrs
1617
Crude mean (SD) 6.20
BDI score,
Age-adjusted mean
Crude %
(4.30)
13
Age-adjusted %
5.2
285 457
4.93 (3.65) 6.10** (4.20)
5.61
2.0 4.2
3.2
435 510
6.22 (4.32) 7.065 (4.55)
6.70*+*
6.1 7.4
6.8***
?? p < 0.01; ?? *JJ < O.OOl-comparing younger to older age groups; ***p < O.OOl-comparing men to women.
included frequency of alcohol consumption, smoking history and amount of physical exercise. Risk factor distribution, mean depressive symptom scores and prevalente rates were determined separately for men and women and for those 65-74 and 75 years or older. Mean depressive symptom scores were adjusted for age and compared using an analysis of covariance procedure. Prevalente rates were age-adjusted using the direct method [34], with the total sample comprising the standard population. Rates were also multiplied by the sensitivity coefficient (0.79) reported by Nielsen and Williams [32] to provide a more accurate assessment of depressive symptom prevalente. The Mantel-Haenszel age-adjusted chi-square test [35] was used to compare the age-adjusted prevalente rates and rate ratios. However, no adjustment was made for the possibility of a Type 1 error due to multiple comparisons.
RESULTS
The mean age of the population selected for analysis was 75.2 years (SD = 5.9 years). Mean scores and prevalente rates of scores 13 or above (per 100 persons) for study subjects are provided in Table 1 by age and sex. The prevalente of mild or more severe depressive symptoms for the total population was 5.2%. Only one person could be categorized as having severe depressive symptoms, based on a score 2 31, and an additional 10 persons could be classified as being moderately depressed with a score between 21-30; the remainder fel1 within the mildly depressed range (13-20). Women had significantly higher scores and rates of depressive symptoms than men in both age groups. Age was significantly related to depressive symptoms as defined by the mean score but not by categorical criteria in both men and women.
Table 2. Age-adjusted BDI score and prevalente of BDI score B 13 in men age 65 years and older by health status; Rancho Bemardo, Calif., 1984-1987 Women
Men
Health statuP Retterb game Worse
n
Mean
571 151 20
5.06 i:“***
No. of chronic medical conditions Noneb 69 4.42 : 159 135 4.56 5.83 3 or more No. of medications Noneb 1 32 or more
% > 13
n
Mean
681 148 44
6.01 E***
1.3 3.2 1.2
37 123 185
5.17 5.99 5.35
0.0 3.2
1.6 9 2*** 11:9**
% 2 13 4.9 9.1* 28.7***
289
6.36++*
5.0
466
7.32***
9:;
231 163
5.04 5.49
2.7 2.4
247 231
5.91 6.47
3.6 6.6
154 194
6.29 6.00*
3.4 5.1
185 206
6.54 7.89**+
‘p < 0.05; “p < 0.01; ?? **p < 0.001. Tompared to ethers of the same age.
bReference category for rate comparisons.
*:::**
1134
LAWRENCE A. PAL~NICAS et al.
The relationship between depressive symptom prevalente and health status of study subjects is described in Table 2. The mean depressive symptom score was significantly related to selfperceptions of current health status, increasing number of reported chronic diseases and increasing number of reported medications for both men and women. The prevalente of depressive symptom scores of 13 or greater was significantly related to poor health status compared to others for women. Depressive symptorn prevalente among women who reported taking three or more medications was approx. 3 times greater than the rate in women who reported taking no medications.
To further examine the relationship between history of chronic conditions and use of medications and depressive symptoms, type of chronic conditions and medication taken were compared by mean BDI depressive symptom scores and prevalente rates. As shown in Table 3a, men with histories of diabetes, emphysema or chronic bronchitis, gallstones or gallstone surgery, diverticulitis, chronic constipation and stroke reported more depressive symptoms than men without these conditions. The prevalente of depressive symptom scores of 13 or greater was also significantly related to a history of diabetes, stroke and gallbladder surgery among men. As shown in Table 3b, women with histories of
Table 3a. Age-adjusted BDI score and prevalente of BDI score 2 13 in men age 65 years and older by medical/surgical history; Rancho Bemardo, Calif., 1984-1987 Mean BDI score Self-reported medical condition (% of sample with condition)
Without medical condition
Hypertension (38.8%) Cancer (34.2%) Arthritis (3 1.2%) Ulcers (18.5%) Kidney disease (16.4%) Diabetes (14.8%) Chronic constipation (14.7%) Diverticulitis (13.8%) Gallstones (11.5%) Gallbladder surgery (10.8%) Stroke/TIA (9.4%) Liver disease (7.7%) Thyroid/goiter (7.6%) Heat? surgery (7.1%) Emphysema/chronic bronchitis (7.0%) Hip fracture (1.1%)
5.58 5.48 5.43 5.54 5.61 5.51 5.38 5.42 5.45 5.43 5.48 5.67 5.65 5.66 5.56 5.63
*p < 0.05; “p < 0.01; ***p < O.OOl-eompared
With medical condition
Prevalente (%) of BDI score 3 13 Without medical condition
5.79 5.96 6.16, 6.18 5.80 6.48* 7.24*+* 7.02*** 7.195’5 7.47*** 7.3855W 5.52 5.48 5.46 7.012 7.38
2.8 3.3 3.2 3.5 3.2 2.7 2.8 2.8 2.9 2.8 2.8 3.5 3.5 3.2 3.0 3.2
With medical wndition 4.1 2.8 3.7 2.9 4.0 6.3* 5.9 5.2 6.1 7.2* 7.0’ 1.7 2.1 4.3 7.3 8.8
to those without the medical condition.
Table 3b. Age-adjusted BDI score and prevalente of BDI score > 13 in women age 65 years and older by medical/surgical history; Rancho Bernardo, Calif., 1984-1987 Mean BDI score Self-reported medical condition (% of sample with condition)
Without medical condition
With medical condition
Prevalente (%) of BDI score 2 13 Without medical condition
With medical condition
Arthritis (44.3%) Hypertension (41.9%) Thyroid/goiter (29.7%)
5.99 6.27 6.43
7.48+++ 7.25*+ 7.17’
4.7 5.5 6.2
Cancer (27.5%) Chronic constipation (24.1%) Diverticulitis (18.2%) Gallstones (18.1%) Gallbladder surgery (17.0%) Ulcers (13.8%) Emphysema/chronic bronchitis (10.4%) Liver disease (8.5%) Diabetes (8.1%) Kidney diseases (6.3%) Stroke/TIA (5.6%) Heart surgery (2.2%) Hip fracture (2.6%)
6.42 6.35 6.49 6.54 6.59 6.51
7.33” 7.65+*+ 7.42+ 6.85 6.99 7.485
5.8 5.6 6.3 6.9 6.9 6.6
1;.;** 918 7.2 7.0 7.5
6.48 6.65 6.63 6.64 6.51 6.64 6.69
8.18++* 6.87 7.10 7.14 9.22*** 7.14 7.63
5.7 6.4 6.8 6.6 6.3 6.8 7.0
15.9*** 9.2 7.1 8.8 13.9’ 2.9 -
‘p < 0.05; “p < 0.01; ***p < O.OOl-compared
to these without the medical condition.
9.4** 8.7 8.5
Chronic Ilhmss and Depressive Symptoms in the Elderly Table 4a. Age-adjwted
1135
BDI score and prevalente of BDI score 2 13 in men age 65 years and older by medication usage; Rancho Bernardo, Calif., 1984-1987 Mean BDI score
Medication (% of sample taking medication)
Not taking medication
Antihypertensives (31.0%) Aspirin (27.8%) Diuretics (22.0%) Laxatives (14.0%) Anti-arrhythmics (12.4%) Anticoagulants (10.1%) Digitalis (9.7%) Angina medication (8.6%) High uric acid or gout medication (6.3%) Cortisone medication (4.8%) Androgen (4.3%) Thyroid medication (4.3%) Diabetes pil1 (2.6%) Insulin (1.3%) Cholesterol medication (1.2%)
5.60 5.42 5.54 5.54 5.62 5.56 5.63 5.52 5.67 5.64 5.65 5.65 5.64 5.58 5.63
‘p < 0.5; ?? *p < 0.01; ***p < 0.001-compared
Takillg medication 5.75 6.24* 6.03 6.35 5.87 6.44 5.82 7.00” 5.37 5.86 5.64 5.63 6.05 10.69*** 7.35
Prevalente (%) of BDI score > 13 Not taking medication
Taking medication
2.9 2.8 2.8
4.1 4.4 4.3 6.2 4.5 6.2 4.7 5.0 -
3:2 2.9 3’.: 3:6 3.2 3.3 i.3 3:o 3.2
3.9 2.3 4.3 3.5 23.8+** 6.1
to those not taling medication.
Table 4b. Age-adjusted BDI score and prevalente of BDI score > 13 in women aged 65 yean and older by medication use; Rancho Bernardo, Calif., 198&1987 Mean BDI score Medication (% of sample taking medication) Estrogen (35.6%) Antihypertensives (35.1%) Diuretics (27.3%) Aspirin (21.3%) Laxatives (18.9%) Thyroid medication (17.8%) Anti-arrhythmics (6.9%) Digitalis (6.7%) Angina medication (6.3%) Anticoagulants (4.3%) Androgen (4.2%) High uric acid or gout medication (3.1%) Cortisone medication (2.9%) Diabetes pil1 (1.3%) Cholesterol medication (1 .O%) Insulin (0.1%)
Not taking medication 7.02 6.45 6.48 6.61 6.57 6.64 6.57 6.54 6.48 6.62 6.59 6.55 6.57 6.64 6.67 6.67
*p < 0.5; **p < 0.01; ***p < O.OOl-compared
Taking medication 6.27 7.04 7.15. 6.86 7.06 6.76 7.84. 8.26” 9.32+** 7.45 8.33” 10.13*** 9.17” 8.04 5.72 0.00
Prevalente (%) of BDI score 2 13 Not taking medication 2: 6:2 6.3 6.0 2:: z.3 6:8 6.6 6.3 6.3 6.6
Taking medication 5.3 7.8 8.4 8.5 9.7 7.2 12.2 10.5 17.1* 5.0 10.5 20.8** 22.0” 11.8 -
to those not taking medication.
hypertension, emphysema or chronic bronchitis, arthritis, thyroid or goiter disorders, ulcers, diverticulitis, chronic constipation, cancer and stroke reported more depressive symptoms than women without these conditions. A history of emphysema or chronic bronchitis, arthritis, chronic constipation and stroke was also significantly related to the rate of depressive symptom scores of 13 or greater among women. Tables 4a and 4b provide a comparison of mean BDI scores and prevalente rates for men and women by type of medication used. Men taking insulin reported significantly higher mean symptom scores and exhibited a higher
rate of depression symptom scores of 13 or greater than men not taking insulin. Significantly higher symptom scores were also observed among men who reported taking angina medication and aspirin. Women taking angina medication, mic acid or gout medication and cortisone-related medication reported significantly higher symptom scores and exhibited higher rates of mild or more severe forms af depressive symptoms than women not taking these medications. Use of diuretics, digitalis and anti-arrhythmics was significantly related to mean symptom scores but not to prevalente among women.
LAWRENCE A. PALINKASet al.
1136
Table 5. Age-adjusted BDI score and prevalente of BDI score > 13 in men and women 65 years and older bv selected health behaviors; Rancho Bernardo, Calif., 1984-1987 Men
Women
Mean
% B 13
n
Mean
% > 13
Frequency of alcohol consumption Neve? 65
0895-4356/90 $3.00 + 0.00 Copyright Q 1990 Pcrgamon Pres8 pk
CHRONIC ILLNESS AND DEPRESSIVE SYMPTOMS IN THE ELDERLY: A POPULATION-BASED STUDY LAWRENCEA. PALINICAS,‘~* DEBORAHL. WINGARD~and ELIZABETHBARRETT-CONNOR~ Divisions of ‘Family Medicine (T-007) and *Epidemiology, Department of Community and Family Medicine and Medicine, School of Medicine, University of Califomia San Diego, La Jolla, CA 92093, U.S.A. (Received in revised form 26 April 1990)
Abstract-A cross-sectional study of the distribution of depressive symptoms and association between depressed mood and chronic illness was conducted in a geographically defined population in southem Califomia of 1617 men and women aged 65 years and older. The prevalente of depressed mood for the total population was 5.2%. Women exhibited a significantly higher mean depressive symptom score and a prevalente rate almost twice that of men. Depressive symptoms were associated with several risk factors in both sexes, including age, self-perception of current health status, number of reported chronic diseases and medications and amount of exercise. However, the relationship between physical illness and depressive symptoms appeared to differ by sex with respect to the nature of the disease or disability and the type of medication currently used. These findings indicate that the risk of depression does not diminish with age among the elderly as other studies have suggested. Depressive symptoms Sex differentiation
Geriatrics
Aged
INTRODUCTION Individuals with one or more chronic illnesses often experience a number of psychological disturbances, ranging from depressive symptoms to major psychiatrie disorders [l-51. Several clinical conditions, such as cancer [6,7J, stroke and other neurological disorders [8,9], thyroid disorders [lol, diabetes [l 1, 121 and arthritis [1] have been found to increase the risk of depressive symptoms either because of their direct hormonal or neuroendocrine effects or as a side effect of drug treatment. The fear, uncertainty, negative body image, loss of selfesteem and sense of identity, and effects on employment status and interpersonal relationships associated with chronic illness in genera1 *Author for correspondence.
Chronic disease
Health surveys
may also contribute to an increased risk of depressive symptoms [2]. Although the association between chronic illness and depressive symptoms has been welldocumented among medical inpatients [ 13-151, relatively few attempts have been made to examine this relationship in the genera1 population [ 161. An understanding of the risk of depressive symptoms associated with chronic illness in noninstitutionalized adults is important for three reasons. First, the clinical assessment of patients with psychiatrie disorders and patients with chronic medical conditions is complicated by the presence of depressive symptoms in both sets of conditions. Consequently, psychiatrie disorders such as major depression and dysthymia in patients with other medical diseases frequently go undetected and untreated [4]. Wond, depressive symptoms increase the risk
1131
LAWRENCE A. PALINKAS et al.
1132
of treatment noncompliance, making effective treatment of chronic illness in an outpatient setting problematic [ 171. Third, depressive symptoms may further weaken the immune system, making persons with chronic illness susceptible to disease complications and increased clinical severity [18, 191. Many chronic illnesses are known to increase with age, making older adults a potential risk group for depression [20,21]. However, results of the NIMH Epidemiologic Catchment Area (ECA) surveys of psychiatrie disorders indicate that current and lifetime rates of major depressive disorders in adults 65 years of age and older are significantly lower than for any other age group [22,23]. Older adults were treated as a single age group in these studies, however, and the possibility of age-related differences within this segment of the population was not examined. Moreover, while the prevalente of clinical depression appears to decrease with age, a number of studies have noted an increase in the prevalente of depressive symptoms in the elderly [24,25]. Transient depressions may occur in as many as 30% of the elderly [26]. This paper describes a cross-sectional study of the relationship between chronic illness and depressive symptoms in a noninstitutionalized community of older adults who have been followed for 15 years. Three specific components of chronic illness are examined: (1) specific clinical condition or diagnosis; (2) medications currently used; and (3) health behaviors related to the risk of chronic illness. MATERIALS AND METHODS
Between 1972 and 1974, 82% of al1 adult residents of Rancho Bernardo, Calif. participated in a survey of risk factors for heart disease as part of a Lipid Research Clinic Prevalente Study [27]. Since the time of this visit, al1 original study participants have been contacted annually. In 1984, al1 surviving participants who were 40 years of age or older at the first visit were invited to participate in a follow-up visit designed primarily to screen for diabetes and other chronic diseases. Over 79% of the men and 74% of the women attended a clinic visit between January 1984 and June 1987. Subjects were administered questionnaires during this visit which obtained information on personal medical history, current drug and vitamin usage, exercise, alcohol, smoking and depressive symptoms. Depressed mood was
assessed on the basis of responses to 18 of 21 items of the Beek Depression Inventory (BDI) [28]. Three of the original21 items (guilt, expectation of punishment, self-hate) were excluded from the questionnaire. However, because the scale does not weigh any particular item as being more important to measuring depression than any other item, the use of the 18-item scale should not have compromised the scale’s validity. This was supported by studies of similar self-reported symptom scales which suggest that as many as three-fourths of the items from highly reliable measures can be dropped without much loss in sensitivity or specificity [29]. Total scores were proportionally adjusted to correspond to scores and cut-points established for the full 21-item scale. Only subjects who answered each of these items were included in the study. Of the 1721 adults 65 years of age and older who were eligible for the study, 104 individuals were excluded from further analysis because of incomplete or missing answers. Because many of these individuals may indeed have been depressed, prevalente figures may be underestimated. Scale reliability (Cronbach’s tl) for the Rancho Bernardo elderly population was 0.72. Although higher reliability coefficients have been reported for this scale, it compares favorably with coefficients based on samples of elderly community volunteers (a = 0.76) and depressed outpatients (tl = 0.73) [30]. A cutpoint of 13 was used to define cases of mild or severe depression among study subjects based on its use as a reliable indicator of mild to severe depressive symptoms in populations at risk for chronic disease and disability [31, 321. Nielsen and Williams [32] found a score between 12 and 13 to have 0.79 sensitivity and 0.77 specificity in an outpatient medical population. As defined by Beek and Beek [33], scores of 21-30 indicate moderate depression, and 31 and over indicate severe depression. The relationship between depressive symptoms and health status of subjects was evaluated in terms of physical health and certain healthrelated behaviors. Physical health status was assessed by means of self-reported health status compared with health status of others their own age. Subjects were also asked to report history of chronic conditions and number of current medications. These indicators were then regrouped into four categories ranging from no conditions or medications to three or more. Health behaviors selected for examination
Chronic Illness and Depressive Symptoms in the
Elderly
1133
Table 1. Mean BDI score and prevalente of BDI score 2 13 by age and sex; Rancho Bemardo, Calif., 1984-1987 Mean BDI score n Total Men 65-74 yrs 75+ yrs Women 65-74 yrs 75+ yrs
1617
Crude mean (SD) 6.20
BDI score,
Age-adjusted mean
Crude %
(4.30)
13
Age-adjusted %
5.2
285 457
4.93 (3.65) 6.10** (4.20)
5.61
2.0 4.2
3.2
435 510
6.22 (4.32) 7.065 (4.55)
6.70*+*
6.1 7.4
6.8***
?? p < 0.01; ?? *JJ < O.OOl-comparing younger to older age groups; ***p < O.OOl-comparing men to women.
included frequency of alcohol consumption, smoking history and amount of physical exercise. Risk factor distribution, mean depressive symptom scores and prevalente rates were determined separately for men and women and for those 65-74 and 75 years or older. Mean depressive symptom scores were adjusted for age and compared using an analysis of covariance procedure. Prevalente rates were age-adjusted using the direct method [34], with the total sample comprising the standard population. Rates were also multiplied by the sensitivity coefficient (0.79) reported by Nielsen and Williams [32] to provide a more accurate assessment of depressive symptom prevalente. The Mantel-Haenszel age-adjusted chi-square test [35] was used to compare the age-adjusted prevalente rates and rate ratios. However, no adjustment was made for the possibility of a Type 1 error due to multiple comparisons.
RESULTS
The mean age of the population selected for analysis was 75.2 years (SD = 5.9 years). Mean scores and prevalente rates of scores 13 or above (per 100 persons) for study subjects are provided in Table 1 by age and sex. The prevalente of mild or more severe depressive symptoms for the total population was 5.2%. Only one person could be categorized as having severe depressive symptoms, based on a score 2 31, and an additional 10 persons could be classified as being moderately depressed with a score between 21-30; the remainder fel1 within the mildly depressed range (13-20). Women had significantly higher scores and rates of depressive symptoms than men in both age groups. Age was significantly related to depressive symptoms as defined by the mean score but not by categorical criteria in both men and women.
Table 2. Age-adjusted BDI score and prevalente of BDI score B 13 in men age 65 years and older by health status; Rancho Bemardo, Calif., 1984-1987 Women
Men
Health statuP Retterb game Worse
n
Mean
571 151 20
5.06 i:“***
No. of chronic medical conditions Noneb 69 4.42 : 159 135 4.56 5.83 3 or more No. of medications Noneb 1 32 or more
% > 13
n
Mean
681 148 44
6.01 E***
1.3 3.2 1.2
37 123 185
5.17 5.99 5.35
0.0 3.2
1.6 9 2*** 11:9**
% 2 13 4.9 9.1* 28.7***
289
6.36++*
5.0
466
7.32***
9:;
231 163
5.04 5.49
2.7 2.4
247 231
5.91 6.47
3.6 6.6
154 194
6.29 6.00*
3.4 5.1
185 206
6.54 7.89**+
‘p < 0.05; “p < 0.01; ?? **p < 0.001. Tompared to ethers of the same age.
bReference category for rate comparisons.
*:::**
1134
LAWRENCE A. PAL~NICAS et al.
The relationship between depressive symptom prevalente and health status of study subjects is described in Table 2. The mean depressive symptom score was significantly related to selfperceptions of current health status, increasing number of reported chronic diseases and increasing number of reported medications for both men and women. The prevalente of depressive symptom scores of 13 or greater was significantly related to poor health status compared to others for women. Depressive symptorn prevalente among women who reported taking three or more medications was approx. 3 times greater than the rate in women who reported taking no medications.
To further examine the relationship between history of chronic conditions and use of medications and depressive symptoms, type of chronic conditions and medication taken were compared by mean BDI depressive symptom scores and prevalente rates. As shown in Table 3a, men with histories of diabetes, emphysema or chronic bronchitis, gallstones or gallstone surgery, diverticulitis, chronic constipation and stroke reported more depressive symptoms than men without these conditions. The prevalente of depressive symptom scores of 13 or greater was also significantly related to a history of diabetes, stroke and gallbladder surgery among men. As shown in Table 3b, women with histories of
Table 3a. Age-adjusted BDI score and prevalente of BDI score 2 13 in men age 65 years and older by medical/surgical history; Rancho Bemardo, Calif., 1984-1987 Mean BDI score Self-reported medical condition (% of sample with condition)
Without medical condition
Hypertension (38.8%) Cancer (34.2%) Arthritis (3 1.2%) Ulcers (18.5%) Kidney disease (16.4%) Diabetes (14.8%) Chronic constipation (14.7%) Diverticulitis (13.8%) Gallstones (11.5%) Gallbladder surgery (10.8%) Stroke/TIA (9.4%) Liver disease (7.7%) Thyroid/goiter (7.6%) Heat? surgery (7.1%) Emphysema/chronic bronchitis (7.0%) Hip fracture (1.1%)
5.58 5.48 5.43 5.54 5.61 5.51 5.38 5.42 5.45 5.43 5.48 5.67 5.65 5.66 5.56 5.63
*p < 0.05; “p < 0.01; ***p < O.OOl-eompared
With medical condition
Prevalente (%) of BDI score 3 13 Without medical condition
5.79 5.96 6.16, 6.18 5.80 6.48* 7.24*+* 7.02*** 7.195’5 7.47*** 7.3855W 5.52 5.48 5.46 7.012 7.38
2.8 3.3 3.2 3.5 3.2 2.7 2.8 2.8 2.9 2.8 2.8 3.5 3.5 3.2 3.0 3.2
With medical wndition 4.1 2.8 3.7 2.9 4.0 6.3* 5.9 5.2 6.1 7.2* 7.0’ 1.7 2.1 4.3 7.3 8.8
to those without the medical condition.
Table 3b. Age-adjusted BDI score and prevalente of BDI score > 13 in women age 65 years and older by medical/surgical history; Rancho Bernardo, Calif., 1984-1987 Mean BDI score Self-reported medical condition (% of sample with condition)
Without medical condition
With medical condition
Prevalente (%) of BDI score 2 13 Without medical condition
With medical condition
Arthritis (44.3%) Hypertension (41.9%) Thyroid/goiter (29.7%)
5.99 6.27 6.43
7.48+++ 7.25*+ 7.17’
4.7 5.5 6.2
Cancer (27.5%) Chronic constipation (24.1%) Diverticulitis (18.2%) Gallstones (18.1%) Gallbladder surgery (17.0%) Ulcers (13.8%) Emphysema/chronic bronchitis (10.4%) Liver disease (8.5%) Diabetes (8.1%) Kidney diseases (6.3%) Stroke/TIA (5.6%) Heart surgery (2.2%) Hip fracture (2.6%)
6.42 6.35 6.49 6.54 6.59 6.51
7.33” 7.65+*+ 7.42+ 6.85 6.99 7.485
5.8 5.6 6.3 6.9 6.9 6.6
1;.;** 918 7.2 7.0 7.5
6.48 6.65 6.63 6.64 6.51 6.64 6.69
8.18++* 6.87 7.10 7.14 9.22*** 7.14 7.63
5.7 6.4 6.8 6.6 6.3 6.8 7.0
15.9*** 9.2 7.1 8.8 13.9’ 2.9 -
‘p < 0.05; “p < 0.01; ***p < O.OOl-compared
to these without the medical condition.
9.4** 8.7 8.5
Chronic Ilhmss and Depressive Symptoms in the Elderly Table 4a. Age-adjwted
1135
BDI score and prevalente of BDI score 2 13 in men age 65 years and older by medication usage; Rancho Bernardo, Calif., 1984-1987 Mean BDI score
Medication (% of sample taking medication)
Not taking medication
Antihypertensives (31.0%) Aspirin (27.8%) Diuretics (22.0%) Laxatives (14.0%) Anti-arrhythmics (12.4%) Anticoagulants (10.1%) Digitalis (9.7%) Angina medication (8.6%) High uric acid or gout medication (6.3%) Cortisone medication (4.8%) Androgen (4.3%) Thyroid medication (4.3%) Diabetes pil1 (2.6%) Insulin (1.3%) Cholesterol medication (1.2%)
5.60 5.42 5.54 5.54 5.62 5.56 5.63 5.52 5.67 5.64 5.65 5.65 5.64 5.58 5.63
‘p < 0.5; ?? *p < 0.01; ***p < 0.001-compared
Takillg medication 5.75 6.24* 6.03 6.35 5.87 6.44 5.82 7.00” 5.37 5.86 5.64 5.63 6.05 10.69*** 7.35
Prevalente (%) of BDI score > 13 Not taking medication
Taking medication
2.9 2.8 2.8
4.1 4.4 4.3 6.2 4.5 6.2 4.7 5.0 -
3:2 2.9 3’.: 3:6 3.2 3.3 i.3 3:o 3.2
3.9 2.3 4.3 3.5 23.8+** 6.1
to those not taling medication.
Table 4b. Age-adjusted BDI score and prevalente of BDI score > 13 in women aged 65 yean and older by medication use; Rancho Bernardo, Calif., 198&1987 Mean BDI score Medication (% of sample taking medication) Estrogen (35.6%) Antihypertensives (35.1%) Diuretics (27.3%) Aspirin (21.3%) Laxatives (18.9%) Thyroid medication (17.8%) Anti-arrhythmics (6.9%) Digitalis (6.7%) Angina medication (6.3%) Anticoagulants (4.3%) Androgen (4.2%) High uric acid or gout medication (3.1%) Cortisone medication (2.9%) Diabetes pil1 (1.3%) Cholesterol medication (1 .O%) Insulin (0.1%)
Not taking medication 7.02 6.45 6.48 6.61 6.57 6.64 6.57 6.54 6.48 6.62 6.59 6.55 6.57 6.64 6.67 6.67
*p < 0.5; **p < 0.01; ***p < O.OOl-compared
Taking medication 6.27 7.04 7.15. 6.86 7.06 6.76 7.84. 8.26” 9.32+** 7.45 8.33” 10.13*** 9.17” 8.04 5.72 0.00
Prevalente (%) of BDI score 2 13 Not taking medication 2: 6:2 6.3 6.0 2:: z.3 6:8 6.6 6.3 6.3 6.6
Taking medication 5.3 7.8 8.4 8.5 9.7 7.2 12.2 10.5 17.1* 5.0 10.5 20.8** 22.0” 11.8 -
to those not taking medication.
hypertension, emphysema or chronic bronchitis, arthritis, thyroid or goiter disorders, ulcers, diverticulitis, chronic constipation, cancer and stroke reported more depressive symptoms than women without these conditions. A history of emphysema or chronic bronchitis, arthritis, chronic constipation and stroke was also significantly related to the rate of depressive symptom scores of 13 or greater among women. Tables 4a and 4b provide a comparison of mean BDI scores and prevalente rates for men and women by type of medication used. Men taking insulin reported significantly higher mean symptom scores and exhibited a higher
rate of depression symptom scores of 13 or greater than men not taking insulin. Significantly higher symptom scores were also observed among men who reported taking angina medication and aspirin. Women taking angina medication, mic acid or gout medication and cortisone-related medication reported significantly higher symptom scores and exhibited higher rates of mild or more severe forms af depressive symptoms than women not taking these medications. Use of diuretics, digitalis and anti-arrhythmics was significantly related to mean symptom scores but not to prevalente among women.
LAWRENCE A. PALINKASet al.
1136
Table 5. Age-adjusted BDI score and prevalente of BDI score > 13 in men and women 65 years and older bv selected health behaviors; Rancho Bernardo, Calif., 1984-1987 Men
Women
Mean
% B 13
n
Mean
% > 13
Frequency of alcohol consumption Neve? 65
