Depressive symptoms and depression among elderly people in Athens Madianos MG, Gournas G, Stefanis CN. Depressive symptoms and depression among elderly people in Athens. Acta Psychiatr Scand 1992: 86: 320-326. A total of 251 elderly rcsidents of 2 boroughs of greater Athens were examined by a psychiatrist. For the assessment of depressive symptoms, the Center for Epidemiological Studies Depression (CES-D) Scale was used. Cognitive functioning was also evaluated. The prevalence of affective disorders of any type was estimated by a clinical examination with a semistructured psychiatric interview (PEF) supplemented by DSM-111 criteria. A total of 27.1 % of the elderly respondents reported a significant number of dysphoric or depressive symptoms and were identified as depressed cases. Respondents who had lower socioeconomic status, were widowed, were experiencing stressful life events or were living alone exhibited a significant degree of depressive psychopathology. An association between depressed mood and cognitive impairment was also found. A total of 9.5% of the sample was diagnosed as suffering from any type of affective disorder (1.6% major depression, 0.6% bipolar, 5.5”/, dysthymic disorder and 2.0% adjustment disorder with depressed mood). Affective disorders constitute nearly half of the total number of psychiatric diagnoses (20.3 % at the sample). It is interesting that, of the 27.1 % of the sample with depressed mood ( 2 16 score on CES-D Scale), only 9.5% of the sample were diagnosed as suffering from clinical types of depression.
It has long been recognized that affective disorders of any type among the elderly population living in the community constitute a major psychopathological issue and prevalence studies on this aspect have therefore drawn considerable attention (1- 12). From the clinical point of view, depressive illness in the elderly tends to last longer and is often complicated with cognitive impairment (13, 14). Another important clinical aspect is that a significant proportion of depressed elderly people are undergoing a recurrent episode of depression (6, 14). Epidemiologic research has focused mainly on the detection of cases of elderly individuals living in the community by self-reporting dysphoric or depressive symptoms on symptom-screening scales (15-22). Fewer field surveys have used diagnostic methods to screen clinical types of depression among their elderly general population samples (9, 1I, 23-26). From the social point of view, affective disorders in the elderly population are causing impairment of roles and can be a serious threat in their social functioning. Depressive illness is often associated with socioenvironmental factors such as lower socioeconomic status, poor housing, isolation, suffering from serious life events and widowhood. This requires the development of specific strategies and policies, given
320
M. G. Madianos’, G. Gournas’, C.N. ~ t e f a n i s ~
’
Department of Psychiatry, Community Mental Health Center, University of Athens, Department of Psychiatry, Soteria General Hospital, Department of Psychiatry, Medical School, University of Athens, Greece
Key words: affective disorder; epidemiology, cognitive impairment M.G. Madianos MD MPH, Department of Psychiatry, University of Athens, CMHC Ryron - Kessariani, 1 4 Delou, Kessariani, G- 16 12 1 Athens, Greece Accepted for publication June 15, 1992
the fact that the elderly population in almost all western societies constitute a growing proportion (4, 7, 9,21,28-3 1). Therefore, psychiatric epidemiology is a useful tool for the planning and organization of social support systems for the elderly. In Greece, life expectancy is 7 1 years for men and 74 years for women (32). Age-specific mortality rates are considered among the lowest in Europe and birth rates are continuously declining (32, 33). It is estimated that, between 1960 and 2000, the population of people 60 years and over will double from 10.0% to 21.0% (33). During the same period, profound social and cultural changes, such as industrialization, urbanization, nuclear family transformation and the weakening of family ties and the strength of kinship are occurring (33). All these phenomena are playing an important role in the wellbeing and adaptation of elderly people in Greece. Based on the need for the epidemiologic assessment of mental disorders and related issues, especially for affective disorders, among the elderly general population of greater Athens, two representative boroughs were chosen for a field survey with a probability sample of elderly residents. This study is part of a systematic epidemiologic
Depression in Athens
research on the assessment of mental health needs of the two neighboring boroughs served by a community mental health center (34, 35). In this study we tried to combine two types of assessments of depressive psychopathology: first, the case identification of the elderly people who expressed dysphoric or depressive symptoms and second, the diagnosis of those who were suffering from any type of clinical affective disorder. In particular we tried to answer the following questions: Are there any dTfferences in the prevalence of depressive symptoms between the sexes? What are the causal effects influencing depressive symptoms? Is there any association between cognitive impairment and depression? Is there any association between stressful life events and depressive symptom formation? Are there any differences in the prevalence of clinical types of depression between the sexes and age groups? Material and methods
A total of 307 eligible subjects, ages > 65 years, were randomly selected from a master, two-stage systematic sampling of 1600 households, representing 15% of 2 boroughs of greater Athens. The 2 boroughs cover an area of 8.4 km2 and contain a total population of about 95,000, consisting mostly of workingand middle-class people. The elderly population comprised 9904 people, 40.3% men and 59.7% women. The area’s Age Dependency Index was higher (48.6) than that of the whole greater Athens (45.0). The final sample included 25 1 respondents; the rest were either dead (8.8%) or refused to participate (7.1 %). No correlation was found between refusals and geographic location of the household. The participation rate (82%) is similar to the one reported by others (9, 36). Table 1 presents the sociodemographic characteristics of the sample. Measures
Respondents were independently interviewed in their households by one psychiatrist. The survey’s questionnaire consisted of 3 parts. In the first part, all basic sociodemographic data and the respondents medical history were included. In the second part, mental health status was assessed by two symptomscreening scales, the 22-item scale developed by Langner (37) and the CES-D Scale developed by the Center for Epidemiological Studies (USA) (38). Both instruments were standardized and found reliable for the Greek population in previous crosssectional studies (39,40). Additional information on recent experiences from stressful life events and so-
Table l . Sociodemographic characteristics of the sample ( ~ 2 1 )5 Sex Male Female
%
37.8 63.2
Age (mean) Male Female Total Marital status
74.6k6.3 73.6t6.4 74.0t6.6
%
Single Married Divorced Widowed Cohabiting
10.4 39.8 4.4 44.6 0.8
Education
%
Illiterate/ some elementary school Elementary school/ some high school High school graduates University graduates Socioeconomic level* Upper Middle Lower middle Lower
43.1 38.6 15.1 3.2
% 3.3 18.2 53.2 25.3
* OccupationXeducation.
cia1 difficulties, use of psychotropic medication and previous help-seeking, was also obtained. In the last part of the questionnaire, each subject was evaluated for possible cognitive impairment and disability by the Short Portable Mental Status Questionnaire (SPMSQ) and the Stockton Geriatric Scale respectively (41,42). The SPMSQ consists of 10 questions on cognitive functioning. All questions are to be scored correctly: 8- 10 errors constitutes severe cognitive impairment. Stockton Geriatric Scale consists of 33 items with a score ranging from 0 to 66 and a cut-off score 1 2 0 characterizing a subject as disabled. Mental status was examined by a semistructured and comprehensive psychiatric interview, the Psychiatric Evaluation Form (43) supplemented by the DSM-I11 criteria for a clinical diagnosis (44). The Psychiatric Evaluation Form consists of 19 subscales describing large dimensions of psychopathodology. Definitions of these subscales are provided by the authors. This instrument was translated and validated in a previous psychiatric epidemiologic survey in Athens (45). This article presents data on the prevalence of depressive or dysphoric mood by the use of the
321
Madianos et al. CES-D Scale and the association between depressed mood and the experience of stressful life events and cognitive impairment. Stressful life events were recorded on a list, culturally responsive, and previously used in a n’ationwide study in Greece (39). Finally the diagnostic distribution of the respondents suffering from any type of affective disorder is provided. Reliability and validity studies of the CES-D Scale, SPMSQ, Stockton Geriatric Scale and DSM-I11 diagnoses were conducted. The CES-D Scale was validated against the diagnosis of depression by the DSM-I11 criteria. Of 24 depressed respondents, 20 scored < 16 in the CES-D Scale. The cut-off score > 16 provided high sensitivity (83.4%) and specificity rates (85.9%). Test-retest reliability study in a subsample of respondents has shown statistically significant product-moment coefficients for the CES-D Scale (0.76), Stockton Geriatric Scale (0.61) and SPMSQ (0.59). The internal consistency of the SPMSQ and Stockton Geriatric Scale has proven to be high, with Cronbach’s C;I coefficients of 0.78 and 0.83 respectively (46). Finally, an interater reliability study on the agreement of DSM-I11 diagnoses of affective disorders was carried out by a second psychiatrist who reviewed the protocols. The degree of agreement between the 2 raters was high (K: 0.81 2: 11.0, P
It has long been recognized that affective disorders of any type among the elderly population living in the community constitute a major psychopathological issue and prevalence studies on this aspect have therefore drawn considerable attention (1- 12). From the clinical point of view, depressive illness in the elderly tends to last longer and is often complicated with cognitive impairment (13, 14). Another important clinical aspect is that a significant proportion of depressed elderly people are undergoing a recurrent episode of depression (6, 14). Epidemiologic research has focused mainly on the detection of cases of elderly individuals living in the community by self-reporting dysphoric or depressive symptoms on symptom-screening scales (15-22). Fewer field surveys have used diagnostic methods to screen clinical types of depression among their elderly general population samples (9, 1I, 23-26). From the social point of view, affective disorders in the elderly population are causing impairment of roles and can be a serious threat in their social functioning. Depressive illness is often associated with socioenvironmental factors such as lower socioeconomic status, poor housing, isolation, suffering from serious life events and widowhood. This requires the development of specific strategies and policies, given
320
M. G. Madianos’, G. Gournas’, C.N. ~ t e f a n i s ~
’
Department of Psychiatry, Community Mental Health Center, University of Athens, Department of Psychiatry, Soteria General Hospital, Department of Psychiatry, Medical School, University of Athens, Greece
Key words: affective disorder; epidemiology, cognitive impairment M.G. Madianos MD MPH, Department of Psychiatry, University of Athens, CMHC Ryron - Kessariani, 1 4 Delou, Kessariani, G- 16 12 1 Athens, Greece Accepted for publication June 15, 1992
the fact that the elderly population in almost all western societies constitute a growing proportion (4, 7, 9,21,28-3 1). Therefore, psychiatric epidemiology is a useful tool for the planning and organization of social support systems for the elderly. In Greece, life expectancy is 7 1 years for men and 74 years for women (32). Age-specific mortality rates are considered among the lowest in Europe and birth rates are continuously declining (32, 33). It is estimated that, between 1960 and 2000, the population of people 60 years and over will double from 10.0% to 21.0% (33). During the same period, profound social and cultural changes, such as industrialization, urbanization, nuclear family transformation and the weakening of family ties and the strength of kinship are occurring (33). All these phenomena are playing an important role in the wellbeing and adaptation of elderly people in Greece. Based on the need for the epidemiologic assessment of mental disorders and related issues, especially for affective disorders, among the elderly general population of greater Athens, two representative boroughs were chosen for a field survey with a probability sample of elderly residents. This study is part of a systematic epidemiologic
Depression in Athens
research on the assessment of mental health needs of the two neighboring boroughs served by a community mental health center (34, 35). In this study we tried to combine two types of assessments of depressive psychopathology: first, the case identification of the elderly people who expressed dysphoric or depressive symptoms and second, the diagnosis of those who were suffering from any type of clinical affective disorder. In particular we tried to answer the following questions: Are there any dTfferences in the prevalence of depressive symptoms between the sexes? What are the causal effects influencing depressive symptoms? Is there any association between cognitive impairment and depression? Is there any association between stressful life events and depressive symptom formation? Are there any differences in the prevalence of clinical types of depression between the sexes and age groups? Material and methods
A total of 307 eligible subjects, ages > 65 years, were randomly selected from a master, two-stage systematic sampling of 1600 households, representing 15% of 2 boroughs of greater Athens. The 2 boroughs cover an area of 8.4 km2 and contain a total population of about 95,000, consisting mostly of workingand middle-class people. The elderly population comprised 9904 people, 40.3% men and 59.7% women. The area’s Age Dependency Index was higher (48.6) than that of the whole greater Athens (45.0). The final sample included 25 1 respondents; the rest were either dead (8.8%) or refused to participate (7.1 %). No correlation was found between refusals and geographic location of the household. The participation rate (82%) is similar to the one reported by others (9, 36). Table 1 presents the sociodemographic characteristics of the sample. Measures
Respondents were independently interviewed in their households by one psychiatrist. The survey’s questionnaire consisted of 3 parts. In the first part, all basic sociodemographic data and the respondents medical history were included. In the second part, mental health status was assessed by two symptomscreening scales, the 22-item scale developed by Langner (37) and the CES-D Scale developed by the Center for Epidemiological Studies (USA) (38). Both instruments were standardized and found reliable for the Greek population in previous crosssectional studies (39,40). Additional information on recent experiences from stressful life events and so-
Table l . Sociodemographic characteristics of the sample ( ~ 2 1 )5 Sex Male Female
%
37.8 63.2
Age (mean) Male Female Total Marital status
74.6k6.3 73.6t6.4 74.0t6.6
%
Single Married Divorced Widowed Cohabiting
10.4 39.8 4.4 44.6 0.8
Education
%
Illiterate/ some elementary school Elementary school/ some high school High school graduates University graduates Socioeconomic level* Upper Middle Lower middle Lower
43.1 38.6 15.1 3.2
% 3.3 18.2 53.2 25.3
* OccupationXeducation.
cia1 difficulties, use of psychotropic medication and previous help-seeking, was also obtained. In the last part of the questionnaire, each subject was evaluated for possible cognitive impairment and disability by the Short Portable Mental Status Questionnaire (SPMSQ) and the Stockton Geriatric Scale respectively (41,42). The SPMSQ consists of 10 questions on cognitive functioning. All questions are to be scored correctly: 8- 10 errors constitutes severe cognitive impairment. Stockton Geriatric Scale consists of 33 items with a score ranging from 0 to 66 and a cut-off score 1 2 0 characterizing a subject as disabled. Mental status was examined by a semistructured and comprehensive psychiatric interview, the Psychiatric Evaluation Form (43) supplemented by the DSM-I11 criteria for a clinical diagnosis (44). The Psychiatric Evaluation Form consists of 19 subscales describing large dimensions of psychopathodology. Definitions of these subscales are provided by the authors. This instrument was translated and validated in a previous psychiatric epidemiologic survey in Athens (45). This article presents data on the prevalence of depressive or dysphoric mood by the use of the
321
Madianos et al. CES-D Scale and the association between depressed mood and the experience of stressful life events and cognitive impairment. Stressful life events were recorded on a list, culturally responsive, and previously used in a n’ationwide study in Greece (39). Finally the diagnostic distribution of the respondents suffering from any type of affective disorder is provided. Reliability and validity studies of the CES-D Scale, SPMSQ, Stockton Geriatric Scale and DSM-I11 diagnoses were conducted. The CES-D Scale was validated against the diagnosis of depression by the DSM-I11 criteria. Of 24 depressed respondents, 20 scored < 16 in the CES-D Scale. The cut-off score > 16 provided high sensitivity (83.4%) and specificity rates (85.9%). Test-retest reliability study in a subsample of respondents has shown statistically significant product-moment coefficients for the CES-D Scale (0.76), Stockton Geriatric Scale (0.61) and SPMSQ (0.59). The internal consistency of the SPMSQ and Stockton Geriatric Scale has proven to be high, with Cronbach’s C;I coefficients of 0.78 and 0.83 respectively (46). Finally, an interater reliability study on the agreement of DSM-I11 diagnoses of affective disorders was carried out by a second psychiatrist who reviewed the protocols. The degree of agreement between the 2 raters was high (K: 0.81 2: 11.0, P
