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a Center on Aging, National Research Council, Padova, Italy
Nadia Minicuci, Center on Aging, National Research Council, Clinica Medica 1°, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy E-mail: nadia.minicuci{at}unipd.it.
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Abstract |
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Methods. A random sample of noninstitutionalized men (n = 867) and women (n = 1531), aged 65 years and older, from the Veneto region, northeastern Italy, were interviewed and participated in a brief physical examination in their homes. The prevalence rates of DS and the associated physical, social, and psychological factors were analyzed.
Results. The overall prevalence rate of DS was 58% in women and 34% in men (p < .0001), but there was no significant trend with age. Women were at higher risk of DS (OR = 1.63) than men, even after adjusting for traditional risk factors, such as fair-poor self-rated health, sleep disturbances and use of sleep medications, lack of support from social and family network, and physical and cognitive impairment.
Conclusions. This study provides evidence that older women more frequently report DS than men, independently from the presence of traditional risk and associated factors. Cultural and lifestyle factors throughout life might explain this gender difference.
DEPRESSIVE symptoms (DS) represent a major concern in geriatric medicine, because of their high rates and frequent association with diseases, disability, and mortality (1)(2)(3)(4). Behavioral factors, health and functional status, and psychosocial variables, such as loneliness, isolation, and lack of social and family support, are considered strong determinants of DS (5)(6)(7)(8)(9)(10)(11)(12)(13). Literature reviews report that the prevalence rates of DS in community-dwelling individuals older than 65 years of age range between 6% and 47% among men and between 10% and 54% among women (1)(14). The cross-national differences reported in the literature might be real and related to different prevalence rates of risk factors across countries, or they might be due to differences in the cultural perception and reporting of symptoms. Indeed, studies conducted in Southern Europe, for example in Spain (15)(16), Italy (17), and France (18), found higher rates than in North America and Asia (14), and, therefore, cultural influences cannot be ruled out. In spite of these differences, generally, the findings of higher rates among women than men are consistent across studies, although the magnitude of the difference varies. Several explanations have been given for the gender differences in the prevalence of DS, including higher rates of comorbidity, disability, loneliness, and poverty among women (19), as well as biological reasons (20). Some studies conducted in North America found that the gender differences were much lower or disappeared when adjusting for confounding factors, such as socioeconomic, health, and functional status (19). However, a study conducted in Spain showed that the differences between genders remained after adjusting for all traditional risk factors (15).
The purpose of this cross-sectional study is to estimate the prevalence of DS in a community-dwelling population of older Italians and to determine the associated factors, such as gender and physical, social, and psychological variables.
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Methods |
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Eighty-nine percent (n = 2402) of people identified as eligible participated in the study. The 298 nonrespondents included those who refused to participate, those who were not found at home after three attempts on different days, and those for whom a proxy refused their participation due to severe dementia or terminal illness (approximately 2%). Only basic demographic data for nonrespondents were collected from a proxy; all data presented herein were provided by the respondents themselves. After exclusion of four people with missing or incorrect demographic data, the final number available for analysis was 2398.
Assessment of Participants
All participants were administered a comprehensive interview and a brief physical examination in the home. The interview obtained information on sociodemographic characteristics, living arrangements, family composition, social support, income (including family contributions), participation in social activities, self-reported history of medical conditions, health status, physical functioning [including activities of daily living (ADLs) (23) and instrumental activities of daily living (IADLs) (24)], health behaviors, self-rated health, and use of health and social services. Cognitive impairment was defined as a score of 0.8 or less for the ratio of the number of questions answered correctly to the number of possible answers (i.e., fewer than 24 correct answers out of 30, if all questions were applicable), or an adjusted score (number of questions answered correctly divided by the number answered, if some of the questions were not applicable) on the Mini-Mental State Examination (MMSE) (25). The interviewers were physicians enrolled in a postgraduate geriatric medicine program, trained to administer performance measures in a standardized manner and certified by a scientific training committee. The examination included assessments of height, weight, vision, hearing, and a qualitative assessment of physical performance.
Assessment of Depressive Symptomatology
The Italian version of the Center for Epidemiological Studies-Depression Scale (CES-D Scale) (26), which has been validated and extensively used in Italy, was administered to all participants (27). The possible range is 0 to 60, and a score of 16 or more was adopted to define DS. If more than four questions had missing answers, the score was not computed.
Assessment of Social Network
Social support was assessed with a questionnaire investigating the nature and size of the social network. Data were collected on the frequency (never, every 6 months, every 2 to 3 months, every month, more often) of personal and telephone contacts with family members (children and siblings), with other relatives, and with friends as well. Information on the support expected in case of financial or emotional needs were gathered by asking: "In case of need, do you expect your family (or relatives, or friends) would help you?"
Health Status Indicators and Medical Conditions
Participants were classified as having a disability in the ADLs if they reported that they either needed help from another person or were unable to perform one or more of the following activities: bathing, dressing, getting out of bed, or eating. Mobility disability was classified as "difficult" or "impossible" to climb stairs or to walk 800 meters without resting, the need for help from another person, or being unable to walk across a room.
Participants were asked how often they have trouble falling asleep, have trouble with waking up during the night, have trouble with waking up too early and not being able to fall asleep again, and feel really rested when they wake up in the morning. Insomnia included those who reported often or always having trouble falling asleep and/or waking up too early. Night awakeners were defined as those who reported often or always waking up during the night. Awakened not rested included those who reported that they never or rarely feel really rested when they wake up in the morning.
History of arthritis, diabetes, hypertension, chronic respiratory disease, stroke, heart disease, parkinsonism, gastrointestinal disorders, and cancer was ascertained by asking participants if a doctor had ever told them that they had the condition.
Data Analysis
To account for the oversampling of people aged 85 years and older, the prevalence of DS was calculated using weights determined by the ratio between the population fraction relative to the 1991 census population and the sampling fraction relative to the age-stratum. All statistical analyses were conducted using the SAS statistical analysis package (SAS, Inc., Cary, NC) (28). Differences between groups were analyzed by X2 test or two-sample t test for independent samples. The association of DS with the sociodemographic, behavioral, health, and other factors was assessed in multivariate logistic regression models with DS as the dependent variable.
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Results |
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In Table 2 , data regarding the prevalence rates of DS in the main sociodemographic and health domains are presented for both genders. A higher percentage of DS was found among people with lower levels of education and among those who reported not having any close friends or having negative expectations of support from family members or other relatives in case of need. Women reporting few contacts with family members or relatives or negative expectations of support from friends also had a higher prevalence of DS, as did men with fewer family contacts and friends. On the other hand, a lower percentage of DS was found for men and women who reported to be current users of alcohol and among married men.
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Table 3 shows the odds ratios for the association of sociodemographic and health-related variables with depression. All variables included in the multivariate analyzis were first analyzed with a hierarchical entry: socioeconomic variables, health and functioning, life habits, and social relations. Only the significant odds ratios are presented in the table. Female gender, not being married, fair/poor self-rated health, sleep disturbances, such as insomnia and awakening not feeling rested, taking sleep medications, mobility and IADL disability, and cognitive impairment were all independent predictors of DS. Among all diseases considered, only incontinence and parkinsonism were significantly associated with DS. Being 80 or older and having more than 5 years of education made participants less likely to be depressed.
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Discussion |
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In a previous cross-national comparison, researchers also indicate that the differences in the rates, with higher frequency in the European countries compared to Asian countries, could be due to a reluctance to acknowledge emotional distress among Asian populations (19). This factor, however, cannot be the only explanation, and differences in the determinants of depression should be taken into account. We have assessed in a logistic model the association of several chronic conditions, comorbidity, and physical function with DS. While we found an association of mobility and IADL disabilities with DS, comorbidity and specific conditions, except incontinence, parkinsonism, and sleep disorders, were not independently associated with DS. It seems reasonable to hypothesize that physical disability is in the pathway from chronic conditions to DS and that diseases become risk factors for DS only when affecting the capability of independent living. A poor self-perceived health status and mild cognitive impairment are associated with more than double the risk of DS, and this finding was also expected, as it has been reported previously in several studies (6)(29)(30)(31)(32)(33)(34)(35).
Many studies have also shown that individuals who are socially isolated and lacking in social ties and support are at increased risk of DS (36)(37). Therefore, smaller and more tightly integrated communities, such as those in Italy or in Spain, should report less DS than countries with more social disintegration, such as the United States. However, we also know that high frequency or intensity of family and social relations do not necessarily relate to well-being, suggesting that other important characteristics, such as higher quality of relations and expectations from the family and social contacts, could be more important. Of course, we cannot exclude major differences in risk factors that were not included in our study. For example, Italy is undergoing major socioeconomic transformations, with increasing numbers of older people living alone and losing the traditional support and strong ties with family members. Therefore, although still remarkable, the family network might no longer meet the expectation of our older people. Of particular interest is the fact that women remain at higher risk of DS even after adjusting for all traditional risk factors discussed above. This seems to support the hypothesis that, in our country, social disadvantages of women, who have lower social roles compared to men during their entire lives, might be the underlying cause of DS at advanced age. This hypothesis would hold true, particularly for the older cohorts of Italian women.
The present study has some methodological limitations. First of all, it is based on a cross-sectional assessment; therefore, a survival effect cannot be ruled out. Older women with depression and other risk factors might experience a higher mortality rate, and, therefore, our population might be predominantly one of selected survivors. Moreover, although the rate of nonrespondents did not differ from previous studies in the elderly and they were comparable to the participants in terms of age and gender distribution, a selection bias could have occurred, and the inclusion of a selected sample compared to the general older population cannot be excluded. Second, the use of cross-sectional data does not allow the assessment of the cause-and-effect relationship between DS and associated conditions. For example, sleep complaints could be either risk factors for DS or consequences of them. Third, information on medical conditions and physical function was self-reported. However, several studies support the reliability of information on health status reported by the older population (38)(39). Moreover, the prevalence of diseases investigated was comparable to that reported in other studies (40).
This study has some peculiar strengths, such as the high response rate and the representativeness of the sample, that allow the generalizability of our results to the older population of Italy.
In conclusion, despite their very high prevalence, DS often go unrecognized and, therefore, untreated in the elderly, probably because they co-present with physical illnesses associated with prominent somatization and/or stressful life events (41). Most studies have revealed about a twofold prevalence of DS in women compared to men. This difference has been attributed to biological reasons, to unfavorable social roles, to higher rates of diseases and comorbidity, and to a more accurate way to report symptoms among women. However, sound conclusions are not yet available (42)(43). More research, therefore, should be done on the determinants of gender differences within and between countries, in order to explain the higher prevalence of DS among older women.
Received July 12, 2001
Accepted October 1, 2001
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  L. C. Barry, H. G. Allore, Z. Guo, M. L. Bruce, and T. M. Gill Higher Burden of Depression Among Older Women: The Effect of Onset, Persistence, and Mortality Over Time Arch Gen Psychiatry, February 1, 2008; 65(2): 172 - 178. [Abstract] [Full Text] [PDF]
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