|Year : 2017 | Volume
| Issue : 1 | Page : 22-28
A study of risk factors associated with depression in medically ill elderly patients
Deepika Singh1, Jahnavi S Kedare2, Chetan Vispute3
1 Department of Psychiatry, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
2 Department of Psychiatry, B.Y.L. Nair Hospital and T.N. Medical College, Mumbai, Maharashtra, India
3 Department of Psychiatry, MGM Medical College, Mumbai, Maharashtra, India
|Date of Web Publication||19-Jun-2017|
Department of Psychiatry (OPD-10), 2nd Floor, OPD Building, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Hingna Road, Nagpur - 440 019, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Medically ill elderly patients are more prone to develop depression. Stressful life events which the patient experiences as well as the absence of perceived social support all act as risk factors for developing depression. Moreover, if the coping mechanisms are faulty the risk of developing depression increases. Aim: This study was conducted to assess the prevalence of depression in medically ill elderly patients and the risk factors associated with faulty coping mechanisms, perceived social support, and stressful life events. Materials and Methods: This was a cross-sectional study conducted at a tertiary care hospital, wherein 100 patients fulfilling the inclusion and exclusion criteria were chosen. Patients were administered a semi-structured questionnaire to obtain details about sociodemographic profile and diagnosed medical illnesses. Geriatric Depression Scale, Coping Inventory for Stressful Situations, Multidimensional Scale of Perceived Social Support, and Presumptive Stressful Life Event Scale were used. Results: Prevalence of depression was 72% among the medically ill elderly patients. Depressed patients used more of emotion-oriented coping and less of task-oriented and avoidance coping mechanisms the perceived social support in the form of family and friends was significantly less in depressed patients. The more the number of stressful life events experienced by the patients the more depressed they were. Conclusion: Early identification of risk factors and early diagnosis of depression may help us in carrying out timely interventions and thus improve the quality of life of our patients.
Keywords: Depression, elderly, risk factors
|How to cite this article:|
Singh D, Kedare JS, Vispute C. A study of risk factors associated with depression in medically ill elderly patients. Ann Indian Psychiatry 2017;1:22-8
|How to cite this URL:|
Singh D, Kedare JS, Vispute C. A study of risk factors associated with depression in medically ill elderly patients. Ann Indian Psychiatry [serial online] 2017 [cited 2019 Jan 22];1:22-8. Available from: http://www.anip.co.in/text.asp?2017/1/1/22/208346
| Introduction|| |
In the population over 70 years of age, more than 50% of patients suffer from one or more chronic medical conditions. Patients with chronic medical conditions are at an increased risk of significant psychological distress including depression, resulting in impairment in functioning, increase in treatment costs, decrease in compliance with medical regimens, and worsened disease course leading to higher mortality and disability. Social and economic conditions such as poverty, break-up of joint families, and poor services for the elderly pose a psychiatric threat to them. Many older adults suffer from a mixture of problems in multiple life domains, such as a number of stressful life events as well as co-morbid medical conditions, these make them vulnerable to adverse outcomes. According to a study by Sidik et al., the prevalence of depression among the elderly with chronic medical illness is 9% compared to respondents without chronic medical illness (5.6%).
Risk factors of depression in old age are reported as genetic susceptibility, lower level of education which leads to poor coping mechanisms, co-morbid medical condition, adverse stressful life events (widowhood, separation, divorce, bereavement, poverty, and social isolation), and lack of adequate social support.
Aldwin and Revenson  found that individuals in poorer mental health and under greater stress tended to employ less adaptive coping strategies and that these coping efforts affected the level of mental health. Coping with medical conditions may also be influenced by the patients' perception of the illness and the emotional response to the same. Thus poorer coping with medical illness predisposes an elderly individual to develop depression.
Social support is defined as the physical, mental, emotional care received from family members or friends to aid in coping. Conversely, loneliness in old age has been suggested to be a risk factor for morbidity and mortality.
According to Krause, received social support is the amount of tangible help provided by the social network, whereas perceived support is the subjective evaluation of the received help.
Perceived support is a crucial resource when stress is experienced, It is the perception of the person of the availability of others' support such as family and friends. It signifies the cognitive evaluation of the availability and adequacy of support. According to a study done by Tiple et al. on psychiatric morbidity in geriatric people, depressive disorders were the most common psychiatric illnesses and perceived social support was poor for these patients.
The review of epidemiological studies of life events and psychiatric disorders has shown that 32% of the psychiatric cases can be attributed to stressful life events. According to the study, it was found that the elderly depressed patients experienced a significantly higher number of stressful life events as compared to the control group.
There are very few studies which assess risk factors for depression in elderly with co-morbid medical conditions in a tertiary care teaching hospital population. Therefore, we decided to conduct a study with the aims to study the prevalence of depression in medically ill elderly patients. To study faulty coping strategy, perceived social support and stressful life events as a risk factor for depression. To compare coping strategies, perceived social support and life events in depressed versus nondepressed elderly patients with medical illnesses.
| Materials and Methods|| |
This was a cross-sectional observational study done at a tertiary care hospital and teaching institute. The study population included medically ill elderly patients attending the psychiatric outpatient department (OPD) and geriatric OPD of the hospital. After the ethics committee approval, 100 consecutive patients fulfilling the inclusion and exclusion criteria were selected for the study. Written informed consent was obtained and the confidentiality was ensured. Inclusion criteria were: (1) AGE above 60 years (2) patients with one or more chronic medical illnesses which were diagnosed by a physician, they should have physician's notes/case paper and/or reports of investigations and/or prescription for the said chronic medical illness.
(3) Patients without cognitive impairment, i.e., Mini Mental State Examination (MMSE) score > and = 24 and (4) those willing to give consent.
Exclusion criteria were: (1) age below 60 years, (2) those with cognitive impairment, i.e., MMSE score <24 (3) patients with aphasia and psychotic features on clinical assessment and (4) those not willing to give informed consent.
Patients were administered a semi-structured case record form to obtain details about the sociodemographic profile, diagnosed medical illnesses, duration of illness, and treatment taken. Furthermore, Geriatric Depression Scale (GDS), Coping Inventory for Stressful Situation 21 (CISS-21), Multidimensional Scale of Perceived Social Support (MSPSS), Presumptive Stressful Life Event Scale (PSLES), and MMSE were administered to assess geriatric depression, coping strategies, perceived social support, stressful life events, and cognitive function, respectively.
The GDS, by Yesavage et al., is a brief, 30-item questionnaire in which participants are asked to respond by answering yes or no in reference to how they felt over the past week. A score of 0–9 is diagnosed as “normal,” 10–19 as “mildly depressed,” and 20–30 as “severely depressed.”
This 30-item scale's reliability and concurrent validity have been demonstrated among active elderly community residents and those receiving medical or psychiatric treatment in in- and out-patient settings.,,
CISS-21 is formed by Endler and Parker. The CISS-21 is assumed to assess coping by three basic coping strategies: emotion-oriented, task-oriented, and avoidance coping. Each scale of the CISS-21 includes 7 items. Respondents are asked to rate each item on a five-point scale ranging from (1) “not at all” to (5) “very much.”
The MSPSS  was originally developed on university students (Zimet, Dahlem, Zimet, and Farley, 1988) and was later validated in a wide range of samples, including older adults, doctor-trainees, and psychiatric patients. MSPSS provides an assessment of three sources of support: family (FA), friends (FR), and significant other (SO).
Singh et al. PSLES consisting of 51 life events with a mean stress score for each  is used to identify life events associated with depression and chronic medical illness. This standardized scale comprises items which are shown to be relevant to Indian culture and representative of the typical life events as experienced by this population.
MMSE  is a scale by Folstein et al. It tests five areas of cognitive function: orientation, registration, attention and calculation, recall, and language. The maximum score is 30. A score of 24 or lower is indicative of cognitive impairment.
Statistical analysis was performed using Statistical Package for Windows, Version 16.0. Chicago, SPSS Inc. All frequency distribution tables were made using appropriate statistical methods. Fisher's exact test, t-test, and Spearman's coefficient of correlation test were administered.
| Results|| |
Prevalence of depression
The study population includes 100 medically ill elderly patients. Of these 100 participants, 72 patients scored ≥10 on GDS and hence diagnosed as having depression. Those scoring between 10 and 19 were diagnosed as having mild depression, i.e., 48 patients while those scoring between 20 and 30 were diagnosed with severe depression, i.e., 24 patients.
There was high prevalence of depression (72%). Two-third (n = 48; 66.67%) of patients who had depression, had mild depression and one-third (n = 24; 33.33%) of patients had severe depression based on their scores on GDS.
Majority of patients, i.e., 96 of 100 patients in the study population were ≤75 years of age and only four patients were >75-year-old. Of these 96 patients, 72 were depressed and 24 were nondepressed. All four patients of above 75 years age group were nondepressed. Prevalence of depression was significantly more in the young old population, i.e., ≤75 years on administering Fisher's exact test with P = 0.0052.
Of 100 total patients, there were 38 males and 62 females. In these 38 male patients, 26 were depressed and 12 were nondepressed. Similarly out of 62 female patients, 46 were depressed and 16 were nondepressed.
As shown in [Table 1], 63.9% of depressed patients were females as against 36.1% of males. However, the difference between males and females was not statistically significant with P = 0.6471.
Of the total 72 depressed patients, 55.6% (n = 40) of patients were married as against 44.4% (n = 32) patients who were widowed. The difference between married patients and widowed patients was not statistically significant according to Fisher's exact test with P = 0.1764. In the present study, 57 patients were uneducated and 43 patients were educated primary level or above. Nearly 66.66% of depressed patients were illiterate and only 33.33% of patients were educated primary level or above. On administering Fisher's exact test, it was found that the difference between groups of levels of education was statistically significant with the value of P = 0.0017.
This shows depression to be seen more often in an illiterate patient group, which emphasizes that people with lower level of education are more prone to depression as compared to the educated group.
Considering that unemployment poses a risk factor for depression a comparison was carried out between patients who were working (working means those who were currently employed at some place and getting a salary or having some business and earning through it) versus those who were not working. Hence of 100, 20 patients were working, whereas 80 patients were not working. Housewives were considered not working as they were not employed anywhere and also retired subjects were considered not working. Nearly 75% of patients who were not working were depressed as compared to 25% of patients who were working, but this difference was not statistically significant according to Fisher's exact test with P = 0.0533, considered not significant. Hence, this study points towards unemployment as one of the possible risk factors for developing depression.
Coping strategies and depression in elderly
T-test was administered to compare coping mechanisms used in depressed and nondepressed patients [Table 2]. It was seen that nondepressed patients used more of task-oriented and avoidance coping as against depressed patients who used more of emotion-oriented coping and the results were statistically significant.
Perceived social support and depression in elderly
The perceived social support between depressed and nondepressed patient was compared using t-test. In the study, for MSPSS depressed patients had less perceived social support from family members and friends as compared to nondepressed patients and this difference was statistically significant with P< 0.05. However, with respect to support from significant others, no statistically significant difference was found [Table 2].
Stressful life events and depression in elderly
Stressful life events act as a risk factor for patients to develop depression. Depressed patients have poor coping toward stressful events and therefore are more prone for depression.
In the study, 29 of 100 patients had experienced < 10 number of stressful life events in their lifetime, whereas 71 patients had ≥10 number of stressful life events. Of 29 patients, 3 were depressed and 26 were nondepressed. Of 71 patients having ≥10 stressful life events, 69 were depressed and only 2 were nondepressed.
Of the depressed patients, 95.83% of patients had faced ≥10 stressful life events as compared to 4.17% of patients with <10 and this difference was statistically significant according to Chi-square test (P < 0.0001).
So in the present study, the more number of stressful life events experienced by the patients the more depressed they were. In the study population of 100 patients, 44 had <3 number of stressful life events in the last 1 year.
Of these 44 patients, 16 were depressed and 28 were nondepressed. Fifty-six patients faced ≥3 number of stressful life events. All these 56 patients were depressed.
Of the 72 depressed patients, 77.78% of patients had faced ≥3 stressful life events in the past 1 year as compared to 22.22% of patients with <3 and this difference was statistically significant (P < 0.0001).
Thus in the study, the depressed patients had experienced more number of stressful life events in the last 1 year as compared to nondepressed patients.
Futhermore, out of 51 stressful life events in PSLES by Singh et al., In this study, change in sleeping habits (62%), financial loss or problems (58%), death of close family member (51%), illness of family member (48%), family conflict (48%), self or family member unemployed (46%), excessive alcohol or drug use by family member (45%), were the most common stressful life events experienced by the patients.
Correlation of geriatric depression with coping strategies, perceived social support and presumptive stressful life events
In this study, Spearman's correlation was used to assess the correlation between the severity of depression (based on GDS score) with coping strategies, perceived social support and presumptive stressful life events.
It was found that as the level of depression increased the task and avoidance coping decreased while emotion oriented coping increased. So, severity of depression was negatively correlated (−0.908) with task and avoidance coping mechanisms and positively correlated with emotion based coping. It was also seen that as the level of depression increased the perceived social support decreased. Hence, severity of depression was negatively correlated with perceived social support in any form – family, friend or significant others.
With Spearman's correlation, it was found that as the total number of stressful events experienced throughout the life time increased, level of depression increased. Furthermore, when the number of stressful life events experienced in the past 1 year increased, the severity of depression increased. Hence, severity of depression was positively correlated with the total number of stressful life events and also in those experienced in the past 1 year.
| Discussion|| |
Majority of elderly people suffer from one or more medical illnesses. Medical illnesses result in functional disability in these people. They also cause an additional economic burden on an elderly individual. In addition to medical co-morbidities, the stressful events which a person experiences are a risk factor for the development of depression.
Every individual tries to cope with stressful situations in life. Those having healthy coping remain healthy, but those having faulty coping tend to develop psychiatric complications, depression being one of them. It is important to assess patients with medical illness for depression. Early diagnosis and early intervention will help in improved patient outcome. Psychosocial interventions in these patients are equally important.
In this study, 72% of patients were depressed. This is a very high prevalence. There may be two reasons for the same. First, this study was conducted in a tertiary care hospital, and the study population of medically ill elderly patients was selected from psychiatry and geriatric OPD of the hospital, wherein chances of patient being depressed was high as compared to community sample. Second, depression was assessed with the help of GDS, in which mild depressive symptoms are also identified. A study conducted in the community by Jain and Aras  also shows a high prevalence of 45.9%.
From sociodemographic profile, it was seen that majority of patients were in the age group of 60–75 years. According to a study done by Silva Pereira et al., 70% of the sample was between 60 and 69 years. Increase in age is significantly associated with an increased risk of depression. Old age is associated with various physical disabilities which lead to dependency on others for daily activities, which may be a reason for depression in elderly.
With respect to gender, depression was seen significantly more in females as compared to males. Females are more vulnerable to depression. Additional work and home responsibilities, caring for grandchildren, change in social roles, abuse, poverty, and economic dependence may trigger a depressive episode. Similar findings were seen in study by Barua and Kar  on screening for depression in elderly Indian population, where 36.0% were males, whereas 64.0% were females.
Widowed patients are expected to be more vulnerable for depression. Loneliness, poor social support and financial dependence all act as risk factors for depression. However, in this study, more number of depressed patients were married than widowed. There were no divorced/separated or unmarried patients in the study sample. Similar findings were seen in a study, wherein 76.24% of the patients were married and 17.23% of them were divorced.
As shown in [Table 1], depression was more prevalent in illiterate patient group. According to a study by Akhtar et al., a low level of education was directly associated with depression in the elderly subjects. The educated elderly have better coping and hence can easily adjust with the situation as compared to illiterates and therefore are at a lesser risk for depression.
There was a high prevalence of depression among medically ill elderly patients not working as compared to patients who were working though this difference was not statistically significant. Studies by Ramachandran et al. and Broadhead et al. had reported a high prevalence of depression among the unemployed individuals.
Elderly dependent on children, pension, charity, or other family members for financial support were at higher risk for depression than those who were self-dependent. Lower income and financial dependency on others for fulfillment of daily needs as well as health care expenses of a person in late life produces depressive symptoms.
Thus, it was seen that predisposing factors for developing depression in medically ill elderly patients were an age group of 60–75 years, female gender, being married, illiterate, and not working at present.
As shown in [Table 2], depressed individuals used more of emotion oriented coping and nondepressed patients used task oriented and avoidance coping mechanisms.
Furthermore, it was found that as the level of depression increased the task and avoidance coping decreased while emotion based coping increased.
According to results of a study by Myers et al., patients with high scores of Emotion-Focused coping strategies also had significantly high scores on diverse psychopathology factors including elevations on depressive mood, intrusive experiences, anger state, and general anger scores. In contrast, those who used task-oriented strategies and who used avoidance-focused strategies had less psychopathology including low positive emotion scores.
In this study, the perceived social support from family members, friends was significantly less in depressed patient group as compared to nondepressed group. In addition, it was found that severity of depression was negatively correlated with perceived social support in any form – family, friends or significant others. Results of the study by Altay and Avci indicate that fewer depression symptoms in elderly people are correlated with more perceived social support.
According to a study done by Tiple et al. on psychiatric morbidity in geriatric people, depressive disorders were the most common psychiatric illnesses. Objective social support was moderate for the majority of patients but perceived social support was poor for these patients.
Increasing number of life events cause an increasing amount of stress on the elderly. In this study, depressed patients had more number of stressful life events in total and in the past 1 year as compared to nondepressed patients. It was found that severity of depression was positively correlated with the number of stressful life events. Similar findings were also seen in a study by Agrawal and Jhingan. It was found that the elderly depressed patients experienced significantly higher number of stressful life events as compared to the control group. The stressful life events were specifically more in the females, those with low “per capita income,” and those who perceived crisis in the family.
This study included medically ill elderly patients. Medical illness itself acts as a stressor in an elderly person's life. Furthermore, other stressful events like death of loved one, family conflict or excessive alcohol or drug use by family member makes them more vulnerable to develop depression.
| Conclusion|| |
Chronic medical illnesses are seen very commonly in elderly population. The presence of multiple medical illnesses increases the risk of developing depression in these patients.
It has been observed that depressed patients use unhealthy coping mechanisms like emotion oriented coping. Their perception of the social support is also very low. Apart from medical illness they also experience many stressful life events. All these act as risk factors for developing depression in medically ill elderly patients. Depression in medically ill elderly patients affects the outcome of medical illness in them. It causes despair and a low motivation in treatment leading to increased morbidity and mortality. This interaction between medical illness and depression plays a key role in deciding the quality of life in elderly patients. An early diagnosis of depression in these patients will definitely help in carrying out timely interventions in terms of medications and also in terms of psychotherapeutic management.
Those patients who have better ways of coping, who instead of emotionally blaming themselves focus on problem solving are less prone to go into depression with similar co-morbid medical conditions and stressful life events.
Interventions should, therefore, be aimed at improving coping strategies of patients. Family interventions will also be needed to improve the social support required by the patients. Quality of life of elderly depressed patients will improve with such interventions.
This study was conducted at a tertiary hospital, which may not be representative of the general population. In addition, this is a cross-sectional study and the sample size was small.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]