International Journal of Mental Health & PsychiatryISSN: 2471-4372

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Research Article, Int J Ment Health Psychiatry Vol: 2 Issue: 3

Depression in Geriatric Outpatients at Tertiary Care Center in India

Akash Rajender1*, Gaurav R2, Krishna Kanwal3 and Priyanka Choudhary4
1Department of General Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
2Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India
3Department of Psychiatry, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
4Intern, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
Corresponding author : Dr. Akash Rajender
B-2, Opposite Pink Square Mall, Raja Park, Govind Marg, Jaipur - 302004, Rajasthan, India
Tel: +91-9571815555
E-mail: [email protected]
Received: April 12, 2016 Accepted: July 07, 2016 Published: July 11, 2016
Citation: Rajender A, Gaurav R, Kanwal K, Choudhary P (2016) Depression in Geriatric Outpatients at Tertiary Care Center in India. Int J Ment Health Psychiatry 2:3. doi:10.4172/2471-4372.1000128

Abstract

Background: Aging is a progressive process beginning with life and ending with death. There is a massive growth in elderly population and age associated diseases. Depression is frequently associated with aging, associated comorbidities and treatment compliance in this fragile age group.

Aims and Objective: To study prevalence of depression in elderly using Geriatric Depression Scale (GDS) and its associated risk factors.

Method: Three hundred elderly (≥ 60years) patients were assessed at Mahatma Gandhi Medical College and Hospital, Jaipur in an observational, cross sectional study using Geriatric Depression Scale (GDS). Correlation with associated risk factors were evaluated. Statistical analysis was done using SPSS version 12.0.

Results: Prevalence of depression was 29.3% of which 62 (20.67%) were mildly depressed and 26 (8.67%) were severely depressed. Depression was significantly higher in elderly subjects with comorbid chronic disease (p 0.0001), inadequate sleep (p 0.001), absent social participation (p 0.002) and in those who did not engage themselves in daytime work or hobbies (p 0.0002).

Conclusions: Depression is common in elderly, its undiagnosed and overlooked. Prevention of risk factors and early diagnosis may significantly reduce morbidity, mortality and improve quality of life.

Keywords: Depression; Elderly; Prevalence; Risk factors

Keywords

Depression; Elderly; Prevalence; Risk factors

Introduction

Aging is a progressive process which begins with life and continues throughout lifecycle, finally ending with death [1]. It is a universal phenomenon [2] resulting in a process called “demographic transition” [3] i.e. is a shift from high mortality and fertility to low, thus causing an increase in elderly population.
India, is presently in demographic transition with 72 million above 60 years of age, which is expected to increase to 179 million in 2031 and further to 301 million in 2051. This massive increase in geriatric population will put an enormous pressure on health care services [4]. India being a developing nation needs to be prepared for this challenge, with more knowledge on the disease and comorbidity pattern in this population at risk. Early diagnosis and treatment remains the mainstay to reduce the burden of this disease.
Elderly being economically unproductive, are commonly neglected [5], stressed and more prone to mental disorders [3] of which depression is common. Depression is difficult to Diagnose, especially when associated as a comorbidity in chronic diseases of elderly. Depression leads to an increase in morbidity, mortality, health care utilization, treatment cost, along with a reduction in quality of life [6]. Depressed elderly adhere less to diet, exercise, and medication. Depression is projected to become the second-leading cause of disease burden after ischemic heart disease by the year 2020 [7].
Early diagnosis and treatment remains the main stay to reduce depression burden in elderly. Studies on depressed elderly are very few in India, this study is an attempt to diagnose elderly with depression, determine factors responsible and suggest preventive measures [8-10].

Method

Source of data
In our study, 300 patients with age ≥ 60 years were selected at Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India; over a study period from October 2013 to November 2014 using simple random sampling. Patients with known psychiatric comorbidity, psychiatric treatment (pharmacological or nonpharmacological) or severe unstable condition and associated conditions interfering with interview were excluded from the study. A formal written consent was taken from all patients.
General protocol
Patient’s clinical profiles were reviewed and information was procured pertaining to demographic aspects, past medical history, and use of medications. The subjects suspected to be suffering from depression and ready to give written consent were assessed by consultant psychiatrists. The psychiatrist confirmed the diagnosis of Major Depressive Disorder (MDD) according to DSM-IV TR criterion. Geriatric depression scale (GDS) was used for assessment of major depression and its severity. GDS screens for seven characteristics of depression in elderly, which are somatic concerns, lower affect, cognitive impairment, feelings of discrimination, impaired motivation, lack of future orientation and lack of self-esteem. It consists of 30 questions with a maximum score of 30. A score of 10 and more were diagnosed with depression. Socio economic profile and risk factors for depression were evaluated with pre-structured Performa.
Statistical analysis
Descriptive statistics was used for analysis. Chi-square test was used to find out the association between two variables and p<0.05 was considered to be statistically significant. Statistical analysis was carried out using the SPSS12.0.

Results

Of the 300 study subjects who participated in the study, 186 (62%) were females and 114 (38%) were males. 88 (29.33%) were diagnosed with major depression (GDS score ≥ 10) (Table 1).
Table 1: Prevalence of Major Depression in Elderly subjects using Geriatric Depression scale (GDS).
Table 2 summarizes the socio-demographic characteristics of the elderly studied. The mean age of the studied subjects was 66.7 years. Most of the sample consisted of Hindus (238, 79.33%), illiterates (164, 54.67%), non-working (177, 59%), married (206, 68.67%) and living in joint families (115, 38.33%). More than one third 113 (37.67%) belonged to class IV SES (Modified B.G. Prasad Classification 2011).
Table 2: Socio-Demographic Characteristics of Elderly subjects.
Of the 300, overall prevalence of depression was 64 (29.36%), of which 62 (20.67%) were mildly depressed and 26 (8.67%) were severely depressed. Female gender and Age group ≥ 70 years were more depressed. Depression showed a significant association with age ≥70 years, illiterates, lower socio-economic status (SES) and single (widowed/unmarried/divorced) marital status. An inverse relationship was seen between SES and depression, with depression being higher in low socio economic group. Association of socio-demographic characteristics with depression is shown in Table 3.
Table 3: Correlation of Depression with Sociodemographic characterstics of Elderly.
On evaluating the risk factors leading to depression in elderly, 113 (53.3%) physically active subjects were not depressed as compared to 66 (75%) in active subjects suffering from depression (p 0.0001).
Depression was significantly higher in elderly subjects with comorbid chronic disease (p 0.0001), inadequate sleep (p 0.001), absent social participation (p 0.002) and in those who did not engage themselves in daytime work or hobbies (p 0.0002). Association of risk factors in causation of depression in elderly is discussed in Table 4.
Table 4: Risk Factors for depression in Elderly.

Discussion

Depression in elderly is a commonly missed, undiagnosed, unrecognized clinical diagnosis. It is mostly assumed to be a normal response to aging, comorbidity, physical losses or other life events. It causes excess physical and psychological disability and has an adverse impact on physical health [11].
In our study, almost one third of elderly subjects (29.33%) attending OPD at tertiary care center suffered from depression. Those elderly subjects found to be prone for depression, were found to be commonly associated with several risk factors like higher age, low socio-economic status, single or widowed marital status, physical inactivity, presence of chronic diseases, lack of social participation and inadequate sleep.
In our study, females were more depressed than their male counterparts (67.05% vs 32.95%), this can be attributed to Indian socio-cultural factors and psychological factors, as women throughout their lifetime face more stressful events and have a greater sensitivity towards them. Similarly, the prevalence of depression has been found to be higher in elderly women in other Indian studies done by Jain [12], Raj Kumar et al. [13] and by Poongothai et al. [14]. On the contrary, Sandhya et al. [4] showed that the prevalence of depression was lower in females (22.9%) when compared to males (29.1%) in a study done in a rural community in South Kerala.
In our present study, single (widowed/unmarried/divorced) elderly subjects showed a significant (p 0.001) higher prevalence of depression (51.14%). In late life, more emotional support is required as to face challenges posed by physical and psychological stressors, debility, worsening of chronic disease condition due to improper treatment compliance and neglect. Death of a spouse causes irreparable psychological damage, making the vulnerable to depression. Adjustment disorders are common in late life divorce or separation, leading to depressive symptomatology. Single individuals; lack the much required support of spouse and children in late life. Kamble et al. [5] in a study showed similar results, that marital disruption, widowhood and single status were associated with a higher prevalence of depression in both men and women.
Elderly subjects with lower socio-economic status showed a higher prevalence of depression in our study. Similar results were showed in several Indian studies by Jain et al. [12] and Rajkumar et al. [13]. This can be attributed to increased stress, insecurity, uncertainties to future, poor accessibility to health care system and neglect of chronic disease process causing its worsening. Hence, making them more prone to depression.
Three forth of the depressed subjects (75%) were physically inactive and more than half (54.55%) had at least one chronic disease. Poor physical activity can make an individual more prone to depression owing to worsening to worsening of physical debility, chronic disease, visio- spatial coordination and sensory deprivation. Lack of physical activity makes the individual more dependent on care takers, curbs independence, lowers self-esteem, enormously changing the way a person lives, copes to stressors and his perception of himself and his surroundings. Similar results on association of poor physical health with depression was seen in Seby et al. [4] and Rajkumar et al. [13].
Lack of social participation showed an association with depression in our study. Social participation maintains the liveliness and gives a feeling of bonding with the group or community. Lack of social participation makes an individual alone, gives a feeling of worthlessness and emptiness. Sandhya et al. [4] had similar results in a study done in rural community in South Kerala.
Disturbed sleep pattern as seen among 80.68% subjects were also a statistically significant risk factor leading to depression in present study, as also stated by Jain et al. [12]. Depression in elderly is both preventable and treatable as observed by Korte et al. [15]. It’s easy diagnosis, prognostic significance, impact on quality of life and health care cost in elderly population makes it an important issue to address in this population.

Conclusion

India in this era of demographic transition, has an enormous geriatric population prone to depression. One in every three elderly subjects in our study, attending outpatient services at tertiary care center was found to be suffering from major depression. Depression is common comorbidity associated with chronic diseases and often overlooked attributing to disease related factors. Understanding of its risk factors and making consolidated efforts towards its early diagnosis and treatment may go a long way in reducing morbidity, mortality and quality of life of elderly.

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