Department of Psychiatry, Kaohsiung Medical University, Kaohsiung, Taiwan
Department of Psychiatry, National Cheng Kung University, Tainan, Taiwan
Correspondence: Dr Mian-Yoon Chong, Associate Professor and Director, Department of Psychiatry, Kaohsiung Medical University, 100 Shih-Chuan First Road, Kaohsiung 807, Taiwan. Tel: 886 7 3208219; fax: 886 7 3112492; e-mail: mchong{at}cc.kmu.edu.tw
Declaration of interest The National Health Research Institute of Taiwan funded this project.
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ABSTRACT |
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Aims To study the prevalence of depressive disorders among community-dwelling elderly; further, to assess socio-demographic correlates and life events in relation to depression.
Method A randomised sample of 1500 subjects aged 65 and over was selected from three communities. Research psychiatrists conducted all assessments using the Geriatric Mental State Schedule. The diagnosis of depression was made with the GMS-AGECAT (Automated Geriatric Examination for Computerised Assisted Taxonomy); data on life events were collected with the Taiwanese version of the Life Events and Difficulties Schedule.
Results One-month prevalence of psychiatric disorders was 37.7%, with 15.3% depressive neurosis and 5.9% major depression. A high risk of depressive disorders was found among widows with a low educational level living in the urban community, and among those with physical illnesses.
Conclusions Contrary to most previous reports, we found that the prevalence of depressive disorders among the elderly in the community in Taiwan is high and comparable to rates reported in some studies of UK samples.
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INTRODUCTION |
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METHOD |
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Case definition and research instruments
Instruments used in this project include the Geriatric Mental State
Schedule (GMS) and the Life Events and Difficulties Schedule (LEDS).
The GMS is a standardised, semi-structured interview designed to assess psychopathology for patients over 65 years of age. It enables patients to be classified by symptom profile, and can demonstrate changes in that profile over time (Copeland et al, 1976). A community version of the GMS was derived from the parent schedule by omitting many of the items designed to tap psychotic disorders less likely to be encountered in the community; this version of the GMS has been used in European community studies (Copeland et al, 1999). The GMS was translated into Mandarin (GMS-M), and modified with colloquial terms relevant to the Taiwanese communities. Psychiatrists participating in the study had received training at the Institute of Psychiatry, London. Interrater reliability assessments of the GMS were carried out with their London colleagues and also among the eight research psychiatrists in Taiwan before the study began.
Depressive disorders and other types of psychiatric morbidity were
diagnosed by means of a computer-assisted system, the Automated Geriatric
Examination for Computer Assisted Taxonomy (AGECAT). Its development has been
described elsewhere (Dewey & Copeland,
1986; Copeland et al,
1986,
1999). In brief, it uses
scores on the symptoms components obtained from the GMS interview described
above to derive diagnostic clusters. Each subject is awarded a score (0-4 or
0-5) for each diagnostic cluster. The levels on each cluster are then compared
to each other according to a hierarchy of diagnoses: organic brain syndrome,
schizophrenia, mania, depression (major and neurotic), and obsessional,
hypochondriacal, phobic and anxiety neuroses. The system arrives at a main
diagnosis and subsidiary diagnosis. A subject who has no symptom components is
referred to as well, while subjects with diagnostic confidence
levels 1 and 2 are referred to as sub-cases, and those with
diagnostic confidence levels 3, 4 or 5 are cases. The diagnostic
agreement between the research psychiatrists and AGECAT was good, with
generalised scores of 0.87 for depressive disorders and 0.73 for
organic brain syndrome.
The LEDS was used to collect detailed information about the occurrence and
context of adverse life events during the year prior to the interview. This is
a semi-structured interview developed by Brown & Harris
(1978), of Bedford College,
London University, for describing discrete events and ongoing long-term
difficulties experienced by an individual. The Taiwanese version (LEDS-T) was
modified from the original version, and each category of event or difficulty
was extensively defined. The exact date of an event or difficulty was sought
out and recorded during the interview. The degree of threat contained in each
life event was rated on a four-point scale: 1 indicating a marked
threat; 2, a moderate threat; and 4, little or no
threat. If an event rated moderate affected the subject, it was
classified as an important moderately threatening event. The
interrater reliability of threat rating was satisfactory (=0.75). The
average annual rate of life events reported per subject was 0.8. The mean
range of uncertainty about the date of events was 2.1 weeks (s.d.=3.8); 25.5%
felt certain about the exact date on which an event had occurred; 29.3% felt
certain within 1 week; 17.5% felt certain within 1-2 weeks; and 25.3% felt
certain within 3-4 weeks.
Subjects
Estimation of sample size
In the pilot study, 120 randomised subjects aged 65 and above were selected
from a community. A senior psychiatrist trained in using the GMS assessed all
subjects. Thirteen subjects (10.9%; 95% CI 5.3-16.5) were diagnosed as having
depressive disorders using the GMS-AGECAT system. With this estimate as a
reference, an adequate sample size required for the main study was then
calculated as 1485 (to achieve a power of 0.95, with P <
0.05).
Study population and sampling
Three communities - respectively from a rural (Nan-hwa), a
semi-urban (Alian) and an urban location (metropolitan
Kaohsiung) in south Taiwan - were selected for the study. In order to
avoid a selection bias towards underestimation of the true
residency of old people in these communities, the census was first consulted
at the respective registration offices. It was then scrutinised for different
age groups and re-checked for their residence by local officials before the
study was carried out.
A random selection procedure was used to select subjects with a probability proportional to the size of the aged population studied. A multi-stage random selection was adopted in the urban community, first in selecting districts, then the Li and Ling (district subdivisions in Taiwan). In the semi-urban and rural communities, randomised selection proportional to size was adopted because of the relatively smaller number of elderly in the population. For logistical reasons, a total number of 1500 subjects (500 from each community) were recruited for the main study.
Data analysis
The prevalence of all psychiatric and depressive morbidity was calculated
using the GMS-AGECAT, with a 95% CI. Univariate analyses of various
socio-demographic variables and life events were performed in relation to the
depressive disorders, first with descriptive statistics, including odds ratio
(with 95% CI). Identified significant variables were then further analysed
with multivariate analyses using logistic regression (applying the likelihood
ratio estimation).
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RESULTS |
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Altogether, 1350 (90.0%) subjects successfully completed the interview (the respondents); 123 (8.2%) subjects refused (non-respondents); and 27 (1.8%) died before the interview. Most of those who died suffered from chronic physical illness related to ageing. The respondent rates were especially high in the rural (95.6%) and semi-urban (95.4%) communities, and somewhat lower (at 81.1%) in the urban community.
Socio-demographic characteristics of respondents
Respondents consisted of 673 (49.9%) males and 677 (50.1%) females
(Table 2). Most of them (88.9%)
were ethnic Taiwanese, while 11.1% were Chinese. Males outnumbered females in
the urban and suburban communities. The structure of the aged population in
Taiwan is different from that in most Western countries. According to 1997
population statistics for Taiwan, there were more aged males (8.5%) than
females (7.6%). This was due to the mass migration of Chinese soldiers from
mainland China to Taiwan during the civil war in the late 1940s through the
1950s (when the Nationalist government retreated to Taiwan after the
Communists took over China). Many of these Chinese resided in the urban
regions and were concentrated in government quarters for the armed forces,
forming an ethnicgeographical distribution distinctive to Taiwan. They
represented about 30% of the sample studied in the selected urban
community.
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Two-thirds of the subjects (66.1%) were aged 65-74, while 27.3% were between 75 and 84 years old, and only 6.6% were of the oldest-old group aged 85 and above. Their mean age was 73.2 years (s.d.=6.2). There were no mean age differences among the three communities. Since this was a geriatric sample, one-third were widows/widowers. About 90% of the subjects had three or more children, and the majority (88.5%) were living with their family. Their educational level was generally low (average 3.3 years). Half of them had not received any formal education, with the greater proportion in the rural and semi-urban communities. Most of those with religious beliefs practised a mixture of Buddhist and Taoist rituals.
Psychiatric and physical morbidity
Using the GMS-AGECAT system, the 1-month prevalence rate of any psychiatric
morbidity in this sample was found to be 37.7% (95% CI 35.1-40.3%). The
prevalence rates of various psychiatric disorders were estimated as follows:
depressive neurosis, 15.3% (95% CI 13.4-17.3%); organic mental disorders,
14.3% (95% CI 12.4-16.2%); major depression, 5.9% (95% CI 4.7-7.3%);
schizophrenia, 0.7% (95% CI 0.4-1.4%); anxiety neurosis, 0.7% (95% CI
0.4-1.4%); hypochondriasis, 0.5% (95% CI 0.2-1.1%); obsessive-compulsive
disorder, 0.1% (95% CI 0.06-0.4%); and phobic neurosis, 0.1% (95% CI
0.06-0.4%).
The 1-month prevalence rate of depressive disorders (major and neurotic) was estimated at 21.3% (95% CI 19.1-23.4%).
Among the respondents 85% had some kind of physical illness. The risk of developing depressive disorders among those with physical illness was 3.7 times (95% CI 2.2-6.2) higher than in those without any physical problems. The physical illnesses varied, with one or more chronic illnesses such as cataract (29.7%), arthritis (24.4%), hypertension (24.4%), gastro-intestinal dysfunction (15.6%) and coronary heart disease (12.5%). About 1% of the respondents were severely disabled and were completely dependent on care by others.
Life events and depression
From the year prior to the interview 995 events had been collected. Among
these, health events (53.9%) appeared to be the most common and the most
widely experienced, followed by the death of someone with close ties (13.5%),
events connected with relationships with children and family members (9.2%),
with matters related to money or possessions (6.2%), reproduction (5.6%),
housing (4.7%), employment (1.6%), and legal problems (1.3%).
Eleven out of 287 subjects with depression - compared to 10 of 839 without any psychiatric diagnosis (non-cases) - had experienced at least one markedly threatening life event in the year prior to the interview; the odds ratio (OR) was 3.30 (95% CI 1.38-7.86). Life events of an important moderate or mildly threatening nature were also significantly associated with depression; their ORs were 2.94 (95% CI 1.88-4.60) and 1.93 (95% CI 1.40-2.66), respectively. Experience of general moderate threatening life events (OR=1.47; 95% CI 0.59-3.69) and events holding little threat (OR=1.23; 95% CI 0.91-1.67) were not significantly associated with depression. When the mild events were further examined, a high proportion of health events were found to be in this category. This association was insignificant after the exclusion of all mild health events in the analysis (OR=1.53; 95% CI 0.94-2.52).
Socio-demographic factors, physical illness and depression
Tables 3 and
4 show the relationship between
individual socio-demographic factors, physical illness, life events and
depressive disorders (major and neurotic). In univariate analysis
(Table 3), there was a
significant difference in area distribution in depressive disorders, with the
trend from lower rates in rural and semi-urban communities to a much higher
rate in the urban metropolis. A preponderance of depressive disorders was also
found in females, among widows, among those with low education, and among the
older ages (the oldest-old) and in those with physical
illness.
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The rates of depressive disorders were 2.1 times higher in women than in men (OR=2.7; 95% CI 2.1-3.6; P<0.001). The risk for females as against males of neurotic depression (138 v. 69; OR=2.95; 95% CI 2.14-4.07; P<0.001) was slightly higher than of major depression (48 v. 32; OR=2.2; 95% CI 1.4-3.5; P<0.001).
When the above significant factors were analysed for the risk of depressive disorders using multiple regression, it was found that female gender, low education and urban region exerted significant independent effects, while female gender and urban region demonstrated a significant interactive effect (Table 4). Age was confounded by physical illness, for older ages had a higher risk of physical illness. In summary, a high risk of depressive disorders was typically found in an urban widow with a low level of education, while those with physical illness were highly vulnerable to depression.
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DISCUSSION |
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In this study trained and experienced senior psychiatrists conducted all assessments and measurements. An epidemiological study using trained psychiatrists to conduct interviews is costly, but it enables the acquisition of more reliable information than lay interviewers are able to provide, because psychiatrists have little difficulty in distinguishing patients with depression from normal subjects who have depressive symptoms.
The measurement of life events was carried out by means of a comprehensive, interview-based schedule, the LEDS-T. Because of the considerable length of the full and probing interview, the quality of life-event information collected is of great importance, particularly when used in a community epidemiological survey of elderly people. The results show a satisfactory interrater reliability of threat rating, a short mean range of uncertainty and limited fall-off.
High response rates were found in this study, especially in the semi-urban and rural communities. The importance of a sound response rate in any epidemiological study has long been stressed. Similarly high response rates were also noticed in epidemiological surveys of other types of psychiatric morbidity in the community in Taiwan (Cheng, 1987; Chong, 1992). They were accounted for by the close collaboration of various professions, particularly public nurses and local community officers. With their assistance and thanks to their frequent communication with the subjects and their families, high response rates were able to be achieved. Besides, because interviews were conducted at temples that also served as community centres in some villages, subjects were more likely to cooperate and provide reliable information.
Prevalence studies
A high prevalence rate of depression in old age was found in this study,
which contradicted the findings of most previous studies in Taiwan
(Table 1) and other Oriental
countries (Komahashi et al,
1994; Kua et al,
1996), where lower rates have long been emphasised. Comparison
with these studies is difficult, because of differences in research
methodology, diagnostic criteria and instruments used.
In general, significantly lower rates of depression were found in a study employing lay interviewers to collect information using the Diagnostic Interview Schedule (DIS) (Yeh et al, 1994). The DIS is based on the criteria of DSM-III (American Psychiatric Association, 1980), which require high specificity. This is appropriate for biological research but not suitable in a community survey where high sensitivity is needed to identify cases for treatment. This being so, it is not surprising that studies using the DIS in community surveys generally demonstrated consistently lower rates than most studies with other standardised instruments.
When comparing different studies using the GMS, it was found that the prevalence rate of depression in old age in this study is comparable to that recorded in a recent report on migrants from the Indian subcontinent living in Bradford, UK (Bhatnagar & Frank, 1997), but higher than those reported from Liverpool (Copeland et al, 1976), Dublin (Kirby et al, 1997) and other European (Beekman et al, 1999) and most Asian studies. Moreover, the prevalence rate of depression in old age is three times higher than that reported from Singapore (Kua et al, 1996), a community composed predominantly of ethnic Chinese. There were, however, great differences in rates of suicide between Singapore and Taiwan, with a higher rate as well as a trend of higher suicidal risk with age in Taiwan (Kok & Tseng, 1992; Chong & Cheng, 1995). The high rate of depression in this study is also comparable to that shown in a recent study using the Geriatric Depression Scale (Brink et al, 1982) in Kimen, an island just off the coast of mainland China, which is populated by Chinese (Liu et al, 1997).
Socio-demographic correlates of depression
Gender
Depressive symptomatology in late life is usually found to be more
prevalent among women than men. This gender difference has also been
established in most general population surveys
(Cheng, 1989) and clinical
settings. The excess rate had been accounted for by the finding that women
were more likely to detect and report depressive symptoms than men. These
symptoms are more frequently observed in a clinical setting, where it is
culturally and logically more acceptable to express distress in somatic form.
In this study, experienced psychiatrists carried out all the assessments, and
for them it was not difficult to differentiate a functional symptom from one
denoting physical illness. On the other hand, most subjects were able to
express their distress eloquently in colloquial Taiwanese terms, such as
kan-kor (emotional distress), ul-juit (depression) or
funlow (upset). The risks of depressive disorders in this study,
leaving aside the benefits of better reporting or detection, were, however,
twice as high in women than in men. A similar gender ratio distribution was
also seen in other surveys of minor psychiatric morbidity in Taiwan
(Cheng, 1987;
Chong, 1992).
Marital status
The relation of marital status to depression among elderly people is less
controversial. It is generally believed that depression associated with
widowhood is probably due to the bereavement. In addition, loneliness, one of
the depressive manifestations, is commonly seen in elderly people regardless
of their marital status.
Education and social environment
A high risk of depression was found among the elderly of a lower
educational level. Education is one of the general criteria in the assessment
of socio-economic status, besides job and income. The educational level of the
subjects in this study sample was generally low, with more than half being
illiterate. Their low level of education was accounted for by the unpopularity
of formal education during their childhood, a time when China was war-torn and
when Taiwan was under Japanese control (1895-1945). It is well established
that low socio-economic status is frequently associated with poor health, a
condition related to depression.
Despite the vast social and economic transformation that has taken place in Taiwan in recent decades, social welfare for the elderly is still inadequate and far below that in most industralised countries. Many of the elderly are looked after by family members, predominantly sons, who take their share in turn. Taking care of the elderly has become a burden for poor families, who are generally of a low educational level. In the urban community, where a higher risk of depression was found, limitations in the number of rooms and restrictions on movement for the elderly were noticed. By contrast, in the rural areas, healthy old couples were seen living together, in their own house and on their own land, carrying out light farm work. Communication with their children was maintained by telephone. Thus the support and daily activities as well as the mental health of elderly people in the rural community are extended.
Physical morbidity and other life events
Health difficulties exhibited the highest risk for depressive disorders in
this cross-sectional study - more than any other single socio-demographic
factor. The majority of the incidences of physical morbidity in this sample
were chronic illnesses. Having a health problem is in itself stressful. It may
lead to disability and impairment, which contribute to the onset and
continuance of late-life depression
(Henderson et al,
1997; Prince et al,
1998). This finding is compatible with those of other community
studies, where poor health and disability accounted for 35% of the total
variance in depression and outranked demographic, social support and life
events (Kennedy et al,
1989). High physical morbidity in this sample might contribute to
the high rates of depression, which most previous studies in Taiwan did not
address.
Health problems, difficulties in relationships and financial problems were the three main stressful life events. Similar findings were also noted in a survey in another Chinese community (Boey & Chi, 1998). Relationship problems, particularly those regarding children or daughters-in-law, are significant in the Chinese family. Financial difficulty is very much correlated with the quality of life. During the period of the study, some local governments in Taiwan, including those of the communities from which our study samples were drawn, initiated monthly subsidiary benefits for the elderly. These benefits, despite their relatively small amounts, were substantially significant for those in need. Support from both the family and community are thus essential for the mental health of the elderly.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication November 4, 1999. Revision received April 25, 2000. Accepted for publication June 19, 2000.
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