Department of Psychiatry and Institute for Research of Extramural Medicine (EMGO), Vrije Universiteit Amsterdam, The Netherlands
Institute of Psychiatry, Department of Epidemiology, King's College, University of London, UK
Department of Psychiatry and Institute for Research of Extramural Medicine (EMGO), Vrije Universiteit Amsterdam, The Netherlands
Department of Psychiatry/Neuropsychology, Social Psychiatry and Psychiatric Epidemiology, University of Maastricht, The Netherlands
Institute of Psychiatry, Department of Epidemiology, King's College, University of London, UK
Department of Psychiatry and Institute for Research of Extramural Medicine (EMGO), Vrije Universiteit Amsterdam, The Netherlands
Unit of General Practice, Turku University Hospital and Satakunta Central Hospital, Turku, Finland Hospital, Turku, Finland
Department of Psychiatry, Jonathan Psychiatry, Jonathan Swift Clinic, St James' Hospital, Dublin, Ireland
Heilsugæslustöð, Grundarfirði, Iceland
Department of Psychiatry, Ludwig Maximilians Universität, Munich, Germany
INSERM U593, Université Victor Segalen, Bordeaux, France
Psychiatrische Klinik und Poliklinik, Freie Universität Berlin, Germany
Scientific Institute of Public Health, Unit of Epidemiology, Brussels, Belgium
Department of Psychiatry and Institute for Research of Extramural Medicine (EMGO), Vrije Universiteit Amsterdam, The Netherlands
Universidad de Zaragoza, Servicio de Psicomá, Zaragoza, Spain
Institute of Clinical Neurosciences, Sahlgrenska University Hospital, Göteborg University, Sweden
Dipartimento Materno Infanile, Facoltà di Medicina, Università degli studi di Brescia, Italy
Scientific Institute of Public Health, Unit of Epidemiology, Brussels, Belgium
Section of Old Age Psychiatry, University of Liverpool, UK
Correspondence: A.W. Braam, LASA/EMGO, Van der Boechorststraat 7, 11081 BT Amsterdam, The Netherlands. Tel: +31 (0) 20 4446770; e-mail: a.braam{at}vumc.nl
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To examine cross-national differences in the association between physical health and depressive symptoms in elderly people across western Europe.
Method Fourteen community-based studies on depression in later life in nine western European countries contributed to a total study sample of 22 570 respondents aged 65 years and older. Measures were harmonised for depressive symptoms (EURO-D scale), functional limitations and chronic physical conditions.
Results In the majority of the participating samples, the association of depressive symptoms with functional disability was stronger than with chronic physical conditions. Associations were slightly more pronounced in the UK and Ireland.
Conclusions The association between physical health and depressive symptoms in later life is consistent across western Europe.
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INTRODUCTION |
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METHOD |
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Measures
Outcome variable
The depressive symptom measure in the current study was the EURO-D scale
(Prince et al, 1999).
This harmonised depressive symptom scale has been developed to enhance
analyses of the pooled EURODEP data-set, because not all centres used the same
depression assessment procedure (Table
1). Eight centres used the Geriatric Mental State Examination
(GMS; Copeland et al,
1986), three other centres used the Center for Epidemiologic
Studies Depression Scale (CES-D; Radloff,
1977), one the Comprehensive Psychopathological Rating Scale
(CPRS; Asberg et al,
1978), one the short version of the Comprehensive Assessment and
Referral Evaluation (SHORT-CARE; Gurland
et al, 1984), and one a DSM-III interview
(American Psychiatric Association,
1980) with identical items to those used in the GMS. To obtain a
pooled EURODEP data-set, these five instruments were harmonised according to a
procedure developed and validated by Prince et al
(1999). This resulted in the
EURO-D scale, which comprises 12 items: depressive affect, pessimism, wishing
death, guilt, sleep, interest, irritability, appetite, fatigue, concentration,
enjoyment and tearfulness (0=`not present'; 1=`present', range 0-12). For each
centre, the EURO-D has been internally consistent, with Cronbach =0.72
for the current pooled sample, with
ranging between 0.65 (in Dublin)
and 0.83 (in Finland). The EURO-D scale was applied with standardised standard
deviations (s.d.=1), as recommended by Prince et al
(1999).
Demographic variables
These include gender, age, marital status and education. Marital status was
categorised as `married' v. `non-married', the latter comprising
those who were never married, the divorced or separated, and the widowed.
Education was assessed in several ways: years of education, level of
education, or non-specified classifications into `lower', `intermediate' and
`higher'. To maintain maximal variability, a range of index scores was
computed with values between 0 and 1.
Physical health
Two measures of physical health were available for most samples: functional
disability and presence of chronic physical conditions.
For functional disability, several versions of `activities of daily living' scales were employed (Table 2). To obtain comparable measures, total scores of each scale were trichotomised into `no', `intermediate' or `high' levels of disability. The category of `high' level of disability was defined as the scores that fell in the highest tertile of the range of the scale.
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A similar procedure was used for the variable `number of chronic conditions', resulting in the categories `no', `one' and `two or more'. The types and numbers of chronic conditions showed considerable variation (Table 3). Furthermore, the types of questions also varied; this mostly concerned the self-reporting of specific chronic conditions, but sometimes was limited to the self-reporting of essential symptoms of conditions such as congestive heart failure or Parkinson's disease. From the Irish centre, no data were available on the type or number of chronic conditions. The physical health instrument used in Verona permitted categorisation of both disability and number of chronic conditions, but not the type of chronic condition.
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The procedure of harmonisation employed in the present study has the advantage that the variability of the estimates is largely maintained. This `inclusive approach', however, has the disadvantage that the comparability may be reduced. Therefore, for both variables, a `selective approach' was explored, in which only items were included that explicitly cover the same types of functional disability (ability to wash, dress, use toilet, move out of bed, and eat, which correspond to the five items of the Katz index) and chronic conditions (namely, cardiovascular disease, diabetes and stroke), in a majority of study centres.
Cognitive functioning
In 11 centres, cognitive functioning was assessed using the Mini-Mental
State Examination (MMSE; Folstein et
al, 1975). In London, the Dementia Diagnostic Scale score was
derived from the SHORT-CARE interview
(Livingston et al,
1990). In Finland, the Wilson Mental Capacity scale
(Wilson, & Brass, 1973) was used (ten items on memory and orientation, ranging from 0, `no cognitive
impairment' to 10, `severe cognitive impairment'). Cognitive functioning was
not assessed in Iceland.
European `building blocs'
The European countries can be categorised into interlocking and overlapping
regions according to sociological and historical factors, which are denoted as
`European building blocs' (Davie,
1992). The following blocs are distinguished: `Western Isles'
(England and Ireland), `Nordic' (Iceland, Sweden and Finland), `Western
continent' (Belgium, Germany and The Netherlands) and `Southern/Mediterranean'
(south of France, Italy and Spain). France is normally ranked within the
`Western continent' category. The classification has been adapted, because the
`Western continent' category would include more than half of the pooled
EURODEP sample. As the French sample is drawn from the Aquitaine region in the
south-west of France, the French study is classified as Southern European.
Statistical procedures
Associations between physical health measures and depressive symptoms
(EURO-D scores) were analysed separately for each centre using linear
regression analysis, computing regression coefficients, adjusted for effects
by demographics. The physical health measures were divided into three
categories, to check for non-linear associations. The reference category was
`no disability' or `no chronic conditions'. Two alternative models were also
examined, in which the `selective approach' was followed, including only
centres in which all questions on functional disability were identical, or in
which the same chronic conditions were assessed. The next series of models
focused on the relative contributions of both physical health variables to
depressive symptoms when entered in one model.
Finally, the data from the different centres were pooled into one EURODEP sample. Associations between the estimates of physical health and EURO-D score were examined using multilevel analysis (Bryk & Raudenbush, 1992). Multilevel random regression modelling (MLRM) is ideally suited for conglomerate data-sets of nested subsets for which each data point cannot be considered as equally independent. In fact, individuals from the same country are more similar to each other than those from different countries. Although sampling characteristics, sample sizes, the assessment instruments used, and research design and context can differ among the centres included in the study, the target relation under study can be considered as fixed. These differential levels of independence are corrected for by MLRM, which also allows the control of known characteristics of the different subsets as well as the differential weighting of unknown dependencies within the data. Moreover, MLRM allows the analysis of associations between higher-level characteristics and lower-level characteristics, while controlling for covariates on either level, and allows the assessment of interactions between variables on the higher and lower level.
In the present study, the unit of measurement on the lower level was that of the individual respondent. Characteristics on this level include EURO-D score, physical health variables and demographics. The unit of measurement on the higher level was that of the contributing centres. For the pooled analysis, two types of multilevel models were employed. First, the associations between the physical health variables and EURO-D score were examined in one model based on the pooled data-set. The analyses were adjusted for effects by demographics, as well as the relevant interactions between gender and age with each other, and with marital status and education. Second, we examined whether the strength of the association between physical health and depressive symptoms is modified by living in one of the four European `building blocs'. In these analyses, the building bloc of the `Western Isles' was used as the reference category.
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RESULTS |
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Centre comparisons: inclusive approach
There was substantial congruence between centres in the association between
functional disability and depressive symptoms
(Table 4). The variance was
higher in most centres where instruments were used with a higher number of
items on disability (London, Liverpool, Finland), although the variance was
also high in Ireland, where a one-item estimate was used.
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The associations for chronic conditions were less pronounced than those for disability (Table 5). Furthermore, the findings are less prominent or even non-significant in the older samples of Iceland, Munich and Gothenburg. The combined physical health assessment in Verona may have been less sensitive than those used in the other centres.
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Centre comparisons: selective approach
In ten centres, a strict (`selective') approach was possible with respect
to functional disability, using five items on the same activities of daily
living (Table 6). The pattern
of associations across the centres did not change dramatically. The percentage
of variance for EURO-D scores in Iceland and Belgium remained high. In London
and Liverpool, the amount of variance increased because of the reduction in
the number of items in the functional disability measure.
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The `selective' approach of harmonisation of chronic conditions, which covers three diseases only (cardiovascular disease, diabetes and stroke), is shown in Table 7. In the octogenarian samples, the prevalence of these diseases was notably higher. The association between the diseases and EURO-D score was very similar in most samples, except for the British centres, where stronger associations were found.
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Functional disability and chronic conditions in one model (inclusive)
Table 8 shows the
multivariate analyses of both physical health variables in one model. For both
physical health variables, the trichotomised scores were used as a brief
scale, because of the linear relationship found in the previous analyses.
Expressed as standardised coefficients, the strength of the association
between functional disability and depressive symptoms ranged between 0.16 and
0.37. The strength of the association between chronic diseases and depressive
symptoms in these models was smaller, ranging between 0.08 and 0.20. There is
some more variation in the amount of variance explained (see final column,
Table 8), mostly ranging
between 4% and 9%, but higher in Belgium, and the English samples (up to 15%).
When cognitive functioning was included as a control variable, no substantial
differences were found (results not shown).
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Pooled data-set: effect modification by building blocs
The associations between functional disability, chronic diseases and EURO-D
score in the pooled data-set are shown in
Table 8. When the three dummy
variables for European building blocs were introduced in the regression
analysis, no direct effects were found between the building blocs and
depressive symptoms (results not shown). However, the building blocs modified
the associations under study. Compared with the `Western Isles' building bloc,
significant interaction terms with functional disability and depressive
symptoms were found for the Western continent (B=-0.12, s.e.=0.02,
P<0.001) and for the Nordic building bloc (B=-0.18, s.e.=0.03,
P<0.001). This indicates that in the Western Isles, the
association between functional disability and depressive symptoms is more
pronounced than in the Western continent and in the Nordic region. For chronic
diseases, very similar interaction terms were found, again with the Western
Isles as comparison group (Western continent: =-0.08, s.e.=0.03,
P=0.012; Nordic: B=-0.15, s.e.=0.04, P<0.001;
Southern/Mediterranean: =-0.10, s.e.=0.03).
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DISCUSSION |
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`Modern maturity' confined to Britain?
In their worldwide study of adults between 15 and 65 years of age, Ormel
et al (1994)
described a fairly consistent association between disability and depression
across five continents. The present study provides evidence of a similar
consistency in the older population, at least, in western Europe. It may be
inferred that the mutual relationship between physical decline and depression
is fairly universal. Therefore, sociological and cultural factors seem to give
way to life-cycle perspectives and biological mechanisms that pertain to all
people, irrespective of cultural traditions.
Within the framework of associations between physical health and depressive symptoms, some significant differences between the main regions in Europe were observed. In contrast to what was expected, the association between physical health and depressive symptoms was somewhat more pronounced in the UK and Ireland, but not in western Europe or in the Scandinavian countries. Moreover, no support was found for the hypothesis that in southern European countries traditional views of ageing would attenuate the association between physical health and depressive symptoms. The conclusion that expectancies about successful ageing and `modern maturity' are only more pronounced in the British Isles is uncertain. Issues of assessment procedures and translation of instruments are likely to be more relevant than the sociocultural climate on ageing in Britain.
An alternative explanation is that health services were more accessible in other European regions under study than in Britain. Indeed, the Organisation for Economic Co-Operation and Development data show that the national health expenditure per capita in Britain in 1990 was clearly below that of most other western European countries (Braam et al, 2004), in spite of at least equally high standards in the British healthcare system. Nevertheless, further study into healthcare facilities seems to be warranted, to determine which aspects of healthcare may be relevant, such as distance of travel to the general practitioner or availability of formal home nursing and other ancillary services.
Depression on syndrome level
Because of the attempt to follow a congruent harmonisation procedure across
the 11 countries, the current approach focused on depressive symptoms only.
Provisional analyses (data not shown), however, did show completely similar
patterns of associations between functional disability and depression on the
syndrome level, defined by the GMS in most centres, and by DSM diagnosis or
high CES-D scores in the remaining centres. The associations with chronic
conditions were somewhat less pronounced. One may conclude that the mental
consequences of physical decline are not restricted to limited levels of
depressive symptoms, but also reach the level of depressive disorder.
Methodological concerns
An unavoidable limitation of the present study is the varying response rate
across the participating studies. Generally, the oldest and the more disabled
elderly people are under-represented in community studies. This may have led
to less pronounced findings and possibly the risk of overlooking
cross-national differences. The exact pattern of effects of non-response,
however, is difficult to reconstruct.
A second limitation is that the measurement of the aspects of physical health and the depression instruments showed considerable variation across the centres. Although the harmonisation procedures followed are straightforward and easy to reproduce, some categorisations may include a bias. For example, functional disability instruments with more items may be more reliable than those with few items. The `selective approach', however, made clear that using scales with equal numbers of items affected the pattern of associations only to a modest degree. Another example is that in London and Liverpool, the chronic disease data differ slightly from diagnostic information and are closer to disability as a concept. Possibly for that reason, the associations in the English samples between chronic disease and depressive symptoms are stronger than in most other centres. Moreover, the very low prevalence of chronic conditions in Spain and Belgium suggests measurement errors, in spite of the regular interview procedure used in these centres.
A third limitation is that the current cross-cultural study was confined to a range of countries in the Western world, and comparison with aged populations in eastern European countries and other continents still needs to be addressed. It is, however, promising that a straightforward harmonisation of assessment procedures seems to be feasible and may be employed for further cross-cultural comparisons, even when restricted to secondary analyses.
Finally, the current study design did not include several possible relevant factors, such as family support and loneliness, income and living accommodation, duration of disease, pain or acute illness, and treatment.
Fatalism or simultaneous treatment
For those who suffer both depressive symptoms and physical decline, a
mutual and unfortunate pathway has been demonstrated by longitudinal studies
(Ormel & Von Korff, 2000;
Geerlings et al,
2001). However, epidemiological studies of disability and
depressive symptoms may be criticised because of the possibility of overlap:
those who do not feel well, obviously do not function well, and vice versa.
Lenze et al (2001),
on the other hand, suggested that the depressed state itself is disabling.
Therefore, ignoring depressive symptoms among those with physical decline
should be regarded as fatalistic. When both processes affect each other,
simultaneous treatment may be rational and is probably essential for
management. The rate of recognition of depression is likely to increase
because of a greater awareness both in research
(Cole & Dendukuri, 2003)
and in training programmes (Bramesfeld,
2003). Nevertheless, there should be close cooperation between
those offering practical help to adapt domestic surroundings because of
functional limitations and the mental healthcare team.
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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 May 18, 2004. Revision received November 5, 2004. Accepted for publication November 16, 2004.
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