This study was an investigation that demonstrates an association between socio-demographic variables, lifestyle characteristics and chronic conditions with DS among the older adults in rural setting of Nepal. Our results showed that being female, Buddhist, Dalits and Madhesi ethnicity, unemployed, low family income, the presence of multiple morbidity and smoking are significant risk factors for DS among older adults in Nepal.
Nearly 55.8% of the older adults were found to be suffering from depressive symptoms. This is lower than reported from other studies in Nepal (7, 17). A possible explanation for the heterogeneity of prevalence in Nepal could be that different study settings were used, or samples were drawn from diverse ethnicities and castes from the southern plain region were included. The prevalence was also higher than that of a community-based study conducted in rural setting of India (37.8%) and Bangladesh (45%) (4, 19). In support of our findings, research from low and middle income countries noted a higher proportion of depression among the older population than that of high income countries such as USA, Canada and Australia (20–23).
Our study found that, social determinants (such as gender, religion, ethnicity, income and occupation) were associated with DS and females were more likely to have DS. This is consistent with findings reported by Chalise and Rai from Nepal where authors reported females were more depressed than their male counterparts (24). A possible explanation for this could be that females in a patriarchal society in Nepal may have low self-esteem, low social status and empowerment, feeling helplessness, low health literacy, a longer life expectancy and limited access to health services compared to the males. This is supported by the low position of Nepal in the gender inequality index 0.476 [115th position] in the world, which depicts the disparity of health across genders (25). In the present study, the subjects who ascribed to Buddhism religion was also found to be more depressed, which could be because of the poor socio-economic status of this minority group in the study setting. However, we are cautious in interpreting this result because of the small number of participants (n = 19 to n = 794) in this group. Moreover, we could not find any other studies confirming this association.
In contrast to another study from Nepal (7), we found smoking was associated with DS in our study population. Our finding is in line with the findings to that from China and Japan (10, 26). The underlying mechanism linking smoking and DS are complex: Nicotine has antidepressant properties that release dopamine in the mesolimbic reward pathway, which in turn elevate the mood and alleviate stress (27). However, evidence suggests that smoking plays an important role in changing neurophysiology that increases a smoker’s risk of DS (28). Additionally, one author mentioned that association between smoking and mental disorders are a result of shared environmental and genetic factors (28).
Literacy, an important socioeconomic factor, was not found to be significant with the occurrence of DS. In contrast, the studies from various settings showed illiteracy as a strong predictor of DS (5,7,29). The underlying reason for this discrepancy is not clearly understood. Unemployment and insufficient family income were both associated with DS. The possible explanation could be that older adults engaged in low income occupation might have led to financial constraints in their life, eventually leading to depression. Adding to this, 2019 Human Development Index has revealed that 34% of the Nepalese population is multi-dimensionally poor and 23% is vulnerable to multidimensional poverty which shows that the country has a deep chasm to fill when it comes to addressing health equity (25). Meanwhile, in the Nepalese context, most of the older adults depends on family members/caregivers for their daily needs, where families tend to provide better care if the older adults have some economic resources. This situation may turn to increased conflict at the family level, which in turn puts older populations at risk of mistreatment, which may increase the risk of depression (30, 31). However, in this current study we haven’t accessed the association between elder mistreatment and depression.
In the Nepalese context, caste/ethnicity has been a central feature to describe the level of poverty, poor health literacy and health status. In this light, our study demonstrated that the risk of DS was two times higher in Dalits compared to those of higher caste. Emerging evidence shows that Dalits experience a wide range of social and economic discrimination at various levels (poor living conditions, poor nutrition, low literacy, poor empowerment, poor access to health services and stigmatization) and this results in a severe form of health inequalities (15, 31, 32). Stigmatization is pervasive and worsens psychological stress for those in the Dalit communities (33).
The prevalence of depression among the older population suffering from chronic multi-morbidities was significantly higher (71.55%) than those with one or fewer conditions. This is consistent with findings from other studies (34, 35). This is the first study from Nepal to report an association between multi-morbidity and DS among Nepalese older adults. This finding is consistent with a meta-analysis that showed chronic illness to be a major risk for depression among older adults (36). Evidence has shown that people among whom depression co-existed with multi-morbidity may have more functional impairment, poorer quality of life and increased mortality (37). Depression impairs independence in the older population and, over time, worsens functional outcomes among the multi-morbid group. The decline in functional status may make them more dependent and vulnerable to mistreatment.
Our findings underscore the need for programs to detect, prevent and manage DS in these groups. More specifically, programs needs to adopt a population-based approach that includes screening and diagnosis of DS, mental health literacy of patients and use of evidence-based practices to manage the DS in the community setting. In addition, the Government of Nepal is in the process of scaling up the “Package of Essential Non-Communicable disease (PEN)” throughout Nepal. This is a great opportunity to consider the establishment of health and wellness centers under this program to encourage participation of older adults in yoga, relaxation techniques and meditation, which may be useful for good psychological health. Furthermore, peripheral health care professionals, community health workers, psychologists and psychiatrists need to work together to reach and treat older adults with depression in rural Nepal.
Strengths of our study include its large sample size and high response rate (more than 95%). Another strength of this study includes the strong methodology and use of locally trained enumerators for data collection. However, our study is subjected to certain limitations too. All the associations in this study were cross sectional and cannot evaluate causality. There is a need for longitudinal studies to establish this casual pathway and evaluation of interventions that could address the impact multi-morbidity. As this study only involves the participants from two districts of Nepal, findings cannot be generalized to other setting of Nepal. Another limitation was the use of self-reported data, where social-desirability bias may have occurred.