Depressive symptoms and health service utilization among Chinese middle aged and older adults: A national population-based longitudinal survey

Discussion And Implications

Discussion

Consistent with an emerging body of literature on the relationship between depressive symptoms and adults’ health services utilization, the study findings show a consistent association between depressive symptoms and inpatient and outpatient service use among Chinese middle aged and older adults. Unlike previous literature that predominantly focused on health services utilization in acute care settings, the present study investigated Chinese adults’ health services utilization in both inpatient and outpatient settings.

First, depressive symptoms were positively associated with a greater likelihood of outpatient health services utilization. Due to relatively low awareness of mental disorders in mainland China, middle aged and older adults are more likely to present somatic symptoms when they experience depressive symptoms [6]. Thus, it has been well documented that depressive symptoms and depression among middle aged and older adults are largely underdiagnosed and under-treated in primary care settings [21]. As a result, Chinese middle aged and older adults with depressive symptoms may seek care from physicians. It is consisted with priors’ studies, which found that when an elderly person is not diagnosed for depression, this person may unnecessarily use healthcare services such as outpatient visits to primary care physicians, emergency departments, and urgent care centers, thereby increasing medical resource utilization [8]. Therefore, appropriate screening and treatment of depressive symptoms need to be incorporated in clinical encounters, thereby preventing the onset of depression and associated physical diseases, and improving the quality of life among elderly in China.

Furthermore, the findings suggest that depressive symptoms were also related to Chinese middle aged and older adults’ utilization of inpatient health services. It is likely that middle aged and older adults experience chronic medical conditions that often comorbid with depressive symptoms, such as diabetes and heart disease [22]. When experiencing somatic symptoms of depression, Chinese middle aged and older adults may likely to misinterpret these signs as their physical conditions getting worse. This may possibly explain the increased inpatient service use because, as their depression further develops, they start to think outpatient services are simply not enough. Another possible explanation is because of depression associated disability and functional decline. Depressed adults are less likely to adapt well to their physical conditions and often will have increased burden of disease due to low motivation to manage their physical conditions [23]. Consequently, as their physical health further deteriorates, their inpatient services utilization will increase. A final possible explanation is due to over-investigation and unnecessary referral to hospitalization often known as “a diagnostic stumbling block” in the mainland China healthcare system. One distinct characteristic of mainland China’s healthcare system is that most patients seek primary and secondary healthcare services in tertiary hospitals. Somatic symptoms and hypochondriasis due to depression may be misdiagnosed as worse physical conditions, resulting in inappropriate treatment and referral to inpatient care.

It is also worth noting that the relationships between depressive symptoms and health service use were consistent across rural and urban settings, indicating the robustness of such findings across geographic areas. Moreover, the findings suggest Chinese old adults in urban areas had a higher rate of utilization of health service in general than those in rural areas. Many factors play an important role in explaining this result. First, this may partly be attributable to the urban-rural inequality in health care in China. Ma et al [24] said that there had long been large urban-rural disparities in health and health care in China due to urban-rural dualistic systems. Moreover, health care is related with income [25]. The expense of health services, especially inpatient service, most part of which cannot be reimbursed by Chinese public health system, might be responsible for the lower rate of health services utilization among rural residents. Additionally, depression literacy or traditional cultural can also affect utilization of health services among old people with depression. It was found that those who lived outside major cities regarded counselors or psychologists as less helpful than those who lived in major metropolitan cities [26].

Implications For Public Health Policy

First, an early screening and intervention to improve primary care providers’ recognition of depression symptoms and to provide specialized mental health treatments may reduce the chances of elderly people suffering from chronic diseases, physical discomfort, and even committing suicide. Specifically, China have implemented a public health policy which was applied to the free adult preventive care services among adults aged 65 and over since 2017. However, these services mainly focus on physical examinations; thus, they should be extended to mental status examinations by adding a CES-D survey to serve as the initial attempt to detect depressive symptoms. Secondly, it is necessary to provide a well-established set of interventions and routine medical checkups to high risk groups among elderly people, especially rural people. Thirdly, in view of the various comorbid chronic conditions and complex care needs of elderly people, it is believed that comprehensive geriatric assessments such as outpatient geriatric evaluation and management is a possible approach to reduce the burden of morbidity and medical utilization. This would enable better screening for depression among elderly patients with chronic disease.

Strengths And Limitations

Different from existing studies, most of which focus on Chinese geriatric immigrants and health services in emergency department, this study used a sample of geriatric participants from mainland China and investigated the relationship between geriatric depression and both in- and out-patient services utilization. Several limitations should be considered when interpreting the findings. First, CES-D is a depressive symptom screening tool rather than clinical diagnostic measure. Future studies need to validate the findings using clinical diagnostic measures of depressive symptoms. Second, both depressive symptoms and health care utilization were self-reported, which may be subject to recall bias. Particularly, considering stigma associated with mental illness among Chinese populations, depressive symptoms may be underreported. Lastly, other potential variable that may predict health service use, such as health beliefs and health literacy, were not included in the present study.

Conclusion

The study findings suggest that depressive symptoms are significantly associated with both in-patient and out-patient health service utilization in Chinese middle aged and older adults. Screening for depressive symptoms needs to be incorporated in these care settings in China. Appropriate treatment of depressive symptoms and timely referrals to mental health services may optimize utilization of health services among Chinese middle aged and older adults.

Abbreviations

CHARLS: China Health and Retirement Longitudinal Study; WHO: World Health Organization; US: United States; CESD-10: 10-item Center for Epidemiological Studies Depression Scale; N: number; Std.:Standard deviation; OR: Odds Ratio; 95% CI: 95% confidence interval.

Declarations

Ethics approval and consent to participate: The study protocol was approved by the Institutional Review Board of Peking University, Beijing, China. All participants gave written consent after being informed to the aim of the survey and their rights to refuse to participate.

Consent for publication: Not applicable.

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests

Funding: No funding has been received in this study.

Authors' contributions: JG, DK, LF, & YZ draft the manuscript; AZ & MC was involved in the revised. All authors approved the finally version.

Acknowledgements: Not applicable

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