Study of Prevalence of Depression and Associated Stressors Among Geriatric Patients Attending Psychiatry Department of Kathmandu Medical College; a Descriptive Cross Sectional Study

doi:10.21203/rs.3.rs-2731206/v1

Background

Depression in old age is an important public health problem causing considerable morbidity and disability worldwide. This study aimed to establish prevalence and factors associated with geriatric depression in tertiary care center.

Objective

Study of prevalence of depression and associated stressors among geriatric patients attending Psychiatry Department of Kathmandu Medical College

Method

A hospital based cross-sectional study was conducted among 101 elderly patients and diagnosis was made as per ICD-10 DCR criteria. GDS was used to screen depression. PSLES was used to identify various stressful life events. Data analysis was done and results were calculated.

Result

Study conducted among 101 elderly patients showed that depression was present in 49.5% and among 51 stressful events, nineteen were present in participants. Among 50 patients diagnosed as depression, 7 (14%) had mild, 39 (78%) had moderate, 4 (8%) had mild depression. Stressful life events were significantly associated with geriatric depression.

Geriatric Psychiatry is a branch of psychiatry concerned with the mental disorders that accompany old age and forms part of the multi-disciplinary delivery of mental health care to older people. The specialty is sometimes referred to as old age psychiatry or psychogeriatrics.¹ The word “geriatric” was coined in 1909 by Ignatz L. Nascher.². From 2001 to 2003, the World Health Organization (WHO) conducted a series of household survey among people of age group 14–65 years and above across 14 countries to estimate the prevalence, severity, and unmet need for treatment of mental disorders, the World Mental Health Surveys. Most prevalent lifetime disorders were major depression (10.6%), specific phobia (7.5%), social phobia (6.6%), and alcohol abuse (6.2%). A total of 26.1 percent of the respondents age 60 or older had one or more lifetime psychiatric disorders.³

Depressive symptoms are common among older adults and are associated with functional impairment and decline, mortality, increased health service utilization, and decreased quality of life.^4,5 Major depression and dysthymia as well as depressive symptoms are more common in older women in comparison to men.^6,7 Risk factors and correlates of depression in late life include factors such as being widowed or otherwise unmarried, impaired functional status, impaired social support, perceived loneliness, perceived poorer health, and low internal locus of control.^8,9,10 Older adults with major depression are more likely to have a family or past history of major depression. In addition, loss of a partner in the previous year may be associated with risk. ^11,12 Risk factors for depressive symptoms may also include, in addition, fewer years of education, living in an urban area, lower socioeconomic status and having one or more chronic physical illnesses. ^13,14 In addition to these social and psychological risk factors, depression in late life may be linked to biological risk factors such as underactive serotoninergic neurotransmission and hypersecretion of cortisol.¹

Depressive symptoms are associated with an increased risk of mortality in older adults, although this risk is confounded by factors such as physical health and health behaviors, especially alcohol and tobacco use.¹⁵ Finally, major depression is a risk factor for suicide in older adults.¹⁶

The aim of our study was to find the prevalence of depression and associated stressors among geriatric patients attending Psychiatry Department of Kathmandu Medical College.

This study was hospital based cross-sectional study conducted from November 2019 to October 2019 among 101 elderly patients (inclusion criteria: age more than 60 years and written consent and exclusion criteria: Clinical conditions and/ or medications which interfered with the assessment, including life threatening conditions.). GDS was used to screen depression. PSLES was used to identify various stressful life events.

Each patient was assessed and diagnosis was made by consultant psychiatrist as per ICD-10 DCR. Geriatric Depression scale (GDS) was used to assess symptoms related to depression in each patient. GDS-15 item version was also used to correlate the symptoms each patient was having with life stressors and other socio-demographic variables.

Geriatric Depression Scale is a tool used to screen depression in elderly developed by J.A. Yesavage and others in 1982.¹⁷ It is a brief questionnaire in which study participants are asked to respond to the 30 questions by answering yes or no in reference to how they felt on the day of administration. Scores of 0–9 are considered normal, 10–19 indicate mild depression and 20–30 indicate severe depression. Geriatric Depression scale is available in English language. For this study the scale was translated in Nepali by a clinical psychologist. After translating into Nepali, back-translation into English was done by another translator and tallied both previous original scales with new English scale.

GDS-15 item English version was used as there was no validation in Nepalese setting done in the year 2018 when the thesis was formulated. The validation of GDS-15 Nepali version was carried out by Risal et al.in 2019.¹⁸

PSLES (Presumptive Stressful Life Events) is a scale introduced for determining life stressor on Indian background by Gurmeet Singh which is based upon Social Readjustment Rating Questionnaire (SRRQ) by Holmes and Raphe. It consists of 51 life events, initially scored from 0–4 on basis of perceived stress but later stress were described on basis of paisa weightage 0-100. Life events were categorized as desirable/undesirable and personal/impersonal and two time space in past years and last one year. Inter rater reliability of this test is 0.8.¹⁹

Ethical consideration: Ethical approval was obtained from the concerned authority of the college. Verbal informed consent was obtained from the participants. Purpose of data collection was explained to the patients before interviewing. Privacy and confidentiality of all respondents was maintained

The collected data was systematically compiled. Filled questionnaire was checked, edited and coded and the data was entered and analyzed using SPSS version 26. Consistency of entered data was further checked.

All available 101 patients were screened and among them 50 (49.5%) had depression .Most of the respondents (59.45%) were of age group 60 to 69 years. Nearly equal distribution for age was noted and (51.5%) were male. In regards to religion most of them were Hindu 77 (76.2%).The caste distribution among the respondents was Brahmin/Chhetri 61%, Newar 23%, Lama/Tamang 6%, and others 9%. Major all of the patients were illiterate (74.3%).More than half of the patients (78.2%) were unemployed. More than four by fifth patients (81.2%) belonged from joint family. And, nearly around half of the patients belonged from lower middle class socio-economic status as depicted in demographic information of respondents (Table 1)

Table 1

Frequency distribution of participants according to socio-demographic variables
VARIABLES	CATEGORY	FREQUENCY	PERCENTAGE (%)
AGE (years)	60–69	60	59.4
	70–79	30	29.7
	80 and above	11	51.5
GENDER	Male	52	51.5
GENDER	Female	49	48.5
RELIGION	Hindu	77	76.2
	Buddhist	20	19.8
	Christian	1	1
	Others	3	3
CASTE	Brahmin	46	46
	Chhetri	15	15
	Newar	23	23
	Tamang	6	6
	Others	9	9
EDUCATION	Illiterate	75	74.3
	Primary school	22	21.8
	High school	3	3
	Undergraduate	1	1
FAMILY TYPE	Nuclear	82	81.2
FAMILY TYPE	Joint	19	18.8
OCCUPATION	Unemployed	78	77.2
OCCUPATION	Employed	23	22.3
MARITAL STATUS	Married	73	72.3
	Unmarried	1	1
	Separated	1	1
	Widow/widower	25	24.8
	Divorced	1	1
Socio-economic Status	Upper	2	1.9
	Upper lower	36	35.6
	Upper middle	17	16.5
	Lower middle	46	45.5

Table 2

Absence/ Presence of stressful life events among participants sorted according to frequency
STRESSORS	FREQUENCY
Change in sleeping habit	32
Family conflict	29
Financial loss	25
Excessive alcohol/drug abuse by family members	17
Death of spouse	15
Change in eating habit	14
Illness of family members	7
Marital conflict	5
Large loan	4
Change in residence	4
Major construction of house	2
Trouble with neighbor	2
Unfulfilled commitment	1
Detention in jail of self or close family members	1
Death of close family members	1
Sexual problems	1
Marriage of daughter/dependent sister	1
Change in social activity	1
Suspense/dismissal from job	1
Marital separation/divorce	0
Extra marital relation	0
Lack of son	0
Property/crop damage	0
Death of friend	0
Robbery/theft	0
Conflict with laws	0
Broken engagement /love affair	0
Major personal injury	0
Trouble at work colleagues/subordinate	0
Prophecy of astrologer/palmist	0
Wife begins/stops work	0
Appearing for examination	0
Getting married/engaged	0
Change/expansion of business	0
Outstanding personal experience	0
Begin/end of school	0
Pregnancy of wife	0
Self/family members unemployed	0
Lack of son	0
Minor violation of law	0
Breakup with friend	0
Death of pet	0
Failure of examination	0
Going in pleasure trip/pilgrimage	0
Reduction in number of family function	0
Gain of new family member	0
Change in working condition/transfer	0
Conflict for dowry	0

Among 51 life stressors, 19 stressful life events were present in 101 participants.32 patients had change in sleeping habits,29 had family conflict,25 had financial problems,17 had excessive alcohol or drug use by family member,15 had death of spouse,14 had change in eating pattern,7 had illness of family members,5 had marital conflict,4 had large loan,4 had change in residence,2 had major construction of house,2 had trouble with neighbor,1 had sexual problems,1 had unfulfilled commitments,1 had marriage of daughter/dependent sister,1 had loss of family members,1 had suspense/dismissal from job,1 had detention in jail of self or close family members and 1 had change in social activities.

According to ICD-10 DCR diagnosis, 50 (49.5%) were found to be depressed followed by others (n = 51, 50.5%) which included Insomnia (9.9%), Anxiety Disorder (7.9%), Dementia(7.9%), Alcohol Dependence Syndrome (5%), Paranoid Schizophrenia (4%), Bipolar Affective Disorder-Current Episode Manic without Psychotic Symptoms (5%), Somatoform Disorder (1%),Mixed anxiety depressive disorder (4%) and Adjustment disorder (5.9%) respectively

Table 3

CHI- Square: Association between socio demographic profile and Depression (N = 101)
VARIABLES	CATEGORY	PREVALENCE OF DEPRESSION		P-value
VARIABLES	CATEGORY	Present	Absent	P-value
Age group (year)	60–69	28(27.7%)	32(31.7%)	0.584
	70–79	15(14.9%)	15(14.9%)
	80 and above	7(6.9%)	4(4%)
Gender	Male	11(10.9%)	41(40.6%)	0.00**
Gender	Female	39(38.6%)	10(9.9%)	0.00**
Family type	Nuclear	9(8.9%)	10(9.9%)	1
Family type	Joint	41(40.6%)	41(40.6%)	1
Marital status	Married	33(32.7%)	40(39.6%)	0.229
	Unmarried	0(0%)	1(1%)
	Separated	1(1%)	0(0%)
	Divorced	0(0%)	1(1%)
	Widow/widower	16(15.9%)	9(8.9%)
Socio-economic status	Lower middle class	25(24.8%)	21(20.8%)	0.840
	Upper lower class	16(15.8%)	20(19.8%)
	Upper middle class	8(7.9%)	9(21.8%)
	Upper class	1(1%)	1(1%)
Education	Illiterate	37(36.6%)	38(37.6%)	0.720
	Primary	11(10.9%)	11(10.9%)
	High school	2(2%)	1(1%)
	Undergraduate	0(0%)	1(1%)
Occupation	Unemployed	40(39.6%)	38(37.7%)	0.511
Occupation	Employed	10(9.6%)	13(12.9%)	0.511
Religion	Hindu	37(36.6%)	40(39.6%)	0.650
	Christian	0(0%)	1(1%)
	Buddhist	11(10.9%)	9(8.9%)
	Others	2(2%)	1(1%)
Caste	Brahmin	24(24%)	22(22%)	0.235
	Newar	13(13%)	10(10%)
	Chhetri	5(5%)	10(10%)
	Tamang	1(1%)	5(5%)
	Limbu	1(1%)	0(0)
	Others	6(6%)	3(3%)

Study showed that there is significant relation between gender and depression. However, it was found that there was no significant relation between depression and age group, religion, marital status, address, education, occupation, socioeconomic status and family type. Out of 73 married patients, 33 (32.7%) were found to be depressed. Out of 25 widowed patients, 16 (15.9%) had depression.

Table 4

ANOVA TEST: Relationship between Socio-demographic profile and Depression
Variable		DEPRESSION (GERIATRIC DEPRESSION SCALE)
		Mean +/- Std. Deviation	P-value	F-value
Age group	60–69	5.82 ± 3.648	0.863	0.147
	70–79	5.60 ± 3.440
	80 and above	6.27 ± 3.069
Sex	Male	4.08 ± 2.820	0.00**	34.812
	Female	7.63 ± 3.232
Occupation	Unemployed	6.01 ± 3.496	0.267	1.245
	Employed	5.09 ± 7.502
Socio-economic status	Upper class	6.50 ± 3.536	0.991	0.35
	Upper lower class	5.72 ± 3.731
	Lower middle class	5.80 ± 3.449
	Upper middle class	5.88 ± 0.835
Family type	Nuclear	5.93 ± 3.617	0.459	0.552
	Joint	5.26 ± 2.978
Number of stressor	No stressor	2.86 ± 1.580	0.00**	21.900
	1 stressor	3.38 ± 2.729
	2 stressor	5 ± 1.633
	3 stressor	7.60 ± 3.024
	4 stressor	8.50 ± 1.446
	5 stressor	9.27 ± 3.069

Compared to other demographics worldwide in the twenty-first century, the senior population is expanding quickly. To lessen the population's abrupt negative influence on the health infrastructures in the future, the health sectors of nations like Nepal should have adequate planning to address the population's expanding medical and mental demands.

One of the mental health issues affecting the elderly population is depression. It arises as a result of maladjustment under stressful conditions. In our study, it was discovered that elderly people (49.5%) had a significant prevalence of depression. Similar research on depression in the geriatric population in Nepal, which found that 53.2% of the samples suffer from depressed disorder according to GDS, complements the conclusion of our study.⁹

In this study, depression was present among 38.6% female and 10.9% male. This study was similar to the study done by D NK et al. conducted in South India where depression was more in elderly females (51.8%) than in male subjects (39.66%)and gender was statistically significant with depression.²⁰

In this study, depression was present among 32.7% who were married followed by widowed (15.9%) and separated (1%) respectively. This might be due to frequent marital conflict which has been seen as one of the major stressors associated with depression in our study, that lead to psychological stress and overall morbidity.

In this study, depression was present among 36.6% of Hindu, 11% of Christian and 2% of others which included Kirat and Muslim. Prevalence of depression in Hindu followers is more as compared to those following other religion. It could be because maximum number of the patients in this study followed Hinduism which also corresponds to National Population and Housing Census of Nepal, 2011 which states that Hinduism is the largest religion followed by 81.3% of population.²¹

Depression was present among 24% of Brahmin,13% of Newar,5% of Chhetri,1% of Tamang and 1% of Limbu and 6% 0f others which included Rai, Limbu, Tharu, Magar, Yadav and Muslim.

These findings are consistent to data of National population and Housing Census of Nepal 2011, which showed high percentage of Brahmin/Chettri among different castes in Nepal. ²¹Thesefindings differ with findings by Kohrt et al where depression was more prevalent in Dalit followed by Brahmin and Chettri. Difference in this findings may be due location of study, as study done by Brandon et al was carried out in far western region in Nepal, where distribution of Dalit /Nepali caste is higher.²²

In this study, prevalence of depression was 36.6% among illiterate, 10.9% among those who attended passed primary school level,2% who had passed high school level. This finding is consistent with the finding of studies done by the study ²³ where lower level of education was associated with depression.

In this study, depression was present among 39.6% of unemployed and 9.6% of employed. Unemployment is found to be the risk factor for depression in some of the studies conducted by Ganatra et al and Al-Shammari et al. ^24,25

In this study, depression was present in 40.6% of people living in joint family followed by 8.9% of people living in nuclear family. This finding could be due to the socioeconomic burden of number of family members living in joint family and family conflict which was also found to significantly associate with depression in our study, thus leading to psychological stress and depression. However, in some of the studies, it was concluded that elderly living in nuclear family or living alone lead to depression.²⁶

Depression was found to be most common psychiatric illness (49.5%), followed by Non-Organic Insomnia (9.9%), Dementia (7.9%), Anxiety Disorder (7.9%), Adjustment Disorder (5.9%), Alcohol Dependence Syndrome (5%), BPAD current episode manic without psychotic symptoms (5%), Paranoid Schizophrenia (4%), Mixed Anxiety Depressive Disorder (4%) and Somatoform disorder (1%).This finding was consistent with those of a study by Seitz et al, which found that dementia, depression, and anxiety disorders are the most prevalent psychiatric disorders among older adults in long-term care facilities. Substance use disorders, substance use disorders, and schizophrenia were also found to be prevalent.²⁷ Additionally, it was compatible with Ritchie et al research's findings²⁸ and a study²⁹ conducted in Nepal, which found that mood disorders predominated among other illnesses and were followed by psychosis, dementia, anxiety disorders, and alcohol dependence syndrome.

The PSLES was used in this study to assess 51 stressors from everyday life that are linked to depression. The study's subjects experienced a total of 19 stressors. This indicated that the quantity of stresses was substantially related to depression. Additionally, the results were comparable to those of a study by Shaikh et al., which revealed that participants experienced 20 stressful life events. The majority of the stressful situations were comparable. This might be as a result of Nepal and India having comparable sociocultural traits.³⁰

Geriatric depression has been highly linked to changes in sleeping and eating patterns, marital conflict, financial loss, family conflict, and spouse death, which is also consistent with research by El-Gilany et al, Li D et al, and Girgus JS et al.^10,31,32 It was also in match with the findings of a study by Simkhada et al., which showed that depression in older adults was significantly associated with illiteracy, physical immobility, the presence of physical health problems, not spending any time with family members, and not being taken into account in family decision-making.33

Additionally, this study demonstrated a connection between physical disease and depression. In this study, it was discovered that chronic illnesses such Diabetes Mellitus, Hypertension, Rheumatoid Arthritis, and Ankylosing Spondylitis were linked to depression in patients. It is comparable to a study where depression was strongly correlated with a physical health status measure.³⁴ Chronic illness lead to psychological stress, flares up inflammatory process which is suggested hypothesis for Depression.

This study included 101 participants in which the mean age of participants was 68.26 years. Male outnumbered female in our study and majority of the participants were illiterate, unemployed and belonged to joint family.

The prevalence of depression was found to be 49.5% out of which 14% had mild, 78% had moderate and 8% had severe depression. It was also found that gender was statistically significant with depression. It was also concluded that depression was more common in patients who were illiterate, unemployed and belonged to low socio-economic status and residing in joint family.

Similarly, among 51 life stressors, nineteen were present in our study and it was statistically significant with depression. It was also concluded that Geriatric Depression Scale could adequately pick up cases of depression diagnosed according to ICD-10 DCR.

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No competing interests reported.

Study of Prevalence of Depression and Associated Stressors Among Geriatric Patients Attending Psychiatry Department of Kathmandu Medical College; a Descriptive Cross Sectional Study

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Abstract

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Objective

Method

Result

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Introduction

Method

Results

Discussion

Conclusion

References

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