Byline: Sandeep. Grover, Nidhi. Malhotra
To review the existing literature on depression among elderly arising from India. Search was carried out using PubMed, Google Scholar, Google, and Medknow search engines to identify the relevant studies. Most of the literatures that are available are in terms of prevalence of depression. Community-based studies involving 70 to 7,150 elderly subjects report prevalence rate varying from 8.9% to 62.16%. Clinic-based studies involving 50 to 5,260 participants report prevalence rates ranging from 42.4% to 72%. Studies have reported depression to be more common among females. Other demographic factors that have been associated with depression among elderly include being unmarried, divorced or widowed elderly, residing in rural locality, being illiterate, increasing age, lower socioeconomic status, and unemployment. Depression has also been shown to be associated with various psychosocial factors, lifestyle and dietary factors, and presence of chronic physical illness. There are limited data on various therapeutic interventions. Available data suggest usefulness of pranayam, cognitive behavior therapy, and electroconvulsive therapy. The review of data suggests that prevalence of depression among elderly in India is high. However, there is lack of data on symptom profile and limited data is available on various therapeutic interventions for the management of depression in elderly from India. There is urgent need to conduct large multicentric studies to fill this void in research.
Introduction
Over the last 70 years, life expectancy has increased in India. In 1951, life expectancy at birth was 36.7 years and as per the recent data of 2012, it is reported to be about 67 years. [sup][1] Resultantly, the proportion of the elderly population in India has risen from 5.6% in 1961 to 8.5% in 2011, and it will further rise to 9% by 2016. [sup][2] The Indian elderly population is currently the second largest in the world. [sup][3] Projections are being made that India will house 300 million elderly by 2050 and elderly will form 19% of the total population. [sup][3]
Age is an important determinant of mental health. Old age is a period of transition when one has to deal not only with the physical aging, but also with the challenges affecting the mental and social well-being. Due to normal aging of the brain, deteriorating physical health and cerebral pathology, the overall prevalence of mental and behavioral disorders tends to increase with age. [sup][4] Disability arising due to various illnesses, loneliness, lack of family support, restricted personal autonomy, and financial dependency are other important contributing factors for higher prevalence of mental and behavioral disorders.
Among the various mental disorders, depression accounts for the greatest burden among elderly. Depression decreases an individual's quality of life and increases dependence on others. If depression is left untreated, it can have significant clinical and social implications in the lives of the elderly. [sup][5] Early recognition, diagnosis, and initiation of treatment for depression in older people present opportunities for improving their quality of life, preventing suffering or premature death, and maintaining optimal levels of function and independence. Early diagnosis and effective treatment of depression in old age can also lead to significant reduction in mortality due to suicide and medical illnesses, and health care costs.
Although India is the second-most populous country in the world in terms of elderly population, there has been meager research on depression in elderly, and none of the review articles has attempted to compile the available literature. In this background, this review article attempts to look at the available literature arising from India with respect to depression in elderly. For this various search engines that is PubMed, Google Scholar, Google, and Medknow were searched using keywords that is elderly, geriatric, India, depression, symptomatology, prevalence, epidemiology, treatment, management, antidepressants, electroconvulsive therapy (ECT), psychotherapy, outcome, prognosis, and adverse effects in various combinations. The reference lists of the available articles were further evaluated to locate other possible articles. Available review articles [sup][6],[7],[8] related to the topic were also looked at to improve the comprehensiveness of the literature. Data presented in this review provide a comprehensive review of available literature.
Epidemiology of Depression among Elderly in India
Compared to other aspects of depression in elderly, a significant amount of literature is available on the prevalence of depression among elderly and many studies have been conducted in the last decade. As shown in [Table 1], we could locate 53 studies [sup][9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61] which have evaluated the prevalence of depression among elderly.{Table 1}
These studies have been done in various set-ups such as community, [sup][9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42] psychiatric clinics, [sup][47] inpatients in a hospital, [sup][47],[49],[50] and outpatient of medical clinics [sup][48],[51],[53],[57] etc. Occasional studies have also looked at the prevalence of depression in special populations like elderly living in old age homes. [sup][58],[59],[60],[61] However, most of these studies are community-based. The sample has largely been recruited from preassigned rural areas and urban slums. Few authors have recruited the entire population living in a village by house to house surveys, while others have selected the study population using various randomization techniques to recruit the sample. The most common instrument that has been used to evaluate depression has been Geriatric Depression Rating Scale (GDS), used in 24 of the 53 studies. Other instruments that have been used to diagnose depression include international classification of diseases (ICD), tenth revision (ICD-10) criteria, patient health questionnaire-9, Zung depression scale, and case detection schedule, etc. In most of the studies, the age cut-off which has been used to identify elderly patients is 60 or above. The sample size in community-based studies has ranged from as low as 70 to as high as 7150 and prevalence of depression has ranged from 8.9% to 62.16%. Some of the community-based studies have evaluated the prevalence of other psychiatric disorders too and have reported depression/affective disorders to be the most common psychiatric morbidity. [sup][10],[31],[47]
In a review of world literature, Barua et al ., (2011) [sup][62] evaluated the median prevalence rates of depression in elderly population of India and compared the same with the rest of the world. The median prevalence rate of depression among elderly was reported to be 18.2%, which was significantly higher than the rest of the world (5.4%). However, it is important to note that the comparison was based on only six relevant studies from India, which formed only 0.5% of total study sample evaluated, in contrast to the 68 studies from the rest of the world covering 99.5% of the participants. The largest community-based data arising from India come from the study on Global aging and adult health Wave-1 study. [sup][38] This study was conducted from 2007 to 2010 in six countries (China, Ghana, India, Mexico, Russian Federation, and South Africa) across the world. Depression was diagnosed on the basis of reporting of one or more of three symptoms (1) had a sad, empty, or depressed feelings (2) lost interest in most things that they usually enjoy such as personal relationships, work, hobbies/recreation, and (3) decreased energy or feeling tired all the time for 2 weeks in 12 months. Multistage, stratified, random cluster sampling design was used and those above 18 years of age were recruited. Data of those above 50 years of age extracted from this study show that the prevalence of depression among those aged above 50 years is highest in India (27.1%) followed by Mexico (23.7%), Russia (15.6%), Ghana (11%), South Africa (6.4%), and least in China (2.6%).
Prevalence of depression in clinic-based studies has ranged from 42.4% to 72%. The sample has varied from patients attending psychiatry units to multidisciplinary wards. Studies that have compared patients with specific medical illnesses with those without illnesses, in general, suggest that elderly patients with medical illnesses such as diabetes mellitus have a higher prevalence (42.4% versus 18%) of depression. [sup][51]
Studies comparing prevalence rate across different settings
Some of the studies have recruited subjects across different setting and have reported prevalence rates of depression. These studies suggest that the prevalence rate of depression is more in inmates of old age homes when compared with those either living in the community, affluent societies, and slums. [sup][58],[60],[61] Tiple et al ., 2006 [sup][59] did a study in Varanasi where they studied the psychological morbidity in four groups. Group A consisted of geriatric subjects who visited the Psychiatric Outpatient Department. Group B consisted of geriatric subjects suspected to have psychiatric illness and referred from the Geriatric Clinic. Group C consisted of householders living in Varanasi in the hope of attaining "moksha" and were paying for their boarding and lodging. They had occasional contact with their family members. Group D consisted of ascetics who had left their families earlier, and their daily living costs were borne by Mumukshu Bhavan (old age home). This study suggested that the prevalence of depressive disorders (Single episode, recurrent depression, and dysthymia) was highest among those suspected to have psychiatric disorders referred to geriatric clinics and least in ascetics.
Correlates/Factors associated with Depression in Elderly
Studies have consistently shown depression to be higher in elderly females [Table 2]. Other demographic factors that have been linked with depression among elderly include being unmarried, divorced or widowed elderly, residing in rural locality, being illiterate, increasing age, lower socioeconomic status, and being unemployed. The various psychosocial factors which have been shown to be associated with depression in elderly include loneliness, poor social/family support, isolation, dependency, lack of family care, and affection, insufficient time spent with children, stressful life events, perceived poor health, lower level of spirituality, and higher use of emotion-based coping. The lifestyle and dietary factors that have been linked with depression include lack of hobby, irregular dietary habits, substance use/smoking, and lack of exercise. In general, data also suggest that presence of chronic physical illnesses increases the risk of depression.{Table 2}
Prevalence of Physical Illnesses in Elderly Depressed Subjects
Some of the studies have focused on the physical health of elderly patients with depression. Sagar et al ., 1992 [sup][66] compared depressed with nondepressed elderly and found that though the prevalence of previously diagnosed physical illnesses did not differ between the two groups; however, previously undiagnosed physical illnesses were significantly higher in those with depression. Also, multiple physical illnesses were more commonly seen in the depressed group. Among specific disorders, hypertension, osteoarthritis, and cataract were significantly more common among depressives. On similar lines, Satapthy et al ., 1997 [sup][67] reported undiagnosed physical illnesses to be more common among elderly patients with depression than among matched control. In this study, 40 elderly subjects with depression were compared with a control group of 20 elderly subjects without psychiatric morbidity from general population. Multiple illnesses were present in 90% of the study group, in contrast to only 20% in the control group. The most common system involved was musculoskeletal followed by cardiovascular and ophthalmological systems. The common diagnoses in order of frequency were osteoarthritis 77%, hypertension 55%, cataract 47%, chronic respiratory disease 25%, ischemic heart disease 17%, and diabetes mellitus 12%. Among these, hypertension, osteoarthritis, and cataract were significantly more in the study group compared to the control group. The physical disabilities such as impairments of locomotion and vision were found in about 60% of patients and were significantly more in patient group than in controls. According to the authors, in 67% of the study samples, the physical illnesses and disabilities had an aggravating role in depression while in 7% depression was possibly secondary or unrelated. Of the all physical morbidities, in 76% of elderly depressed subjects, the physical illnesses were previously undiagnosed compared to 71% in control group. A community-based study reported that osteoarthritis (43.9%) followed by cataract (25.2%), hypertension (17.6%), diabetes (7.6%), and heart diseases (3.9%) were the common physical disorders seen in elderly patients with depression. [sup][30] Other authors have reported the association of cardiac illnesses, transient ischemic attack, past head injury, diabetes, [sup][11] stroke, and hypothyroidism [sup][17] to be more commonly seen among elderly patients with depression.
Depression associated with specific causes
A study evaluated the association of depression in elderly with various pharmacologic agents and concluded lack of association. [sup][68] A case report has linked depression in elderly with amiodarone. [sup][69] Another case report documented the association of bipolar depression with vitamin b12 deficiency. [sup][70]
Comparison of Sociodemographic and Clinical Profile with Young Adults
Occasional studies have compared the profile of elderly and adult patients with depression. Chakrabarti et al ., [sup][71] evaluated 31 elderly depressed subjects and compared them with 30 younger patients with depression. Patients in both the groups had similar sociodemographic and clinical profile. In addition, both the groups reported poor perceived support, an excess of undesirable life events before their episode.
Validation of Scales for Assessment of Depression among Elderly
Ganguli et al ., [sup][72] developed a Hindi version of the GDS and administered the same to 1,554 mostly illiterate Hindi-speaking residents' participants in rural community of Ballabgarh in Northern India. They found that Hindi version of the GDS-H had high internal consistency and a factor structure comparable to the original English language version. The overall distribution of scores was higher than reported from other populations. Higher scores on the GDS-H were associated with older age and illiteracy. Among the illiterate, there was no gender difference while, among the literate, higher GDS-H scores were found among women. Cognitive impairment and functional disability were independently associated with higher scores on the GDS-H after adjustment for age, gender, and literacy. Kannada version of the scale was also developed. [sup][33] Gujarati version of Beck Depression Inventory (BDI) has been pretested. [sup][52]
Symptom Profile/Phenomenology of Depression among Elderly
Studies from the west suggest that the symptoms of depression among elderly may be slightly different than that noted among adult population with anxiety symptoms and somatic symptoms being more common. [sup][73] However, studies from India have not evaluated the symptom profile of depression among the elderly patients. Occasional case reports have described the phenomenology of Cotard's syndrome in elderly patients with depression. [sup][74]
Perception and Attitude about Mental Illness
A study from Goa evaluated the cultural perceptions of mental illnesses and care arrangement using focus group discussions. [sup][75] They found that depression among elderly was not thought to constitute a health condition; rather it was considered a social condition. Tension, mental problem, depression, and worry were the terms used; it was attributed to abuse, neglect, or lack of love on the part of children toward a parent. They also found that the system of family care and support for older persons was less reliable than has been claimed. A caring family, a positive attitude, spiritual programs, "laughter clubs", talking to others, prayer, keeping up with varied interests, watching television, and seeing a psychiatrist were thought to be potentially effective interventions. The authors concluded that there is a need to raise awareness about mental disorders in late-life in the community and among health professionals, and to improve access to appropriate health care for the elderly with mental illness.
Impact of Depression
Few studies have evaluated the impact of depression in elderly. In a study on morbidity profile and its relationship with disability and psychological distress, Joshi et al . [sup][76] from Chandigarh found that among all the symptoms, depressive symptoms in the form of feeling of sadness was the most common symptoms, reported by 70.5% of the subjects. They also found that there was an inverse relationship between the number of physical morbidities and psychological well-being, and the disability increased with a decrease in psychological well-being. Depression in patients with Parkinson's disease has been reported to be associated with higher level of disability, poor quality of life, [sup][65] and higher motor disability. [sup][77] In patients with diabetes mellitus, depression has been shown to be associated with high postprandial sugar levels. [sup][51]
Suicidality in Elderly Depression
Surprisingly there is lack of research on suicidal behavior in elderly patients with depression. A study reported that suicidality in elderly patients with depression was strongly associated with impulsivity and hopelessness. [sup][78]
Prognosis of Late-Onset Depression
Only one study has evaluated the 12 months outcome of 50 patients. [sup][79] The authors reported that at the end of 1-year 28% of the patients had recovered, 30% had partially recovered, 23% had relapsed, 6% had been continuously ill, 11% had died, and 6% had developed comorbid dementia. Overall 12 months outcome was found to be poor in elderly individuals with late-onset depression. However, shorter duration of the episode at the baseline assessment and joint family system were associated with good outcome.
Management of Depression in Elderly
There is marked deficiency of research in the area of management. There are almost nondata in terms of evaluation of the efficacy of various antidepressant medications.
Pharmacological treatments
There has not been a single efficacy trial of antidepressants from India, which has specifically evaluated a medication among elderly patients with depression. A recent trial looked at the efficacy of milnacipran in 15 patients of poststroke depression, some of whom were older than 60 years (age range: 45-75, mean age-60), and reported remission rate of 85.7% for 12 patients who competed the study. [sup][80] A case report has shown the usefulness of modafinil in the treatment of a patient with treatment-resistant bipolar depression who had not responded to adequate trials of various mood stabilizers and antidepressants. [sup][81]
Nonpharmacological treatments
In contrast to studies on pharmacological treatment, higher numbers of studies have evaluated the beneficial effect of interventions like pranayama, music therapy, myofascial release therapy and, cognitive behavior therapy in the management of depression among elderly. The role of pranayama has been most commonly studied and it was shown to be helpful in reducing depression scores on GDS and BDI and improving the quality of life in elderly with depression. [sup][82],[83],[84] One study showed that use of music therapy decreased the prevalence of depression as rated by Quick Inventory of Depressive Symptomatology Scale reduced from 76.7% to 50%. [sup][85] A study evaluated the role of myofascial release therapy in reducing depression in elderly with chronic low back pain and found it to be effective in significantly reducing the depression scores on BDI. [sup][86] One study adopted the preexperimental and evaluative approach to assess the effectiveness of cognitive behavioral therapy in reducing the level of depression among geriatric people in Nattrampalli Taluk, Vellore District, Tamil Nadu. Depression was assessed by G. L. Brink depression scale among 4,258 geriatric subjects. Among them, 541 (12.7%) were found to have depression. Of these, 300 patients were selected by simple random sampling. The results of the study showed that in pretest 62% of them had mild level of depression, 38% had moderate level of depression. In posttest, 34.7% of them were rated to be normal, 62.7% had mild level of depression, 2.7% had moderate level of depression after receiving cognitive behavioral therapy, and there was significant reduction in depression. [sup][37]
Electroconvulsive therapy
In a survey of practice of ECT in teaching hospitals in India, Chanpattana et al ., [sup][87] found that subjects aged more than 65 years of age formed the third largest group of subjects who were administered ECT in various teaching hospitals in India. Although data specific to elderly were not available, overall depression was the second most common reason (after schizophrenia) for which ECT was used. One study from North India evaluated the effectiveness of ECT among elderly patients. The authors reported that elderly formed 15% of all the patients who received ECT. This retrospective study involved review of case records of 56 elderly patients receiving ECT, of whom 96% of patients received ECT for depressive episode. [sup][88] The index depressive episode for which ECT was used was severe in 91.6% of the subjects, and 68% had not responded to adequate psychotropic treatment before ECT. Comorbid medical illnesses were present in 66% of cases and were associated with significantly higher risk of cognitive side effects. With ECT, 70% of the patients showed more than 50% reduction in the scores on standardized scales and 12% of patients showed partial response in the form of 25-50% reduction in the in the scores on standardized scales. Those who had received inadequate antidepressant treatment before ECT were significantly more likely to respond to ECT. However, side effects were usually mild; there were no serious untoward events caused by ECT. About 80-90% showed some response to treatment. [sup][88]
A recent study assessed the knowledge about and attitude toward ECT among 102 elderly patients with severe mental disorders who had never received ECT. Most (94%) of these patients had an affective disorder with unipolar depression being the diagnosis in 78.4% of the patients. Authors reported that none of the patients had full knowledge about ECT and majority of the patients were not aware of the basic facts about ECT. Except for the fact that ECT involves the use of electric current and can be given by a doctor, more than two-third of the patients were unaware of the basic facts about the procedure of ECT. Less than half of the patients were aware of the need for informed consent. Knowledge about indications, efficacy, and side effects of ECT was also very poor. In terms of attitude toward ECT, on most (15 out of 16) of the items of the scale used, positive attitudes toward ECT were found in less than half of the patients (8.8-44.1%). In addition, significant proportions of patients were uncertain about their attitudes to ECT (35.3-66.7%) or had a negative attitude toward ECT (4.9-32.4%). There was a significant positive correlation between the total knowledge and attitude score, suggesting that higher knowledge was associated with more positive attitude and vice versa. There was no relationship of total knowledge and total attitude score with demographic and clinical variables. [sup][89]
Side effects of antidepressants
There are a few case reports [Table 3], which have reported side effects with antidepressants. Most commonly reported side effect with antidepressants is hyponatremia. Other side effects seen in few case reports include serotonin syndrome and worsening of hypertension.{Table 3}
Prescription patterns
One study evaluated the commonly prescribed psychotropics among elderly attending the walk-in clinic of a Tertiary Care Hospital. This study suggests that among the elderly patients with depression, escitalopram is the most commonly prescribed antidepressant, followed by sertraline, venlafaxine, and mirtazapine. [sup][101]
Discussion
The elderly population is on rise in India and Asia, and this suggests that there is a need to develop the area of Geriatric Psychiatry. [sup][102],[103] Accordingly, there is a need to understand the commonly occurring disorders in this population.
What are the implications of available data?
Available literature arising from India suggests that the prevalence rate of depression is significantly high among elderly population. Cross nation data suggest that the prevalence rate of depression among elderly in India is possibly higher than other developing and less developed countries. [sup][38],[62] At present, major proportion of the elderly population in India resides in rural localities, which have poor assess to mental health services, as psychiatric services are more or less concentrated in the urban areas. Accordingly, most of the care to the elderly is provided by the primary care physicians. Keeping this in mind, it is important to train the primary care physicians to diagnose and manage depression among elderly. Further, keeping in mind the fact that depression is more common among those suffering from various physical illnesses, there is a need to train the specialists from different disciplines to identify and manage depression.
Data from India suggest that various psychosocial factors such as loneliness, poor social/family support, isolation, dependency, lack of family care and affection, insufficient time spent with children, stressful life events, perceived poor health, lower level of spirituality, and higher use of emotion-based coping increase the risk of depression among the elderly. Traditional joint family structure in India is on a downhill, and it is being replaced by nuclear families. [sup][104] If one takes this into account along with the psychosocial factors associated with depression among elderly, it can be said that over the years there would be a significant rise in depression among the elderly. Hence, before such a scenario arises, there is a need to emphasize the importance of joint family structure and encourage people to follow the same.
The lifestyle and dietary factors linked with depression suggest that there is a need to encourage geriatric patients to indulge in regular exercise, abstain from various substances including smoking, maintain regular dietary habits and develop hobbies to keep themselves occupied.
Studies from India are in concordance with the findings from other countries which suggests that in medically ill geriatric patients depression is associated with higher level of disability, dysfunction, poor quality of life, and poor outcome. [sup][105],[106],[107] Accordingly, all elderly patients suffering from various physical illnesses must be screened for depression, and it must be treated adequately.
What are the deficiencies in the literature?
At present, it can be said that research on elderly depression from India is meager. Although many studies have evaluated the prevalence of depression in elderly, the majority of them have relied just on the use of various rating scales by nonpsychiatrists. Only a few studies have relied on diagnostic instruments to confirm the diagnosis of depression. All the available studies are single center studies. Hence, there is a need for a multicentric study relying on two-stage evaluation (screening followed by confirmation of diagnosis by a psychiatrist) to study the prevalence of depression among elderly. Till date, none of the studies has specifically focused on the incidence of depression among elderly. There is a need to follow-up a cohort of elderly patients to study the incidence rates.
There is lack of data on the symptom profile, etiology, suicidal behavior, neurobiology, management, course and outcome, association of depression with other psychiatric disorders such as dementia and delirium, and bidirectional relationship of depression with various physical illnesses. Similarly, there are no data on resilience. Many cultural factors, such as religion and spirituality, can play an important role in the prevention of depression and also have important implications in the management of depression. These have also not been evaluated thoroughly. Researchers working in the area of Geriatric Psychiatry must take-up studies to fill this void. Surprisingly there are no data on bipolar disorders among elderly.
To conclude, this review suggests that depression is quite common among elderly living in the community in India. Prevalence of depression is also quite common among elderly patients attending different medical set-ups. These high prevalence rates suggest that there is a need to sensitize the primary care physicians and specialists from different specialties to identify and manage depression. There is a significant gap in research evaluating various aspects of depression in elderly in India. Accordingly, there is an urgent need to focus on depression among elderly. There is a need for multicentric, longitudinal studies evaluating various aspects of depression.
Financial support and sponsorship
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Conflicts of interest
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