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Even mild depression reduces health related quality of life (HRQL) among healthy elderly.

INTRODUCTION

Demographic transition is occurring very rapidly throughout the world resulting in an increasing absolute number as well as relative amount of elderly people in developing and developed countries. (1) Inevitably, increasing age is associated with increased exposure to risk factors and reduced adaptability (2), which results in disease, vulnerability and reduced quality of life. (3,4) During the last decades the evaluation of quality of life among older adults has become increasingly important in health as well as in social sciences. (5-12) Within the medical sciences the term quality of life is a concept with a history dating back to the sixties, although the initial attempts to quantify and analyze social phenomena, comparable to quality of life, but using other terms, were introduced in the 19' century, in England. Since the seventies the number of papers focusing on quality of life or health related quality of life increased exponentially and the concept of quality of life became a key term in medical indexes. (13) This concept however remained problematic because no compulsory definition was accepted. Therefore in 1991 the WHO (World Health Organisation) started to develop a unifying and trans-cultural definition of the quality of life. They defined it as "the individual's perception of his or her position in life, within the cultural context and value system he or she lives in, and in relation to his or her goals, expectations, parameters and social relations. "It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships and their relationship to salient features of their environment". (14)

Based on this definition the concept of health related quality of life was introduced, which is a broad and multidimensional model that includes various domains of physical, psychological and social health. (14) The process of senescence affects all these domains and reduce health related quality of life among the elderly in general. Beside the expected somatic impairment such as poor physical health and increased vulnerability, there are age-typical psychosocial problems, first of all loneliness and geriatric depression, which contribute to marked reduction of well being among old aged people. Although major depression is less common among elderly in comparison to middle aged populations (15-18), depression is the most prevalent mental function disorder among elderly worldwide. (19-20) Also, although depression is not age-related and not a part of normal ageing, especially mild depression has been considered a "normal" effect of ageing. (21-23) Therefore the impact of depression on health related quality of life was predominantly tested among people suffering from major depression, among hospitalized people and nursing homes residents. (24-26) These studies have shown that depression--first of all major depression--is one of the major causes of decline in health related quality of life of elderly persons. But it should not be forgotten that depression in later life is largely an undetected and untreated condition. Mild depression is interpreted as a normal part of ageing and studies considering the effects of mild depression on health related quality of life are rare.

The aim of the present study is to assess the impact of mild depression on health related quality of life among healthy and independently living elderly.

SUBJECTS AND METHODS

* Subjects and data collection The participants enrolled in the study were totally 161, aged between 57 and 95 years old (x=71.8 +/- 8.6). The sample comprised 63 male participants ageing between 58 and 89 years (x=71.8 +/- 7.7) and 98 women ageing between 57 and 94 years (x=71.9 +/- 9.1). The first participants were contacted with the help of senior organizations. Then recruitment continued by broadcasting in newspapers and snowball system.

All participants originated from Austria. It was a strict inclusion criterion that the participants were active and not needing constant attention. They lived independently in private homes and not in geriatric homes for old aged people. The participants were assessed objectively through the Mini Mental State Examination and were considered cognitively able to answer the questions. Acute diseases, severe chronic diseases and a history of depressive or psychic disorders were exclusion criteria.

All participants of the present study belonged to the typical social middle class in Austria. All had a regular income and--as everybody in Austria--a health insurance. The monthly income of female participants was lower (insignificantly), in comparison to that of the male participants. The income was not integrated in the analyses because some participants (19%) did not give information regarding their income.

At the time of investigation all participants were healthy and were informed about the objectives and methodology of the study. Beside the objectives of the study, the right to withdraw at any time was explained. Strict confidentiality was ensured.

The data collection process took place by means of face to face interviews. Trained interviewers conducted the interviews based on a structured questionnaire in the private homes of the participants.

The study was conducted in compliance with the Ethical principles for medical research involving human subjects, according to the Helsinki Declaration.

* Questionnaire The questionnaire was divided into three parts. The first part comprised socioeconomic, medical and reproductive history information. The second part comprised a scale for measuring depression in the elderly. Part three comprised the WHOQOL-BREF questionnaire. Before starting the data collection a pre-testing was carried out on twenty participants in order to screen for potential problems in the questionnaire. As no problems were observed the data collection started.

Part 1

This part included questions regarding socio-economic parameters such as educational level, professional training, marital status, living situation (alone versus partnership) and place of residence. Additionally, medical and reproductive history as well as social contact frequency were reported.

Part 2

The German version of the 15 item Geriatric Depression Scale (GDS) was incorporated in the interview. The Geriatric Depression Scale was designed specifically for rating depression in ages more than twenty five years. (27) Up to now the GDS is the most common testing tool for older population. This originally 30-item, yes/no questionnaire has been shown over the years to be a valid instrument for assessing depressive symptoms. Nevertheless in 1986 a short form of the GDS comprising 15 items was developed by Sheikh and Yesavage. This 15-item GDS is a short version of the original GDS, including items more strongly correlated to the detection of depression. According to the obtained depression score, the participants were classified as non depressive (score 0 to 4), mildly depressive (score 5 to 10) or severely depressed (score 11-15). The validity and reliability of the GDS-30 as well as the GDS-15 has been proved in several studies. (28-32)

Part 3

WHOQOL-BREF

Health related quality of life was determined by means of the WHOQOL-BRE. WHO developed a 100-item quality of life (QOL) assessment instrument, the WHOQOL-100 based on the definition of WHO definition of health related quality of life, presented in the introduction. (33) The WHOQOL-100 was developed simultaneously in 15 field centres around the world. The important aspects of quality of life and ways of asking about quality of life were drafted on the basis of statements made by patients with a range of diseases, by healthy people and by health professionals of different cultural background. The WHOQOL-100 was rigorously tested to assess its validity and reliability in each of the field centres. (33)

The World Health Organization's Quality of life questionnaire (WHOQOL-BREF) was used in the present study, for the assessment of health related quality of life. This questionnaire is an abbreviated 26 item version of the WHOQOL-100 and it has been developed using data from the field trial version of the WHOQOL-100. According to the WHOQOL Group (33) the WHOQOL-BREF provides a valid and reliable alternative to the assessment of domain profiles using the WHOQOL-100. The high reliability and validity of the WHOQOL-BREF has been shown for several populations worldwide. (34-36) Therefore the WHOQOL-BREF seemed to be suitable for the present study, too (the German version of the WHOQOL-BREF according to Angermeyer et al (37)).

The WHOQOL-BREF contains two items from the Overall Quality of Life and general Health facet and one item from each of the remaining 24 facets. (33) These facets are categorized into four main domains:

(DOM I)--Physical capacity, comprising 7 items, (DOM II)--Psychological Well-being, comprising 6 items, (DOM III)--Social Relationships comprising 3 items and (DOM IV)--Environment, comprising 8 items.

All items were rated on a 5-point scale with the higher score indicating a higher quality of life. The domain scores were calculated by multiplying the mean of all facet scores included in each domain by a factor of 4 and accordingly, potential scores for each domain ranged from 4 to 20.

* Statistical analysis Statistical analyses were carried out using SPSS for Windows version 15.0. After calculating descriptive statistics (means, standard deviations, range, absolute and relative frequencies) student t-tests and [chi square] were computed to test group differences with respect to their statistical significance. Additionally linear regression analyses were performed to test the impact of depression, age, number of offspring, educational level and family status on health related quality of life. The critical value for testing significance was p < 0.05.

RESULTS

* Socioeconomic factors and reproductive history The socioeconomic factors and the reproductive history data of the participants are presented in table (1). While women and men did not differ in number of children and offspring, significant gender differences in family status, living situation and educational level were observed.

* Assessment of depression The development of depression was moderate among the study participants. According to the depression score with the use of the Geriatric Depression Scale, no participant could be classified as severely depressive. Only the 12.2 of women and the 12.1.% of men exhibited symptoms corresponding to the definition of mild depression. The mean depressive score was 2.80 +/- 2.06 among women and 2.79 +/- 2.31 among men. In other words no gender differences in the frequency and the degree of depression were observable.

* Depression and health related quality of life

Comparing the individual domains between depressive and non depressive males and females, it turned out, that depressive women and men rated their quality of life significantly lower (p <0.000) than their non depressive counterparts. This was true of global quality of life, physical capacity (DOM I), psychic capacity (DOM n), social relationships (DOM III) and environment (DOM IV) (see table 2).

* Factors affecting health related quality of life

According to the results of the multiple regression analyses, depression, estimated by the depression score, had a significant impact on general quality of life. This was true of both genders. With increasing depression score the level of health related quality of life decreased significantly. Additionally age had a significant impact on global domain and physical capacity (DO I) among female participants. Marital status and the number of offspring affected the global domain significantly in both genders and the environmental domain the males. The most important factor influencing health related quality of life however, was the depression score (see table 3).

DISCUSSION

Depressive illness can manifest as mild or severe depression characterized by a collection of depressive symptoms ranging from dysphoria, which may affect almost everyone from time to time, to a diagnosed depressive disorder. (38) According to the WHO it is also projected that depressive illness during old age will represent the second leading cause of disability world wide in 2020. (39) Old age depression may be the commonest but also the most reversible mental health problem. (40) Nevertheless depression affects quality of life and even heath related quality of life during old age. Unfortunately the impact of depression has been tested among severely depressed elderly suffering from various acute or chronic diseases such as heat failure, hip fractures or persons living in geriatric nurses homes so far. (10,41,42) The impact of mild depressive symptoms among healthy independent ling elderly on their health related quality of life has not been tested.

The current study focuses on the impact of mild depressive disorders among older adults on their health related quality of life. There is no doubt that experiencing symptoms of depression, a mood disorder characterized by chronic sadness and feelings of hopelessness, is a relatively common occurrence among elderly. (43) Studies of the prevalence of depression in community samples of older people have been reported from several countries. The results of those studies however, are remarkably inconsistent and major depressive symptoms are mostly considered. According to Buys et al (44) approximately one third of older rural Australians (37%) and Americans (28%) exhibited depressive symptoms. Paivarinta et al (45) reported a prevalence of 44% of minor and 4% of clinically relevant depression among older Finnish adults. In contrast, a study carried out in Zaragoza (Spain) yielded only 4.8% minor and 1.0% major depression among people aged over 65 years. (46) A low prevalence of depressive disorders was also reported in studies coming from Athens (Greece) (47), Canberra (17) and Edmonton (Canada). (48)

In the present study 12.1% of the enrolled men and 12.2% of the enrolled women expressed symptoms of mild depression. Nobody could be classified as major depressed according to the categories of the Geriatric Depression Scale. (27) This percentage of minor depression is slightly higher than those reported in some studies mentioned above, but is significantly lower than those presented by Paivarinta et al (45), Buys et al (44) and Jeste et al (49), who pointed out that between 15 and 25% of adults aged 65 and older are affected by clinically relevant depression. The relatively low percentage of depressive symptoms among the participants of the present study may be due to the fact that only healthy independent living men and women without a history of mental or psychic disorders were enrolled in the present sample. Comparable prevalence of mild depression was published by Fiske and Jones (50), who found minor depression in 3 to 13% of older adults.

The majority of studies described mark gender differences in the prevalence of depressive symptoms among older adults. Generally elderly women are more affected than men of comparable age. (18,51-55) Therefore depression is often considered typical of women and especially in aged women. In the present study this assumption could not be proved, because women and men exhibited nearly the same frequency of mild depression. The aim of the present study however, was not to search about gender differences, but to assess the impact of mild depression on health related quality of life among healthy independently living elderly.

The comparison of depressive and non depressive subjects yielded a significant reduction in the health related quality of life among depressive persons. This was true in all domains of health related quality of life, and not only in psychic or social domains. Additionally no gender differences in this aspect were observable.

Looking at the impact of depression score and several socioeconomic factors on the individual domains of health related quality of life, it turned out, that in men and in women the depression score influenced all domains of health related quality of life significantly, while no significant impact of other socioeconomic factors on the individual domains were observable. These results are in accordance with those of Koivumaa-Honkanen et al (56) and Pyne et al (57), who also reported a worse perception of health related quality of life among elderly persons suffering from depressive disorders.

Health related quality of life during old age varies between people according to their individual experience of health and disease. Depression, even the mild form, impacts many on the life of elderly in many ways. Depressed mood might lead to feelings of hopelessness and helplessness and a reduced meaningfulness of life. Physical health problems, described to be the reasons for depression and the health related quality of life measurements by many authors (10,19,41,42,58,59) are not applicable in the outcomes of the present study. Furthermore, economic problems, low educational level or/and low social status may contribute to a reduced health related quality of life according to Breeze et al (60), are also to be excluded as explanation in the present sample, because all participants belonged to the social middle class, none reported economic problems an all were well integrated in the well-working social security system of Austria.

In conclusion, we found the presence of 12% mild depression sufferers in the group of our study on healthy elders and we found that depressive symptoms had a negative impact on the perception of their state of health and the health related quality of life. Since only few studies consider the impact of mild depression on health related quality of life among healthy not impaired elderly, future research seems to be absolutely necessary.

* Acknowledgements The authors are gratefully indebted to their probands for their cooperation. The project was supported by the Hochschuljubil umsfond (project number: H 1667/2006).

* Conflict of interest: None declared.

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Sylvia Kirchengast * Beatrix Haslinger

Department of Anthropology, University of Vienna, Austria

Address for correspondence: Univ. Prof. Dr. Sylvia Kirchengast

University of Vienna

Department of Anthropology

Althanstrasse 14

A-1090 Vienna, Austria

E-mail: sylvia.kirchengast@univie.ac.at
Table 1. Parameters of reproductive history and socioeconomic
description

                                        women

Age in years                      71.9 [+ or -] 9.1
Age at menarche                   13.3 [+ or -] 1.6
Age at menopause                  49.8 [+ or -] 4.9
Number of Children (n)             1.9 [+ or -] 1.6
Number of offspring                4.4 [+ or -] 4.5

Marital status

Single                               15 (15.6%)
Married                              43 (44.8%)
Partnered                             2 (2.1%)
Separated                             2 (2.1%)
Divorced                              6 (6.3%)
Widowed                              28 (29.2%)

Living situation

Alone                                   56.1%
With a partner                          43.9%

Educational level

Primary school                       13 (13.4%)
Professional training                15 (15.5%)
Secondary school                     31 (32.0%)
College diploma                      24 (24.7%)
University degree                    14 (14.4%)

                                         men

Age in years                      71.8 [+ or -] 7.7
Age at menarche                          --
Age at menopause                         --
Number of Children (n)            2.2 [+ or -] 1.5
Number of offspring               5.5 [+ or -] 5.2

Marital status

Single                                3 (4.9%)
Married                              53 (86.9%)
Partnered                             0 (0.0%)
Separated                             0 (0.0%)
Divorced                              4 (6.6%)
Widowed                               1 (1.6%)

Living situation

Alone                                   24.2%
With a partner                          75.8%

Educational level

Primary school                        3 (4.8%)
Professional training      [chi sqaure] = 14.1515 (24.2%)
Secondary school                      8 (12.9%)
College diploma                      18 (29.0%)
University degree                    18 (29.0%)

                           Significance ([chi square])/t-value

Age in years                            n.s.
Age at menarche                          --
Age at menopause                         --
Number of Children (n)                  n.s.
Number of offspring                     n.s.

Marital status

Single
Married                         [chi square] = 33.49
Partnered                             P <0.000
Separated
Divorced
Widowed

Living situation

Alone                           [chi square] = 15.73
With a partner                        P <0.000

Educational level

Primary school
Professional training           [chi square] = 14.15
Secondary school                      P <0.007
College diploma
University degree

Table 2. Health related quality of life and depression

WHOQOL BREF                             women

                       depression       No depression
                       x(SD)            x(SD)             p-value

DOM global             12.44 (2.88)     16.09 (2.07)         0.000
DOM I physical         12.99 (2.47)     16.55 (2.43)         0.000
DOM II psychic         13.39 (1.41)     16.16 (1.50)         0.000
DOM III social         13.33 (1.89)     16.26 (2.29)         0.001
DOM IV environment     15.09 (1.66)     17.26 (1.69)         0.000

WHOQOL BREF                             men

                       depression       No depression
                       x(SD)            x(SD)               p-value

DOM global             12.00 (4.21)     15.73 (2.38)         0.002
DOM I physical         12.03 (4.25)     16.44 (2.37)         0.000
DOM II psychic         12.11 (2.17)     16.35 (1.60)         0.000
DOM III social         14.09 (2.16)     15.89 (2.25)         0.050
DOM IV environment     15.21 (1.70)     17.26 (1.89)         0.009

Table 3. Multiple regression analysis

WHOQOL BREF Domains         [R.sup.2]      coefficient      p-value

                                              Women

Global

Depression score              0.44           -0.52            0.00
Age                                          -0.09            0.01
Educational level                             0.04            0.84
Marital status                                0.24            0.05
Number of offspring                          -0.22            0.04

DOM I physical

Depression score              0.57           -0.63            0.00
Age                                          -0.13            0.00
Educational level                             0.13            0.45
Marital status                               -0.17            0.13
Number of offspring                          -0.20            0.54

DOM II psychic

Depression score              0.47           -0.52            0.00
Age                                          -0.02            0.39
Educational level                             0.25            0.06
Marital status                               -0.01            0.95
Number of offspring                          -0.01            0.97

DOM III social

Depression score              0.23           -0.49            0.00
Age                                          -0.05            0.19
Educational level                             0.08            0.71
Marital status                               -0.07            0.62
Number of offspring                          -0.15            0.69

DOM IV environment

Depression score              0.31           -0.46            0.00
Age                                          -0.02            0.33
Educational level                             0.10            0.49
Marital status                               -0.02            0.84
Number of offspring                          -0.12            0.63

WHOQOL BREF Domains       95% confidence    [R.sup.2]      coefficient
                             interval

                                                       men
Global

Depression score           -0.75 - -0.29        0.39         -0.71
Age                        -0.14 - -0.03                      0.06
Educational level          -0.35 -  0.42                     -0.25
Marital status             -0.01 -  0.48                     -0.32
Number of offspring        -0.39 -  0.86                      0.88

DOM I physical

Depression score           -0.82 - -0.43        0.49         -0.81
Age                        -0.18 -  0.08                     -0.03
Educational level          -0.21 -  0.47                      0.10
Marital status             -0.39 -  0.05                      0.31
Number of offspring        -0.85 -  0.45                     -0.22

DOM II psychic

Depression score           -0.67 - -0.38        0.64         -0.73
Age                        -0.05 -  0.02                     -0.01
Educational level          -0.01 -  0.49                     -0.23
Marital status             -0.17 -  0.16                      0.13
Number of offspring        -0.41 -  0.39                      0.15

DOM III social

Depression score           -0.75 - -0.23        0.09         -0.27
Age                        -0.11 -  0.02                     -0.01
Educational level          -0.23 -  0.27                     -0.22
Marital status             -0.37 -  0.22                     -0.11
Number of offspring        -0.89 -  0.59                      0.06

DOM IV environment

Depression score           -0.63 - -0.29        0.42         -0.47
Age                        -0.06 -  0.02                      0.01
Educational level          -0.19 -  0.39                      0.10
Marital status             -0.21 -  0.17                      0.52
Number of offspring        -0.62 -  0.38                      0.54

WHOQOL BREF Domains          p-value        95% confidence
                                               interval

                                      Men

Global

Depression score              0.00           -1.07 - 0.36
Age                           0.33           -0.07 - 0-19
Educational level             0.42           -0.87 - 0.37
Marital status                0.59           -1.43 - 0.79
Number of offspring           0.04            0.03 - 1.73

DOM I physical

Depression score              0.00           -1.11 - 0.51
Age                           0.62           -0.13 - 0.08
Educational level             0.69           -0.40 - 0.60
Marital status                0.37           -0.38 - 1.00
Number of offspring           0.09           -0.48 - 0.04

DOM II psychic

Depression score              0.00           -0.92 - 0.54
Age                           0.95           -0.07 - 0.06
Educational level             0.14           -0.52 - 0.07
Marital status                0.55           -0.29 - 0.55
Number of offspring           0.49           -0.29 - 0.59

DOM III social

Depression score              0.08           -0.59 - 0.04
Age                           0.92           -0.11 - 0.10
Educational level             0.40           -0.73 - 0.29
Marital status                0.78           -0.83 - 0.62
Number of offspring           0.88           -0.69 - 0.87

DOM IV environment

Depression score              0.00           -0.69 - -0.26
Age                           0.72           -0.06 -  0.09
Educational level             0.55           -0.23 -  0.46
Marital status                0.04            0.02 -  1.02
Number of offspring           0.04            0.02 -  1.05
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Title Annotation:ORIGINAL ARTICLE
Author:Kirchengast, Sylvia; Haslinger, Beatrix
Publication:Journal of Medical Psychology
Article Type:Report
Geographic Code:4EUUE
Date:Jan 1, 2009
Words:5559
Previous Article:Welcome to the journal of medical psychology.
Next Article:Psychoanalytical theory of affects and its applicability on the affect regulation and affect experience Q-sort test (AREQ).
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