Research paperCourse of depressive symptoms and associated factors in people aged 65+ in Europe: A two-year follow-up☆
Introduction
Depressive disorders are common and affect more than 40.2 million people across Europe, with a prevalence of 5.1% in women and 3.6% in men (major depression and dysthymia), and they account for 8.1% of all years lived with disability (WHO, 2017). Depression is also the main indicator associated with lower quality of life (Conde-Sala et al., 2017, Portellano-Ortiz et al., 2018).
The review studies indicate that prevalence rates for clinically relevant depressive symptoms in older adults vary widely (7.2–49.0%) due to the different instruments, criteria, settings and methodologies used to collect data (Djernes, 2006). Although major depressive episodes are less common in older age (1–4%), what is referred to as sub-clinical depression is a particularly relevant phenomenon (8–16%), (Alexopoulos, 2005, Blazer, 2003).
In a recent study with a sample of people aged 65+ from 12 European countries, prevalence was 12.6% for cases of depression and 15.2% for sub-threshold depression, assessed with the Geriatric Mental State Examination (GMS-AGECAT) (Braam et al., 2014). However, the WHO study of the European region (WHO, 2016) warned that due to increasing life expectancy the burden of depression will progressively shift towards older age groups, among whom risk factors for depression such as bereavement and comorbid health conditions are more frequent.
Some of the most commonly used instruments to assess depressive symptoms are CES-D (Radloff, 1977), GDS-15 (Sheikh and Yesavage, 1986), and EURO-D (Prince et al., 1999), and they show higher prevalence than other instruments assessing only depressive disorders. Studies that have used the EURO-D scale to assess depressive symptoms in European countries have reported prevalence rates, between 17.8%−38.3% for the over-50s (Castro-Costa et al., 2007, Peytremann-Bridevaux et al., 2008) and 15.8%−41.4% in people aged 65 + (Damian et al., 2013, Conde-Sala et al., 2017, Belvederi Murri et al., 2018). The related factors are poorer self-rated health, female gender, financial difficulties, widowhood, fewer social activities and low educational level (Portellano-Ortiz et al., 2017). It is important to note that the prevalence of depressive symptoms varies according to geographical region, with rates being lower in northern Europe (Sweden, Denmark, The Netherlands) and higher in more southern countries (Italy, Spain, France), (Castro-Costa et al., 2007). This variability across different geographical areas is supported by other studies that have highlighted the importance of social and cultural factors such as level of education, income and loneliness (Guerra et al., 2016, Ylli et al., 2016).
Incidence rates for depressive disorders in Europe range between 3.4 and 4.2/100 person- years (Luppa et al., 2012a, Weyerer et al., 2013). Higher incidence has been associated with female gender, physical health problems, functional impairment, poor social networks and, in some studies, with older age (Weyerer et al., 2013).
Persistence rates range between 23.0% and 61.0% (Comijs et al., 2015, Gallagher et al., 2013, Luppa et al., 2012a), the associated factors being chronic disease, functional impairment, female gender, a history of depression and younger age at onset.
Remission rates are also variable (4.8%−60.0%) (Comijs et al., 2015, Houtjes et al., 2014, Luppa et al., 2012a), with the likelihood of remission being linked to less depression at baseline, less anhedonia and fewer neurovegetative symptoms at baseline (Andreescu et al., 2008), and better health and younger age (Kennedy et al., 1991) with respect to persistent cases. Remission has also been shown to be less likely among women (Barry et al., 2008).
The general aim of this study was to determine the course of depressive symptoms in a sample of people aged 65+ from 14 European countries over a two-year period. The specific aims were: 1. To identify the variables associated with depressive symptoms and their prevalence. 2. To determine the incidence, persistence and remission rates and to identify predictor variables and 3. To explore differences between four European regions: Northern, Continental, Eastern and Southern.
Section snippets
Study design
This was a prospective population-based study using data from waves 5 and 6 of the Survey of Health, Ageing and Retirement in Europe (SHARE), (Börsch-Supan et al., 2013), corresponding to the years 2013 and 2015 respectively. The data analyzed were for people aged 65+. The SHARE study provides information about sociodemographic variables, physical and mental health, quality of life, socioeconomic status and activities. This information was collected by means of a computer-assisted personal
Differences between valid and missing participants
From the total eligible sample of 31,491 participants aged 65+, 8,290 (26.3%) were lost to follow up for unknown reasons. At baseline (wave 5) and compared with cases that were followed up, lost cases were older, 81.3 ± 7.7 vs. 74.5 ± 6.6(t, p < 0.001,Cohen's d = 0.94), had fewer years of schooling, 7.4 ± 4.3 vs. 9.9 ± 4.4(t, p < 0.001, d = 0.57) and were more commonly female, 65.7 vs. 56.9% (χ2,p < 0.001,V = 0.04).More importantly, lost cases had poorer self-rated health, 68.2 vs. 45.2% (χ2,p
Factors associated with the prevalence of depressive symptoms
Regarding the first study aim, the multivariate analyses showed that the main variables associated with more depressive symptoms were poorer self-rated health, loneliness, impairment in ADL, female gender and financial difficulties.
The relationship between self-rated health and depression has been studied in various cultural contexts: Australia, Mexico, USA and Europe (Ambresin et al., 2004, Bustos-Vázquez et al., 2017, Jang et al., 2012, Portellano-Ortiz et al., 2017), and as in our analysis
Conclusions, strengths and limitations
Our results highlight important differences between European regions, especially between North and South Europe. The rates of depressive symptoms cannot be explained by individual factors alone, and cultural and socioeconomic aspects, according to the different welfare models, may have also a relevant role. The results of the study highlight the need for countries, especially in Eastern and Southern Europe, to provide greater support, resources and social benefits to the elderly, mainly those
Conflict of interest
All authors declare that they have no conflicts of interest.
Contributors
JL. Conde-Sala designed the study and wrote the manuscript jointly with O. Turró-Garriga. J. Garre-Olmo designed and supervised the statistical analysis. L. Calvó-Perxas, O. Turró-Garriga and J. Vilalta-Franch made significant contributions and a critical review of the manuscript. All authors contributed and approved the final manuscript
Acknowledgments
This paper uses data from SHARE Wave 5 (10.6103/SHARE.w5.610), and wave 6 (10.6103/ SHARE.w6.610), see Börsch-Supan et al., 2013 for methodological details. The SHARE data collection has been primarily funded by the European Commission through FP5 (QLK6-CT-2001-00360), FP6 (SHARE-I3: RII-CT-2006-062193, COMPARE: CIT5-CT-2005- 028857, SHARELIFE: CIT4-CT-2006-028812) and FP7 (SHARE-PREP: No. 211909, SHARE-LEAP: No. 227822, SHARE M4: No. 261982). Additional funding from the German Ministry of
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Author statement
JL. Conde-Sala designed the study and wrote the manuscript jointly with O. Turró- Garriga. J. Garre-Olmo designed and supervised the statistical analysis. L. Calvó-Perxas, O. Turró Garriga and J. Vilalta-Franch made significant contributions and a critical review of the manuscript. All authors contributed and approved the final manuscript.