The present study revealed that the elderly living in a nuclear family system were more likely to be depressed as compared to those in a joint family system. The prevalence of depression was moderately high among the elderly in our study population. About one in five of the elderly being depressed is a cause of concern. It was also shown that several important socio-demographic variables had a significant association with depression in the elderly.
Prevalence of Depression
The prevalence of depression in the elderly in our study was 19.5%. No published data was found which reported the prevalence of depression in the elderly in Pakistan. A recent systematic review revealed that the prevalence of anxiety and depressive disorders in Pakistan was 34% [
11]. Local studies have shown great variation in the prevalence of depression: 10% [
31] to 66% [
12]. It is unclear whether this variation reflects methodological differences in study designs and instruments or true differences in prevalence. The prevalence among the elderly in our study is high and a cause of concern. It cannot be said whether the prevalence is higher or lower in the elderly as compared to adults (15–64 years), because there are no large scale epidemiological studies present.
The prevalence of depression in Caucasian elderly populations in the West varies from 1% to 42% [
32]. As for developing countries, there is paucity of literature on elderly populations. India is a neighboring country of Pakistan with a similar socio-demographic structure. The prevalence rates for depression in community samples of elderly in India have varied from 6% to 50% [
17,
18]. The prevalence computed in our study lies in the lower part of this spectrum.
Family Systems
The traditional family system in South Asia is the joint family system [
13]. The greater proportion of the population in Pakistan (66%) lives in rural areas where the main occupation is agriculture [
9]. The joint family system is predominant in the rural areas. One of the main advantages of a joint family system is the availability of a large workforce for occupations which demand one, like agriculture. Also, housing costs are shared. There is usually a joint economic production from the male members of the household.
In a joint family system, there exists a strong differentiation of authority across generations, and a relatively passive role of females. The elderly male holds an authoritative place in the family because he controls the family's property and exerts control over the younger generation. Their position demands obedience and loyalty. On the contrary, elderly females possess limited authority over the household and its matters. Despite the disparity in roles, both elderly males and females are shown respect by the younger generation in the family.
In urban areas, dissolution of the joint family system is likely due to the problems of housing (large families being unable to live under one roof) and occupational alternatives which result in the younger generation undergoing separation of economic production. One of the main consequences of this separation is a loss of the 'elderly power' over the younger generation [
33,
34]. This promotes nucleation of family systems, since the elderly male has lost his source of power over the younger generation: the possession of the family's resources. Nucleation leads to a decrease in co-residence of the elderly with adult children and therefore a decrease in care and support of the elderly.
Mason and Bongaarts have both suggested that urbanization would lead to nucleation of family systems in developing countries and a decrease in the support of the elderly [
13,
14]. A companion paper has suggested that more and more people were adopting the nuclear family system in Karachi [
15]. This suggests a possible erosion of the joint family system in Karachi.
Consistent with the effects of urbanization on elderly care and family structures discussed above, the current study found that the elderly living in a nuclear family system were four times more likely to suffer from depression than those living in a joint family system. A joint family is much better able to provide support to the elderly than a nuclear family system, especially physical, social and emotional support. Financial support of the elderly can still be ensured by children or relatives even if they reside elsewhere. A study done in India showed that living in a joint family system was associated with a favorable outcome in elderly suffering from depression [
35].
When the elderly contract a chronic somatic illness and undergo functional decline, it makes them strongly susceptible to depression [
32,
36]. In a nuclear family system, there are less caregivers to provide physical support and this can contribute to depression because the morbidities associated with chronic illnesses can be compounded if there is insufficient physical support. In a joint family system, the elderly have more interactions with people at home. These social interactions are experienced less in a nuclear family system. Prince et al. showed that social support deficits had a strong association with depression in the elderly [
37]. Nuclear family systems also lack the emotional support which is provided to the elderly in a joint family system. Multiple other problems like spousal death, accidents, ill-health, or financial burdens are much more bearable by the elderly if family support is present.
Four studies done in Pakistan evaluated the association between depression and family systems [
12,
31,
38,
39]. Three of these studies were done by the same author using the same instrument in rural areas of Pakistan. Out of the four studies, two reported no association with family systems [
38,
39], one reported that women living in nuclear family systems were more likely to suffer from depression [
12] and one reported that females living in joint family systems were more likely to suffer from depression [
31]. These findings were not conclusive on the subject. Our findings indicate that living in a nuclear family system is a stronger risk factor for depression in the elderly than adults.
Gender
The prevalence of depression in female elderly subjects was twice that in males (33% vs. 15.7%). Female gender was also a significant risk factor for depression on multivariate analysis. This finding is concurrent with the contemporary literature. Two recent reviews showed that female gender is consistently a significant risk factor for depression in the elderly [
32,
40]. Most of the studies done in Pakistan also report a high prevalence of depression in women, ranging from 25% to 66% [
12,
31,
39,
41]. Female gender has been significantly associated with depression in most of the studies including one which showed a significant association between depression and females who lived in a nuclear family system [
12,
41,
42].
When comparing gender in Pakistan, female gender has been consistently associated with a higher prevalence of depression. It is likely that this high prevalence of depression in adult females (15–64 years) has carried over into old age. Mason has suggested that the problem of care for elderly females in countries like Pakistan is likely to be acute [
13]. Elderly females are more likely to be depressed than elderly males because the extensive gender and generational asymmetries in a joint family system are likely to put elderly females at a particular risk of non-support, especially in the face of changes that degrade the family's traditional system of care [
13]. Death of the spouse could lead to dissolution of the joint family system, leaving the elderly female without support.
Education
In our study, a low level of education was directly associated with depression in the elderly subjects. Many studies have reported this finding [
36,
43], including studies in developing countries [
44,
45]. A large number of studies in Pakistan have also reported a significant association of low educational status with depression [
12,
31,
39,
41].
A low level of education makes it difficult for an individual to accomplish certain tasks satisfactorily in an urban city like Karachi. Examples include consultation with doctors, filling out forms in English and managing household finances. The elderly who face such problems are at a greater risk of suffering from depression.
The problem may be compounded if the elderly are residing in a nuclear family system. The elderly with a low level of education are generally dependent on family members and relatives for the above mentioned chores. If there are no family members to take care of these issues, as in a nuclear family system, it could contribute to depression in the elderly. This is illustrated in Figure
1, which shows that while uneducated subjects as a whole are more depressed, those uneducated people who are living in a nuclear family system are more depressed than subjects residing in a joint family system.
Marital Status
The prevalence of depression was found to be significantly higher in the elderly who were single (never married), widowed, divorced or separated (See Table
3). Several studies have found these as risk factors for depression in the elderly [
36,
46,
47]. A study done on adult females in Pakistan also concurred with our finding [
41]. The finding that the elderly who had lost their spouse were suffering from a higher rate of depression could be explained by the fact that late life support by the partner is of importance to their psychological health. Dependence of the elderly on their spouse increases as they age. Death of a spouse renders them vulnerable to mental stress. Indeed, widowhood has been found to be strongly associated with depression in several instances [
48,
49].
Circumstances which lead to divorce or separation, especially if it occurs at a late stage, can lead to adjustment problems, which may manifest as depressive symptoms. A study showed that marital disruption was associated with a higher prevalence of major depression in both men and women [
50]. In addition, people who remain single lack children and spousal support. Life-events hence are much more unbearable, especially at an old age. Such factors may inevitably lead to psychological stress and depression.
Employment Status
As populations stop working, they lose not only the economic but also the social and psychological benefits of activity and purpose [
51]. Ageing and employment, ideally have an inverse relationship, with global statistics indicating a mean retirement from employment at the age of 61–62 years [
52]. This is not entirely representative of a developing nation such as Pakistan, where low socio-economic resources per household compel the aged to continue working. Although the formal retirement age in Pakistan is 60, individual companies allot retirement ages as per requirement. Even for an urban setting, limited or no retirement benefits (gratuity, provident funds) press the elderly for seeking yet another job, non-availability of which renders them stressed and under financial burden. Such a scenario serves as a nidus for depression at this age, which is supported by our finding that unemployed/retired subjects were twice more likely to suffer from depression than those who were employed. While there are health benefits of an early retirement in some parts of the world, these benefits do not always adequately cover the increasing medical costs that accompany age [
51]. The association of unemployment and depressive symptoms has been extensively studied. Studies have revealed that unemployment can give rise to reduced hope and financial problem, which in turn contribute to depression. [
53‐
55].
Other socio-demographic variables
Other socio-demographic variables which achieved significance on univariate analysis but not on multivariate analysis included: living alone and being childless. The elderly who lived alone were found to be at a high risk of depression [
56], which was consistent with our findings. One study showed that being childless had no direct role in predisposing the elderly to depression [
57]. However our study was not in accordance.
The absence of a caregiver was deduced to be a possible risk factor for depression. However, we did not find any significant association with depression in our study. One possible reason for this finding could be that we did not ask the number of caregivers or who the caregiver was. The elderly who were residing in a joint family system were likely to have more caregivers as well as more adult children as caregivers.
Limitations
The main limitation of our study was the use of a translated version of the GDS-15. This was done due to the unavailability of a validated Urdu version of the GDS-15. Although it is possible that the GDS-15 may not retain its high psychometric values after our translation, we believe that the values will not differ greatly. The wordings and meaning of the questions were preserved after back translation to English. We used a cut-off value of 5 to identify depression. This value has been shown to be highly sensitive and specific in other populations [
26,
27]. However, the cut-off for depression may differ in different populations. This may introduce bias in our results.
Studies have shown that the psychometric properties of the GDS are weaker when used on people with cognitive impairment [
23]. Screening for people with cognitive impairment was not done in our study.
Since we collected the sample from only one location in Karachi, the generalizability of our results may be restricted. The generalizabilty is also affected by the fact that since this was a hospital survey, a fair proportion of the sample consisted of patients. It is known that people with co-morbids are more likely to suffer from depression [
32,
40]; therefore, the prevalence of depression in our sample may be over-estimated. However, due to the central location of the hospital, it is still a good site for collection of this sample, as it receives people from all over the city.