|Year : 2014 | Volume
| Issue : 2 | Page : 83-89
A study of depression in medically ill elderly patients with respect to coping strategies and spirituality as a way of coping
Deepika Singh1, Jahnavi Kedare2
1 Department of Psychiatry, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India
2 Department of Psychiatry, Seth G.S. Medical College and KEM Hospital, Maharashtra, India
|Date of Web Publication||3-Mar-2015|
Dr. Jahnavi Kedare
Department of Psychiatry, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Medically ill elderly patients are more prone to develop depression. Faulty coping mechanisms increase the risk of developing depression. Spirituality is known to decrease this risk.
Aim: This study was conducted to assess the prevalence of depression in medically ill elderly patients, coping strategies used and spirituality as a way of coping. A comparison was made between coping strategies used by depressed and nondepressed elderly patients with medical illnesses.
Materials and Methods: This was a cross-sectional study carried out at a tertiary care hospital. A total of 100 consecutive patients were evaluated on Geriatric Depression Scale, Coping Inventory for Stressful Situations-21, and Spiritual Attitude Inventory.
Results: Prevalence of depression was 72% among the medically ill elderly patients. Of those found to have depression, two third had mild depression and one-third had severe depression. On comparing coping and spirituality between depressed and nondepressed patients it was found that non depressed patients had better coping towards stressful situation, they used more of task oriented and avoidance based coping, whereas depressed patients used more of emotion oriented coping. Non-depressed patients were more spiritual when compared to depressed patients. Severity of depression positively correlated with emotion oriented coping mechanisms and it was negatively correlated with task and avoidance oriented coping mechanisms and spirituality in all four domains.
Conclusion: The present study shows that 72% of medically ill elderly patients have depression and compared to those with one medical illness, the prevalence of depression is more among those who have 2 or more medical illnesses. Compared with those without depression, patients with depression more often used emotion based coping, less often used task and avoidance coping mechanisms and were less spiritual.
Keywords: Coping, depression, medically ill, spirituality
|How to cite this article:|
Singh D, Kedare J. A study of depression in medically ill elderly patients with respect to coping strategies and spirituality as a way of coping. J Geriatr Ment Health 2014;1:83-9
|How to cite this URL:|
Singh D, Kedare J. A study of depression in medically ill elderly patients with respect to coping strategies and spirituality as a way of coping. J Geriatr Ment Health [serial online] 2014 [cited 2020 Feb 24];1:83-9. Available from: http://www.jgmh.org/text.asp?2014/1/2/83/152427
| Introduction|| |
The aged population in India is currently the second largest aged population in the world.  There is a high prevalence of medical disorders in elderly population. In the population over 70 years of age, more than 50% suffer from one or more chronic conditions.  The chronic illnesses usually include hypertension, coronary heart disease, and cancer. Patients with chronic medical conditions are at an increased risk of significant psychological distress including depression, resulting in impairment in functioning increase in treatment costs, decrease in compliance with medical regimens and worsened disease course leading to higher mortality and disability. According to study done in Nepal 53.9% of elderly patients with depression had some physical illness, hypertension being the commonest (18.8%).  Parkinsonism More Details (11.6%), cerebrovascular accident (5.8%), and diabetes (3.6%) were the other common diagnoses. Prevalence of depression can rise from 10 to 30% in patients with chronic illnesses.  A study among the elderly in a rural community in Malaysia, found that 57.4% have some chronic illness such as hypertension, diabetes mellitus, ischemic heart disease or respiratory disease. Some of them had a combination of two or three illnesses. The prevalence of depression was higher among respondents with chronic illness (9.0%) compared to respondents without chronic illness (5.6%).  Studies have also shown that the prevalence of depression often follow an increasing trend as the number of co-morbid chronic conditions increase , with prevalence of depression being highest among those with four or more co-morbid chronic conditions.
An important variable in coping, according to Zeidner and Saklofske,  is depression, because in addition to interfering with the interpretation of a situation, some depressive features affect the selection of strategies for coping and the perception of its real effectiveness. According to Lazarus and Folkman,  there are two forms of coping, that is, "emotion-focused coping" and "problem-focused coping." Emotion-focused coping is employed when someone fails to see a solution to a stressful situation and works to regulate the emotions that are generated by that dilemma. An individual chooses problem-focused coping when the possibility of a solution to that problematic stressful situation is considered feasible.
Aldwin and Revenson (1987)  examined the relationship between coping and mental health. They found that individuals in poorer mental health and under greater stress tended to employ less adaptive coping strategies and that these coping efforts affected the level of mental health.
Coping with medical conditions may also be influenced by the patient's perception about the illness and the emotional response to the same.  Thus, poorer coping with medical illness predisposes an elderly individual to develop depression.
Spirituality is an important determinant of physical, emotional, and social health.  Interest in the relationship between spirituality, religion, and clinical care has grown over the years. Spirituality and religion affect health and illness in different ways and different aspects of religiosity affect mental health differently. Praying, for instance, may hasten recovery and positively influence healthcare decisions, and religious devotion is associated with greater life satisfaction, improved psychological health and lower incidence of psychiatric disorders. 
According to Fisher, spirituality can be divided into four domains; personal, communal, environmental and transcendental. So spirituality is multi-faceted and not only attached with religious behavior.  Spirituality and religion can be considered as an asset while coping with stress, depression, suicide, anxiety and substance abuse. 
Studies which have examined relationships between intrinsic religiosity and variables such as well-being  and internal locus of control  have shown significant positive correlations between these variables.
There has been increasing interest in the effects of religious belief and activity on mental health,  particularly in regard to depression.  Studies of elderly medically ill patients have shown that a substantial proportion (more than 50%) use religious belief or activity to cope with the stress of physical illness, and these patients appear less depressed than those who do not rely on religion. ,
Although the exact mechanism is uncertain, religious beliefs may provide a world view in which medical illness, suffering, and death can be better understood and accepted. Alternatively, they may provide a basis for self-esteem that is more resilient than sources that decline with increasing age and worsening health.
A study conducted on elderly Korean adults regarding spirituality, depression and perceived health showed that those who had a higher level of spirituality reported a lower level of depression and a higher level of general health. 
A study carried out on homebound elderly examined whether spirituality could be a protective factor when it comes to loneliness and depression. The study used face-to-face interviews with over 40 elderly people, age 60 or older. The findings were that spirituality might prevent loneliness from turning into depression.  Elderly who are spiritual have a better mental health and are less depressed than those who are not. In these studies, spirituality has also been considered to be a positive asset for coping with depression. ,
Hence while coping with stresses of old age, including chronic medical illnesses, apart from problem focused and emotion focused coping, spiritual coping becomes an important dimension in improving quality of life, in inducing optimism, and speedy recovery.
Accordingly aims of the study were to study prevalence of depression in medically ill elderly patients, to study socio demographic profile of depressed medically ill elderly patients, to evaluate the coping strategies used by depressed medically ill elderly patients in stressful situations as well as spirituality as a way of coping and to compare coping strategies and spirituality used in depressed versus nondepressed elderly patients with medical illnesses.
| Materials and Methods|| |
This was a cross-sectional study done at a tertiary care hospital. Institutional Ethics Committee approval was obtained.
Study population and sample characteristics
Cases were medically ill elderly patients attending the psychiatric outpatient department [OPD] and geriatric OPD of a tertiary care hospital. 100 consecutive patients fulfilling the inclusion and exclusion criteria were selected for the study after taking written informed consent. Inclusion criteria for the study were age >60 years, patients with one or more chronic medical illnesses diagnosed by a Physician, patient should have Physician's notes/case paper and/or reports of investigations and/or prescription for the said chronic medical illness, patients who provided consent and those without cognitive impairment, that is, Mini Mental State Examination (MMSE) score ≥24. Those aged <60 years, with cognitive impairment (i.e., MMSE score <24), aphasia and psychotic features on clinical assessment were excluded. Similarly those who did not provide informed consent were excluded.
Procedure of study
Patients were administered a semi-structured questionnaire to obtain details about sociodemographic profile, diagnosed medical illnesses, duration of illness and treatment taken. The following scales were administered to patients.
Geriatric depression scale
The Geriatric Depression Scale (GDS), developed by Yesavage, et al.,  is a brief, 30-item questionnaire in which participants are asked to respond by answering yes or no in reference to how they felt over the past week. A score of 0-9 is diagnosed as "normal", 10-19 as "mildly depressed", and 20-30 as "severely depressed".
Coping inventory for stressful situations-21
This was designed by Endler and Parker.  The Coping Inventory for Stressful Situations (CISS-21)  is assumed to assess coping by three basic coping strategies: Emotion-oriented, task-oriented and avoidance coping. Each scale of the CISS-21 consists of 7 items. Respondents are asked to rate each item on a five point scale ranging from (1) "not at all" to (5) "very much."
Spiritual attitude inventory
The 28-item Spiritual Attitude Inventory (SAI)  was developed by combining four currently validated measures of religion and spirituality. It was developed by the U.S. Army Center for Health Promotion and Preventive Medicine in consultation with Dr. Harold Koenig at the Duke University Center for Spirituality, Theology and Health. It was approved for public release; distribution unlimited through their technical guide TG 323 March 2009. It addresses the following areas: Religious spiritual practice was measured by the Duke Religion Index (DUREL). Higher scores indicate higher levels of religiosity. Religious/spiritual belief was measured by the negative religious coping (NRCOPE) scale, higher scores on NRCOPE indicate lower levels of NRCOPE. Sense of purpose/connection was measured by the Existential well-being scale (EWBS), with higher scores on EWBS indicate greater existential well-being. Sense of hope/control is measured by the internal/external subscale of the Multiple Health Locus of Control Scale (MHLC), higher scores on MHLC indicate greater internal locus of control. The total score of all subscales gives the score on SAI. Higher scores on SAI indicate greater spirituality.
Mini mental state examination
Mini Mental State Examination  is a scale by Folstein et al. It tests five areas of cognitive function: Orientation, registration, attention and calculation, recall, and language. The maximum score is 30. A score of 24 or lower is indicative of cognitive impairment.
Statistical analysis was done by using statistical package for social science (SPSS) version 16.0 for Windows. SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc. All frequency distribution tables were made using appropriate statistical methods. Fisher's exact test, Chi-square test, t-test, and Spearman's coefficient of correlation test were administered as per the requirement.
| Results|| |
Depression-prevalence and severity
As mentioned in [Table 2], there was high prevalence of depression, that is, 72 out of 100 medically ill elderly patients had depression. Two-third (n = 48; 66.67%) of patients who had depression, had mild depression and one-third (n = 24; 33.33%) patients had severe depression based on their scores of GDS.
As shown in [Table 1], majority of the subjects in both groups, that is, depressed and non-depressed group were younger than 75 years of age and the prevalence of depression was significantly higher among those younger than 75 years of age. In terms of gender, majority of the patients in both the groups were females and married and there was no statistically significant difference between the two groups on these two variables. In terms of education, 38 were illiterate, 34 were primary educated, 16 were secondary educated, 6 were higher secondary educated and 6 were graduate. When the study population was divided into 2 groups, that is, those educated up to primary level, and those educated up to secondary level or above, it was noted that prevalence of depression was significantly higher in those who were educated less than or up to primary level [Table 1]. Only one-fifth of the participants was working while 80 patients were not working. Housewives were considered as, not working as they were not employed anywhere. Although the prevalence of depression was more among those who were not working the difference statistically nonsignificant [Table 1].
|Table 2: Prevalence of comorbid medical illness in those with and without depression |
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Chronic medical illnesses in elderly
In the study, it was seen that most patients suffered from hypertension followed by diabetes. Other disorders were heart ailments, osteoarthritis, stroke [Figure 1].
In the present study, 34 patients had 2 or lower number of comorbid medical illnesses and 66 patients suffered from more than 2 chronic medical illnesses. It was seen that those who were depressed had significantly higher prevalence of more number of comorbid medical illnesses.
Coping strategies and depression in elderly
The CISS assesses coping by three basic coping strategies: Task-oriented, emotion-oriented and avoidance coping.
The mean scores on the various subscales and the total score of CISS are shown in [Table 3]. As is evident from [Table 3], those with depression had significantly lower mean scores on all the subscale and also on the total CISS score.
Spirituality and depression in elderly
As is evident from [Table 4], those without depression had significantly higher scores on the DUREL Scale, Existential Well-Being Scale (EWBS) and MHLC scale and lower scores on the NRCOPE scale.
|Table 4: Assessment of religiosity, sense of purpose and sense of hope by using spiritual attitude inventory of those with and without depression |
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Correlation of geriatric depression with coping strategies
In the study, Spearman's correlation was used to assess the correlation between the severity of depression with coping strategies. Severity of depression correlated negatively with task and avoidance coping mechanisms and positively correlated with emotion based coping [Table 5]. Severity of depression also correlated negatively with spirituality in the form of religiosity, essential well-being, NRCOPE and multiple health locus of control.
| Discussion|| |
Majority of elderly people suffer from one or more medical illnesses. Medical illnesses result in functional disability in these people. They also cause an additional economic burden on an elderly individual. This may lead to depression in elderly individual's life. In addition to medical co-morbidities, the stressful events, which a person experiences are a risk factor for the development of depression.
Every individual tries to cope with stressful situations in life. Those having healthy coping remain healthy, but those having faulty coping tend to develop psychiatric complications, depression being one of them.
Amongst the various ways in which elderly people cope with stressful situations spiritual attitude is observed to be very helpful. A highly spiritual way of looking at life gives strength to the individual to face the stress. Spirituality helps in inducing a sense of well-being, a purpose and meaning to life and helps in controlling emotional upheavals. A person with faulty coping mechanisms may develop depression; however spirituality protects the individual from developing the same.
It is important to assess patients with medical illness for depression. Early diagnosis and early intervention will help in improved patient outcome. Psychosocial interventions in these patients are equally important.
The role of spirituality in alleviating depression is also gaining importance. Spirituality helps in dealing with depressive thinking. An assessment of all these factors will point towards population at risk for developing depression.
In the present study, 72 patients out of 100 medically ill elderly patients were depressed. This is a very high prevalence. There may be two reasons for the same. First, this study was conducted in a tertiary care hospital, and the study population of medically ill elderly patients was selected from psychiatry and geriatric OPD of the hospital, wherein chances of patient being depressed was high as compared to community sample. Secondly, depression was assessed with the help of GDS, in which mild depressive symptoms are also identified. A study conducted in the community by Jain RK et al also shows a high prevalence of depression of 45.9%. According to a meta analysis done by Ankur Barua et al the median prevalence rate of depressive disorders for the elderly population is 10.3%. The median prevalence rate of depression among the elderly Indian population was determined to be 21.9%.
In our study, those with depression had significantly higher load of medical comorbidity. The prevalence of depression often follows an increasing trend as the number of co-morbid chronic conditions increase and this trend was also found to be statistically significant in the studies conducted by Kennedy et al.  and Barua et al.  where the prevalence of depression was highest among those with four or more co-morbid chronic conditions and this difference as compared with other groups was found to be statistically significant.
Chronic illness apart from its effect on the physical state has a significant impact on the psyche of the individual, decline in productivity and financial status, and disruption of the family and social life. Chronic illness thus is stressful, which unlike acute illness has an extended time course and produces long term emotional stress.
Coping or attempting to restore order into one's life is a psychological process evoked by stress in dealing with the changes in the environment. It serves as an internal source of emotional strength and mediates an individual's reaction to perceived stress; internal or external. Task-oriented coping involves addressing the problem causing distress. Examples are making a plan of action or concentrating on the next step, and attempts to alter the situation. Emotion-oriented coping has negative emotions toward self because of which the person cannot cope up with situation effectively. This form of coping includes emotional responses, self-preoccupation, fantasizing, self-blame and a feeling of guilt. Avoidance coping refers to the avoidance of stress by distracting oneself with a substitute task or by seeking social diversion, such as being in the company of other people. This prevents a direct encounter with the problem at hand and the emotional upheaval secondary to the problem.
In the present study, coping mechanisms used by depressed individuals were different than non-depressed individuals. Depressed individuals used more of emotion oriented coping and non-depressed patients used task oriented and avoidance coping mechanisms. According to results of a study by Myers et al.,  patients with high scores of emotion-focused coping strategies also had significantly high scores on diverse psychopathology factors including elevations on depressive mood, intrusive experiences, anger state, and general anger scores. In contrast, those who used Task-Oriented strategies and who used Avoidance-Focused strategies had less psychopathology including low positive emotion scores.
Spiritual/religious coping is the process by which an individual, through spirituality, religious beliefs or religious behavior, attempts to understand and/or deal with important personal or situational challenges in their life.
In this study, SAI total score, differed significantly between those with and without depression. Spirituality was less on all the domains, that is, religiosity, essential well-being, NRCOPE, multiple health locus of control, in depressed patients when compared to nondepressed patients. In terms of the relationship of spirituality and severity of depression, it was seen that severity of depression correlated negatively with all the domains of spirituality.
Studies of elderly medical patients have shown that a substantial proportion use religious belief or activity to cope with the stress of physical illness, and these patients appear less depressed than those who do not rely on religion. ,
According to study by Koenig  on 'Religiosity and Remission of Depression in Medically ill older patients', Patients with higher intrinsic religiosity scores experienced faster remission of depression than did those with lower scores. For every 10-point increase in intrinsic religiosity score, there was a 70% increase in speed of remission.
Bekelman et al. also reported that higher 'Spiritual well-being' among patients with heart failure was associated with lower rates of depression.
To conclude, the present study suggests that 72% of medically ill elderly patients have depression. Rate of depression is higher among those with lower level of education, those who are employed and those who have a higher number of medical comorbidities. Depressed patients used more of emotion based coping and less of task and avoidance coping mechanisms which seems to have predisposed them to depression. Depressed patients were less spiritual on all the four domains including religiosity, essential well-being, NRCOPE and multiple health locus of control. Low spiritual attitude made medically ill elderly patients more prone to depression. Severity of depression was positively correlated with emotion oriented coping mechanisms. It was negatively correlated with task and avoidance oriented coping mechanisms, spirituality in all four domains, that is, religiosity, essential well-being, NRCOPE and multiple health locus of control and perceived social support in any form, be it family, friends or significant others.
There are few limitations of this study. This study was conducted at a tertiary hospital, which may not be representative of the general population. This is a cross-sectional study and not a longitudinal study. The sample size was small. Future studies must overcome the limitations of this study.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]