|Year : 2017 | Volume
| Issue : 1 | Page : 18-25
Symptom profile of depression in elderly: Is assessment with geriatric depression rating scale enough?
Aseem Mehra, Sandeep Grover, Subho Chakrabarti, Ajit Avasthi
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||20-Jun-2017|
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Aim of the Study: This study aimed to evaluate the symptom profile, including somatic symptoms among elderly patients with first episode depression using the Geriatric depression scale (GDS-30) and Patient Health Questionnaire-15 (PHQ-15) items version scale. Additional aims were to carry out the factor analysis of symptoms reported on GDS-30 and PHQ-15 among elderly. Methodology: Seventy-nine elderly patients (age ≥60 years) were evaluated on GDS-30 item Hindi version and Hindi version of the PHQ-15. Results: As per GDS-30, the most common symptom noted among elderly was “dropped many of your activities and interests” (91.1%), mind not as clear as it used (88.6%), feeling that life is empty (86.1%), bothered by thoughts you cannot get out of your head (86.1%) and hard to get started on new projects (86.1%), prefer to avoid social gatherings (86.1%). All patients reported at least one somatic complaint as per PHQ-15. The most common somatic symptoms were trouble sleeping (97.5%), feeling tired or having little energy (96.2%), feeling that the heart is racing (52.9%), constipation, loose bowels, or diarrhea (49.6%), shortness of breath (46.8%), nausea, gas or indigestion (45.6%), pain in the arms, legs, or joints (43.3%), and back pain (41.8%). The prevalence of somatic symptoms was not influenced to a large extent by the demographic variables, clinical variables and presence or absence of physical comorbidity. However, the severity of somatic symptoms correlated positively with GDS-30 score. Factor analysis of Hindi version of GDS-30 yielded a four-factor solution, which was similar to many studies across the world. The addition of items of PHQ-15 items of factor analysis still yielded a four-factor solution. Factor 1 of combined GDS-30 and PHQ-15 items included items only from GDS-30 and Factor 3 and 4 included items only from PHQ-15. There was some overlap of items on Factor 2. Conclusion: The present study suggests that GDS-30 does not tap all the symptoms of depression among elderly in the Indian context. Further, the present study shows that GDS-30 is not a one-dimensional scale. Accordingly, the symptom evaluation among elderly depressed patient should go beyond GDS-30.
Keywords: Depression, elderly, geriatric depression scale, somatic symptoms
|How to cite this article:|
Mehra A, Grover S, Chakrabarti S, Avasthi A. Symptom profile of depression in elderly: Is assessment with geriatric depression rating scale enough?. J Geriatr Ment Health 2017;4:18-25
|How to cite this URL:|
Mehra A, Grover S, Chakrabarti S, Avasthi A. Symptom profile of depression in elderly: Is assessment with geriatric depression rating scale enough?. J Geriatr Ment Health [serial online] 2017 [cited 2020 Jul 7];4:18-25. Available from: http://www.jgmh.org/text.asp?2017/4/1/18/208605
| Introduction|| |
According to the current nosological systems,, depressive disorders are diagnosed using the same diagnostic criteria across all age groups. However, there is some evidence to suggest that the symptom profile of depression among elderly differ from that of adults. A review which included 11 studies, in which patients were evaluated on the Hamilton Depression Rating Scale (HDRS), showed that compared to adult patients, elderly patients have more agitation, hypochondriasis, and gastrointestinal somatic symptoms; however, they had lower prevalence of guilt and loss of sexual interest.
Data from developing countries suggest a high prevalence of somatic symptoms among adult patients with depression. Studies from India, including a multicentric study, show that all patients with depression manifest somatic symptoms., The multicentric study evaluated patients aged 18–65 years, with at least one somatic symptom as per the Bradford somatic inventory. The somatic symptoms which were seen in about half of the patients were lack of energy (weakness) much of the time, severe headache and feeling tired when not working, pain in legs, aware of palpitations, head feeling heavy, aches and pains all over the body, mouth or throat getting dry, pain or tension in the neck and shoulder, and head feeling hot or burning. A study, which used Patient Health Questionnaire-15 (PHQ-15) items version to assess somatic symptoms among adult patients with depression reported at least one somatic symptom in all patients and the symptoms which were present in two-third of the study sample included feeling tired or having little energy, followed by symptoms of trouble sleeping, nausea, gas and indigestion, headache, pain in arms, legs, or joints, and feeling the heart racing. However, studies are inconsistent about the relationship of somatic symptoms with demographic and clinical variables, with some suggesting that demographic factors and clinical features such as duration of illness and physical comorbidity did not influence the prevalence of somatic symptoms, whereas others suggest that the prevalence and type of somatic symptoms are related to severity of depression and sociodemographic profile.
However, little is known about the clinical features of depression among elderly patients in the Indian context. A recent review concluded that none of the studies from India has described the symptom profile of depression among elderly. In this background, the present study aimed to (1) evaluate the symptom profile, including somatic symptoms among elderly patients with first episode depression using the Geriatric depression scale (GDS-30) and PHQ-15 items version scale, respectively; (2) compare the prevalence of somatic symptoms among elderly with adult patients with depression; (3) evaluate the association of somatic symptoms with other symptom dimensions, and (4) to carry out the factor analysis of symptoms reported on GDS-30 and PHQ-15 among elderly.
| Methodology|| |
The study was carried out at the psychiatry outpatient clinic of a tertiary care multispecialty teaching hospital in North India. This study was approved by the Institute Ethics Committee, and all the patients were recruited after obtaining written informed consent. For this study, all the consecutive new patients attending the psychiatry walk-in clinic and diagnosed with depressive disorder as per the International Classification of Diseases-10 criteria by a qualified psychiatrist were approached. To be included in the study, the patients were required to have the first episode of depression at the age of 60 years or more and duration of current episode >1 month. Patients who had onset of depressive disorder before 60 years were excluded from the study. Patients who were uncooperative or were very sick were excluded. Patients with a history of mania or those with bipolar depression were also excluded from the study. The study sample comprised of 79 patients.
For comparison of somatic symptoms among elderly and adults, PHQ-15 data of patients aged 18–59 years from one of the earlier studies from our centre was used.
Geriatric Depression Scale-30-long form
GDS is a 30 item self-rated questionnaire with “yes” or “no” responses. Each item is assigned a score of “0” or “1” and the total score ranges from 0 to 30. A score of ≤9 is considered as normal, a score of 10–19 indicates mild depression, and a score of 20–30 indicates severe depression. The scale has established reliability and validity to assess geriatric depression. The scale has also been shown to have a high degree of internal consistency. For this study, validated Hindi version was used.
Patient Health Questionnaire-15
PHQ-15 is a self-rated instrument. The scale includes 15 items which are based on the prevalence of various somatic symptoms seen in patients presenting to the outpatient setting. The scale rates by taking the previous 4 weeks into account, and each item is rated as 0 (not bothered at all), 1 (bothered a little), or 2 (bothered a lot). Accordingly, the total score of PHQ-15 ranges from 0 to 30. On the basis of the total score, the severity of somatic symptoms is graded as mild (0–4), moderate (5–9), and severe (≥10). The full version of Primary Care Evaluation of Mental Disorders PHQ has been translated into Hindi by following the World Health Organization methodology for translation of scales and has been shown to have good psychometric properties. For the present study, the Hindi version was used. Out of the 15 items, one item is specific to women (Menstrual cramps or other problems with your periods). However, as we used the scale in elderly patients, this item was considered to be redundant and was excluded from the study.
Statistical Package for the Social Sciences, Windows version 14 (SPSS-14, SPSS Inc., Chicago) was used for analysis. Continuous variables were analyzed in the form of mean and standard deviation (SD). Frequencies along with percentages were calculated for categorical variables. Comparisons were done using Chi-square test. An association of somatic symptoms with other symptoms of depression, clinical variables, and demographic variables was studied by using Pearson's product moment correlations and Spearman rank correlations. Principal components analysis was used for factor analysis to assess the minimum number of factors which could account for the high level of variance in the data. Varimax rotation was used to have the best fit of the data.
| Results|| |
The study included 79 patients with first episode depression starting at the age of 60 or more. The sociodemographic profile of the study sample is depicted in [Table 1]. The mean age at the time of assessment and mean duration of education were 66.13 (SD-5.33) and 7.63 (SD-5.56) years, respectively. About two-third of the participants were male (63.3%) and from nonnuclear families (67.1%). More than three-fourth (81%) of the participants were married. More than half were from rural background (54.4%) and from middle socioeconomic status (54.4%). Slightly more than one-third (38%) of the patients were in paid employment.
The mean duration of illness was 8.93 (SD-15.61; range 1–20; median-4) months. Majority of patients had an insidious onset of illness. The precipitating factor in the form of a life event could be identified in one-fourth (25.3%) of the cases. About two-third of the patients had at least one comorbid physical illness. However, very few patients had comorbid psychiatric diagnosis (n = 2), comorbid substance use disorder (n = 50), and family history of mental disorders (n = 11) [Table 1].
Symptom profile of depression
As per GDS-30, the most common symptom noted among elderly was “dropped many of your activities and interests” (91.1%), mind not as clear as it used (88.6%), feeling that life is empty (86.1%), bothered by thoughts you cannot get out of your head (86.1%), hard to get started on new projects (86.1%), prefer to avoid social gatherings (86.1%), feeling hopeless (84.8%), frequently get upset over little things (84.8%), often feel helpless (83.5%), feel pretty worthless (83.5%), lack of feeling of full of energy (83.5%), often get bored (81%), afraid that something bad is going to happen (81%), often feel downhearted and blue (81%), and do not enjoy getting up in the morning (81%). Other symptoms are shown in [Table 2]. The only symptom which was present in less than half of the patients was 'do not think it is wonderful to be alive' (45.6%). The mean GDS score of the study sample was 23.5 (7.56) (range from 10 to 30). More than four-fifth of the participants (n = 65; 82.3%) had severe depression as per GDS.
|Table 2: Symptom profile of depression as per Geriatric Depression Scale and Patient Health Questionnaire-15|
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As per PHQ-15 (PHQ-14 in the present study), all patients reported at least 1 functional somatic complaints as assessed on PHQ-15. Five or more somatic symptoms were present in more than three-fourth (76.9%) of patients. In terms of severity of somatic symptoms, the mean PHQ-14 total score was 7.35 (2.67; range 1–14); about two-third of the patients had mild somatization (n = 50; 63.3%) as indicated by total score of 5–9. The most common symptoms were trouble sleeping (97.5%), and the other symptoms which were present in more than one-third of the patients included symptom of feeling tired or having little energy (96.2%), feeling the heart is racing (52.9%), constipation, loose bowels, or diarrhea (49.6%), shortness of breath (46.8%), nausea, gas, or indigestion (45.6%), pain in the arms, legs, or joints (43.3%), and back pain (41.8%) [Table 2].
Comparison of frequency of somatic symptoms in elderly and adults
For comparison, data from one of the earlier studies from our centre, which evaluated somatic symptoms among patients with first episode depression, was extracted. This study included 164 patients aged ≥18 years. For comparison, PHQ-15 data pertaining to 143 patients aged 18–59 years was used. As shown in [Table 3], compared to adult patients, elderly patients had higher prevalence of sleep disturbance and feeling that heart is racing. However, the prevalence of most of somatic symptoms was lower. The symptoms which were less often seen among elderly included pain in stomach, pain in arms, legs and joints, chest pain, dizziness, fainting, shortness of breath, and pain during sexual intercourse [Table 3]. There was no significant difference in a headache, constipation, loose bowels, or diarrhea, nausea, gas or indigestion, and feeling tired or having little energy.
|Table 3: Comparison of Patient Health Questionnaire-15 profile of adults and elderly|
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Relationships of depressive symptoms as per geriatric depression scale-30 and Patient Health Questionnaire-15 with demographic and clinical variables
When the relationship of type of depressive symptoms with demographic and clinical variables was evaluated, there was no difference in the prevalence of any of symptoms as per GDS-30 between the two genders. In terms of PHQ-15, symptoms which were significantly more prevalent among females included pain in arms, legs or joints (Chi-square test value − 5.02*; P = 0.02), and headache (Chi-square test value − 5.14*; P = 0.023).
GDS-30 symptom of “lack of happiness most of the time” was more prevalent among those who were married (Chi-square test value − 6.93**; P = 0.008). In terms of PHQ-14, those who were married more often reported symptoms of constipation, loose bowels, or diarrhea (Chi-square test value − 6.38*; P = 0.011). Those not in paid employment reported higher prevalence of “life not been wonderful to live now” (Chi-square test value − 4.72*; P = 0.03) and more often avoided social gatherings now' (Chi-square test value − 4.52*; P = 0.033), headache (Chi-square test value − 6.81**; P = 0.009). Headache (Chi-square test value − 3.85*; P = 0.05) was also more common among those of low socioeconomic status, whereas and constipation, loose bowels, or diarrhea (Chi-square test value − 3.93*; P = 0.047) was more common among those from middle/higher socioeconomic status (Chi-square test value − 3.85*; P = 0.05). Locality and type of family did not have an effect on the type of symptoms.
Those without physical comorbidity reported higher prevalence of “getting upset over little things” (Chi-square test value − 6.94*; P = 0.008) and “nausea, gas, or indigestion” (Chi-square test value − 3.98*; P = 0.046).
Age, education in years, and duration of illness did not have any significant correlations with severity of depression as per GDS-30 and severity of physical symptoms. Higher severity of depression as per GDS-30 was associated with a higher severity of somatic symptoms (Pearson's correlation coefficient 0.376***; P = 0.001).
Factor analysis of the geriatric depression scale-30 and Patient Health Questionnaire-15
Principal component factor analysis was used to evaluate the various symptom clusters of depression in elderly. Varimax rotation was used to have the best fit of the data. Kaiser–Guttman Rule was followed to determine the optimum number of the factors. A loading of ≥0.4 for each item on various factors was considered significant. When any items had loading of ≥0.4 or above on more than one factor, it was included, in the factor where it had the highest loading. Scree plot was used to determine the optimal number of factors and the final factor solution. Previous factor analysis studies of GDS have come up with 2–9-factor solutions, with four-factor solution being most commonly replicated.,
In this study, three separate factor analysis were carried out, i.e., one for GDS-30 items, second for PHQ-14 items, and third-factor analysis included items of both the scales. For factor analysis, purpose data on PHQ-14 were used as present (Score 1) or absent (Score 0) to match with the GDS-30. Negatively worded GDS-30 items were given weightage of 1 if these symptoms were present in the patients.
Null hypothesis was tested using Bartlett's test of sphericity and the Chi-square value for GDS-30 data was 169.5 with a degree of freedom of 435, which was significant at the <0.001 level. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy for the sample was 0.772, suggesting that factor analysis was an appropriate method for analyzing the current data. Initial factor analysis yielded a seven-factor solution which explained 70.24% of variance of data. Scree plot showed a tailing between Factor 4 and 5. Multiple factor analyses were done and when the five-factor model was evaluated, one factor had only two items loaded onto it. Hence, a four-factor model was preferred [Table 4] and [Table 5]. Based on the various items, these factors were named as negative mood (Factor 1), social withdrawal-anxiety-cognitive (Factor 2), dysphoria (Factor 3), and miscellaneous (Factor 4).
|Table 5: Symptom profile of depression as per geriatric depression scale and Patient Health Questionnaire-15|
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For PHQ-14, Bartlett's test of sphericity and the Chi-square value for was 207.8 with a degree of freedom of 91, which was significant at the <0.001 level. The KMO measure of sampling adequacy for the sample was 0.570. Initial factor analysis yielded a six-factor solution which explained 68.51% of variance of data. However, tailing was noted between Factor 3 and 4 on the scree plot. Based on multiple factor analysis, a three-factor model was found to be suitable [Table 4] and [Table 5]. The three factors were named as somatic anxiety (Factor 1), disturbed sleep and tiredness (Factor 2), and aches and pain (Factor 3).
When the data of both the scales were combined Bartlett's test of sphericity and the Chi-square value for was 23,008 with a degree of freedom of 946, which was significant at the <0.001 level. The KMO measure of sampling adequacy for the sample was 0.695. Initial factor analysis yielded a 13-factor solution which explained 74.65% of variance of data. Based on multiple factor analysis, a four-factor model for the combined data was found to be suitable. Two items of PHQ-15 (items 5 and 10) did not load on any of the factors, and the four-factor model explained 45.58% of variance of the data [Table 4] and [Table 5]. The various items of these factors were named as negative mood (Factor 1), dysphoria (Factor 2), somatic aches and pains (Factor 3), and somatic anxiety (Factor 4).
| Discussion|| |
The present study evaluated the symptom profile of elderly patients with first episode depression using two standardized instruments at the psychiatric outpatient setting.
GDS-30 is a scale, which has been designed to assess depression, specifically among elderly patients. However, GDS does not include items for assessment for common somatic symptoms such as loss of appetite and sleep disturbances. Accordingly, it at times may not reflect the complete clinical picture of depression in elderly.
The present study suggests that the symptom profile of depression among elderly patient goes beyond the symptoms described in GDS-30 and also includes somatic symptoms. The commonly noted somatic symptoms include trouble sleeping (97.5%), feeling tired or having little energy (96.2%), feeling that heart is racing (52.9%), constipation, loose bowels, or diarrhea (49.6%), shortness of breath (46.8%), nausea, gas, or indigestion (45.6%), pain in the arms, legs, or joints (43.3%), and back pain (41.8%). Identification of these symptoms is important because many of these are given diagnostic importance in the existing nosological systems. In addition, it is important to understand that these symptoms often shape the perception of illness among patients and can lead to the belief that their illness is of physical origin, which can lead to multiple consultations with other specialities resulting in overutilization/misutilization of medical resources, wrong diagnosis, and delay in starting of treatment.
Previous studies which have described somatic symptoms among elderly with depression by using HDRS suggest that these are more prevalent among elderly patients when compared to adult patients. The symptoms reported to be more common among elderly included agitation, hypochondriasis, and gastrointestinal somatic symptoms; however, they had lower prevalence of guilt and loss of sexual interest. In contrast to these studies, the present study suggests that compared to adults, elderly patients have a higher prevalence of sleep disturbance and feeling that heart is racing. However, the prevalence of most of the somatic symptoms is lower among elderly patients. This difference in finding of the present study from the existing literature can be understood from the perspective of difference in assessment scale. In contrast, to the earlier studies which relied on HDRS to extract somatic symptoms, present study relied on a scale specifically designed for assessment of somatic symptoms. Further, it is important to understand that in general somatic symptoms are highly prevalent among patients with depression in the Indian context. Hence, the lower prevalence among elderly could have been affected by the same. Accordingly, it can be said that the issue is not yet settled, and there is a need for large sample size studies, involving adult and elderly patients, using the same assessment instruments. As PHQ-15 is considered to be one of the most valid instruments to assess somatic symptoms across different disorders, it should be used along with other validated scales such as HDRS, Beck Depression rating scale, etc.
The present study suggests that in general, demographic and clinical variables such as duration of illness and presence of comorbid physical illnesses do not influence the clinical manifestations of depression in elderly. In general, studies among adult population  and elderly also suggest that the symptom profile is not affected much by these variables. However, occasional studies suggest that the symptom profile is influenced by the comorbid physical illnesses, however, present study does not support the same. Accordingly, it can be said that our findings are consonance with most of the existing literature.
In general, whenever GDS-15/GDS-30 is used, only total score is calculated considering it to be a one-dimensional scale. However, some of the factor analysis studies contradict this and suggest that the items of GDS load onto more than one factor.,,,,,, However, occasional studies which have carried out confirmatory factor analysis of GDS-15 item version suggest that the scale has only one dimension. The number of factors in these studies have ranged from 2,, to 9, depending on the version of GDS used and the method used for factor analysis (exploratory factor analysis vs. confirmatory factor analysis), and study population. Studies also suggest that the factor structure of GDS also depends on up to the respondents' language and the cultural background. One meta-analytic study  which described the factor structure of GDS of different languages including the data based on Hindi GDS-30 suggested that in general, the items separate into four factors. However, this paper did not provide specific information on the Hindi version of GDS-30. Accordingly, there is need for studies from India to evaluate the factor structure of GDS in the Indian context. The present exploratory study attempted to fill this void. In the present study, initial factor analysis of GDS-30 resulted in four-factor solution, which were named as negative mood (Factor 1), social withdrawal-anxiety-cognitive (Factor 2), dysphoria (Factor 3), and miscellaneous (Factor 4). In contrast to some of the previous studies, in the present study, only one of the items was lost in the factor analysis, i.e., all the items loaded on one of the identified factor. When we compare the findings with the meta-analytic study  certain similarities were evident. First, the items were distributed into the four factors. Second, the factors could also be broadly be categorized as described in the meta-analytic study. However, in the present study, the reverse coded items were given a weightage score of 1; hence, the negative mood factor which has emerged in the present study appears to be similar to the positive mood factor. Second, the meta-analysis  also reported 3 out of the 4 factors to be consistent across different languages, and these factors are similar to the first three factors seen in the present study. Accordingly, it can be said that the present study provides preliminary information about the factor structure of GDS-30 in the context of Indian culture and suggests that GDS-30 may not be a one-dimensional scale.
However, an interesting finding of the present study is that when PHQ-14 items were added to GDS-30, still the factor analytic solution, which fitted the data, was that of four factors. However, when one evaluates these factors, Factor 1 includes only items from GDS-30, Factor 3 and 4 included items only from PHQ-14. Only Factor 2 had mix of items from both the scales. These findings can be interpreted in different ways. First, these findings suggest that depression in elderly have symptom clusters other than those tapped by GDS. Second, these findings suggest that, although GDS does not tap the somatic symptoms, it possibly evaluates the most important symptoms of depression among elderly.
The present study has certain limitations. First, the study was limited to a clinic attending population at a tertiary care center; hence, the findings may not be generalizable to community samples or those attending primary care clinics. The study involved cross-sectional assessment and it is quite possible that the symptoms may vary over time. Accordingly, the present study does not reflect the same. The assessment of the symptom profile of depression was limited to GDS-30 and PHQ-15. It is quite possible that certain other symptoms such as anxiety symptoms, obsessive-compulsive symptoms, and cognitive symptoms which are occasionally seen in elderly patients with depression could have been missed. The present study also did not evaluate loneliness, which is shown too common among elderly with depression. Although the present study shows that the symptom profile of depression was not affected much by the presence or absence of a physical illness, but still the symptom profile may not generalizable to depression seen in those with neurological disorders or those with organic depression. The control group included in the present study was limited to only PHQ-14 and other symptoms were not compared with. Sample size of the present study could be considered as small for factor analysis. Although statistically, there was no problem in carrying out factor analysis on the data, the small sample size could be considered as a limitation of the findings. Future studies must include a larger sample size to overcome the limitations of the present study.
| Conclusion|| |
The present study suggests that somatic symptoms are present in elderly patients with depression. However, the prevalence of certain somatic symptoms is less than that seen among adult patients. The prevalence of various symptoms of depression is in general not affected by the sociodemographic and clinical variables. Various items of GDS-30 load into four factors, namely, negative mood (Factor 1), social withdrawal-anxiety-cognitive (Factor 2), dysphoria (Factor 3), and miscellaneous (Factor 4). However, the four-factor structure is maintained when PHQ-14 items are added. The combined factor structure, in general, suggest that GDS-30 items load into first two factors, namely, negative mood (Factor 1) and dysphoria (Factor 3), whereas the PHQ-14 load into other two factors, namely, somatic aches and pains (Factor 3), and somatic anxiety (Factor 4). The present study suggests that assessment of somatic symptoms must not be neglected among elderly patients with depression.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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