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ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 35-48

Indian Association for Geriatric Mental Health's multicentric study on depression in elderly: Symptom profile and influence of gender, age of onset, age at presentation, and number of episodes on symptom profile


1 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Psychiatry, GMERS Medical College, Gandhinagar, Gujarat, India
3 Department of Psychiatry, AIIMS, Jodhpur, Rajasthan, India
4 Department of Psychiatry, Calcutta National Medical College, Kolkata, India
5 Department of Psychiatry, Advanced Medical Research Institute, Kolkata, West Bengal, India
6 Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India
7 Department of Psychiatry, SKIMS Medical College, Srinagar, Jammu and Kashmir, India
8 Department of Psychiatry, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India

Date of Web Publication27-Jun-2018

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_26_17

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  Abstract 


Aim of the Study: To assess the symptom profile of depression among elderly patients presenting to psychiatric outpatient settings. An additional aim was to evaluate the influence of gender, age of onset, age at presentation, and type of episode (i.e., the first episode versus recurrent depressive episodes) on symptom profile of geriatric depression. Materials and Methods: This multicentric study was conducted at eight centers in which 488 elderly patients (aged ≥60 years) with depression were evaluated on Geriatric Depression Scale (GDS-30), Generalized Anxiety Disorder-7 Scale (GAD-7), Patient Health Questionnaire-15 (PHQ-15) scale, and Columbia Suicide Severity Rating Scale. Results: Males had significantly higher prevalence of comorbid substance dependence, whereas females had significantly higher prevalence of comorbid psychiatric disorders. As per the GDS-30, about two-third or more of the study sample had symptoms of feeling helpless (71.7%), often getting restless and fidgety (70.1%), dropped many of their activities (68.4%), frequently feel like crying (67.4%), trouble concentrating (67%), feels pretty worthless (66.4%), often feeling downhearted and blue (65.8%), frequently getting upset over little things (64.8%), and not satisfied with life (62.9%). More than two-third of the sample had all the symptoms of anxiety as per the GAD-7 and 7 out of the 14 somatic symptoms as per the PHQ-15. When comparisons were made between males and females, significant difference in prevalence was noted for some of the depressive symptoms as assessed by the GDS-30 and somatic symptoms as assessed by the PHQ-15, but no differences emerged in terms of anxiety symptoms. Significantly higher proportion of females reported active suicidal ideation with specific plan and intent and had higher intensity of suicidal ideations. Differences in symptom profile were also noted with regard to age of onset (<60 and ≥60 years), age at presentation (<70 and ≥70 years), and type of depression (single versus multiple episodes). Conclusion: The present study suggests that somatic and anxiety symptoms are highly prevalent among elderly patients with depression. Further, it is evident that there are certain differences in the symptom profile of depression among male and female patients with depression. The present study also reveals that age of onset, age at presentation, and number of episodes could also influence the symptom profile of depression among the elderly.

Keywords: Depression, elderly, gender, symptom profile


How to cite this article:
Grover S, Avasthi A, Sahoo S, Lakdawala B, Nebhinani N, Dan A, Dutt A, Tiwari SC, Gania AM, Subramanyam AA, Kedare J. Indian Association for Geriatric Mental Health's multicentric study on depression in elderly: Symptom profile and influence of gender, age of onset, age at presentation, and number of episodes on symptom profile. J Geriatr Ment Health 2018;5:35-48

How to cite this URL:
Grover S, Avasthi A, Sahoo S, Lakdawala B, Nebhinani N, Dan A, Dutt A, Tiwari SC, Gania AM, Subramanyam AA, Kedare J. Indian Association for Geriatric Mental Health's multicentric study on depression in elderly: Symptom profile and influence of gender, age of onset, age at presentation, and number of episodes on symptom profile. J Geriatr Ment Health [serial online] 2018 [cited 2018 Dec 18];5:35-48. Available from: http://www.jgmh.org/text.asp?2018/5/1/35/235369




  Introduction Top


Depression accounts for a significant proportion of burden of mental illnesses among the elderly. Depression impairs the quality of life of the person, leads to higher dependency need on others, and is associated with high rates of suicidal behavior.[1],[2] Depression in the elderly is associated with higher rates of difficulties with activities of daily living,[3] physical comorbidities,[4],[5] cardiovascular diseases,[6] mortality,[7] obesity,[8] insomnia,[9] and cognitive impairments.[10] Unfortunately, depression in the elderly is often underdiagnosed and is considered as part of aging.[11]

Accordingly, there is a need to recognize depression among the elderly and treat it effectively. Proper diagnosis of depression among the elderly requires understanding the symptom profile of depression. Although depression in the elderly is diagnosed as per the same nosological criteria, it is often suggested that there is a lack of consensus in terms of differences in the symptom profile of depression among adult and elderly patients. Some of the studies suggest that elderly patients more often report somatic symptoms, have more suicidal thoughts, and wish to die.[12] Others suggest that there is no difference in the symptom profile of depression among adult and elderly patients.[13] Some of the authors have also shown that compared to adults, the elderly have higher prevalence of anxiety symptoms [14],[15],[16],[17] and comorbid anxiety disorders.[18],[19]

Cultural factors have also been reported to influence the clinical picture of depression. Studies across the globe suggest that there is some evidence for higher prevalence of somatic symptoms in people from Eastern countries.[20],[21] Further studies from India, which have evaluated the symptom profile of depression among elderly, suggest that compared to elderly, somatic symptoms are highly prevalent in adult patients.[22]

Surprisingly, despite a reasonable amount of data from India on the epidemiology of depression among the elderly, symptom profile of depression among the elderly has received little attention.[1]

A recent study from North India evaluated the symptom profile of depression among elderly patients using Geriatric Depression Rating Scale (GDS-30) and Somatic symptoms module of Patient Health Questionnaire (PHQ-15) and reported that the most common symptoms as per the GDS-30 are dropped many of your activities and interests (91.1%), mind not as clear as it used to be (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%), and prefer to avoid social gatherings (86.1%). In terms of somatic symptoms, 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%), and constipation, loose bowels, or diarrhea (49.6%).[23] However, this study was limited to a single center and included only 79 patients.

Epidemiological data suggest that compared to males, depression is more common in females.[24],[25],[26] Studies which have evaluated the gender differences in the profile of depressive symptoms in adults suggest that compared to males, females have higher prevalence of comorbid anxiety disorders and atypical presentation. Additionally, it has been shown that females have higher prevalence of associated psychological problems such as neuroticism, more chronicity, and more somatization.[27],[28],[29] In contrast, males have higher rates of comorbid substance abuse, poor help-seeking behavior, and higher rates of suicidal behavior.[27],[28] However, some of the studies have reported lack of gender differences in terms of somatic symptoms, when the participants of both the genders were matched for nonsomatic symptom scores (cognitive/affective).[30] Studies which have looked at gender differences among elderly patients with depression suggest that there are certain gender differences in the prevalence, presentation, and prognosis of geriatric depression too.[31],[32],[33],[34],[35] Studies suggest that while agitation is more common in elderly depressed males, elderly depressed females present with more number of depressive symptoms and more vegetative symptoms such as decreased appetite, joylessness, and insomnia.[32],[34],[36]

Growing age also affects the symptom profile of depression as is suggested by longitudinal studies among the elderly from the age of 50–80 years. These studies suggest that there is a gradual increase in the scores of depression in females at ages 50 and 60 and higher depressive scores in males at ages 60–80 years.[37] However, after 80 years, the symptom scores of depression are more or less similar and there exists no change in the prevalence of somatic symptoms across the ages (females > males). Studies which have evaluated symptom profile among the elderly have relied on instruments such as Composite International Diagnostic Interview (CIDI),[32],[38] Center for Epidemiologic Studies– Depression scale,[34],[39],[40] and the GDS-30.[41] The symptom profile of geriatric depression includes various cognitive, affective, somatic, and anxiety symptoms and there exists several limitations of these scales to pick up the entire symptom profile of geriatric depression. Hence, use of single scale often does not provide a comprehensive clinical picture of depression among the elderly.

In this background, the present multicentric study aimed to assess the symptom profile of depression among elderly patients presenting to psychiatric outpatient settings. An additional aim was to evaluate the influence of gender, age of onset, age at presentation, and type of episode (i.e., the first episode versus recurrent depressive episodes) on symptom profile.


  Materials and Methods Top


This multicentric study was conducted under the aegis of the Indian Association for Geriatric Mental Health and was approved by the local Institutional Ethics Committees of the centers at which the study was conducted. The study was conducted at eight centers, of which three centers were in the North India (Chandigarh, Srinagar, and Jodhpur), two centers in eastern part of the country (both in Kolkata), two centers in western part of the country (1 center in Mumbai and another in Ahmedabad), and one center in Central India (Lucknow).

The study followed a cross-sectional design in which participants were assessed only once. Participants were recruited after obtaining written informed consent. To be included in the study, patients were required to be aged ≥60 years, of either gender, fulfilling the criteria of major depressive disorder as per the Diagnostic and Statistical Manual of Mental Disorders-IV Edition criteria (DSM-IV)[42] which was confirmed using Mini International Neuropsychiatric Interview (MINI) PLUS.[43] Patients with comorbid intellectual disability, comorbid dementia, too sick to participate in the interview, or those who did not consent were excluded. All the patients were rated on the GDS-30,[44],[45] Generalized Anxiety Disorder Questionnaire (GAD-7),[46] PHQ-15,[47] and Columbia Suicide Severity Rating Scale (C-SSRS).[48]

Instruments used in the study were described as follows:

  1. MINI PLUS:[43] The MINI-PLUS is a brief structured interview designed for making diagnosis of certain psychiatric disorders as per the DSM-IV and ICD-10 criteria, for example, major depressive episode, dysthymia, and psychoactive substance use disorders. MINI PLUS version is particularly designed for research. Studies comparing the MINI with the Structured Clinical Interview for DSM-III-R patient version (SCID) and the CIDI for ICD-10 have shown it to be an instrument with high validity and reliability. It is used by clinicians and can be administered over a short period of time
  2. Geriatric Depression Rating Scale (GDS-30):[44] This is a 30-item scale, in which all the items are worded simply and are rated as either “yes” or “no,” which enhances the ease of its use in ill or moderately cognitively impaired individuals. Each item is rated as either 1 or 0 with a total score of 0–9 indicating no depression, 10–19 indicating mild depression, and 20–30 indicating severe depression. It has been found to have a sensitivity of 92% and a specificity of 89%. It has well-established reliability, validity, and a high degree of internal consistency to assess depression among the elderly.[44] For this study, the 30-item Hindi version of GDS was used.[45]
  3. GAD-7:[46] It is a 7-item questionnaire developed to screen patients for anxiety and rate the severity of anxiety. Each item is rated on a 4-point scale (0–3) on the basis of presence and severity of the symptoms in the previous 2 weeks. Scores of 5, 10, and 15 are taken as the cutoff for mild, moderate, and severe anxiety, respectively. The threshold score of 10 is considered to have a sensitivity of 89% and a specificity of 82% for GAD. Additionally, it is considered to be moderately good screening tool for patients with panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%), and posttraumatic stress disorder (sensitivity 66%, specificity 81%).[46]
  4. The PHQ-15:[47] It is a self-rated instrument which includes 15 items which are based on the prevalence of various somatic symptoms seen in patients presenting to the outpatient setting. Ratings are done by considering the last 4 weeks and each item is rated as 0 (not bothered at all), 1 (bothered a little), or 2 (bothered a lot), with the total score ranging 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).[47] The full version of PHQ has been translated into Hindi and has been shown to have good psychometric properties.[48] For the present study, the Hindi version was used. Out of the 15 items, one item, which is specific to women (menstrual cramps or other problems with your periods) was considered redundant for the elderly and was not included in the study. Hence, 14 items were used for this study (PHQ-14).
  5. C-SSRS:[49] The C-SSRS was designed to assess the full range of suicidal ideation and behavior. The scale measures four constructs, i.e., the severity of ideation, the intensity of ideation, behavior, and lethality. The severity of ideation is rated on a 5-point ordinal. The intensity of ideation subscale comprises of five items, each rated on a 5-point ordinal scale. Suicidal behavior subscale is rated on a nominal scale. Lethality subscale assesses actual attempts, and actual lethality is rated on a 6-point ordinal scale.[50] The C-SSRS has been found to be reliable and valid in the identification of suicide risk in several research studies.[49],[51]


In addition to the rating scales, all the patients were also rated for various depressive ideations and psychotic symptoms based on clinical interview by a qualified psychiatrist and the symptoms were rated as present or absent. Data generated were processed using SPSS version 14 (Chicago, IL, USA). Descriptive analysis involved calculation of mean and standard deviation (SD) with a range for continuous variables, and frequency and percentages were calculated for ordinal or nominal variables. Comparisons were done using the Chi-square test, Fisher's exact test, t-test, and Mann–Whitney test. Correlation analysis involved calculation of Pearson's correlation coefficient and Spearman's rank correlation coefficient.


  Results Top


The study included 488 patients from the eight centers. The highest number of patients were from Ahmedabad center (n = 124; 25.4%), followed by Chandigarh (n = 115; 23.6%) and Jodhpur centers (n = 85; 17.4%). There were fewer patients from other centers, namely, Kolkata 1 and 2 (50 [10.2%] and 40 [8.2%], respectively), Mumbai (n = 27; 5.5%), Lucknow (n = 26; 5.3%), and Srinagar (n = 21; 4.3%).

Males comprised of 53.7% (n = 262) of the sample. When comparisons were done between males and females, males were significantly older, more educated, more often on paid employment, from nonnuclear families, and had higher income [Table 1]. Significantly higher proportion of females were currently single (unmarried/widowed/separated/divorced) as compared to males. However, there was no urban–rural difference between the two genders.
Table 1: Sociodemographic profile of the study sample (n=488)

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Majority of the patients were diagnosed with first-episode depression (FED) (60.9%; n = 297) and the rest were diagnosed with recurrent depressive disorder (RDD) (39.1%; n = 191). In terms of various clinical parameters, no significant gender differences were noted for participants of either gender for age of onset of depression, total duration of illness, duration of current treatment and overall treatment duration, presence of family history of mental illness, and type of depressive episode (FED/RDD). At least one comorbid physical illness was present in all patients. Compared to females, males had significantly higher prevalence of comorbid substance dependence, whereas females had significantly higher prevalence of comorbid psychiatric disorders [Table 2]. When the prevalence of individual substance use was further evaluated for females, it was evident that benzodiazepine and tobacco were the most prevalent substances, each seen in about 10% of cases.
Table 2: Clinical profile of study sample (n=488)

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Symptom profile as per clinical interview and on different scales

As per the GDS-30, the symptoms which were present in two-third or more of the study sample were feeling nervous, anxious, or on edge (72.1%), feeling helpless (71.7%), often get restless and fidgety (70.1%), dropped many of their activities (68.4%), frequently feel like crying (67.4%), trouble concentrating (67%), feeling pretty worthless (66.4%), often feel downhearted and blue (65.8%), frequently get upset over little things (64.8%), and not satisfied with life (62.9%). Other details are summarized in [Table 3]. When the males and females were compared for symptom profile as assessed by the GDS-30, females had significantly higher prevalence of symptoms of dropped many of the activities, afraid that something bad will happen, feeling helpless, frequently worry about future, feel pretty worthless, and frequently get upset over little things [Table 3]. Compared to females, males had significantly higher prevalence of not satisfied with life, does not find life very exciting, and feel that your situation is hopeless [Table 3].
Table 3: Symptom profile as per Generalized Anxiety Disorder-7, Geriatric Depression Scale-30, and Patient Health Questionnaire-14 scales

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To evaluate the symptom profile, all the items of GAD-7 and PHQ-15 (14) were recoded as “present (1)” or “absent (0).” The most common symptoms as per GAD-7 included not being able to stop or control worrying (88.7%), trouble relaxing (85.5%), worrying too much about different things (84%), feeling afraid as if something awful might happen (83%), becoming easily annoyed or irritable (80.1%), being so restless that it is hard to sit still (78.1%), and feeling nervous, anxious, or on edge (72.1%). No significant difference was noted among participants of either gender in the present study.

As per the various symptoms on PHQ-1/15 scale, symptoms which were present in more than two-third of the study sample included feeling tired or having little energy (90.8%), trouble sleeping (87.1%), nausea, gas, or indigestion (79.9%), constipation, loose bowels, or diarrhea (75.0%), headache (74.4%), pain in arms, legs, or joints (72.5%), and back pain (69.3%). In terms of gender differences, significantly higher proportion of males reported symptoms of pain in stomach, feeling that heart is racing, and pain during sexual intercourse. Whereas, females had significantly higher prevalence of symptoms of back pain, pain in arms, legs, or joints, and trouble sleeping [Table 3].

The mean GDS score for the study sample was 16.96 (SD – 24.03; range 10–30). More than one-fourth of the participants had severe depression as per the GDS. The mean GAD-7 score of the sample was 9.46 and four-fifths of the sample scored ≥10, which is considered to be the cutoff for diagnosis of GAD as per the GAD-7 scale. The mean total PHQ-1/15 score was 11.56 and about 71.7% of the study sample had severe somatization (score >10). The mean number of anxiety symptoms and somatic symptoms as assessed by the GAD-7 and PHQ-1/15 were 5.71 and 8.48, respectively. No significant gender differences were found with regard to severity of depression as per the GDS-30, severity and number of anxiety symptoms as per the GAD-7, and severity and number of somatic symptoms as per the PHQ-1/15 scale [Table 4].
Table 4: Severity of symptoms as per Geriatric Depression -30, Generalized Anxiety Disorder-7, and Patient Health Questionnaire-15 scales

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On clinical interview by a qualified psychiatrist and the symptoms were rated as present or absent. In terms of depressive ideations, about two-fifths of the sample had ideas of guilt (39.1%). Other commonly reported depressive ideations included wish to die (30%), ideas of hypochondriasis (27%), ideas of sin (21.5%), and ideas of catastrophe (13.1%). Compared to females, males had significantly higher prevalence of ideas of persecution and reference [Table 5]. A small proportion (13.1%) of patients had at least one psychotic symptom, with delusions being more prevalent than hallucinations. Very few patients had obsessive and compulsive symptoms. In terms of psychotic symptoms, the most common delusions were those of delusion of persecution (3.9%), reference (3.9%), and nihilism (2.5%). In terms of hallucinations, auditory hallucinations (2.9%) were more than hallucinations in other modalities. However, there were no gender differences in terms of prevalence of various psychotic symptoms.
Table 5: Symptom profile as per clinical interview

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In terms of suicidality, about one-fifth of the participants had wish to die (21.7%), and a small proportion of patients had nonspecific active suicidal thoughts (13.9%), active suicidal ideations without intent with any method (12.7%), active suicidal thoughts with some intent to act without specific plan (78%), and active suicidal ideation with specific plan and intent (5.9%). About one-fifth (18.2%) of the sample reported actual suicidal attempts during lifetime and nonsuicidal behavior was present in 11.9% of the sample. A small proportion of patients reported interrupted attempts (2.3%) and aborted attempts (7.6%) in the lifetime. When comparisons were made for males and females, significantly higher proportion of females reported active suicidal ideation with specific plan and intent and had higher intensity of suicidal ideations [Table 6].
Table 6: Assessment of suicidality as per Columbia-Suicide Severity Rating scale

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Comparison of symptom profile of depression profile as per the age of onset of depression (≥60 years or <60 years)

When the symptom profile of patients with early-onset depression (i.e., age of onset <60 years; n = 198) and late-onset depression (i.e., those with age of onset ≥60 years; n = 290) was compared, those with late-onset depression had significantly lower prevalence of wish to die. On GDS, significant differences were noted between the two groups on 17 out of the 30 items, 1 item of GAD-7, and 7 items of PHQ-1/15. Patients with early-onset depression had significantly higher prevalence of being bothered by thoughts, getting often restless and fidgety, finding hard to get started on new projects, lack of feeling full of energy, feel that your situation is hopeless, and think that people are better off, frequently feel like crying, worrying too much about different things, and having headache and trouble sleeping. On the contrary, those with late-onset depression had significantly higher prevalence of not satisfied with life, feeling life to be empty, not in good spirits most of the time, afraid that something bad will happen, preferring to stay at home, frequently worrying about future, feel pretty worthless, worry a lot about the past, not finding life to be exciting, prefer to avoid social gathering, complained more of chest pain, feeling dizziness, having fainting, shortness of breath, and nausea, gas, or indigestion [Table 7].
Table 7: Differences in symptom profile as per the age of onset of depression (≥60 years or<60 years)

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When the age at presentation was considered and the symptom profile of those aged <70 years (n = 342) at the time of assessment and those aged ≥70 years (n = 146) at the time of assessment was compared, it was found that patients aged <70 years at presentation reported significantly more wish to die on the clinical interview.

With regard to symptoms as per the GDS-30, GAD-7, and PHQ-1/15, patients who presented with depression after the age of ≥70 years had significantly higher prevalence of dropped many of their activities, not hopeful about future, frequently worrying about future, reported problems with memory, felt often downhearted and blue, feel pretty worthless, worry a lot about the past, frequently got upset over little things, had trouble concentrating, reported feeling of nervous, anxious or on edge, were not able to stop or control worrying, and complained of dizziness, fainting, shortness of breath, constipation, loose bowels, or diarrhea and more [Table 8].
Table 8: Differences in symptom profile as per the age at presentation of depression (≥70 years or<70 years)

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Comparison of symptom profile of depression between first-episode depression and recurrent depressive disorder

When the symptom profile of patients with FED (n = 297) and RDD (n = 191) was compared, it was found that patients with RDD had significantly higher prevalence of ideas of hypochondriasis and wish to die as assessed using clinical interview [Table 9]. On the various scales, patients with RDD had higher prevalence of symptoms of feeling that life is empty, being bothered by thoughts, getting often restless and fidgety, finding hard to get started on new projects, lack of feeling full of energy, feel that their situation is hopeless, and think that people are better off, headache, and having constipation, loose bowels or diarrhea, and trouble sleeping [Table 9]. Compared to patients with RDD, patients with FED had higher prevalence of not satisfied with life, not in good spirits most of the time, preferring to stay at home, frequently worrying about future, feel pretty worthless, worry a lot about the past, not finding life to be exciting, not enjoying getting up in the morning, prefer to avoid social gathering, feeling dizziness, and having fainting and shortness of breath [Table 9]. No significant differences were noted on any of the items of GAD-7.
Table 9: Differences in symptom profile in single episode versus multiple episodes of depression ( first-episode depression vs. recurrent depressive disorder)

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Correlation of Geriatric Depression Scale-30 scores with anxiety and somatic symptom severity scores

When the relationship of GDS-30, GAD-7, and PHQ-14 was evaluated, there were no significant correlations between the total scores of GDS-30 and PHQ-14 for any of the groups except for the RDD group. However, GDS-30 correlated significantly with GAD-7. Additionally, the total score of GAD-7 had significant positive correlation with PHQ-14 for all the subgroups [Table 10].
Table 10: Correlation between depression, anxiety, and somatic symptoms

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  Discussion Top


The present multicentric study evaluated the symptom profile of depression among the elderly. The study was conducted over eight centers in India. The study centers were distributed across the various parts of the country except for lack of any center from South India. Accordingly, it can be said that the findings of the present study can be generalized. The patients were recruited from those attending psychiatry outpatient settings. The study sample was relatively larger compared to previous studies which have evaluated the symptom profile of depression among the elderly.[23],[40],[52],[53]

In the present study, three-fifth of the patients were diagnosed with FED and the rest were diagnosed with RDD. In terms of comorbid physical illnesses, all patients had at least one systemic or local physical comorbid illness. Previous studies which have evaluated physical comorbidity among elderly patients with depression also suggest high prevalence of the same and the present study replicates the similar findings.[5],[54],[55],[56],[57],[58] However, presence of physical comorbidity in all patients in the present study reflects more thorough evaluation.

In the present study, about one-third of the participants had a history of substance dependence syndrome, with significant difference between the two genders, with substance dependence being double in males, when compared to females. When one compares this finding with the existing literature from India, the finding of the present study is largely supported by the existing literature in terms of gender difference and prevalence among patients with depression.[50],[59] However, the presence of substance dependence syndrome noted in one-fourth of females in the present study is relatively higher than the existing literature. Further, a closer look at the data suggested that this higher rate among females was related to tobacco and benzodiazepine dependence. These findings suggest that elderly females with depression need to be screened for benzodiazepine dependence and/or abuse.

In terms of symptom profile, as is evident from the rating of symptoms on multiple scales, it is evident from the present study that somatic and anxiety symptoms were much more common than other symptoms. The most common symptoms of depression across different scales included feeling tired or having little energy (90.8%), not being able to stop or control worrying (88.7%), trouble sleeping (87.1%), trouble relaxing (85.5%), worrying too much about different things (84%), feeling afraid as if something awful might happen (83%), becoming easily annoyed or irritable (80.1%), nausea, gas, or indigestion (79.9%), being so restless that it is hard to sit still (78.1%), constipation, loose bowels, or diarrhea (75.0%), headache (74.4%), pain in arms, legs, or joints (72.5%), feeling nervous, anxious, or on edge (72.1%), feeling helpless (71.7%), often getting restless and fidgety (70.1%), back pain (69.3%), dropped many of the activities (68.4%), frequently feeling like crying (67.4%), trouble concentrating (67%), feeling pretty worthless (66.4%), often feeling downhearted and blue (65.8%), frequently getting upset over little things (64.8%), and not satisfied with life (62.9%). In terms of comorbid anxiety, in the present study, four-fifths of the participants scored ≥10, which is considered to be the cutoff for the diagnosis of GAD as per the GAD-7 scale and 71.7% of the study participants scored score >10, which is an indicator of somatization. These findings provide support to the previous studies which have evaluated the symptom profile of depression among the elderly and have reported a high prevalence of somatic and anxiety symptoms.[14],[15],[17],[23],[53],[60],[61],[62] Previous studies from India which have evaluated symptom profile of depression among adult patients have also reported higher prevalence of somatic symptoms.[22] Although it is difficult to compare the findings of the present study with that of the earlier study due to difference in the rating scales used, it can be still said that depression in India more often manifests with somatic symptoms. This finding further lends support to the theories that patients from Eastern countries have difficulties in expressing their cognitive symptoms of depression [20],[63] and more often present with somatic symptoms as a manifestation of depression.[63],[64] Expression of psychological distress in the somatic form provides a model to seek help from the physicians without being stigmatized.[65],[66]

Considering the high prevalence of somatic and anxiety symptoms, it can be said that all elderly patients with these manifestations must be thoroughly evaluated for depression to prevent undertreatment and misdiagnosis of depression. Previous studies from other parts of the world also suggest a high prevalence of comorbid anxiety disorders in elderly patients with depression.[14],[17],[18],[19],[60],[67],[68],[69] The present study lends support to the high prevalence of anxiety symptoms among the elderly. In the present study, there was a significant correlation of anxiety with both depressive and somatic symptoms, but there was no significant correlation between depressive scores and total score for somatic symptoms. Previous studies, which have evaluated anxiety in patients with depression, also suggest an association between anxiety and somatic symptoms.[18] Accordingly, it can be said that anxiety possibly acts as a common factor which binds the somatic and cognitive symptoms of depression.

Beside the symptoms assessed by various scales, other depressive symptoms were also evaluated using clinical interview by a qualified psychiatrist. This revealed that a small proportion of elderly patients with depression also develop ideas of guilt (39.1%), hypochondriasis (27%), sin (21.5%), and catastrophe (13.1%). A high prevalence of hypochondrial ideas may be related to the high prevalence of the somatic symptoms. In terms of psychotic symptoms, the most common delusions were those of delusion of persecution, reference, and nihilism. In terms of hallucinations, auditory hallucinations were more than hallucinations in other modalities. This profile is also very similar to previous studies which have evaluated these symptoms.[70],[71]

About one-fourth (28.9%) of the participants wished to die and one-eighth had nonspecific active suicidal thoughts and active suicidal ideations without an intent with any method. Previous studies which have evaluated suicidal ideations among elderly patients with depression also suggest similar profile.[72],[73],[74] This suggests that the elderly patients must be properly evaluated for suicidal behaviors and if present must be managed appropriately.

In terms of secondary objectives, this study also evaluated the differences in the symptom profile among males and females, patients with FED and RDD, patients with age of onset before 60 years and after 60 years, and those aged <70 years and ≥70 years at presentation.

In terms of gender differences, the present study shows certain differences in the symptom profile of depression among males and females. Compared to males, females more often had symptoms of reduction in activity level, afraid that something bad will happen, feel helpless, frequently worry about future, feel pretty worthless, frequently get upset over little things, suffer from back pain, pain in arms, legs, or joints and trouble sleeping, and have active suicidal ideations and higher intensity of suicidal ideations, whereas males reported higher prevalence of not being satisfied with life, does not find life very exciting, feeling that their situation is hopeless, pain in stomach, feeling that heart is racing, pain during sexual intercourse, ideas of reference, and ideas of persecution. It is important to note that these differences were noted between the patients of either gender, despite lack of difference in the severity of symptoms noted across GDS-30, GAD-7, and PHQ-15,[14] suggesting that these differences cannot be solely attributed to the differences in severity of illness between the participants of either gender. As there is a paucity of literature on this issue, it is difficult to compare the findings of the present study. Studies which have evaluated the gender differences among elderly patients with depression suggest that agitation is more common in elderly depressed males, whereas elderly depressed females present with more number of depressive symptoms and more vegetative symptoms such as decreased appetite, joylessness, and insomnia.[32],[34],[36] Although the present study does not replicate the findings of these studies, it suggests that differences are apparent and there is a need for having gender sensitivity while evaluating depressive symptoms among the elderly.

Studies which have evaluated the gender differences in the symptom profile in adults suggest that females have more psychological problems, have higher levels of neuroticism, more chronicity, and more somatization.[27],[28],[29] In contrast, males have higher rates of comorbid substance abuse.[59],[75] However, some of the studies have reported lack of gender differences in terms of somatic symptoms, when the participants of both the genders were matched for nonsomatic symptom scores (cognitive/affective).[30] The present study supports the findings of higher prevalence of substance use as reported in adults. In contrast to these findings, the present study shows that there are subtle differences in the type of somatic symptoms between patients of either gender.

Gender differences with regard to suicidality are well reported. Higher rates of deliberate self-harm have been found in females and higher rates of completed suicides have been reported in elderly males across several studies.[76],[77],[78] In the present study, there were no significant gender differences in the number of attempted suicides, interrupted attempts, nonsuicidal behavior, and aborted attempts as per CSSR-S. However, significant differences were noted between the two genders, in terms of females having more intensity of suicidal ideations and higher frequency of active suicidal ideation with intent and plan. Previous studies have also reported higher rates of suicidal ideations in elderly females [79],[80] and these have been associated with higher psychological distress and feelings of hopelessness in depressed elderly females.[80] In the present study too, females have reported feeling hopeless more than males and higher intensity of suicidal ideation. These findings suggest that females should receive more attention in terms of evaluation for suicidal behavior.

The present study also revealed that age of onset of depression can also have some influence on clinical manifestation of depression in the elderly. Previous studies which have taken into account the age of onset of geriatric depression have also used the cutoff of 60 years to define early- and late-onset depression and have mainly focused on differences in the cognitive functions and report that patients with late-onset depression have more severe impairment in memory domains, perform poorly in neuropsychological tests, and have prevalence of vascular comorbidities.[81],[82],[83] However, none of these studies have specifically assessed the symptom profile. The present study suggests that although there are differences in the various depressive and anxiety symptoms among the elderly presenting with depression, somatic symptoms are more common in those with late-onset depression. Similar findings have been reported by some of the studies which have compared the symptom profile of depression among adults and elderly.[53],[61],[84]

In the present study, compared to the elderly aged 60–69 years at presentation, those aged ≥70 years had significantly higher prevalence of reduction in activity level, not hopeful about future, frequently worrying about future, reported problems with memory, felt often downhearted and blue, feel pretty worthless, worry a lot about the past, frequently got upset over little things, had trouble concentrating, reported feeling of nervous, anxious or on edge, were not able to stop or control worrying and complained more somatic symptoms of dizziness, fainting, shortness of breath, constipation, loose bowels, or diarrhea. These findings suggest that certain somatic symptoms, anxiety symptoms, depressive cognitions and cognitive symptoms are more common in old-old patients. Previous studies also suggest that as the age increases elderly patients with depression more often report somatic symptoms.[85]

The present study also reveals that symptom profile of those with FED and RDD also differs in terms of certain symptoms, i.e., depressive and somatic symptoms, but not in terms of anxiety symptoms. As none of the previous studies have tried to evaluate the differences in symptom profile of patients with FED and RDD in the elderly it is not possible to compare the findings with the existing literature.

To conclude, the present study shows that somatic and anxiety symptoms are highly prevalent among elderly patients with depression. Further, it is evident that there are certain differences in the symptom profile of depression among male and female patients with depression. The present study also reveals that age of onset, age at presentation and number of episodes could also influence the symptom profile of depression among elderly. These facts must be kept in mind while evaluating elderly patients with depression.

The present study has certain limitations. First, this was a cross-sectional study and did not evaluate the longitudinal course of symptoms of depression among elderly. Second, the study was limited to patients attending the psychiatry outpatient setting. It is known that often patients with depression attending the psychiatric outpatient setting have more severe depression. Accordingly, the study cannot be directly generalized to patients attending other treatment settings such as primary care. Similarly, the study cannot be directly generalized to patients with depression in the community. Some of the patients in the present study could already have been on treatment prior to presentation. It is quite possible that symptom profile could have been colored by the same. There was an unequal distribution of patients across various centers and we did not evaluate the differences across various centers or parts of the country. It is quite possible that these variables can also have some influence on the symptom profile of depression. The present study did not evaluate the psychosocial factors, which could influence the symptom profile of the patients. Future studies must attempt to overcome the limitations of the present study.

Acknowledgment

The present study was supported by a research grant of Rs. 50,000 by the Indian Association for Mental Health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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