|Year : 2017 | Volume
| Issue : 1 | Page : 36-41
Study of psychiatric morbidity among residents of government old age homes in Delhi
Raj Kumar1, Sujata Satapathy2, Vivek S Adhish1, Saxena Nripsuta3
1 Department of Community Health Administration, NIHFW, New Delhi, India
2 Department of Psychiatry, AIIMS, New Delhi, India
3 Department of Information Technology, IGDTUW, New Delhi, India
|Date of Web Publication||20-Jun-2017|
Department of Psychiatry, AIIMS, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Context: The increased demand on long-term old age care homes in urban India is a result of demographic transition together with the disintegration of joint family system and changing social values which make them increasingly vulnerable to mental health problems. Aims: This study attempted to find out an array of mental health problems and associated morbidity among inhabitant of government old age homes. Settings and Design: This was a cross-sectional study which included government run old age homes (OAHs) in Delhi. Subjects and Methods: The sample comprised a total of 148 elderly in four OAHs with a mean age of 72.81 years. The World Health Organization Quality of Life-BREF Scale (QOL), Mini-Mental State Examination, Geriatric Depression Scale, Hamilton Anxiety Rating Scale, Brief Psychiatric Rating Scale, and Kesseler-10 Scale were administered. Statistical Analysis: Data were analyzed through SPSS version 20.0 version. Frequency distribution and cross-tabulation used to create summary tables and compare items. Results: Female constituted two-third of study population whereas one-third of subjects were illiterate and two-third without income. The study demonstrated psychiatric morbidity profile among OAH inhabitants and exhibited mild-moderate anxiety symptoms in almost 95% followed by mild-severe depression reported by 85%, mild-moderate psychotic illnesses, psychological distress, cognitive impairments, and poor QOL. Low income and education, low social connections and loss of spouse were key risk factors. Conclusions and Recommendation: Psychiatric morbidity profile and QOL among OAH residents is influenced by various psychological, social, and economic factors. This emphasized the need for better management of the government-run OAHs to ensure better overall mental health of the residents.
Keywords: Aging, mental health, old age homes, psychiatric morbidity
|How to cite this article:|
Kumar R, Satapathy S, Adhish VS, Nripsuta S. Study of psychiatric morbidity among residents of government old age homes in Delhi. J Geriatr Ment Health 2017;4:36-41
|How to cite this URL:|
Kumar R, Satapathy S, Adhish VS, Nripsuta S. Study of psychiatric morbidity among residents of government old age homes in Delhi. J Geriatr Ment Health [serial online] 2017 [cited 2021 May 13];4:36-41. Available from: https://www.jgmh.org/text.asp?2017/4/1/36/208603
| Introduction|| |
Population aging is a result of demographic transition, and it is experienced fastest in the developing world. Globally, the share of the 60 and above population have increased from only 8% of world population (200 million people) in 1950 to around 11% (760 million) in 2011, with further expected to reach 22% (2 billion) by 2050. According to the 2011 census, population share of elderly in India stands at 8% which is projected to increase to 10.1% by 2021 and 18.3% (300 million) by 2050., Population aged 60 years and above in the city of Delhi is 5.9% according to 2011 census.
Increased proneness to develop psychiatric illnesses during old age has been attributed to multidimensional factors such as aging of the brain, fragile physical health, cerebral pathologies, poor financial condition and living arrangements, and breakdown of the family support system. Irrespective of living arrangements and place of stay, psychiatric morbidity among elderly people is common, severe, and multifaceted. Disorders such as depression, anxiety, cognitive, and psychotic disorders have a high prevalence among elderly. Studies report that up to 20% in community care and about 37% at the primary level care suffer from depression. Over the period of years, perhaps the sequence of the most common psychiatric morbidities among Indian elderly changed from depression, adjustment disorders, anxiety disorders, dementia and delirium (cognitive disorders), psychoses, bipolar disorders and substance-related psychiatric illnesses  to recently reported predominant psychiatric diagnoses as depressive disorders, dementia, generalized anxiety disorder, alcohol dependence, and bipolar disorder. The research in India on the prevalence of these illnesses is divided primarily into community-based cross-sectional studies and old age homes (OAHs). A majority of community research focused on the prevalence of depression and mood disorders among the elderly population. While community-based studies reported the prevalence of depression as 47.0%, cognitive impairment as 43.25%. Studies identified low socioeconomic status, loss of spouse, living alone, chronic comorbidities, cognitive impairment, bereavement, and restricted activities of daily living (ADL) as significant risk factors of depression. Although the prevalence pattern remained the same, few studies reported higher prevalence (32.4%–49%) of these illnesses among urban , as compared to rural elderly population (23.7%). Studies comparing the prevalence of psychiatric illnesses between community and OAHs report psychosis as being more in community , as compared to OAHs and depression found more in OAHs., Interestingly, a study by Tiple, et al., showed people living in OAHs to be less depressed than those stayed with the family. In fact, studies primarily focused on OAHs revealed depression to be significantly increasing with age, shorter duration of stay, sensory impairments, sleep problems, more financial dependence, and in female gender.
The Indian literature on psychiatric illness among elderly in community and OAHs mainly concentrated either on the prevalence or pattern and more so reiterated on the higher prevalence of depression among elderly population. The findings are by and large in the similar lines for the entire elderly population irrespective of the location of living and living arrangements.
While traditional family roles have become more elusive, increasing issues of community care and social support for persons without families are emerging, which results in more demand on long-term old age care homes in urban India. The ownership of Indian OAHs varies from government to nongovernmental organizations (NGOs), charitable trusts, missionary or faith-based groups and private groups. As a number of government policies are directed to this group of population, it is important to know the profile of wider range of mental illnesses and distribution of severity among the inmates of government run OAHs in urban areas. The impetus of this index study comes from the inadequate number of comprehensive mental health profile of the elderly population in different old age institution in urban Delhi area.
This cross-sectional study attempted to find out an array of mental health conditions directly or indirectly related to the mental well-being component included in the World Health Organizations (WHOs) definition of health. Based on the review of literature, six such conditions namely the quality of life (QOL), cognitive functioning, psychopathology, depression, anxiety, and psychological distress were identified and studied their contributing to the mental wellbeing.
| Subjects and Methods|| |
This was cross-sectional descriptive study undertaken in government administered OAHs in Delhi.
Study setting and sample
Although all four government-run OAHs in Delhi were included in the sample, their administrative structure varied in terms of ownership, resident capacity, and payment structure. The structures of these OAHs varied from Delhi government (n = 1, male–female both, resident capacity = 67, free stay) to New Delhi Municipal Corporation (n = 2, one is only females and other one both sexes, resident capacity = 34 and 55, pay and stay) to partnership between government and NGO on public–private partnership (n = 1, both sexes, resident capacity = 26, 50% pay and 50% free) mode. Two of these were pay and stay types, while one was totally free stay, and the other was 50% free and 50% paid. The number of residents was more in the free stay OAH. Except one being female OAHs, all other accommodated both males and females.
The sample included the physically fit old age inmates of both sexes, between 60 and 85 years of age who stayed there at least 1 year and willing to provide informed written consent to participate in the study. Those already medically diagnosed with psychiatric or neurological illnesses were excluded from the study. After official permissions from the appropriate authorities, a total of 148 (out of 182), who met the inclusion criteria constituted the study sample. This is important to mention here that 5 elderly due to some apprehension, very keenly agreed to participate in the study but only with verbal consent. Written consent was provided by the remaining sample.
- Semi-structured pro forma for sociodemographic profile was developed for the study purpose
- WHO-QOL BREF scale: It is a self-report, but researcher assisted 4-point rating scale, which has 26-item spread over 4 domains, such as, physical, psychological, social, and environmental. The scale has good reliability and validity across many culture and adult age groups. Higher score indicated better QOL on the scale.
- Mini-Mental State Examination (MMSE) Considering the cultural and educational difference of study subjects, four items namely backward counting, repetition, visual command, and sentence were used from Ganguli adaptation  MMSE is a widely used clinician-cum-researcher administered reliable scale and has 8-item. The scores indicate normal cognition as well as scores for mild, moderate, and severe cognitive impairments. Higher score indicated better cognition and lower score indicated more severe cognitive impairments on this tool. Considering the culturally and educationally different background of the study population, four items/subtests, i.e., backward counting, repetition, visual command, and sentence were used from Ganguli adaptation
- The Brief Psychiatric Rating Scale (BPRS): It is a 7-point scale comprised 18-item and has good reliability and validity. It was used to measure the major psychotic and nonpsychotic symptoms. Thus, the range of possible BPRS total scores is from 18 to 126, and the ratings are based on both the subjective and objective analysis of the symptoms. The clinical implication of BPRS in this study was done as per Leucht, et al. Thus, a clinical interpretation of “mildly ill” corresponded to a BPRS total score of 31, “moderately ill” to a BPRS score of 41, and “markedly ill” to a BPRS score of 53
- Geriatric Depression Scale: (GDS) GDS is a most widely used reliable self-report (researcher assisted) yes and no type of tool to screen depression. Originally, it has 30-item indicating severity of depression and normal cutoff scores.
- Hamilton Anxiety Rating Scale (HAM-A): HAM-A is a 14-item clinician administered instrument scored on a 0–4 rating scale. The score below 17 indicates mild, between 18 and 25 indicates mild to moderate, and between 26 and 30 indicates moderate to severe anxiety.
- Kesseler-10 Scale (K-10): K-10 consisting of 10 items was used in Hindi to measure psychological distress. The values of Kappa and weighted Kappa range from 0.42 to 0.74. The test-retest reliability was 0.83.
The obtained data were descriptively analyzed with the help of SPSS version 20.0 (Armonk, NY: IBM Corp.). Frequency distribution and cross-tabulation used to create summary tables and compare items.
Approval was obtained from the Academic Committee of NIHFW, New Delhi and Faculty of Medical Sciences of Delhi University. Informed written consent was obtained, and confidentiality and privacy of the study subjects were maintained throughout.
| Results|| |
[Table 1] presents the characteristics of sample in four different OAHs as well as for the total sample. The majority of study sample of 148, was constituted by female residents with 62.8% share (n = 93) while male contributed 37.2% (n = 55) of population. The mean age of the sample was 72.81 years (minimum 61 and maximum 85 years). More elderly were in the age group of 65–70 years (n = 38 and 25.7%), followed by 80–85 (n = 34 and 23%), 70–75 (n = 29 and 19.6%), 60–65 (n = 28 and 18.9%), 75–80 (n = 19 and 12.8%) age groups. A majority of the sample (70.9%, n = 105) was widow/widowers, and 89.2% (n = 132) were not living with the partners. The educational status showed that a total of 45 (30.4%) elderly were illiterate followed by 41 (27.7%) elderly with secondary level education and 37 (25%) with graduation degree. While 95 (64.2%) elderly had no monthly income, 51 (34.5%) had a monthly income of ≥INR.5000.00/. A majority (n = 89, 60.1%) of the elderly has been staying in OAHs for the past 1–5 years followed by 42 (28.4%) between 5 and 10 years, and 17 (11.5%) elderly staying more than 10 years.
[Table 2] exhibited data for the entire sample on various measured variables. It was revealed that the mean scores for physical (mean = 58.99; standard deviation [SD] = 11.33) and psychological (mean = 57.01; SD = 12.01) QOL were better than the social (mean = 50.13; SD = 9.15) and environmental (mean = 50.07; SD = 11.52) QOL. However, the QOL in all domains was better in pay and stay OAHs as compared to either free or 50% free OAHs.
The findings revealed that while 68.9% (n = 102) of the elderly subjects had normal MMSE score, 13.5% (n = 20) constituted the borderline group and 17.6% (n = 26) had impaired cognition. In the line of findings on QOL, more elderly in pay and stay homes 93.1% (n = 27) and 97.8% (n = 44) respectively had normal cognitive functioning as compared to 42.3% (n = 22) of the free and 40.9% (n = 9) of the 50% free OAHs. In contrary, the free structured OAHs contained a majority of elderly with borderline (n = 18; 90%) and impaired (n = 25; 96.2%) cognition.
Similarly, the mean BPRS score for all elderly population was 42.69 (SD = 9.86) with considerable variation in BPRS score among pay and stay home and free structured OAHs. This indicated that the elderly in the former OAHs had lesser severe of psychotic issues as compared to later OAHs.
Interestingly, the residents of OAHs were almost similar in terms of reporting severe (n = 66; 44.6%) and mild (n = 61; 41.2%) depressive illness while 14.1% (n = 21) had normal GDS score. Out of these 48 (72.73%) elderly with severe depressive symptoms were residents of OAHs with free stay structure.
The findings suggested that a half of the study population (n = 74; 50%) constituted elderly with mild anxiety and similar number had moderate anxiety scores (n = 67; 45.2%) whereas a very few (n = 7; 4.7%) had scores falling under severe HAM-A category. In the line of previous findings, a majority of elderly subjects with mild HAM-A score (n = 61; 82.4%) belonged to the pay and stay OAHs. Opposite to this, a majority of residents from free structured OAHs (n = 57; 85.1%) reported moderate depression.
The findings on psychological distress among the elderly population in OAHs indicated a majority (n = 89; 60.1%) reported no psychological distress followed by mild (n = 44; 29.7%), moderate (n = 11; 7.4%), and severe (n = 4; 2.7%) psychological distress. Out of the total residents who reported no psychological distress, a majority (n = 67; 75.3%) was from the pay and stay OAHs while a majority of residents (n = 52; 88.1%) in free or 50% free pay structured OAHs reported either mild or moderate or severe psychological distress.
| Discussion|| |
Results are discussed in terms of psychiatric morbidity profile of elderly inhabitants of different type of OAHs.
The predominant psychiatric conditions found in this study were mild-moderate anxiety symptoms (almost 95% reported this) followed by mild-severe depression (almost 85% reported this), mild-moderate psychotic illnesses, psychological distress, cognitive impairments, and poor QOL. The prevalence of depression in this study was higher than a study carried out in elderly living in OAH in India wherein it was reported as 63.8%. Reason for higher prevalence of anxiety in this study might be attributed to the poor financial status of the sample, which could have generated lot of apprehension and worries related to own health or future. Furthermore, the social alienation from the family could also have contributed to anxiety along with feelings of loneliness and depression. This finding could be very specific to OAHs as Sethi, et al. found elderly subjects living in OAHs are more affected in terms of depression as compared to community-dwelling elder subjects and social alienation from the nearest kin could be one of the key reasons. However, there are studies which report that psychiatric morbidity among elderly was higher irrespective of settings where they live.
The reason for anxiety and depression, as the most common mental health problems in this study, could be attributed to multidimensional risk factors such as financial constraints, lack of spouse/partner/caregiver, poor physical infrastructure of the OAHs, no family association, and physical ailments. In fact, as the sample was female dominated in this study, there are many studies emphasizing on widowhood to be strongly associated with depression. In addition, physical ailments and impairments, which were not the focus of this study, could have affected the anxiety and depression related problems, as found by a study reporting the OAH inhabitants suffering from psychiatric illnesses had one or more associated physical morbidity. Results were in similar line with another study wherein it is reported that the prevalence of depression was significantly more with increased age, in females and physical health problems.
Nearly, two-third of the elderly residents exhibited normal cognitive functioning on MMSE, whereas rest one-third demonstrated borderline and impaired cognitive functioning. Thus, as compared to anxiety and depression, cognitive deficits were less common mental health problems found among the residents and this finding was similar to the findings reported by Kumar, et al. Nearly, 40% of the study sample had exhibited mild-severe psychological distress, therefore, it would not be correct to consider it as very common mental health condition as reported by Heather et al., 2009 study. Rather this study found anxiety and depression as two most common mental health conditions among the OAH residents. This difference may have occurred because of the study emphasis, wherein Heather et al., study included psychological distress as a single psychological variable under study, the current study included more specific measures to include a variety of psychiatric disorders such as anxiety, depression, psychotic disorders and cognitive impairments.
The reported psychiatric conditions were found in the majority of residents belonged to the free structured OAHs as compared to pay and stay structured OAHs. In other words, residents of free structured OAHs exhibited more anxiety, depression, and psychotic problems along with cognitive deficits; psychological distress and poor QOL as compared to residents of pay and stay OAHs. It can be attributed to the poor sociodemographic background, mainly the poor educational and financial background of the residents of the free structured OAHs ; however, there could be other confounding factors which were not covered in this study. This finding was in line of many previous studies emphasizing the significance of lower economic status ,, and living with spouse  in ensuring a better life to the elderly both in community and OAHs. Similarly, subjects who demonstrated normal cognitive functioning, nearly three-fourth were the residents of pay and stay type of OAHs and those with impaired cognitive functioning nearly all were the residents of free type OAHs. Approximately, half of the study population demonstrated severe depression on GDS scale and out which nearly three-fourth were residents of free type OAHs considered together. Half of the study population displayed mild anxiety disorder on HAM-A scale while rest half demonstrated moderate and severe anxiety pathology. Out of elderly with mild level of anxiety more than three-fourth were a resident of pay and stay type OAHs. Whereas more than three-fourth of the residents of free type OAHs were found to have moderate and severe level of anxiety disorder. The finding laid its support to the study reporting education as the most important protective factors of good physical and cognitive functioning, and its indirect effect on the QOL of elderly. This finding also laid its support to few recent studies reporting the association of cognitive impairment, depression, and a disturbed sleep pattern with illiteracy, poverty, loneliness, and the low socioeconomic status of the family.,
Two-third of the elderly residents were found to be classified as likely to be well on K-10 scale whereas one-third displayed a mild, moderate, and severe level of psychological distress. More than three-fourth OAH residents out of those displaying mild, moderate, and severe level of psychological distress were residing in free type OAHs. The finding could be explained in terms low income at old age, which could be an important risk factor for becoming psychologically distressed, and stressors account for part of this increased risk.
| Conclusions|| |
Although aging is a universal phenomenon, its impact and meaning are largely influenced by various biological, psychological, economic, and sociological factors. Low socioeconomic status, loss of spouse, living alone and decreased family association, poor physical infrastructure and health services in OAHs, chronic physical comorbidities, and restricted ADL are some of the significant risk factors of psychiatric illnesses. The findings suggest integrated mental health services aiming at psychological, psychiatric, and cognitive betterment of the institutionalized elderly. Second, even these services should be an integral part of any geriatric clinic and health services provided in the hospitals. The policy and programs for this population must highlight the significance of these services.
| Recommendation|| |
More specifically, the study highlighted the major risk factors of poor mental health of elderly people staying in government OAH. Moreover, to reduce these risk factors firstly the study highlighted the need of robust social security schemes along with regular and enhanced old age pensions, and second, building adequate and appropriate physical infrastructure in OAHs and regular psychosocial and cognitive retaining service provisions in OAHs by the government agencies running these institutions.
Future direction of research
The sample size was small and was limited to government-run OAHs only; therefore, the caution should be taken regarding the generalizability of the findings to other administratively different OAHs. The study could not look at the differences between government run OAHs and totally private (or NGOs) run OAHs. The future researchers could look at an action research to undertake the need and gap analysis for immediate action as a part of administrative and policy intervention. In addition, the impact of any regular psychosocial service provision as a buffer on the prevalence of psychiatric illness can also be looked at.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Population Ageing 1950-2050, Issue 207, United Nations. Dept. of Economic and Social Affairs. Population Division UN; 2002.
Siva Raju S. Ageing in India in the 21st
Century: A Research Agenda. Mumbai: Harmony - Celebrate Age; 2006.
Ingle GK, Nath A. Geriatric health in India: Concerns and solutions. Indian J Community Med 2008;33:214-8.
] [Full text]
Khandelwal SK. Mental health of older people. In: Dey AB, editor. Ageing in India. Situational Analysis and Planning for the Future. New Delhi: Rakmo Press; 2003.
Doraiswamy PM, Khan ZM, Donahue RM, Richard NE. The spectrum of quality-of-life impairments in recurrent geriatric depression. J Gerontol A Biol Sci Med Sci 2002;57:M134-7.
Dening T, Bains J. Mental health services for residents of care homes. Age Ageing 2004;33:1-2.
World Health Organization. Burden of mental and behavioural disorders. The World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva, Switzerland: World Health Organization; 2001. p. 3-4, 19-45.
Sood A, Singh P, Gargi PD. Psychiatric morbidity in non-psychiatric geriatric inpatients. Indian J Psychiatry 2006;48:56-61.
] [Full text]
Seby K, Chaudhury S, Chakraborty R. Prevalence of psychiatric and physical morbidity in an urban geriatric population. Indian J Psychiatry 2011;53:121-7.
] [Full text]
Jariwala V, Bansal RK, Patel S, Tamakuwala B. A study of depression among aged in Surat city. Natl J Community Med 2010;1:47-9.
Reddy NB, Pallavi M, Reddy NN, Reddy CS, Singh RK, Pirabu RA. Psychological morbidity status among the rural geriatric population of Tamil Nadu, India: A cross-sectional study. Indian J Psychol Med 2012;34:227-31.
] [Full text]
Barua A, Kar N. Screening for depression in elderly Indian population. Indian J Psychiatry 2010;52:150-3.
] [Full text]
Nair SS, Hiremath SG, Ramesh, Pooja, Nair SS. Depression among geriatrics: Prevalence and associated factors. Int J Curr Res Rev 2013;5:110-2.
Tiwari SC, Srivastava G, Tripathi RK, Pandey NM, Agarwal GG, Pandey S, et al.
Prevalence of psychiatric morbidity amongst the community dwelling rural older adults in Northern India. Indian J Med Res 2013;138:504-14.
] [Full text]
Nagaraj AK, Mathew J, Nanjegowda RB, Majgi SM, Purushothama SM. Psychiatric morbidity among elderly people living in old age homes and in the community: A comparative study. Online J Health Allied Sci 2011;10:5. Available from: http://www.ojhas.org/issue40/2011-4-5.htm.
[Last accessed on 2015 Jun 13].
Singh AP, Kumar KL, Reddy CM. Psychiatric morbidity in geriatric population in old age homes and community: A comparative study. Indian J Psychol Med 2012;34:39-43. [Full text]
Kumar P, Das A, Rautela U. Mental and physical morbidity in old age homes of Lucknow, India. Delhi Psychiatry J 2012;15:111-7.
Tiple P, Sharma SN, Srivastava AS. Psychiatric morbidity in geriatric people. Indian J Psychiatry 2006;48:88-94.
] [Full text]
Narkhede V, Likhar S, Rana A. A study on depression in elderly inmates living in old age homes in Gujarat. Indian J Res Rep Med Sci 2012;2:21-3.
World Health Organization. WHOQOL-BREF: Introduction, administration, scoring and generic version of the assessment. Programme on mental health. Geneva: World Health Organization; 1996.
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.
Ganguli M, et al
. A Hindi version of the MMSE: The development of a cognitive screening instrument for a largely illiterate rural elderly population in India. Int J Geriatr Psychiatry 1995;10:367-77.
Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychol Rep 1962;10:799-812.
Leucht S, Kane JM, Kissling W, Hamann J, Etschel E, Engel R. Clinical implications of Brief Psychiatric Rating Scale scores. Br J Psychiatry 2005;187:366-71.
Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al.
Development and validation of a geriatric depression screening scale: A preliminary report. J Psychiatr Res 1982-1983;17:37-49.
Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50-5.
Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, et al.
Screening for serious mental illness in the general population. Arch Gen Psychiatry 2003;60:184-9.
Sethi V, Verma V, Singh U. Impact of ageing on depression and activities of daily livings in normal elderly subjects living in old age homes and communities of Kanpur, U.P. Int J Med Res Health Sci. 2013;2:243-9.
Joshi K, Avasthi A, Kumar R. Health-related quality of life (HRQOL) among the elderly in Northern India. Health Popul Perspect Issues 2003;26:141-53.
Heather MO, Louise L, Ronald G. Income and psychological distress: The role of the social environment. In Statistics Canada, Catalogue no. 82-003-XPE. Health Rep 2009;20:1-8.
Alam M. Ageing in India: Socio-economic and Health Dimensions. New Delhi: Academic Foundation; 2006.
Siva Raju S. Situational Analysis of Older Persons in Mumbai. Mumbai: Family Welfare Agency; 2004.
Schoevers RA, Geerlings MI, Beekman AT, Penninx BW, Deeg DJ, Jonker C, et al.
Association of depression and gender with mortality in old age. Results from the Amsterdam Study of the Elderly (AMSTEL). Br J Psychiatry 2000;177:336-42.
Fernández BR. Environmental conditions, health and satisfaction among the elderly: Some empirical results. Psicothema 2001;13:40-9.
Swarnalatha N. The prevalence of depression among the rural elderly in Chittoor District, Andhra Pradesh. J Clin Diagn Res 2013;7:1356-60.
[Table 1], [Table 2]