The prevalence of depression among the elderly people living in rural Wardha.

BACKGROUND: Depression is the most common psychiatric disorder among elderly population in India, which generally remains undiagnosed and undertreated. Exact burden of depression among the elderly population in rural India was not known. AIM: This study was conducted to determine the prevalence of depression among the elderly population in rural population of Wardha, Maharashtra.
MATERIALS AND METHODS: This is a cross-sectional study carried out among the elderly (≥60 years) population of both sexes residing in the field practice area of the department of community medicine. Geriatric depression scale was used for screening depression among the study population. Data collection was completed within 2 months using convenience sampling. Ethical approval was taken before beginning the study. Magnitude was expressed in percentage along with its 95% confidence interval (CI). Univariate and multivariate logistic regressions were done. Odds ratio and 95% CI were used to express association.
RESULTS: Magnitude of depression among the elderly population was found to be 41.7% (95% CI: 36.1-47.4). In this study, we found the following factors to have positively contributed towards depression among elderly population in rural Wardha: female sex, widowed, separated, divorced, decreased decision-making capability, abused, or being suffering from chronic illnesses.
CONCLUSION: Our study showed the prevalence of mild depression to be 26.72% and that of severe depression to be 15.17% among the elderly study participants. Copyright:

With the development of improved treatment regimens, better life-saving drugs, and better prevention of infectious diseases, life expectancy in India has increased by 5 years, from 62.3 years for males and 63.9 years for females in 2001–2005 to 67.3 and 69.6 years, respectively, in 2011–2015, and the projected life expectancy during 2012–2025 will be 69.8 and 72.3 years, respectively.[1] However, as people get older, they are vulnerable to different medical and psychological problems and depression in this age group, which needs a special mention. In rural India, physical problems like pain, deafness, deafness etc and health issues like increased blood pressure and increased blood sugar, which can be measured are generally given more importance.[23] Most of their visits to hospital are as a result of these issues. Unfortunately, the mental health issues, specifically depression, are hardly addressed, both by the patients and by the healthcare personnel. This problem is not new. In 1990, the World Health Organization (WHO) described depression as a major cause of disability globally. Mental and behavioral disorders are estimated to account for 12% of the burden of disease worldwide, which affects approximately 450 million people.[4] It has been postulated that depression will become the single most leading cause of disability-adjusted life years in the developing countries.[5] The WHO estimated that the overall rate of prevalence of depressive disorders among the elderly population generally varies between 10% and 20%, depending on the cultural scenarios.[6] The community-based mental health studies in India have revealed that the point prevalence of depressive disorders in the elderly Indian population varies between 13% and 25%.[78]

Depression among the geriatric population is a neglected problem in India. India is in the phase of demographic transition which is attributed to decreasing fertility and mortality rates as a result of availability of better healthcare services. This has resulted in gradual increase in geriatric population in India.[9] The United Nations Population Fund Report[10] suggests that the number of elderly persons is expected to grow to 2 billion by 2050, accounting for 22% of the total population. Due to modernization, people are now preferring to live in nuclear families, both in rural and urban areas, resulting in loneliness and lack of family, as well as social support to the elderly, which adds on to their deteriorating health conditions, ultimately making them an easy victim of depression. Depression among geriatric population remains an untold truth and is being severely neglected.[4] Although a number of elderly-friendly schemes and programs are being launched in India,[1112] it lacks the zeal to deal with this problem of depression. Adding to it, it is unfortunate to say, in India, that very few studies have been conducted in this topic resulting in lack of proper evidence of the burden of the disease. As a result of all these, the current study has been planned to be executed to know the magnitude of depression among the elderly masses in rural Wardha and to find its correlates.

MATERIALS AND METHODS

Study settings

This is a cross-sectional study carried out in the field practice area of Rural Health and Training Centre (RHTC) Bhidi, under the Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram. RHTC Bhidi covers a population of 10,739. Apart from having a rural hospital (RH) in Bhidi, the RHTC also runs community-owned clinics, called “Kiran Clinic” in five different villages, namely Kajalsara, Anji, Wabgaon, Kharda, and Babhulgaon, which provide curative, preventive, and promotive services to the rural masses. These clinics were established by the department of community medicine in the period of Community-Led Initiative for Child Survival in the field practice area in 2003 and are still running. The clinic is a collaborative partnership between the department of community medicine and the community of village, wherein the department only provides technical support in the form of doctor and nurse staff.[13] There are also weekly specialist clinics including the department of psychiatry, run by MGIMS, Sewagram, at the RH.

Study population

The study was carried out among the elderly population (age ≥60 years) of both sexes residing in the rural area of Bhidi, which was our study population.

Sampling technique and sample size

Taking the prevalence of depression among geriatric population to be 25%[7] and absolute precision of 5, the sample size required for our study was 287 (≈290) for 95% confidence level. The sample size calculation was calculated using OPEN EPI software.[14] For the ease of the study, convenience sampling technique was used.

Measurements

Two tools were utilized for collecting the data for screening depression and their associated sociodemographic parameters.

Depression

Geriatric Depression Scale,[15] long form of 30 questions, was utilized to screen depression among the elderly population and to classify them into (a) normal (0–9), (b) mild (10–19), and (c) severe (20–30) depression. This scale was developed as a basic screening measure for depression in older adults and is widely used. We have used its Marathi version in this study[16] as the study participants were mostly Marathi speaking and were comfortable in answering to the Marathi questionnaire, though we are not sure if the Marathi version of the questionnaire is psychometrically standardized.

Questionnaire for sociodemographic determinants [Questionnaire 1]

This questionnaire was prepared based on the standard questionnaire for the elderly given in the “The Status of Elderly in Selected states of India, 2011.”[17] This questionnaire was pretested and suitably modified to meet with the study objective. Using this questionnaire, we have captured a number of sociodemographic determinants of the participants, among which the following are worthwhile to be mentioned.

Age ≥60 years is taken as geriatric age group in this study. The age groups are divided into three: 60–69 years, 70–79 years, and ≥80 years. We have included both sexes in our study. Marital status, schooling, and whether suffering from any chronic illness or being abused/neglected since 60 years of age by family members/neighbors were also noted. Annual individual income or whether still dependent on family members financially was also noted.

Data collection

As per the curriculum of postgraduate training program in the Department of Community Medicine, MGIMS, the principal investigator was posted in RHTC Bhidi for 2 months from October to November 2015, where he/she had to attend the community health clinics (Kiran Clinics[13]) at five different villages under the field practice area of RHTC Bhidi. This scope of rural posting was utilized for the collection of data by interviewing the elderly (≥60 years) patients or the elderly relatives who visited the weekly field clinics and RH by the principal investigator. Apart from normal days of working of the clinic, the investigator payed extra visit to the village, to complete the data collection. Questions were asked in the language which the study subjects understood. Data collection was completed within the 2 months of posting at RHTC Bhidi. In an average, 3–4 interviews were conducted per day.

Ethical consideration

Ethical approval was taken from the institutional ethical committee before beginning the study. Written informed consent was taken from each participant before starting the interview. All cases of depression who were diagnosed during the study were referred to the weekly psychiatry clinic at the RH for further management and were followed up subsequently.

Analysis

Data entry and analysis were done using EPI Info Software.[18] Prevalence was expressed using percentage and 95% confidence interval (CI). Association with various determinants was studied using odds ratio with 95% CIs derived using univariate and multivariate logistic regressions.

RESULTS

Table 1 shows the age- and sex-wise distribution of the study subjects. Of the 290 study population, 129 were male and 161 were female. It is seen that the maximum number of the population was in the age group between 60 and 69 years.

Table 1

Age and sex distribution among the study population (n=290)

Age group (years)	Male, n (%)	Female, n (%)
60-69	69 (53.5)	82 (50.9)
70-79	49 (38.0)	67 (41.7)
≥80	11 (8.5)	12 (7.4)
Total	129 (44.5)	161 (55.5)

In our study, 41.7% (95% CI: 36.1–47.4) were suffering from depression, among which 63.7% were suffering from mild depression and 36.37% were suffering from severe depression, which is depicted in Figure 1. In our study, the females (60.9%) were found to be more depressed than the males (33.3%) and it was found to be statistically significant.

Figure 1

Prevalence of depression among the study population as per Geriatric Depression Scale-30

Table 2 shows the results of both univariate and multivariate logistic regressions. In univariate logistic regression, higher odds were observed among the females (1.9 [95% CI: 1.2–3.0]) as compared to the males; those elderly who were widowed or separated or divorced were also found to have higher odds (2.5 [95% CI: 1.5–4.2]) when compared to the elderly population who were having spouse. Similar findings of having higher odds of 4.8 (95% CI: 2.5–9.8) were found among those elderly who were suffering from any of the chronic illnesses such as hypertension, diabetes, multiple joint pains, myalgia, respiratory problems, and cancer than those who were not suffering from those diseases. Odds were also found to be higher (4.4 [95% CI: 1.3–20.3]) among the study population whose role as a decision-maker in the family has decreased after becoming aged compared to those who still took important decisions of the family. Finally, the study population who reported to have been victim of abuse or violence or neglect, mostly by family members and neighbors, was also found to have higher odds of 2.7 (95% CI: 1.5–4.9) when compared to those who never suffered from abuse, violence, or neglect. The reference category has been selected after literature review and brain storming. They represented the group of population, who were considered more immune to depression.

Table 2

Association of sociodemographic characteristics and depression (n=290)

Characteristics	Depression present, n (%)	Depression absent, n (%)	OR (95% CI)	Adjusted OR (95% CI)
Age group, years (n)
60-69 (151)	56 (37.1)	95 (62.9)	Reference[19]	Reference
70-79 (116)	51 (43.9)	65 (56.1)	1.3 (0.8-2.1)	0.9 (0.5-1.9)
≥80 (23)	14 (60.8)	9 (39.2)	0.5 (0.2-1.2)	1.6 (0.5-5.1)
Sex (n)
Male (129)	43 (33.3)	86 (66.7)	Reference[20]
Female (161)	78 (60.9)	83 (39.1)	1.9 (1.2-3.0)	1.5 (0.8-2.7)
Marital status (n)
Married (206)	73 (35.4)	133 (64.6)	Reference[21]	Reference
Widowed/separated/divorced (81)	47 (58.0)	34 (42.0)	2.5 (1.5-4.2)	1.4 (0.6-2.7)
Never married (03)	01 (33.3)	02 (66.7)	0.9 (0.0-12.4)	2.5 (0.2-31.9)
Schooling (n)
Attended school (157)	62 (39.5)	95 (60.5)	Reference[2]	Reference
Not attended school (133)	59 (44.4)	74 (55.6)	1.2 (0.7-1.9)	0.6 (0.3-1.2)
Working status (n)
Not working (136)	62 (45.6)	74 (54.4)	1.34 (0.8-2.1)	0.6 (0.3-1.3)
Working (154)	59 (38.3)	95 (61.7)	Reference[3]	Reference
Annual income of individual study participant in INR (n)
<50,000 (135)	73 (54.0)	62 (46.0)	2.7 (0.6-13.4)	1.7 (0.1-30.3)
50,000-1 lac (58)	16 (27.6)	42 (72.4)	0.8 (0.2-4.6)	1.2 (0.06-21.4)
1 lac-2 lac (59)	24 (40.7)	35 (59.3)	1.59 (0.3-8.2)	1.06 (0.0-27.8)
≥2 lac (10)	3 (30.0)	7 (70.0)	Reference[22]	Reference
Don’t know (28)	7 (25.0)	21 (75.0)	0.7 (0.5-4.6)	0.4 (0.0-8.2)
Dependency (n)
Dependent (200)	87 (43.5)	113 (56.5)	Reference[2]	Reference
Not depend (90)	34 (37.8)	56 (62.2)	0.78 (0.7-1.3)	1.2 (0.0-2.3)
Disease status (n)
Disease present (219)	109 (49.7)	110 (50.3)	4.8 (2.5-9.8)	1.9 (0.5-2.5)
Disease absent (71)	12 (16.9)	59 (83.1)	Reference[2]	Reference
Role as a decision-maker in the family (n)
Improved (15)	3 (20.0)	12 (80.0)	Reference[19]	Reference
Remained same (116)	34 (29.3)	82 (70.7)	1.6 (0.4-7.7)	0.9 (0.2-4.0)
Declined (159)	84 (52.8)	75 (47.2)	4.4 (1.3-20.3)	2.3 (0.5-10.9)
Any abuse/violence/neglect by any person since 60 years of age (n)
Yes (62)	38 (61.3)	24 (38.7)	2.7 (1.5-4.9)	0.5 (0.3-1.1)
No (228)	83 (36.4)	145 (63.6)	Reference[23]	Reference

OR - Odds ratio; CI - Confidence interval

Odds of older age groups (≥70 years), illiterate, inability to work at present, decreased individual annual income, and financial and physical dependency were not found to be significantly higher than their counterparts. After adjusting for other factors in multivariate logistic regression, none of the factors were found to be significant.

DISCUSSION

In our study, the prevalence of depression among the elderly population was found to be 41.7%. Various studies have revealed that the prevalence rates for depression in the community samples of the elderly in India varied from 6% to 58%.[24252627] We also tried to look for association of depression with a number of factors such as age group, sex, marital status, schooling, working status, annual income, dependency, disease status, role as decision-maker, and whether being a victim of abuse or not. As we considered that more than one factor of independent variables influenced the variability of dependent variables, so, to draw a more accurate conclusion, we have done the multivariate analysis after the bivariate analysis. Although many of those factors showed positive association in univariate analysis, none of them showed a significant positive association in multivariate logistic regression.

Magnitude of depression (41.7%) among geriatric population, in our study, was found to be at per with other similar studies conducted at Salem, Kanchipuram, and Hoogly,[21] India. However, in a study conducted in Ludhiana,[19] the prevalence of depression among the elderly was found to be only 8.9%; one reason for this could be the inclusion of urban population in their study. Urbanization has its own set of advantages and disadvantages. In spite of overcrowding, pollution, high levels of violence, and reduced social support, people have better facilities and are at ease for early diagnosis of their mental health.[28] Movement of people to urban areas has led to a large number of elderly men and women left to look after themselves in the villages, while the young generation lives in urban areas for their livelihood. Hence, the elderly population in the rural areas are staying all alone most of the time, which gives rise to depression. Poor health infrastructure in the rural setup forbids early diagnosis of their depressed mood, and their condition gradually starts to aggravate. Further, the depressive symptoms are generally dismissed as “normal” by the elderly person, by their family members, and even by the healthcare providers.[29]

In the current study, the magnitude of depression was found to increase with increasing age. Although age effect was not statistically significant, similar findings were found in the prevalent studies conducted by Sengupta and Benjamin[19] and Radhakrishnan and Nayeem.[20] Some of the reasons for the sudden increase in the prevalence from the age of 70 years may be an increased economical and physical dependency, loss of the spouse, negligence by the family members, and loss of self-esteem.[2526]

We found the female elderly population to be suffering more from depression as compared to the male population. Increased rate of widowhood, living alone, negligence by family members, poor social status in the family, increased physical dependency, lack of income, and poor health among the elderly females may contribute to the increased prevalence of depression among them. Studies[192030] conducted in different parts of India came up with the conclusion that females were more depressed than the males.

Elderly people who were living without their spouse, that is either being widowed, or separated, or being divorced, and those who were suffering from chronic illnesses were also found to be suffering from depression in the studies conducted by Radhakrishnan and Nayeem[20] and Maulik and Dasgupta.[21] Study conducted in Hoogly, West Bengal, found that those elderly who were not involved in taking important decisions in the family had a higher prevalence of depression. The studies conducted in Ludhiana, Salem, and Hoogly,[192127] found a higher prevalence of depression among uneducated and non-working elderly people. Similarly, there are studies[2622313233] that found a significant association of depression with no personal income that we did not get in our study. By abuse, we included abuse in the form of psychological abuse, exploitation, physical abuse, and neglect by the family members, mostly their sons or daughter-in-law, and also by the neighbors. It was found that abuse was positively correlated to depression among the elderly study population. In an Indian study,[23] it was found that around 54% of the elderly population with severe depression had experienced abuse.

A reason for all these differences between our study and the studies that have been discussed above[1921273233] might be because of different study settings and sociocultural factors which differ in different settings.

Further, the difference of findings between our current study and the other studies could be explained by Rothman's model of causal pie.[33] In the causal pie model, the outcomes result from sufficient causes. Each sufficient cause is made up of a “causal pie” of “component causes.” Several different causal pies may exist for the same outcome. Now, the outcome here, for example, depression among the elderly population, will occur, if and only if, all component causes of a sufficient cause were present, that is, the causal pie was completed. Hence, the effect of a component cause depended on the presence of the other component causes that constituted some of the causal pie. This explains why we did not get any positive association of depression with any of the factors that we have studied.

The higher prevalence of depression observed among the elderly population was a matter to think about. No clear guidelines were available which mentioned about a routine screening of depression for the geriatric population and for their counseling. At the same time, it is very important to work for community and social support of the elderly people. As a result of strict guidelines, the different governmental schemes for financial support of elderly people (9) are not utilized in the way, it should have been. This type of study worked as an eye-opener for measuring the burden of depression among the elderly. While treating the elderly patients, the health personnel should be aware enough to rule out depression among the elderlies, as many of them come with somatic symptoms such as headache, myalgia, and tension, for which patients visit the general outdoor services, instead of visiting the psychiatrists.

Following limitations were identified in our study: (i) we have used convenience sampling technique and (ii) the cross-sectional nature of study design. Hence, the causal relationships could not be inferred and results could not be generalized. As a result of this, a bigger study might be required to know the actual picture of depression among the geriatric population

CONCLUSION

To deal with this huge social problem of depression among the elderly population, provision of screening programs and timely counseling facilities should be available in the community itself. Social security policies had to be revised and initiatives had to be taken for community participation in dealing with this problem so that the younger members of the family, in spite of moving out of the family, leaving the old parents alone, should be involved in increasing the family support for them. Already existing mental health program should give more stress on the problems of geriatric depressions. Further, there had been a great scope for the nongovernmental organizations and other voluntary workers to participate in this process with a more active and enthusiastic approach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Q101	Unique ID of tde respondent			Remarks
Q102	Sex of respondent	Male ……………. 1
		Female ………….2
Q103	DOB	DD/MM/YY
		……./……./…….
		Don’t know ………. 98
Q104	Age in years
Q105	Current marital status	Never Married ….1 Currently married ….2   Living together………3  Separated/left…4  Divorced …….5 Widowed ……….6		Q109 Q107
Q106	For how many years are you married/living together?	Number of years …… years Don’t know …………98 <1 year ………… 00		Q108
Q107	For how many years are you separated/divorced/widowed?	Number of years … years Don’t know …………98 <1 year ……………… 00
Q108	Have you been married once or more?	Number of times ……….
Q109	If Q108 is≥2, how did the 1st marriage end?	Currently married ….2 Living together………3 Separated/left…4 Divorced …….5 Widowed ……….6
Q110	Years of schooling	No of years ……….years Not attended ……. 00 Don’t know ……….98
Q111	If Q110 is 00 or<6 years, Now I would like you to read this sentence to me. Show a sentence from the newspaper to the respondent If the respondent cannot read the whole sentence, Probe : Can you read any part of the sentence to me?	Cannot read at all……1 Able to red only part of sentence………………….2 Able to read whole sentence. 3 >No newspaper with required language…4 (specify language) Blind/visually Impaired……………. 5
Q112	Religion	Hindu …………….1 Muslim ………….2 Christian …………3 Jainism ……………4 Buddhism …………5 Others ………………6
Q113	Caste	Scheduled tribe ……….1 Scheduled Caste ……….2 OBC …………….3 None of them …………4
Q114	How long you are living in this locality?	Number of years ………. Since birth ………….88 Since marriage ……89 Don’t know …………98

Q201	What is/was your occupation?
Q202	At what age do you start working?
Q203	Have you worked in last 1 year?	Yes ………………1 No………….2
Q204	Did you work by choice or by compulsion?	By choice………1 Economic need ……….2 Other compulsion …….3
Q205	Do you feel any physical/mental strain due to this work?	Yes ……………….1 No………………….2
Q206	How many years before did you stop working?	Years. Don’t know …………98
Q207	Are you paid in cash/kind for the job you are doing now?	Cash only …………….1 Kind only…2 Cash+kind …………3 None…….4
Q208	On average, how many days/week do you work now?
Q209	On average, how many hours you work a day, now?
Q210	Did you receive or have provisions for any of the following benefits from your employer in addition to your wages or salary paid in cash or kind?	Yes	No
	a. Retirement plans	1	2
	b. Pension	1	2
	c. Health benefits	1	2
	d. Food or provisions	1	2
	e. Cash bonuses	1	2
	f. Others	1	2

Q301	What are your sources of income? (If multiple choices are present, circle all the possible outcomes)	Salary/wages ……………1 Employer’s pension .…2 Social pension (old age/widow)…….3 Rental income…………4 Business income ……….5 Agriculture/farm income…………………….6 Returns from share/dividends/bonds ….7 Interest on savings and fixed deposits ………….8 No income …….0 Others …………………….9	Remarks Q305
Q302	How much is your annual income from all the sources mentioned above?	Rs Cannot say …………….88 Don’t know …………….98
Q303	Do you contribute any money to household expenses?	Yes …………………1 No ………………….2 If yes, how much do you contribute annually? Rs.	Q304
Q304	Is your income sufficient to fulfill your basic needs? (food, shelter, clothing, medicine)	Yes ……………….1 No ………………….2
Q305	On whom do you mostly depend for financial support to meet your basic needs? If multiple people are being mentioned by him/her, ask him/her: WHO is the most important support of yours?	Spouse ……………….1 Son …………………….2 Daughter …………….3 Son/daughter-in-law ……4 Grand-son/daughter…5 Other relatives ……….6 NGO ………………….7 Community …………….8 Others ……………………9
Q306	Please let me about your assets	Own land …….1 Own house ……2 Gold/jewelry …….3 Savings in bank deposit/post office ………….4 Bonds/share/mutual funds ….5 Life insurance….6 Others …………….7

Q401	How many children do you had?	Boys - Girls -				Remarks
Q402	How many children do you have now?	Boys - Girls -
Q403	Details of the boys	Married		Unmarried
		Staying with you	Not staying with you	Staying with you	Not staying with you
Q404	Details of girls	Taking care	Not taking care	Taking care	Not taking care
Q405	Has your role as a decision maker changed after you grew older?	Improved …………………1 Remained as same…………2 Declined …………………3
Q406	To what extent do you think you are important to your family?	Important………………….1 Somewhat important …….2 Not important …….3
Q407	Ever since you are 60 years of age, have you ever faced any abuse or violence or neglect or disrespect by any person?	Yes ……………………….1 No ……………………….2
Q408	From whom did you face the abuse during the last one month? (circle all relevant responses)	Spouse ………………….1 Son ………………………2 Daughter ……….………3 Son-in-law ……………….4 Daughter-in-law …………5 Grandchildren ……………6 Relatives ………………….7 Neighbors …….….8 Others …………….…….9
Q409	Did you suffer from any health problems as a result of the abuse?	Yes ……………………1 No …………………….2

Q501	How do you rate your health?	Excellent ……………….1 Very good ……………2 Good ………………….3 Fair ………………….4 Poor ………………….5	Remarks
Q502	Compared to the people of your age in your locality, how do you think your health is?	Better ………………….1 Same …………………2 Worse …………………3 Don’t know ………….98 No response …………99
Q503	Is there any medication that you are taking regularly?	Yes …………………….1 No …………………….2
Q504	Are you suffering from one of the following disease?	HTN ………………….1 DM2 ………………….2 Respiratory problems 0.3 Joint pains ……………4 Body aches …………….5 Others ……………….6
Q505	From where you get the money for purchasing medicine?	Given free from hospital 1 Son …………………….2 Daughter ……………3 Spouse ……………….4 Relatives …………….5 Neighbor …………….6 Son/daughter-in-law …7 Others ……………….8