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Age and Ageing 2007 36(5):562-568; doi:10.1093/ageing/afm111
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Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

Prevalence and symptomatology of depression in older people living in institutions in England and Wales

F. A. McDougall1,, F. E. Matthews2, K. Kvaal3,4, M. E. Dewey3 and C. Brayne1

1 Department of Public Health and Primary Care, Cambridge University Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
2 MRC Biostatistics Unit, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
3 King's College London, Institute of Psychiatry, Section of Epidemiology, London, UK
4 Ullevaal University Hospital, Department of Geriatric Medicine, Oslo, Norway

Address correspondence to: F. A. McDougall. Tel: 01223 763829; Fax: 01223 330330. Email: fm257{at}cam.ac.uk


   Abstract
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 Abstract
Introduction
 Method
 Results
 Discussion
 Key points
 References
 
Background Epidemiological studies have shown that depression is common in institutional settings. However, the symptomatology of depression in this group has not been compared to those living in the community.

Aims To estimate the prevalence of depression and depressive symptomatology in participants living in institutions and compare these to people living in other settings.

Method The Medical Research Council Cognitive Function and Ageing Study (MRC CFAS) is a population-based cohort comprising 13,004 individuals aged 65 and above, from five sites across England and Wales. Following screening, a stratified random sub-sample of 2,640 participants received the Geriatric Mental State (GMS) examination of whom 340 resided in institutions. Diagnoses of depression were made using the Automated Geriatric Examination for Computer-assisted Taxonomy system (AGECAT; [1]).

Results The prevalence of depression in those living in institutions was 27.1% (95% CI 17.8–36.3) compared to 9.3% (95% CI 7.8–10.9) in those living at home. Symptoms relating to depressed mood, severity of illness (e.g. wishing to be dead, future looking bleak) and some non-specific symptoms were more common in those living in residential homes. Depression was significantly associated with younger age (P = 0.002) and high functional disability (P = 0.009) in those living in institutions.

Conclusions Consistent with previous estimates, depression was highly prevalent in institutions, particularly in younger individuals with severe functional impairment. Those in institutions report considerably more symptoms of depression. Finding interventions which address these symptoms might improve quality of life for people in institutions, irrespective of formal diagnoses.

Keywords: depression, prevalence, geriatric psychiatry, homes for the aged, multi-centre study, elderly


   Introduction
Top
 Abstract
 Introduction
Method
 Results
 Discussion
 Key points
 References
 
The Health Survey for England 2000 reported that 4% of the total population aged 65 and above were living in residential care, rising to 30% of those aged 90 and above [2]. The number of residential homes has diminished in recent years; however, as more people are living into very old age, the need for residential care will increase. Understanding the mental health of this population is important for planning their care and appropriate management.

The EURODEP consortium of studies estimated the prevalence of depression in the elderly to be 12% using the Geriatric Mental State Examination-Automated Geriatric Examination for Computer-Assisted Taxonomy system (GMS-AGECAT) algorithm [3]; however, many of these studies excluded those living in institutional settings. A previous analysis in the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS), which included institutionalised participants, resulted in a prevalence estimate of 8.7% for primary depression and 9.7% when depression secondary to dementia was included [4]. Estimates of the prevalence of depression in institutions vary widely between studies depending on the method of diagnosis and the type of institution from which the sample is drawn. A recent review of the literature reported that 44% of elderly people living in institutional care suffer from at least some depressive symptoms, with 16% diagnosed with major depression [5].

Two studies of depression prevalence in existing residents of institutions have been reported in the UK since 1990. In one, depressive symptoms of any level were reported in 34% and case level of depression warranting treatment in 15% (using AGECAT) [6]. The second reported that 40% reached a level warranting intervention (using the Brief Assessment Scale) [7]. This high prevalence could be due to either an increased level of all depressive symptoms, or specific symptoms that may be more common in the institutionalised elderly. Everyday experiences of institutionalised older people are likely to differ from those living in other settings, which could affect the type of symptoms reported. The identification of symptoms that are particularly common in institutional settings could highlight ways in which care could be improved, as well as increase detection of depression by staff; at present less than half of the cases diagnosed by a psychiatrist are recognised by staff nurses [8, 9]. Finally, it may indicate which methods of treatment would be most appropriate. Treatment of depression in the community has been shown to improve both quality of life [10] and physical functioning [11] in older people.

We have previously reported the prevalence of dementia in institutions [12]. This paper reports the prevalence of depression in older people living in institutions, sampled from a population-based study. The full range of residential facilities available to populations, both public and private, are represented in this sub-sample. The aims of these analyses are to assess prevalence and symptomatology of depression in institutions and identify associated factors.


   Method
Top
 Abstract
 Introduction
 Method
Results
 Discussion
 Key points
 References
 
Participants
MRC CFAS is a population-based, multi-centre, prospective cohort study of participants identified from population registers held by Family Health Services of the NHS at six sites across the UK, of which five sites are reported here (Cambridgeshire, Gwynedd, Newcastle, Nottingham, Oxford). All centres received local research ethics committee approval. Inclusion criteria were that participants should be in their 65th year and above on a specified date and living in a defined geographical area. Older individuals were oversampled with 50% of those screened aged 75 and above. After initial screening of 13,004 people, a further group were selected to continue depending on screen-based measures; 2,640 (20%) took part in this detailed assessment interview in which depression items from the GMS-AGECAT [1] were administered. Of these, 340 were living in a residential home, nursing home, or long-stay hospital.

Assessment of depression
Trained nurses administered a version of the GMS examination (GMS-B3; [13, 14]) comprising 157 items, including interviewer observations. The AGECAT algorithm [1] then generates a diagnosis of depression, as well as dementia and anxiety. The severity of each of these conditions is compared to determine the primary diagnosis. For this analysis, we have included anyone with a diagnosis of depression as a case even if it is secondary to dementia.

Participants were divided into three groups: those without any depression (no or very few symptoms present), those with sub-clinical symptoms (minor mood symptoms and some non-specific symptoms), and those with case level depression (depression of a severity that warranted treatment).

Assessment of housing status
Housing status was reported at the screening interview. Included in the institutions group were participants living in a council or private residential home, a long-stay hospital, or a long-stay nursing home. Those living in a house or warden controlled flat were considered to be living in the community.

Assessment of other factors
Socio-economic status was assessed by past employment history and coded using the Computer-Assisted Standard Occupational Classification software [15]. Comorbid medical conditions and functional disability (measured by the Townsend Disability Scale; [16]) were obtained from the baseline interview (self-report). Study dementia diagnoses were obtained from the GMS examination using the AGECAT algorithm.

Analysis
The initial prevalence estimate for depression was weighted to account for the study design and age-standardised. However, it was not possible to age-standardise the prevalence of individual symptoms, as some of these were very rare. To ensure a representative age structure, each person living in an institution was matched on age and sex to a community-based participant. We therefore present the proportion of individuals with symptoms in institutions and compare this to the age- and sex-matched participants living elsewhere.

Participants with missing values on both the self-report and observer ratings were excluded from the sample. These were mainly people with severe dementia. It is possible to receive a diagnosis of depression with severe interviewer ratings alone, and therefore participants who had these ratings but did not respond to the self-report section have remained in the sample. A sensitivity analysis excluding this group of participants was conducted to assess the effect on the prevalence estimate.

Odds ratios and 95% confidence intervals were calculated using logistic regression to determine which factors are associated with depression in those living in institutions.


   Results
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 Abstract
 Introduction
 Method
 Results
Discussion
 Key points
 References
 
Response
The response rate for the screening interview was 80%. Of the 2,640 people who completed the assessment interview, housing status was established in 99% (n = 2,619). Table 1 shows the basic demographic characteristics of the sub-sample by housing status, with the proportions back-weighted to the total sample. Of those in the sub-sample, 13% (n = 340) were living in institutions. These participants tended to be older (49% were aged 85 and above compared to just 8% of the non-institutionalised) and were more likely to be female than male (76% versus 58%).


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  		Table 1. Number of participants living in institutions and in other settings with proportions back-weighted to total sample

 
Missing values
One hundred and five people (48 in institutions, 40 not in institutions and 17 whose housing status was unknown) included at the assessment interview did not have sufficient information to make a valid diagnosis of depression. Of these participants 75% suffered from dementia. A further 86 participants did not respond to the depression section of the questionnaire but did have interviewer ratings of depression.

Prevalence
There were 62 cases of depression in institutions (n = 292) and 284 in those living in other settings (n = 2,239). The prevalence of case level depression in institutions was 27.1% (95% CI 17.8–36.3%) and 9.3% (95% CI 7.8–10.9%) for those not institutionalised. Sub-clinical depression was slightly more common in institutions (26.7, 95% CI 18.4–34.8%) compared to the non-institutionalised (22.6, 95% CI 20.2–24.9%).

Only 1% of participants with observer ratings alone received a diagnosis of depression, suggesting that including these participants underestimates the true prevalence of depression. Excluding those with only observer ratings resulted in an increase in the prevalence of depression in those living in institutions to 30.3% (20.0–40.5%) but has no effect on the prevalence in the non-institutionalised.

Depressive symptoms
The proportion of individuals with depressive symptoms in age- and sex-matched institutionalised and non-institutionalised participants are presented in Table 2 (ordered by highest proportion in the non-institutionalised group).


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  		Table 2. Comparison of the proportion of depressive symptoms in residents of institutions with age- and sex-matched controls

 
Interviewers were more likely to report that participants living in institutions looked or sounded depressed (22% versus 7%, OR = 3.7, 2.2–6.2) compared to those living in other settings. In addition, institutionalised participants were more likely to report depressed mood, crying, wishing to be dead, the future looking bleak and staying away from others. Other common symptoms of depression such as worry, lack of energy, tension, guilt and irritability did not differ between settings.

Non-specific symptoms (e.g. slowing on examination and loss of concentration) were common in both groups, but particularly in institutions where more than half of the sample suffered from these symptoms.

Factors associated with depression in institutions
The prevalence of depression decreased significantly with age (P = 0.002) (Table 3). There was some variation by socio-demographic factors but no clear trends. Depression was more common in those with dementia (OR = 1.5, 95% CI 0.8–2.8) and comorbid medical conditions (OR = 1.9, 95% CI 0.9–4.3), but not significantly so. Depression was significantly higher in those with functional disability (P = 0.009). A multivariable model with age, sex and Townsend disability scale revealed that the relationship between age and depression was robust. A post-hoc analysis of depression in the young–old with high functional disability was conducted in order to examine this relationship further. The prevalence of depression in those aged 80 and under with a high score on the Townsend disability scale (>15) was 54.6% (95% CI 32.5–75.1%).


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  		Table 3. Factors that are associated with depression in people living in institutional settings

 

   Discussion
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
Key points
 References
 
Depressive disorder affected 27% of those in institutions compared to just 9% of those living in other settings. Participants living in institutions were more likely to suffer from depressed mood and symptoms denoting severity. Younger age (P = 0.002) and high functional disability (P = 0.009) were significantly associated with the presence of depression in those living in institutions.

Methodological issues
As with all questionnaire-based interviews conducted in the older population, missing values were common, particularly in those with severe dementia. The GMS-AGECAT algorithm was not designed to rely on interviewer ratings alone, and doing so resulted in an underestimation of depression prevalence, reflected in the increase in prevalence (by 3%) when this group was excluded. Consequently, only limited information is available on those with severe dementia in whom other methods are needed to assess depression (e.g. Cornell Scale for depression in dementia [17]).

The study was not specifically designed for institutional settings, and as such, relatively little information about each institution was gathered. Previous research suggests that additional information such as attitude towards living arrangements [18] and perceived inadequacy of care [19] may be the key to understanding why depression is so common in this setting.

These data were collected in the early nineties; however, there have been few prevalence studies of depression in the UK in the intervening years. Furthermore, reports by both the National Service Framework for Older People [20] and the Audit commission [21, 22] suggest that mental illness is still often undetected in older people, particularly those residing in care homes. These reports suggest that the prevalence estimates reported here are likely to continue to be a robust reflection of the current situation in institutions.

Prevalence of depressive disorder
Our prevalence estimate of 27% was higher than the most recent review of the literature [5], but considerably lower than the 40% reported in the UK [7]. However, participants of that study were all under the age of 90, while 22% of our sample was aged 90 and above. As we report that depression in institutions is more common in the young–old, this may explain the discrepancy between the two estimates.

Sub-syndromal depression and individual symptoms
The prevalence of milder depressive symptoms was also high. Though research into the effects of sub-syndromal depression in institutions is scarce, studies conducted in community-based older people suggests that it is associated with both functional and physical impairment. Sub-syndromal symptoms also increase the likelihood of a subsequent major depressive episode [23], therefore their significance should not be underestimated.

Non-specific symptoms, particularly those relating to slowing and thinking difficulties, were considerably more common in the institutionalised. This might better be explained by the high level of neurological and medical conditions in those living in care, rather than by depression. The institutionalised group also reported a higher frequency of other depressive symptoms, most notably, depressed mood and severe symptoms, such as wishing to die. Our findings support a previous study conducted in residential homes in England reporting that 30% of residents wished to die [24]. This reflects a poor quality of life in people living in institutional care.

Factors associated with depression
In the analysis limited to institutionalised older people, depression was not associated with gender. Similar findings have been reported in other studies conducted in institutions [19, 25, 26], though there are exceptions [27]. The fact that established risk factors for depression in the community are not consistently found to predict depression in institutions, has led to the suggestion that depression in institutions has a specific profile of risk indicators [19]. Our findings support this theory in that many of the factors commonly associated with depression in the community were not found in this study. Furthermore, the differences in the symptomatology in institutions would suggest that it is plausible that there would be a different set of predictors.

We report that depression decreased significantly with age in those living in institutions. Evidence for this association in the literature is mixed. Jongenelis [19] reports no association with age in 333 nursing home patients while other studies have reported that depression in institutions is more prevalent in younger age groups [26, 27]. Relatively few young–old individuals reside in institutions, and those that do are likely to suffer from severe physical or cognitive impairment, that could not be managed at home. The very high prevalence (54.6%) in young participants with severe functional disability reflects this.

Depression was more common in those with many co morbid medical conditions, but not significantly so. Most previous studies of depression in institutional settings have reported an association with both physical and cognitive impairment [9, 18, 19, 26, 28]. One explanation for our findings is that many of our questions ask about medical history rather than current state which is likely to dilute any association.

Of the factors assessed, functional disability was most strongly associated with depression, as reported in previous studies. This association presents a problem for potential interventions, as significantly reducing disability in an institutionalised population is an unrealistic goal. However, other factors related to disability, such as pain, could be a target for intervention. Pain has been associated with depression in both institutions [5] and in the community [29], and has been shown to moderate the relationship between depression and disability [30]. Better management of pain could potentially lead to a reduction in the development of depression.

In addition to possible interventions, future research must focus on improving the identification of depression in residential homes. In a recent survey of consultant old age psychiatrists, only half reported that mental health staff in their region provided training to those working in institutional settings [31]. Frequent monitoring of mental health in residential settings is essential if we are to improve quality of life in our institutions.


   Key points
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Key points
References
 

  • More than a quarter of older people living in institutions suffer from depression of a severity that warrants treatment.
  • Younger residents with severe functional disability are at highest risk of depression.
  • Symptoms of depressed mood, and severe symptoms such as wishing to be dead are particularly common in institutionalised older people compared to those living in the community. Finding interventions which address these symptoms might improve quality of life for people in institutions, irrespective of formal diagnoses.


   Conflicts of Interest
 
None


   References
Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 Key points
 References
 

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Received 7 February 2007; accepted in revised form 23 April 2007.


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