Elsevier

Journal of Affective Disorders

Volume 251, 15 May 2019, Pages 218-226
Journal of Affective Disorders

Research paper
Variation in the prevalence of depression and patterns of association, sociodemographic and lifestyle factors in community-dwelling older adults in six low- and middle-income countries

https://doi.org/10.1016/j.jad.2019.01.054Get rights and content

  • The crude and age-adjusted prevalence of depression was 7.4% and 7.8%, respectively.

  • The crude prevalence of depression varied from 1.5% in China to 15.2% in India.

  • Greater fruit and vegetable intake was associated with lower depression prevalence.

  • Those with lower education and lower wealth had higher depression prevalence.

  • Those who were female, and underweight had higher depression prevalence.

Abstract

Background

: Data from the World Health Organization Study on global AGEing and adult health (SAGE) were used to estimate the prevalence of depression in older adults in six low- and middle-income countries (LMICs), namely China, Ghana, India, Mexico, the Russian Federation, and South Africa, and to examine the relationship between demographic and lifestyle characteristics and depression.

Method

: A total of 33,421 participants aged ≥ 50 years were included. A set of diagnostic questions from the World Mental Health Survey was used within SAGE to define depression.

Results

: The crude population prevalence of depression was 7.4% [95%CI: 6.5%–8.3%] ranging from 1.5% in China to 15.2% in India. It was higher in females 8.6% [7.6%–9.6%] compared to males 6.1% [5.0%–7.2%]. The age-standardized prevalence of depression was 7.8% [6.3%–9.6%] in pooled data, 8.9% [6.9%–11.1%] in females and 6.6% [4.6%–9.0%] in males. Greater fruit (0.89[0.84–0.93]) and vegetable intake (0.94 [0.89–1.00]) was associated with a lower prevalence of depression. Furthermore, those who were older, female, underweight, and with lower education and lower wealth, had higher prevalence of depression.

Limitations

: The cross-sectional design of this study precluded conclusions on causality.

Conclusion

: In nationally-representative samples of older adults in six LMICs, an average of one in every 13 participants suffered from depression. The prevalence of depression varied considerably between countries, sexes, and with wealth and educational disadvantage. Increased fruit and vegetable intake appeared to co-occur with significantly lower rates of depression, suggesting diet as a modifiable factor for addressing depression burden.

Introduction

Depression in older adults is an important global public-health problem due to its substantial adverse consequences and the increasing number of older adults' worldwide (Fiske et al., 2009). According to a WHO report, older adults with depression had a four times higher mortality rate compared to older adults without depression (World_Health_Organisation, 2001). Moreover, depression is estimated to account for 5.7% of Years Lived with Disability (YLDs) in those aged 60 years and older (60+) worldwide (Organization, 2017). It is projected that the total number of older people with depression will increase by 117% between 2000 and 2050 (Heo et al., 2008). More than half of depression cases in older adults had no history of depression in earlier life stages (Fiske et al., 2009). Age-related life changes and the presence of biological risk factors including cardiovascular, endocrine, inflammatory or immune, and neurological factors in older adults makes them potentially vulnerable to depression (Alexopoulos, 2005, Fiske et al., 2009).

While the prevalence and determinants of depression in older adults in high-income countries are well documented, there are scarce data from low- and middle-income countries (LMICs). Identification of key risk factors, particularly those that are modifiable - such as lifestyle behaviours – is an imperative in addressing the large burden associated with depression across the globe. Indeed, the evidence for association between lifestyle behaviours (such as physical activity, smoking and dietary behaviours) and depression in high income countries is consistent and compelling (Lassale et al., 2018, Li et al., 2017, Marx et al., 2017, Schuch et al., 2018) and evident across the lifespan (Fiske et al., 2009, Jacka and Berk, 2013, Marx et al., 2017). Regular physical activity has shown to be associated with lower symptoms of depression among older adults and also as a complementary treatment option for individuals living with depression (Schuch et al., 2018, Schuch et al., 2016). Smoking is associated with higher risk for depression, and smoking cessation associated with an improvement in mental health (Pasco et al., 2008, Taylor et al., 2014). Socioeconomic status has clear effects on depression in high income countries (Everson et al., 2002). Increased fruit and vegetable consumption is a core health promotion message for prevention a broad range of chronic diseases. Observational evidence has shown that increased consumption of fruit and vegetables, as a part of a wider healthful diet, are associated with lower prevalence and risk for depression (Lassale et al., 2018, Li et al., 2017, Psaltopoulou et al., 2013) including among older adults (Payne et al., 2012), and has also demonstrated potential as a treatment strategy (Jacka et al., 2017, Parletta et al., 2017). However, this evidence base is largely limited to higher income countries, and there is a comparative dearth of evidence relating to relationships between lifestyle risk factors and depression prevalence among older adults living in LMICs.

Given the growing older population in the LMICs (United_Nations, 2013), as well as growing prevalence and burden of depression in LMICs (Mathers and Loncar, 2006), we aimed to document the prevalence of depression and to quantify the strength of associations between depression and lifestyle behaviours, as well as physical and socio-economic determinants of depression in older adults in LMICs. To do this we undertook a cross-sectional analysis using the WHO Study on global AGEing and adult health (SAGE) Wave 1, which had the advantages of a sufficiently large sample size across six LMICs countries, and nationally representative age and sex distributions of adults aged 50 + years.

Section snippets

Study population

Data from the WHO Study on global AGEing and adult health (SAGE) Wave 1 (2007–2010) was used in the current study. Details of SAGE were published previously (Kowal et al., 2012). Briefly, SAGE was designed as a multi-wave longitudinal study in China, Ghana, India, Mexico, the Russian Federation, and South Africa. One of the main goals of SAGE was to fill data gaps in lower income countries, using use validated and standardized questions and methods - adapted to the settings and unique issues

Results

Out of 33,421 participants in the current study, 2066 (6.2%) were found to have depression based on the CIDI criteria. Table 1 compares the baseline characteristics of those with and without depression. Generally, those with depression were more likely to have a previous history of depression and to be older, female, rural dwellers, widowed, divorced, or separated, current smokers, and underweight. They also had lower level of education, wealth, alcohol consumption, and fruit and vegetable

Summary of findings

The current study is one of the few population-based studies in community-dwelling older adults reporting the prevalence of depression, along with patterns of association by socioeconomic characteristics and chronic disease risk factors in LMICs. Age-specific and age-standardized prevalence of depression was estimated in each gender and country. In all six countries, the prevalence of depression was higher in women as compared to men. Furthermore, those who were female, underweight and with

Research data

The anonymized datasets is available publicly at: http://apps.who.int/healthinfo/systems/surveydata/index.php/catalog/central. Moreover, the SAGE instruments, protocols and meta- and micro-data is available upon completion of the Users Agreement at: www.who.int/healthinfo/systems/sage. The questionnaires and other materials are available at: http://www.who.int/healthinfo/sage/cohorts/en/index2.html. Authors’ contributors

Author statement contributors

ML, PK, MB, and MM designed the study. PK and MM supervised data extraction and data cleaning. ML performed data analysis under MM supervision. ML wrote the first draft with the support from all authors. All authors provided critical feedback and helped shape the research, analysis and manuscript. MB was the senior psychiatrist who leaded interpretation of findings and conclusion. All authors read and approved the final manuscript.

Declaration of interests

All authors stated that there was no financial and personal relationship with other people or organizations that could inappropriately influence (bias) their work.

Acknowledgements

This research received no specific grant from any funding agency, commercial or not-for-profit sectors. SAGE is supported by WHO and the Division of Behavioral and Social Research (BSR)at the US National Institute on Aging (NIA) through Interagency Agreements (OGHA 04034785; YA1323-08-CN-0020; Y1-AG-1005-01) with WHO and a Research Project Grant R01AG034479. In addition, the governments of China and South Africa provided financial or other support for Wave 1 of their national studies. USAID

Role of funding

Funding sources had no role in the design, analysis or writing of this article.

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