depression in elderly essay

Depression in Older Adults Expository Essay

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Introduction

Depression in older adults, works cited.

This paper examines depression amongst the old adult population in the world with specific references to the United States of America. It gives a background on what depression is and discusses situation under which it develops in older adult population.

Besides, it examines depression in older adult population in relation to such factors as gender where females are found to be more prone to depression than their male counterparts, it also considers sexual orientations in which it discusses how lesbians and gays are more likely to have stress than heterosexuals and it finally compares how race and culture play a role in depression amongst the elderly in society.

With respect to homosexuality, the paper examines the various ways through which older adult population get discriminated by the members of the society who are anti-homosexuality and institutions that do not recognize both lesbianism and gay as a form of lifestyle that should be accepted as in existence.

Depression is a condition that mostly affects the cognition of a human being. It means different thing to different people; it can be symptomatic as when an individual says he or she is feeling depressed, it also be a sign as when someone observes that another person is depressed or at the same time it can be a disorder that is clinically diagnosed.

When a clinical diagnosis of depression is done, it implies a disorder which has a significant length of time and having particularly observable signs and symptoms, that significantly interferes with an individual’s functioning or that causes great personal distress or both (Jefferson 10).

But one may ask “What are the causes of depression?” depression has varied causes amongst the whole of the human race regardless of age or gender. It is almost always caused by a combination of factors. Such factors are inheritance or genetic predisposition, developmental factors such as early loss of parents, cognitive factors such as intense grief reaction and stress such as coping with unemployment and or physical illnesses; these two combine to result into a common pathway for inducement of depression.

Research has indicated that each individual has a pattern of genetic, developmental, environmental, social, personality and physiological factors that coalesce to permit or protect against depression at any point in time.

The understanding and modification of the contributions of these factors is the ultimate goal of the clinicians who engage in the treatment of depression. This paper examines depressions in older adults. It will deal with how depression occurs in older adult population; besides, it will also discuss the main causes of depression in older adulthood and how it affects them (Jefferson 10).

Depression is the most common mental disorder found amongst older adults in the parts of the world, but it should not be seen as part of the aging process; in fact a good number of older adults . It is one of the most disabling conditions among the older adult population. In the United States alone it is approximated that over six million adults aged 65 and above experience clinical depression; the adult population represents about 15% of the adult population above 65 years of age in the United States.

Prevalence estimates in older adults range from 5% in community samples to about 20% in nursing home residents and close to 30% of the older adults witnessed in primary care setting. Research has also indicated that approximately 50% of the adults who are admitted in hospitals experience clinical depression (Williams 59).

It is important to note that depression in older adults is caused by varied numerous factors and may be different from the causative factors leading to depression in the younger people. In addition to the biological etiology of depression in the older adults, there are vividly cognitively contributing factors.

The adult’s life events and the interpretation and response to event contribute to the risk of developing depression. The predominant life events that place older adults at risks for depression as well as contribute to the experience by older adults and receptiveness to treatment for depression are medical illnesses, bereavement or death of a son, daughter or any other significant other, disability, impaired social support and or trauma.

These factors do not necessarily exclusively lead to depression, but may combine with other factors in a chain of events ultimately leading to depression in older adults. Research findings have indicated that the risk factors combined with behavioral, psychodynamic and negative thoughts surrounding the events of life seem to have substantial contribution to depression that comes in late life periods.

For example, older adults may have an perception about their lives that no matter what they attempt to achieve, negative things continue to happen and perpetually continue to experience losses in their lives hence they assume a hopelessness position. It has also been found out through research that older adults may not easily adapt to the physical changes they are experiencing as a result of aging and hence may have some unrealistic expectation and have a feeling or perception of that they are likely to continue in failure as an adult.

Majority of older adults fall into one or more at-risk groups for depression. Nonetheless, many are not aware of their symptoms of depression and hence do not make a request or seek evaluation. Besides, research indicates that many older adults have resistance towards seeking medical attention due to stigma labeled against mental illnesses.

According to several research activities that have been conducted, it has been found that black older adults are more likely to suffer depression as compared to their white counterparts (Bernal 403). Besides, other research also indicate that races with the majority of low income earners like blacks, Hispanics are more vulnerable to issues of depression than the white counterparts.

Given racial and ethnic discriminations, it is important to state that races that are subject or victims of racial discrimination are more likely to suffer depression; the older elders may resign into perception where they feel inferior to the perceived superior whites and hence cause them hopelessness and depression, especially when they see their loved ones or fellow race members being discriminated against.

Taking the case for Western and other developed nations where slavery was practiced, it is crucial recognize that those who come from races that experienced slavery are highly likely to experience depression than those within former slave masters.

Some of the depression symptoms appearing some adults may be traces of depression during childhood with which the adult might have lived to his or her old age; this is coupled by inferiority complex. Meanwhile, ethnicity has also been found to have effects on depression amongst the older adult population (Bernal 327).

Gender also plays a significant role in depression. There are a number of research that have been done on how gender influence experience of depression. The research findings have been compiled from data collected in most countries of the world. According to the findings, women have higher chances of experiencing depression than men.

Even though it is not clear what really accounts for this, but researchers acknowledge the contribution of several factors which entails impact of estrogen on stress hormones, the common victimization of women through rape and domestic violence and cortisol (Fredén 163).

Other research findings reveal that both men and women share depression to a certain proportion; however, what also contributes to the difference is the fact that both men and women express their depression in gender specific ways. According to available literature, men are known to mask their depression through various forms like excessive drinking. This implies that the differentiation of the rate of depression between men and women is just done by way of illusion (Fredén 167).

Many studies have been conducted within cultures and also cross-culture with the aim of identifying symptoms of depression in both men and women. It is argued that women are twice as likely as men to be diagnosed of major depression.

Even though this difference is great, it is because older women are mostly likely to seek professional assistance as compared to their men counterparts; the implication here is that even though men may suffer equal measure of depression as women, they are less likely to seek the services of a profession to help them handle their depression.

Culturally, in some regions of the world, men are encultured not to express their sadness, stress or depression in public; in fact, men who do so are mostly likely to be considered as having feminine behavior, so they choose to endure depression within them. On the side, women share their grief with friends and expose publicly their depression; this makes it easy to notice. Moreover, men who suffer from depression are associated with mental illness and as has been discussed earlier, feminine (Fredén 167).

Other research has also attempted to link the rate of depression with sexual orientation. Even though older adults are highly likely to have low sexual performance, their sexual orientation has been found to play a significant role in contributing to their depression statuses. Research indicates that lesbians are more depressed than their heterosexual counterparts.

Moreover, even though much study have not been done, older adult population is very common with lesbians. In fact, this may be accounted for by the fact that it cannot be expected that when gays and lesbians get old, they should switch their sexual orientation to heterosexuals.

There are a number of older lesbians and gays and this part of the aging population suffer a lot of stigma from anti-lesbians and anti-gays. It is therefore not unusual to here of depressed and isolated older adults in the society. Due to stigma associated with lesbianism and gay sexual orientation, many of the lesbian and gay older adults suffer depression as not so many people want to identify with them (Melillo, et al 10).

Since the older adults are almost entirely dependent on others for livelihood and medical care, the lesbians and gays suffer from lack of concern, especially from the healthcare departments as they do not recognize the existence of lesbians and they are unresponsive to the fact that being lesbian and gay is also a form of lifestyle that should not be used as a point of individual discrimination.

Due to this, old adults who are heterosexuals are the ones who have greatly benefited from healthcare plans in most countries, particularly in the United States of America. The implication of this is that the lesbians and gays are left out in terms of medical care plans and hence are subjected to depression as they ponder about their heath and how to get medical services (Melillo, et al 10).

One fact is than most lesbian and gay partners live together, but when it comes to old age, one partner is not legally allowed to participate in healthcare decisions of another partner and this even include being barred from funeral arrangement in cases of death of one of the partner. This also subjects them to depression which may aggravate due to poor adjustment to aging situations.

Again gays and lesbians are greatly concerned about their housing; they always wish to live in communities that dominated by homosexuals or at least a community in which people recognize existence and the needs of lesbians and gays. The problem is that these groups of people tend be isolated and may further be far removed from children and the young people who are feared by the society may get influenced by these lesbians and gays.

Contrarily, heterosexual older adults are not likely to suffer any depression arising from any of these factors. Instead, they are well recognized by the society and may not suffer much depression as their homosexual counterparts.

The fact that is that homosexuality is the universally accepted sexual orientation in the world and hence forms a larger society than the lesbian and gay community. The heterosexuals are mostly likely to get consolations from groups like Christians groups which make them cope easily with depression (Melillo, et al 23).

Research has indicated that each individual has a pattern of genetic, developmental, environmental, social, personality and physiological factors that coalesce to permit or protect against depression at any point in time. Depression is one of the most disabling conditions among the older adult population in the world today. Depression in older adults is caused by varied numerous factors and may be different from the causative factors leading to depression in the younger people.

In addition to the biological etiology of depression in the older adults, there are vividly cognitively contributing factors. Research has found that race plays a significant role depression amongst older adults; black older adults are more likely to suffer depression as compared to their white counterparts.

Gender also plays a significant role in depression. According to the findings, women have higher chances of experiencing depression than men (Fredén 167). Even though it is not clear what really accounts for this, but researchers acknowledge the contribution of several factors which entails impact of estrogen on stress hormones, the common victimization of women through rape and domestic violence and cortisol.

Other research has also attempted to link the rate of depression with sexual orientation. Even though older adults are highly likely to have low sexual performance, their sexual orientation has been found to play a significant role in contributing to their depression statuses.

Research indicates that lesbians are more depressed than their heterosexual counterparts (Melillo, et al 23). Conversely, heterosexual older adults are likely to get assistances from the general members of the society as they do not engage in what the members of the society may describe as anti-social. Due to this, they are less likely to suffer depression as compared to their lesbian and gay counterparts.

Bernal, Guillermo. Handbook of racial and ethnic minority psychology. New York: SAGE, 2003.

Fredén, Lars. Psychosocial aspects of depression: no way out? New York: Wiley, 1982.

Jefferson, James. Depression and its treatment . New York: American Psychiatric Pub, 1992.

Melillo, Karen et al. Geropsychiatric and mental health nursing . New Jersey: ones & Bartlett Learning, 2005.

Williams, Arthur. Depression research in nursing: global perspectives . New York: Springer Publishing Company, 2005.

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• Open access
• Published: 18 December 2021

Prevalence and determinants of depression among old age: a systematic review and meta-analysis

• Yosef Zenebe   ORCID: orcid.org/0000-0002-0138-6588 1 ,
• Baye Akele 2 ,
• Mulugeta W/Selassie 3 &
• Mogesie Necho 1  

Annals of General Psychiatry volume  20 , Article number:  55 ( 2021 ) Cite this article

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Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease. It is also one of the most common geriatric psychiatric disorders and a major risk factor for disability and mortality in elderly patients. Even though depression is a common mental health problem in the elderly population, it is undiagnosed in half of the cases. Several studies showed different and inconsistent prevalence rates in the world. Hence, this study aimed to fill the above gap by producing an average prevalence of depression and associated factors in old age.

This study aims to conduct a systematic review and meta-analysis to provide a precise estimate of the prevalence of depression and its determinants among old age.

A comprehensive search of PubMed, Scopus, Web of sciences, Google Scholar, and Psych-info from database inception to January 2020. Moreover, the reference list of selected articles was looked at manually to have further eligible articles. The random-effects model was employed during the analysis. Stata-11 was used to determine the average prevalence of depression among old age. A sub-group analysis and sensitivity analysis were also run. A graphical inspection of the funnel plots and Egger’s publication bias plot test were checked for the occurrence of publication bias.

A search of the electronic and manual system resulted in 1263 articles. Nevertheless, after the huge screening, 42 relevant studies were identified, including, for this meta-analysis, n  = 57,486 elderly populations. The average expected prevalence of depression among old age was 31.74% (95% CI 27.90, 35.59). In the sub-group analysis, the pooled prevalence was higher among developing countries; 40.78% than developed countries; 17.05%), studies utilized Geriatrics Depression Scale-30(GDS-30); 40.60% than studies that used GMS; 18.85%, study instrument, and studies having a lower sample size (40.12%) than studies with the higher sample; 20.19%.

A high prevalence rate of depression among the old population in the world was unraveled. This study can be considered as an early warning and advised health professionals, health policymakers, and other pertinent stakeholders to take effective control measures and periodic care for the elderly population.

The elderly people are matured and experienced persons of any community. Their experience, wisdom, and foresight can be useful for development and progress; they are a valuable asset for any nation [ 1 ]. Despite their invaluable wisdom and insight, the aging of the world's population is causing extensive economic and social consequences globally [ 2 ]. The aging population has increased rapidly over the last decades owing to two significant factors, namely, the reduction in mortality and fertility rates and improved quality of life, leading to an increase in life expectancy worldwide [ 3 , 4 , 5 ]. Globally, the number and proportion of people aged 60 years and older in the population are increasing. In 2019, the number of people aged 60 years and older was 1 billion. This number will increase to 1.4 billion by 2030 and 2.1 billion by 2050. By 2050, 80% of all older people will live in low- and middle-income countries [ 6 , 7 , 8 ].

A high geriatric population leads to high geriatric psychiatric problems [ 9 ]. The elderly, in general, face various challenges that are associated with physical and psychological changes commonly associated with the aging process [ 10 ]. The incidence of mental health problems is expected to increase among adults in general as well as in older populations in particular [ 11 ].

Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease [ 12 ]. It is also one of the most common geriatric psychiatric disorders [ 13 ] and a major risk factor for disability and mortality in older patients [ 14 ]. Even though depression is a common mental health problem in the elderly population, it is undiagnosed in about 50% of cases. The estimates for the prevalence of depression in the aging differ greatly [ 15 , 16 , 17 ]. WHO estimated that the global depressive disorder among older adults ranged between 10 and 20% [ 18 , 19 , 20 , 21 ]. Among all mentally ill individuals, 40% were diagnosed to have a depressive disorder [ 22 ]. People with depressive disorder have a 40% greater chance of premature death than their counterparts [ 20 ].

Most of the time, the clinical picture of depression in old age is masked by memory difficulties with distress and anxiety symptoms; however, these problems are secondary to depression [ 23 , 24 , 25 ]. Numerous community-based studies showed that older adults experienced depression-related complications [ 26 , 27 , 28 , 29 , 30 ]. Depression amplifies the functional disabilities caused by physical illness, interferes with treatment and rehabilitation, and further contributes to a decline in the physical functioning of a person [ 31 , 32 ]. It also has an economic impact on older adults due to its significant contribution to the rise of direct annual livelihood costs [ 33 ]. Hence, improvement of mental health among people in late life is considered to be medically urgent to prevent an increase in suicides in a progressively aging society.

Although real causes of depression remain not clear, psychological, social, and biological processes are thought to determine the etiology of depression and comorbid psychiatric diagnoses (e.g., anxiety and various personality disorders) [ 34 ]. Social scientists, postulating the psychosocial theory, posited that depression could be caused by a lack of interpersonal and communication skills, social support, and coping mechanisms [ 35 ]. Old biological theories stated depression is caused by a lack of monoamines in the brain. However, recent theories underscore the role of Brain-derived neurotrophic factor (BDNF) in the pathogenesis of depression [ 36 ]. In general, depression in the elderly is the result of a complex interaction of social, psychological, and biological factors [ 37 , 38 ].

Different factors associated with geriatric depression, such as female sex [ 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ], increasing age [ 37 , 40 , 41 , 44 , 46 , 47 , 48 , 49 ], being single or divorced [ 42 ], religion [ 50 ], lower educational attainment [ 39 , 40 , 41 , 42 , 44 ], unemployment [ 38 , 42 ], low income [ 37 , 39 , 40 , 42 , 44 , 46 , 51 , 52 ], low self-esteem [ 53 ], childhood traumatic experiences [ 54 ], loneliness or living alone [ 40 , 50 , 51 , 55 ], social deprivation [ 45 , 46 , 56 ], bereavement [ 39 , 43 , 57 , 58 ], presence of chronic illness or poor health status [ 37 , 39 , 43 , 44 , 45 , 46 , 49 , 50 , 56 , 59 , 60 , 61 , 62 , 63 , 64 ], lack of health insurance [ 42 ], smoking habit [ 48 ], cognitive impairment [ 39 , 43 , 44 , 45 , 46 , 47 , 61 ] and a history of depression [ 43 , 44 , 47 ].

Compared with other health services, evidence of depressive disorders tends to be relatively poor. Therefore, the level of its burden among older adults is not well addressed in the world. Lack of adequate evidence about depression in older adults may be a factor that contributes to poor or inconsistent mental health care at the community level [ 21 , 65 ]. In addition to the poor setting for mental health care services, there are no up-to-date systematic reviews and meta-analysis studies conducted that could vividly show the global prevalence and determinants of depression among old age. Several studies also revealed different and inconsistent prevalence rates in the world. Therefore, this systematic review and meta-analysis aimed to summarize the existing evidence on the prevalence of depression among old age and to formulate possible suggestions for clinicians, the research community, and policymakers.

Search process

A systematic search of the literature in September 2020 using both international [PubMed, Scopus, Web of sciences, Google Scholar, Psych-info, and national scientific databases] was conducted to identify English language studies, published between August 1994 and January 2020, that examined the prevalence of depression among old age. We searched English keywords of “epidemiology” OR “prevalence” OR “magnitude” OR “incidence” AND “factor” OR “associated factor” OR “risk” OR “risk factor” OR “determinant”, “depression”, “depressive disorder” OR “major depressive disorder” AND “old age” OR “elderly” OR “geriatrics”, “community”, “hospital” and “global”. In addition, the reference lists of the studies were manually checked to obtain further studies.

Inclusion and exclusion criteria

Original quantitative studies that examined the prevalence and determinants of depression among old age were included. The included studies were randomized controlled trials, cohort, case–control, cross-sectional, articles written in English, full-text articles, and published between August 1994 and January 2020. The exclusion criteria were studies which published as review articles, qualitative studies, brief reports, letter to the editor or editorial comments, working papers articles published in a language other than English, researches conducted in non-human subjects, and studies having duplicate data with other studies. The literature search was conducted based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guideline [ 66 ]. All articles were independently reviewed by four researchers against inclusion and exclusion criteria. Any initial disagreement was resolved.

Data extraction and appraisal of study quality

After eliminating the duplicates, four investigators reviewed study titles and abstracts for eligibility. If at least one of them considered an article as potentially eligible, the full texts were assessed by the same reviewers. Any disagreements were resolved by discussion. Detailed information on the country, data source, study population, and results were extracted from each included study into a standardized spreadsheet by two authors and checked by the other two authors. EndNote X7.3.1 was used to organize the identified articles. Two investigators independently assessed the risk of bias of each of the included studies. The quality of studies included in the final analysis was evaluated with the Newcastle Ottawa quality assessment checklist [ 67 ]. The components of the quality assessment checklist include study participants and setting, research design, recruitment strategy, response rate, representativeness of the sample, the convention of valid measurement, reliability of measurement, and appropriate statistical analyses.

Statistical analysis

The data were analyzed with STATA 12.0 [ 68 ]. Prevalence standard errors were calculated using the standard formula for proportions: sqrt [ p *(1 – p )/ n ]; The heterogeneity across the studies in proportion of depression in the elderly population and the contribution of studies attributing to total heterogeneity was estimated by the I 2 statistic. The point estimates from each study were combined using a random-effects meta-analysis model to obtain the overall estimate with the DerSimonian–Laird method. Sources of heterogeneity across studies were examined with meta-regression. Publication bias and small study effects were assessed with the Egger test.

Search result

The search procedure primarily obtained n  = 1263 results, which after reading the title and abstract, full-text, and the application of the inclusion and exclusion criteria were reduced to n  = 42. The selection process is shown in Fig.  1 .

Articles search flow diagram

Characteristics of the study subjects

A total of 42 studies [ 38 , 42 , 50 , 57 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 ] studied our outcome of interest; A total sample size of fifty-seven thousand four hundred and eighty-six (57,486) elderly populations were included in the present study. The geographical province of studies was assessed. We found: Six studies in India [ 72 , 86 , 94 , 95 , 98 , 102 ], five studies in China [ 50 , 77 , 84 , 89 ], three studies in Turkey [ 71 , 82 , 105 ], three studies in Nepal [ 76 , 90 , 97 ], three studies in Thailand [ 70 , 75 , 83 ], two studies in the USA [ 91 , 100 ], two studies in Australia [ 57 , 99 ], two studies in Malaysia [ 42 , 96 ], two studies in Ethiopia [ 81 , 93 ], one study in German [ 103 ], one study in the UK [ 104 ], one study in Norway [ 85 ], one study in Italy [ 79 ], one study in Japan [ 87 ], one study in Mexico [ 78 ], one study in Brazil [ 92 ], one study in Finland [ 74 ], one study in Singapore [ 101 ], one study in Saudi Arabia [ 69 ], one study in the United Arab Emirates [ 80 ], one study in Ghana [ 88 ], one study in Sudan [ 73 ] and one study in Egypt [ 38 ]. Most of the studies in the present analysis were cross-sectional [ 38 , 42 , 50 , 57 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 81 , 82 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 92 , 93 , 95 , 96 , 97 , 98 , 101 , 102 , 103 , 105 ] and four studies were Cohort [ 85 , 94 , 99 , 104 ].

Sixteen studies [ 70 , 73 , 74 , 81 , 86 , 88 , 90 , 92 , 93 , 94 , 97 , 98 , 102 , 103 , 104 , 105 ] used Geriatric Depression Scale-15 (GDS-15), 12 studies [ 38 , 69 , 71 , 72 , 75 , 76 , 77 , 82 , 84 , 89 , 96 ] used Geriatric Depression Scale-30 (GDS-30), four studies [ 50 , 80 , 83 , 101 ] used Geriatric Mental State Schedule (GMS) and ten studies [ 42 , 57 , 78 , 79 , 85 , 87 , 91 , 95 , 99 , 100 ] used others (ICD-10, CIDI, DASS-21, KICA, CES-D, Euro-D, DSM-III, MCS and HADS) tools to measure depression in old age (Table 1 ).

Quality of included studies

The quality of 42 studies [ 38 , 42 , 50 , 57 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 ] was assessed with the modified Newcastle Ottawa quality assessment scale. This scale divides the total quality score into 3 ranges; a score of 7 to 10 as very good/good, a score of 5 to 6 as having satisfactory quality, and a quality score less than 5 as unsatisfactory. The majority (28 from the 42 studies) had scored good quality, nine had a satisfactory quality, and four of the studies had unsatisfactory quality .

The prevalence of depression among old age

The reported prevalence of elderly depression among 42 studies [ 38 , 42 , 50 , 57 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 ] included in this study ranges from 7.7% in a study from Malaysia and Australia [ 57 , 96 ] to 81.1% in India [ 72 ]. The average prevalence of depression among old age using the random effect model was found to be 31.74% (95% CI 27.90, 35.59). This average prevalence of depression was with the heterogeneity of ( I 2  = 100%, p value = 0.000) from the difference between the 42 studies (Fig.  2 ).

Forest plot for the prevalence of depression

Subgroup analysis of the prevalence of depression among old age

A subgroup analysis was done considering the economic status of countries, the study instrument and the sample size of each study. The cumulative prevalence of depression in elderly population among developing countries; 40.78% [ 38 , 42 , 69 , 70 , 71 , 72 , 73 , 75 , 76 , 78 , 81 , 82 , 83 , 86 , 88 , 90 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 101 , 102 , 105 ] was higher than the prevalence in developed countries; 17.05% [ 50 , 57 , 74 , 77 , 79 , 80 , 84 , 85 , 87 , 89 , 91 , 99 , 100 , 103 , 104 ] (Fig.  3 ). The average prevalence of depression was 40.60% in studies that used GDS-30 [ 38 , 69 , 71 , 72 , 75 , 76 , 77 , 82 , 84 , 89 , 96 ] which is higher than the prevalence in studies that utilized GDS-15;35.72% [ 70 , 73 , 74 , 81 , 86 , 88 , 90 , 92 , 93 , 94 , 97 , 98 , 102 , 103 , 104 , 105 ], GMS;18.85% [ 50 , 80 , 83 , 101 ] and other tools;19.91% [ 42 , 57 , 78 , 79 , 85 , 87 , 91 , 95 , 99 , 100 ] (Fig.  4 ). Moreover, studies which had a sample size of below 450 [ 38 , 42 , 57 , 70 , 71 , 72 , 73 , 75 , 76 , 79 , 81 , 86 , 88 , 90 , 92 , 94 , 96 , 97 , 98 , 99 , 102 , 104 ] provided higher prevalence of depression; 40.12% than those who had a sample size ranges from 450 to 999 [ 74 , 80 , 82 , 84 , 85 , 91 , 93 , 95 , 100 , 105 ]; 25.38% and above 1000 [ 50 , 69 , 74 , 77 , 78 , 83 , 87 , 89 , 101 , 103 ]; 20.19% (Fig.  5 ).

Sub-group analysis of depression based on economic status of countries

Sub-group analysis of depression based on study instruments

Sub-group analysis of depression based on sample size of studies

Sensitivity analysis

The sensitivity analysis was performed to identify whether one or more of the 42 studies had out-weighted the average prevalence of depression among old age. However, the result showed that there was no single influential study, since the 95% CI interval result was obtained when each of the 42 studies was excluded at a time (Fig.  6 ).

Sensitivity analysis for the prevalence of depression among old age

Publication bias

There was no significant publication bias detected and Egger's test p value was ( p  = 0.644) showing the absence of publication bias for the prevalence of depression among old age. This was also supported by asymmetrical distribution on the funnel plot for a Logit event rate of prevalence of depression among old age against its standard error (Fig.  7 ).

Funnel plot for publication bias for depression

Factors associated with depression among old age

Among 42 studies [ 38 , 42 , 50 , 57 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 ] included in the present meta-analysis, only 32 [ 38 , 42 , 50 , 57 , 69 , 72 , 73 , 75 , 77 , 78 , 79 , 80 , 81 , 83 , 84 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 101 , 102 , 103 , 104 , 105 ] reported about the associated factors for depression among old age. Our qualitative synthesis for the sociodemographic factors associated with depression in elderly populations showed that female gender [ 38 , 69 , 72 , 75 , 80 , 86 , 89 , 93 , 98 , 102 , 105 ], age older than 75 years [ 38 , 69 , 101 , 102 ], being single, divorced or widowed [ 38 , 42 , 69 , 80 , 81 , 87 , 89 , 98 , 105 ], being unemployed [ 69 , 86 , 96 , 105 ], retired [ 95 ], no educational background [ 75 , 81 , 86 , 89 , 90 , 97 , 102 ] OR low level of education [ 69 , 81 , 84 , 91 , 92 , 105 ], low level of income [ 69 , 72 , 78 , 80 , 94 , 95 , 105 ], substance use [ 75 , 81 , 103 ], poverty [ 95 , 102 ], cognitive impairment [ 81 , 103 ], presence of physical illness, such as diabetes, heart diseases, stroke and head injury [ 42 , 50 , 57 , 72 , 77 , 81 , 83 , 84 , 86 , 87 , 88 , 89 , 95 , 97 , 106 ], living alone [ 88 , 102 , 104 ], disturbed sleep [ 77 , 89 ], lack of social support [ 73 , 77 , 87 ], dependent totally for the activities of daily living [ 50 , 79 , 91 , 92 , 97 , 102 , 103 ], living with family [ 42 , 93 ], history of a serious life events, such as death in family members, conflict in family, chronic illness in family members and those who had 3 or more serious life events [ 72 , 83 , 96 ], poor daily physical exercise [ 89 ] and exposure to verbal and/or physical abuse were strongly and positively associated with depression [ 90 ] (Table 2 ).

As to the researcher’s knowledge, this review and meta-analysis on the prevalence and determinants of depression among old age are the first of their kind in the world. Therefore, the knowledge generated from this meta-analysis on the pooled prevalence and associated factors for depression among old age could be important evidence to different stakeholders aiming to plan policy in the area. The average prevalence of depression among old age using the random effect model was found to be 31.74%. A subgroup analysis was done considering the economic status of countries, the study instrument, and the sample size of each study.

In the present systematic review and meta-analysis, the existing available information varies by the region, where the study was conducted, data collection tools used to screen depression, and the sample size assimilated in the study. Sixty-two percent ( n  = 26) of the studies were found in developing countries. About 38% ( n  = 16) of the incorporated studies utilized GDS-15 to screen depression, around 28% ( n  = 12) studies used GDS-30 to screen depression, ten percent ( n  = 4) studies used GMS to screen depression, whereas the rest utilized other tools. More than half ( n  = 22) of the included studies utilized a sample size of below 450.

The result of this meta-analysis revealed that depression in the elderly populations in the world was high (31.74%). This pooled prevalence of depression among old age in the world (31.74%; 95% CI 27.90 to 35.59%) was higher than a global systematic review and meta-analysis study on 95,073 elderly populations aged > 75 years and 24 articles in which a pooled prevalence of depression was 17.1% (95% CI 9.7 to 26.1%) [ 107 ], a global systematic review and meta-analysis study on 41 344 outpatients and 83 articles in which a pooled prevalence of depression was 27.0% (95% CI: 24.0% to 29.0%) [ 108 ], WHO reports on mental health of older adults over 60 years old with 7% prevalence of depression in the general older population [ 106 ], a Brazilian systematic review and meta-analysis study on 15,491 community-dwelling elderly people average age 66.5 to 84.0 years and 17 articles with a pooled prevalence rates of 7.0% for major depression, 26.0% for CSDS (clinically significant depressive symptoms), and 3.3% for dysthymia [ 109 ] and an Iranian meta-analysis study on 3948 individuals aged 50 to 90 years and 13 articles with a pooled prevalence of severe depression was 8.2% (95% CI 4.14 to 6.3%) [ 110 ]. The reason for such a high prevalence of depression in the globe would be due to the difference in sample size, study subjects, the severity of depression, study area, study instruments, and the means of administration of the tools employed in the studies [ 111 ].

In contrast to our current systematic review and meta-analysis study, the pooled prevalence of depression was lower than a Chinese Meta-Analysis of Observational Studies on 36,791 subjects and 46 articles with a pooled prevalence of depression was 38.6% (95% CI 31.5–46.3%) [ 112 ], and an Indian systematic review and meta-analysis study on 22,005 study subjects aged 60 years and above, and 51 articles with a pooled prevalence of depression was 34.4% (95% CI 29.3 to 39.6) [ 113 ]. The reason for the discrepancy might be due to the wide coverage of the study and the higher sample size utilized in the present study. Furthermore, differences could be due to the poor health care coverage and significant population makes a destitute life both in China and India. In addition, both China and India have a rapidly aging population. Old age causes enforced retirement which may lead to marginalizing older people. Elders are regarded as incompetent and less valuable by potential employers. This attitude serves as a social stratification between the young and old and can prevent older men and women from fully participating in social, political, economic, cultural, spiritual, civic, and other activities [ 114 , 115 , 116 ].

A significant regional variation on the pooled prevalence of depression in the elder population was observed in this review and meta-analysis study. The aggregate prevalence of depression in elderly population among developing countries; 40.78% [ 38 , 42 , 69 , 70 , 71 , 72 , 73 , 75 , 76 , 78 , 81 , 82 , 83 , 86 , 88 , 90 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 101 , 102 , 105 ] was higher than the prevalence in developed countries; 17.05% [ 50 , 57 , 74 , 77 , 79 , 80 , 84 , 85 , 87 , 89 , 91 , 99 , 100 , 103 , 104 ]. The huge variation might be due to absolute poverty, economic reform programs, limited public health services, civil unrest, and sex inequality are very common in developing countries [ 117 ].

Likewise, the greater pooled prevalence of depression in elderly population was observed in studies using a sample size below 450 study subjects (40.12%) [ 38 , 42 , 57 , 70 , 71 , 72 , 73 , 75 , 76 , 79 , 81 , 86 , 88 , 90 , 92 , 94 , 96 , 97 , 98 , 99 , 102 , 104 ] than the pooled prevalence of depression in elders that used a sample size of 450–999 (25.38%) [ 74 , 80 , 82 , 84 , 85 , 91 , 93 , 95 , 100 , 105 ], and above 1000 (20.19%) [ 50 , 69 , 74 , 77 , 78 , 83 , 87 , 89 , 101 , 103 ]. The reason could be a smaller sample size increases the probability of a standard error thus providing a less precise and reliable result with weak power.

Regarding the associated factors; being female, age older than 75 years, being single, divorced or widowed, being unemployed, retired, no educational background, low level of education, low level of income, lack of social support, living with family, current smoker, presence of physical illness, such as diabetes, heart diseases, stroke, and head injury, poor sleep quality, physical immobility and a history of serious life events, such as a death in family members, conflict in the family, chronic illness in family members and those who had 3 or more serious life events were found to have a strong and positive association with depression among old age.

Difference between included studies in the meta-analysis

This meta-analysis study was obtained to have a high degree of heterogeneity between the studies incorporated in pooling the prevalence of depression in the elderly population of the world. The analysis of subgroups for detection of sources of heterogeneity was done and the economic status of the country, where the study was done, data collection instruments, and sample size were identified to contribute to the existing variation between the studies incorporated in the analysis. Besides, a sensitivity analysis was performed using the random-effects model to identify the effect of individual studies on the pooled estimate. No significant changes in the pooled prevalence were found on the removal of a single study.

Limitations should be considered when interpreting the results of this study. Screening tools cannot take the place of a comprehensive clinical interview for confirmatory diagnosis of depression. Nevertheless, it is a useful tool for public health programs. Screening provides optimum results when linked with confirmation by mental health experts, treatment, and follow-up. As this meta-analysis included studies done using screening tools, a further meta-analysis done with diagnostic tools will help to assess the true burden of depression and to determine the need for pharmacological and non-pharmacological interventions. Furthermore, because of the lack of access to the full text of some studies, the researchers failed to include these research findings.

This review and meta-analysis study obtained a pooled prevalence of depression in the elderly population in the world to be very high, 31.74% (95% CI 27.90, 35.59). This pooled effect size of depression in the elderly population in the world obtained is very important as it showed aggregated evidence of the burden of depression in the targeted population. Since the high prevalence of depression among the old population in the world, this study can be considered as an early warning and advice to health professionals, health policymakers, and other pertinent stakeholders to take effective control measures and periodic assessment for the elderly population.

Availability of data and materials

The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Activities of daily living

Adjusted odds ratio

Community-dwelling elderly people

Center for Epidemiologic Studies Depression Scale

Confidence interval

Composite International Diagnostic Interview Short Form

Clinically significant depressive symptoms

Cross-sectional

Depression, Anxiety, and Stress Scale

Diagnostic and Statistical Manual of Mental Disorders

Elderly medical inpatients

Geriatrics depression

Geriatric Depression Scale

Geriatric Mental State Schedule

Hospital Anxiety and Depression Scale

Kimberley Indigenous Cognitive Assessment of Depression

Mental Component Summary

Not reported

Preferred Reporting Items for Systematic Reviews and Meta-analysis

United Kingdom

United States of America

World Health Organization

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Zenebe, Y., Akele, B., W/Selassie, M. et al. Prevalence and determinants of depression among old age: a systematic review and meta-analysis. Ann Gen Psychiatry 20 , 55 (2021). https://doi.org/10.1186/s12991-021-00375-x

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Are you an older adult with depression?

Signs and symptoms of depression in older adults, causes of depression in older adults, medical conditions that can cause elderly depression, dementia vs. depression, self-help for elderly depression, self-help tip 1: reach out and stay connected, tip 2: find meaning and purpose in life, tip 3: adopt healthy habits, tip 4: know when to seek professional help, how to help an older adult with depression, depression in older adults signs, symptoms, and treatment.

Depression can happen to any of us as we age, but there are ways to boost how you feel and make your senior years healthy and happy.

Have you lost interest in the activities you used to enjoy? Do you struggle with feelings of helplessness and hopelessness? Are you finding it harder and harder to get through the day? If so, you’re not alone. Depression can happen to any of us as we age, regardless of our background or achievements. And the symptoms of elderly depression can affect every aspect of your life, impacting your energy, appetite, sleep, and interest in work, hobbies, and relationships.

Unfortunately, all too many depressed older adults fail to recognize the symptoms of depression, or don’t take the steps to get the help they need. There are many reasons why elderly depression is so often overlooked:

• You may assume you have good reason to be down or that depression is just part of aging.
• You may be isolated—which in itself can lead to depression—with few around to notice your distress.
• You may not realize that your physical complaints are signs of depression.
• You may be reluctant to talk about your feelings or ask for help.

It’s important to realize that depression isn’t an inevitable part of getting older—nor is it a sign of weakness or a character flaw. It can happen to anyone, at any age, no matter your background or your previous accomplishments in life. While life’s changes as you age—such as retirement, the death of loved ones, declining health—can sometimes trigger depression, they don’t have to keep you down. No matter what challenges you face as you age, there are steps you can take to feel happy and hopeful once again and enjoy your golden years.

Speak to a Licensed Therapist

BetterHelp is an online therapy service that matches you to licensed, accredited therapists who can help with depression, anxiety, relationships, and more. Take the assessment and get matched with a therapist in as little as 48 hours.

Recognizing depression in the elderly starts with knowing the signs and symptoms . Depression red flags include:

• Sadness or feelings of despair.
• Unexplained or aggravated aches and pains.
• Loss of interest in socializing or hobbies.
• Weight loss or loss of appetite.
• Feelings of hopelessness or helplessness.
• Lack of motivation and energy.
• Sleep disturbances (difficulty falling asleep or staying asleep, oversleeping, or daytime sleepiness).
• Loss of self-worth (worries about being a burden, feelings of worthlessness or self-loathing).
• Slowed movement or speech.
• Increased use of alcohol or other drugs .
• Fixation on death; thoughts of suicide.
• Memory problems .
• Neglecting personal care (skipping meals, forgetting meds, neglecting personal hygiene).

Depressed older adults may not feel “sad”

While depression and sadness might seem to go hand and hand, many depressed seniors claim not to feel sad at all. They may complain, instead, of low motivation, a lack of energy, or physical problems. In fact, physical complaints, such as arthritis pain or worsening headaches, are often the predominant symptom of depression in the elderly.

Is it grief or depression?

As we age, we experience many losses. Loss is painful—whether it’s a loss of independence, mobility, health, your long-time career, or someone you love. Grieving over these losses is normal and healthy , even if the feelings of sadness last for a long time.

Distinguishing between grief and clinical depression isn’t always easy, since they share many symptoms. However, there are ways to tell the difference.

• Grief is a roller coaster involving a wide variety of emotions and a mix of good and bad days. Even when you’re grieving, you’ll still have moments of pleasure or happiness.
• With depression, on the other hand, the feelings of emptiness and despair are constant.
• While there’s no set timetable for grieving, if it doesn’t let up over time or extinguishes all signs of joy—laughing at a good joke, brightening in response to a hug, appreciating a beautiful sunset—it may be depression.

As we grow older, we often face significant life changes that can increase the risk for depression . These can include:

Health problems. Illness and disability, chronic or severe pain, cognitive decline, damage to your body image due to surgery or sickness can all be contributors to depression.

Loneliness and isolation . Factors such as living alone, a dwindling social circle due to deaths or relocation, decreased mobility due to illness or a loss of driving privileges can trigger depression.

Reduced sense of purpose . Retirement can bring with it a loss of identity, status, self-confidence, and financial security and increase the risk of depression. Physical limitations on activities you used to enjoy can also impact your sense of purpose.

[Read: Adjusting to Retirement: Handling the Stress and Anxiety]

Fears . These include a fear of death or dying as well as anxiety over financial problems , health issues, or abuse or neglect .

Recent bereavements . The death of friends, family members, and pets, or the loss of a spouse or partner are common causes of depression in older adults.

It’s important to be aware that medical problems can cause depression in older adults and the elderly, either directly or as a psychological reaction to the illness. Any chronic medical condition, particularly if it is painful, disabling, or life-threatening, can lead to depression or make your depression symptoms worse.

These include:

• Parkinson’s disease
• Heart disease
• Thyroid disorders
• Vitamin B12 deficiency
• Dementia and Alzheimer’s disease
• Multiple sclerosis (MS)

Elderly depression as a side effect of medication

Symptoms of depression can also occur as a side effect of many commonly prescribed drugs. You’re particularly at risk if you’re taking multiple medications. While the mood-related side effects of prescription medication can affect anyone, older adults are more sensitive because, as we age, our bodies become less efficient at metabolizing and processing drugs.

If you feel depressed after starting a new medication, talk to your doctor. You may be able to lower your dose or switch to another medication that doesn’t impact your mood.

Medications that can cause or worsen depression include:

• Blood pressure medication (e.g. clonidine).
• Beta-blockers (e.g. Lopressor, Inderal).
• High-cholesterol drugs (e.g. Lipitor, Mevacor, Zocor).
• Tranquilizers (e.g. Valium, Xanax, Halcion).
• Calcium-channel blockers.
• Medication for Parkinson’s disease.
• Sleeping pills .
• Ulcer medication (e.g. Zantac, Tagamet).
• Heart drugs containing reserpine.
• Steroids (e.g. cortisone and prednisone).
• Painkillers and arthritis drugs.
• Estrogens (e.g. Premarin, Prempro).
• Anticholinergic drugs used to treat GI disorders.

Never assume that a loss of mental sharpness is just a normal sign of old age. It could be a sign of either depression or dementia , both of which are common in older adults. Depression and dementia share many similar symptoms, including memory problems , sluggish speech and movements, and low motivation, so it can be difficult to tell the two apart.

Is it Depression or Dementia?

Whether cognitive decline is caused by dementia or depression, it’s important to see a doctor right away. If it’s depression, memory, concentration, and energy will bounce back with treatment. Treatment for dementia will also improve your quality of life . And in some types of dementia, symptoms can be reversed, halted, or slowed.

It’s a myth to think that after a certain age older adults can’t learn new skills, try new activities, or make fresh lifestyle changes. The truth is that the human brain never stops changing, so as an older adult, you’re just as capable as a young person of learning new things and adapting to new ideas that can help you recover from depression.

Overcoming depression involves finding new things you enjoy, learning to adapt to change, staying physically and socially active, and feeling connected to your community and loved ones.

Of course, when you’re depressed, taking action and putting self-help steps into action can be hard. Sometimes, just thinking about the things you should do to feel better can seem overwhelming. But small steps can make a big difference to how you feel. Taking a short walk, for example, is something you can do right now—and it can boost your mood for the next two hours. By taking small steps day by day, your depression symptoms will ease and you’ll find yourself feeling more energetic and hopeful again.

If you’re depressed, you may not want to do anything or see anybody. But isolation only makes depression worse. On your own, it can be difficult to maintain perspective and sustain the effort required to beat depression. That’s why support matters—so make an effort to connect to others and limit the time you’re alone. If you can’t get out to socialize, invite loved ones to visit you, or keep in touch over the phone or email.

But remember: digital communication isn’t a replacement for face-to-face contact. Do your best to see people in person on a daily basis. Your mood will thank you! And remember, it’s never too late to build new friendships .

Get out in to the world. Try not to stay cooped up at home all day. Go to the park, take a trip to the hairdresser, have lunch with a friend, visit a museum, or go to a concert or a play.

Volunteer your time. Helping others is one of the best ways to feel better about yourself and expand your social network.

Join a depression support group. Being with others facing the same problems can help reduce your sense of isolation. It can also be inspiring to hear how others cope with depression.

Take care of a pet. A pet can keep you company, and walking a dog , for example, can be good exercise for you and a great way to meet people. Dog owners love to chat while their pets play together.

Take a class or join a club to meet like-minded people. Try joining a senior center, a book club, or another group of people with similar interests.

Create opportunities to laugh. Laughter provides a mood boost , so swap humorous stories and jokes with your loved ones, watch a comedy, or read a funny book.

To overcome depression—and stop it coming back—it’s important to continue to feel engaged and enjoy a strong purpose in life. As we age, life changes and you can lose things that previously occupied your time and gave life its meaning. Retirement , the loss of close friends or loved ones, relocating away from your social network, and changes in your physical health , finances, or status can impact your mood, confidence, and sense of self-worth. But there are still plenty of ways you can find new meaning in life and continue to feel engaged in the world. Sometimes it’s just a matter of reframing how you think of yourself or the aging process.

Focus on what you can still do, not what you used to be able to do. Maybe you feel frustrated that you’re not able to do everything you once could, or at least not to the same levels? Or perhaps negative ideas about growing older have dented your self-confidence? Instead of focusing on what you once did, try focusing on the things you can do. You’ll see just how much you still have to offer.

Learn a new skill. Pick something that you’ve always wanted to learn, or that sparks your imagination and creativity—a musical instrument, a foreign language, or a new game or sport, for example. Learning new activities not only adds meaning and joy to life, but can also help to maintain your brain health and prevent mental decline .

Get involved in your community . Try attending a local event, tutoring kids, or volunteering for a cause that’s important to you. Community work can be a great way of utilizing and passing on the skills you honed in your career—without the commitment or stress of regular employment.

Take pride in your appearance. When you retire, it’s easy to let yourself go a little now you don’t have to be at work every day. But putting effort into how you look each morning can give your self-confidence a welcome boost and improve how you feel.

Travel. Once you’re retired and your kids have left home, you likely have more time on your hands to visit the places you’ve always wanted to go. Book a vacation to somewhere new or take a weekend trip to a favorite place. Travel doesn’t have to be extravagant or expensive to boost your mood. Enjoy time in nature by taking a scenic walk or hike, going fishing or camping, or spending a day at the beach.

W rite your memoirs , learn to paint, or take up a new craft.

Everyone has different idea about what brings meaning and purpose to life. The important thing is to find activities that are both meaningful and enjoyable for you. The more you nourish your spirit, the better you’ll feel.

When you’re depressed, it can be hard to find the motivation to do anything—let alone look after your health. But your health habits have an impact on depression symptoms. The better care you take of your body, the better you’ll feel.

Move your body

Exercise is a powerful depression treatment. In fact, research suggests it can be just as effective as antidepressants. And you don’t have to suffer through a rigorous workout to reap the benefits. Take a short walk now and see how much better you feel. Anything that gets you up and moving helps. Look for small ways to add more movement to your day: park farther from the store, take the stairs, do light housework or gardening. It all adds up.

Even if you’re ill, frail, or disabled, there are many safe exercises you can do to build your strength and boost your mood—even from a chair or wheelchair. Just listen to your body and back off if you’re in pain.

Eat to support your mood

Adjusting your dietary habits as an older adult can help you deal with the symptoms of depression.

• Start by minimizing sugar and refined carbs . Sugary and starchy comfort foods can give you a quick boost, but you pay for it later when your blood sugar crashes.
• Instead, focus on quality protein, complex carbs, and healthy fats , which will leave you satisfied and emotionally balanced.
• Going too long without eating can also worsen your mood, making you tired and irritable, so do your best to eat something at least every 3-4 hours.

Support quality sleep

Many older adults struggle with sleep problems , particularly insomnia. But lack of sleep makes depression worse. Aim for somewhere between 7 to 9 hours of sleep each night. You can help yourself get better quality sleep by avoiding alcohol and caffeine, keeping a regular sleep-wake schedule, and making sure your bedroom is dark, quiet, and cool.

Spend time in sunlight

Sunlight can help boost serotonin levels, improve your mood, and cope with Seasonal Affective Disorder (SAD). Whenever possible, get outside during daylight hours and expose yourself to the sun for at least 15 minutes a day.

• Have your coffee outside or by a window, enjoy an al fresco meal, or spend time gardening.
• Exercise outside by hiking, walking in a local park, or playing golf with a friend.
• If you live somewhere with little winter sunshine, try using a light therapy box.

Alcohol and depression in older adults

It can be tempting to use alcohol to deal with physical and emotional pain . It may help you take your mind off an illness, feel less lonely, or get to sleep. But alcohol makes symptoms of depression and anxiety worse over the long run. It also impairs brain function and interacts in negative ways with numerous medications, including antidepressants. And while drinking may help you nod off, it also keeps you from getting the refreshing deep sleep you need.

Depression treatment is just as effective for older adults as it is for younger people. However, since depression in the elderly is often triggered or compounded by a difficult life situation or challenge, any treatment plan should address that issue, too. If loneliness is at the root of your depression, for example, medication alone is not going to cure the problem.

Antidepressant risk factors

Older adults are more sensitive to drug side effects and vulnerable to interactions with other medicines they’re taking. Studies have also found that SSRIs such as Prozac can cause rapid bone loss and a higher risk for fractures and falls. Because of these safety concerns, elderly adults on antidepressants should be carefully monitored.

In many cases, therapy and/or healthy lifestyle changes, such as exercise , can be as effective as antidepressants in relieving depression, without the dangerous side effects.

Counseling and therapy

Therapy works well on depression because it addresses the underlying causes of the depression, rather than just the symptoms.

• Supportive counseling includes religious and peer counseling. It can ease loneliness and the hopelessness of depression, and help you find new meaning and purpose.
• Therapy helps you work through stressful life changes, heal from losses, and process difficult emotions. It can also help you change negative thinking patterns and develop better coping skills.
• Support groups for depression, illness, or bereavement connect you with others who are going through the same challenges. They are a safe place to share experiences, advice, and encouragement.

The very nature of depression interferes with a person’s ability to seek help, draining energy and self-esteem. For depressed seniors, raised in a time when mental illness was highly stigmatized and misunderstood, it can be even more difficult—especially if they don’t believe depression is a real illness, are too proud or ashamed to ask for assistance, or fear becoming a burden to their families.

If an elderly person you care about is depressed, you can make a difference by offering emotional support. Listen to your loved one with patience and compassion. You don’t need to try to “fix” someone’s depression; just being there to listen is enough. Don’t criticize feelings expressed, but point out realities and offer hope. You can also help by seeing that your loved one gets an accurate diagnosis and appropriate treatment. Help your loved one find a good doctor, accompany them to appointments, and offer moral support. See How to Help Someone with Depression .

Other tips for helping a depressed elderly loved one

Invite your loved one out. Depression is less likely when people’s bodies and minds remain active. Suggest activities to do together that your loved one used to enjoy: walks, an art class, a trip to the movies—anything that provides mental or physical stimulation.

Schedule regular social activities. Group outings, visits from friends and family members, or trips to the local senior or community center can help combat isolation and loneliness. Be gently insistent if your plans are refused: depressed people often feel better when they’re around others.

Plan and prepare healthy meals. A poor diet can make depression worse, so make sure your loved one is eating right, with plenty of fruit, vegetables, whole grains, and some healthy protein at every meal.

Encourage the person to follow through with treatment. Depression usually recurs when treatment is stopped too soon, so help your loved one keep up with their treatment plan. If it isn’t helping, look into other medications and therapies.

Watch for suicide warning signs. Seek immediate professional help if you suspect that your loved one is thinking about suicide .

Depression support, suicide prevention help

Depression support.

Find  DBSA Chapters/Support Groups  or call the  NAMI Helpline  for support and referrals at 1-800-950-6264

Find  Depression support groups  in-person and online or call the  Mind Infoline  at 0300 123 3393

Call the  SANE Help Centre  at 1800 18 7263

Call  Mood Disorders Society of Canada  at 519-824-5565

Call the Vandrevala Foundation  Helpline (India)  at 1860 2662 345 or 1800 2333 330

Suicide prevention help

Call  988 Suicide and Crisis Lifeline  at 988

Call  Samaritans UK  at 116 123

Call  Lifeline Australia  at 13 11 14

Visit  IASP  or  Suicide.org  to find a helpline near you

More Information

• Older Adults and Depression - Signs and treatment of depression in older adults. (National Institute of Mental Health)
• Depression in Older Adults - What it feels like, what the risk factors are, and how you can help yourself. (Royal College of Psychiatrists)
• Antidepressant Use Linked to Bone Loss - Covers two Archives of Internal Medicine studies on the connection between SSRI use in adults over 65 and abnormal bone loss. (National Institutes of Health)
• Fiske, A., Wetherell, J. L., & Gatz, M. (2009). Depression in Older Adults. Annual Review of Clinical Psychology, 5(1), 363–389. Link
• Lee, S. L., Pearce, E., Ajnakina, O., Johnson, S., Lewis, G., Mann, F., Pitman, A., Solmi, F., Sommerlad, A., Steptoe, A., Tymoszuk, U., & Lewis, G. (2021). The association between loneliness and depressive symptoms among adults aged 50 years and older: A 12-year population-based cohort study. The Lancet Psychiatry, 8(1), 48–57. Link
• Fiske, A., Gatz, M., & Pedersen, N. L. (2003). Depressive Symptoms and Aging: The Effects of Illness and Non-Health-Related Events. The Journals of Gerontology: Series B, 58(6), P320–P328. Link
• Depressive Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders . American Psychiatric Association. Link

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Depression in older adults

• Related content
• Peer review
• Joanne Rodda , clinical training fellow in old age psychiatry ,
• Zuzana Walker , reader in old age psychiatry ,
• Janet Carter , senior lecturer in old age psychiatry
• 1 Department of Mental Health Sciences, University College London, London W1W 7EJ, UK
• Correspondence to: J Carter j.carter{at}ucl.ac.uk
• Accepted 28 July 2011

Summary points

Depression in older adults is associated with an increased risk of death and disability

Cognitive and functional impairment and anxiety are more common in older than in younger adults with depression

Older adults with depression are at increased risk of suicide and are more likely than younger adults to complete suicide

Depression is associated with cognitive impairment and an increased risk of dementia

A selective serotonin reuptake inhibitor should be the first line pharmacological treatment for depression for most older adults, including those with chronic physical illness

Psychological and drug treatment is as effective in older as in younger adults

Subthreshold depressive symptoms that substantially affect older patients’ lives are common and management with psychosocial and drug strategies may be effective and prevent further deterioration

Depression is a major contributor to healthcare costs and is projected to be the leading cause of disease burden in middle and higher income countries by the year 2030. w1 Depression in later life, traditionally defined as age older than 65, is associated with disability, increased mortality, and poorer outcomes from physical illness. Most clinicians will encounter older patients with depression in their day to day practice, but although treatment is as effective for older patients as for younger adults, the condition is often under-recognised and under-treated. According to WHO data, proportionately more people aged over 65 commit suicide than any other age group, and most have major depression. Older people who attempt suicide are more likely to die than younger people, while in those who survive, prognosis is worse for older adults. 1

With a progressively ageing population worldwide, identification and treatment of depression in older adults becomes increasingly important, especially as older patients may have different presentations and needs than younger ones. We consider recent systematic reviews, meta-analyses, and randomised controlled trials to provide generalists with an understanding of current approaches to the diagnosis and management of patients who develop late life depression.

Sources and selection criteria

We based the review on searches of PubMed, EMBASE, and the Cochrane Database of Systematic Reviews using the search terms “depression”, “elderly”, “aged”, and “old age” published between 2006 and 2011 and limited to English language. We focused on well conducted systematic reviews, meta-analyses, and randomised controlled trials.

What is late life depression and who gets it?

Traditionally, the age of 65 has been used to differentiate between “older” and “younger” adults, although there is no set point at which an individual becomes “older” and assessment and care must be based on individual need. Arbitrary definitions of “late life” and differences between studies in terms of diagnostic criteria and populations sampled have produced varying reports of prevalence. Individuals with late life depression represent a heterogeneous group with symptoms that may fall anywhere on a spectrum ranging from sub-threshold mood disorder to major depression. A recent comprehensive meta-analysis using studies with moderate to high methodological quality showed that the point prevalence of major depression in over 75s ranged from 4.6% to 9.3% 2 whereas rates for sub-threshold depressive symptoms (those failing to reach diagnostic criteria) ranged from 4.5% to 37.4%. A related meta-analysis in people aged over 55 found that sub-threshold depressive symptomatology was two to three times more prevalent than major depression. 2 Most depressive episodes in late life will be a recurrence rather than a first ever episode w2 and the increased female to male ratio is in line with that in younger adults.

Prevalence rates of depression are increased in brain disorders including dementia, Parkinson’s disease, and stroke, and also in systemic disease, for example diabetes mellitus and cardiovascular disease (box 1). Prevalence estimates for depression in Alzheimer’s disease cluster around 30% but range from 0% to 86%, w3 reflecting the difficulty associated with definition and diagnosis of depression in dementia.

Box 1 Risk factors for depression in elderly people 30

Physical factors.

Chronic disease, such as diabetes, ischaemic heart disease, heart failure, chronic obstructive pulmonary disease

Acute myocardial infarction

Organic brain disease: dementia, stroke, Parkinson’s disease, cerebrovascular disease

Endocrine/metabolic disorders: thyroid disease, hypercalcaemia, B12 and folate deficiency

Chronic pain and disability

Psychosocial factors

Social isolation

Change in financial circumstances

Being a carer

Change of role and loss of social status

Bereavement and loss

Difficulty in adapting to illness/pain/disability

Poor defences against anxiety about death

History of depression

Being in institutional care

How is depression diagnosed in older patients?

Box 2 lists the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for diagnosis of a major depressive episode. Ideally diagnosis is based on clinical interview, observation of the patient’s behaviour, and a collateral history from relatives and care givers. When taking a background history it is important to identify factors that may precipitate and maintain depression. The main risk factors for late life depression are comorbid physical illness, cognitive impairment, functional impairment, lack or loss of close social contacts, and a previous history of depression (box 1), according to the findings of large community based studies.

Box 2 DSM-IV criteria for major depressive episode

Nearly every day for the preceding two weeks the patient has experienced five or more of:

Depressed mood for most of the day*

Decreased interest or pleasure in nearly all activities for most of the day*

Marked loss or gain of weight or markedly increased or decreased appetite

Excessive sleep or not enough sleep

Observable psychomotor agitation or retardation

Tiredness or loss of energy

Feelings of guilt or worthlessness

Poor concentration or indecisiveness

Thoughts of dying or suicide, suicide attempt

*One of these features must be present. Depressed mood for ≥2 weeks not meeting these criteria is defined as a minor depressive episode. Diagnostic and statistical manual of mental disorders (DSMIV), American Psychiatric Association, 1994

The risk assessment is important in any psychiatric presentation, and in patients with depression the main area of risk is suicide. Methodologically sound controlled studies have identified some key risk factors for suicide, listed in box 3.

Box 3 Risk factors for suicide in older people 1

Older age, male sex

Bereavement

History of attempts

Evidence of planning

Chronic painful illness or disability

Drug or alcohol use

Sleep disorders

Older patients often have symptoms of depression that do not meet the criteria for a major depressive episode (box 2) but are nonetheless clinically important. Identification of the psychological and functional effects of these symptoms determines whether or not treatment is indicated and who may benefit from interventions.

Current guidance for the assessment and management of depression from the UK National Institute for Health and Clinical Excellence (NICE) ( http://guidance.nice.org.uk/CG90/QuickRefGuide/pdf/English ) recommends the use of rating scales to determine severity, although many are weighted towards the presence of somatic symptoms and may therefore overestimate depression in older people, in whom such symptoms are common.

A recent comparison of several assessment scales (patient health questionnaire, Beck depression inventory, hospital anxiety and depression scale) in a primary care population found that treatment and referral rates were identical even though each tool identified differing numbers of patients with moderate to severe depression. However, regardless of the tool used, rates for treatment in older people still remained lower than for younger adults. w4 Many rating scales are in common use to assess depression but few are well validated in older people, with the exception of the patient health questionnaire, geriatric depression scale, hospital anxiety and depression scale, and the Cornell scale for depression in dementia (box 4).

Box 4 Useful scales for depression

Geriatric depression scale (gds-15)*.

Specifically developed for use in geriatric patients; contains fewer somatic items; suitable only for patients with no, mild, or moderate cognitive impairment (>15/30 on mini-mental state examination)

Well validated in older people. Cut-off score in population over 60 of ≥5 indicates a case of depression: sensitivity 92%, specificity 54% w12 w13

Cornell scale for depression in dementia (CSDD)*

Suitable for patients with cognitive deficit, not diagnostic for depression but higher scores indicate greater need for further evaluation w14

Patient health questionnaire (PHQ-9)*

Self reported depression assessment tool scoring each of the nine DSM-IV criteria as 0 (not at all) to 3 (nearly every day)

Validated in adults over 60 in primary care in the United States and Netherlands. With cut-off score of >9 has sensitivity 88%, specificity 80% w15 w16

Beck depression inventory (BDI)

Self reported seven item scale

Not recommended for use in older people owing to focus on somatic symptoms w17

Hospital anxiety and depression scale (HADS)*

Self-rating scale containing two subscales measuring symptoms of depression (HADS-D) and anxiety (HADS-A) during previous week. Scores >8 for both HADS-A and HADS-D have sensitivity and specificity of 80% and predictive validity of 70%

HADS identifies equal numbers of patients with depression regardless of age w18

Montgomery and Åsberg depression rating scale (MADRS)

Clinician rated 10 item scale, measures severity of depressive symptoms; sensitive to change; mainly used to assess response to treatment but no agreement on cut-off score for remission (between ≤4 and ≤10), popular in Europe

*Validated in older adults

Is depression more difficult to diagnose in older adults?

Several studies have shown that older adults are significantly less likely than younger ones to recognise depressive symptoms, which they attribute to normal ageing or physical illness, and that both patients and their doctors tend to view depression as a problem that can be explained away, rather than as an objective illness that warrants treatment. w5 These findings suggest that older adults might be less able to identify, and therefore seek appropriate treatment for, common depressive symptoms.

In our clinical experience, late life depression differs qualitatively from depression in early life. Somatisation, hypochondriasis, psychomotor retardation or agitation, and psychosis more commonly form part of the clinical picture, although this tendency has not been uniformly demonstrated. 3 Furthermore, late life depression has been associated with cognitive impairment, physical disability, and anxiety, with a large community naturalistic study suggesting that clinically important anxiety coexists in around 50% of patients aged 55-85. 4

Does depression increase the risk of dementia?

Most studies find that depression in late life is accompanied by measurable cognitive impairment, mediated by memory deficits, diminished executive function, and slowed information processing, which may resolve on remission of symptoms, or may persist even after effective treatment of mood. In the past, the term “depressive pseudodementia” was used to describe reversible dementia in depression, but this oversimplifies the complex spectrum of cognitive impairment.

Two systematic meta-analyses of high quality studies 5 6 report that late onset depression (after age 65) increases the risk of dementia twofold, but as yet no research has ascertained whether depression is a risk factor for dementia or represents a prodromal condition. 7

Several mechanisms have been proposed to explain the relation between depression and dementia, including hypercortisolaemia, loss of hippocampal volume, neuroinflammatory processes, increased Alzheimer-type pathology, reduced cognitive reserve, and vascular disease. None has yet been conclusively demonstrated, but the link is probably multifactorial and the mechanisms not mutually exclusive.

Of these potential mechanisms, vascular changes in the brain have attracted most attention. The key hypothesis is that disruption of prefrontal-striatal circuitry by cerebrovascular pathology produces a syndrome of mood disorder and executive dysfunction. This syndrome is variously described as “vascular depression” or “depression executive dysfunction syndrome”, 8 reflecting fundamental nosological differences. However, the concept is controversial, and a prospective population based postmortem study of over 65s found no association between depression and cerebrovascular pathology. 9 Randomised controlled trials have shown that presence of “vascular depression”/“depression executive dysfunction syndrome” may predict a worse response to antidepressant drug treatment 10 and is associated with increased mortality 11 There is currently no evidence to suggest that treating depression in early or late life reduces the incidence of dementia.

How is late life depression managed?

Given the association between medical morbidity and depression, exclusion of underlying causative or exacerbating factors is an important first step in the management of late life depression (box 1). Baseline investigations, for example routine blood tests, may be indicated (box 5).

Box 5: Investigations to consider when depression is suspected

Full blood count

Urea and electrolytes

Liver function tests

Thyroid function tests

Vitamin B12

Fasting glucose

Bone profile

Further tests dictated by clinical presentation

In subsyndromal and mild depression, psychosocial interventions may be sufficient to cause an improvement. These include increasing social contact and adding structure to the day; for example, assistance in accessing local community events, day centres, or befriending services. Evidence from randomised trials suggests that depressive symptoms in older adults may improve with structured exercise programmes. 12 A RCT of a stepped care approach to the management of subthreshold depressive symptoms found that the intervention (watchful waiting, bibliotherapy based on cognitive behavioural therapy, problem solving therapy, and medication) was associated with a 50% reduction in depression and anxiety disorders at 12 months 13 compared with treatment as usual and was cost effective w6 .

Current NICE guidance recommends that patients with mild or sub-threshold illness who do not respond well to initial supportive interventions are offered psychological therapy or antidepressant medication, while a combination of both interventions is recommended for those with moderate or severe illness.

When should I refer?

NICE guidance recommends that patients are referred to specialist services if they have not responded adequately to management options available in primary care; in severe depression, psychosis, or complex psychosocial situations; and where the degree of risk warrants specialist input. We also emphasise the need to refer older people with comorbid cognitive decline.

Services available in the UK vary geographically and are constantly evolving. A randomised controlled trial of home treatment versus conventional outpatient care for patients aged over 64 living independently and recruited from primary and secondary care services in Austria found significantly reduced depressive symptoms, improved global function, fewer admissions and lower costs of care in the home treatment arm at 3 and 12 months’ follow-up. 14 Studies of collaborative care interventions, where care is delivered through integrated mental health and primary care providers, have also repeatedly reported improved outcomes compared with usual care w7 although the effect appeared to be associated with prescription of antidepressant medication rather than better communication between primary care providers and mental health services.

Which medication should be prescribed?

Selective serotonin reuptake inhibitors (SSRIs) are well established as first line treatment for depression in older adults. A Cochrane review included 32 randomised controlled trials of antidepressant treatment in people aged 55 or over and reported that SSRIs and tricyclic antidepressants had similar efficacy, but that tricyclics were associated with more side effects and withdrawal from treatment. 15 It was not possible to compare efficacy for other antidepressant groups. Findings from a 2008 meta-analysis of second generation antidepressants in older adults (SSRIs, selective serotonin and noradrenaline reuptake inhibitors, bupropion, and mirtazapine) found that treatment in studies lasting 10 weeks or longer was associated with an improved response, supporting the long held belief that response to antidepressants is delayed in older adults. 16 A recent meta-analysis showed an advantage of SSRIs or tricyclic antidepressants over placebo in the treatment of patients with depression in the context of chronic physical illness. 17 Furthermore, evidence from randomised controlled trials has shown that antidepressants are efficacious in depression after stroke 18 and myocardial infarction. 19 Interestingly, a 2007 meta-analysis of 10 randomised controlled trials of prophylactic antidepressant treatment after stroke reported a significant reduction in the rate of post-stroke depression in treatment groups. 20 However, a large randomised controlled trial has recently shown that two commonly used antidepressants, sertraline and mirtazapine, were not appreciably different from placebo in treating depression in patients with Alzheimer’s disease. This effect was sustained at 10 months’ follow-up and side effects were increased in the antidepressant group. 21

Overall, an SSRI is usually the safest choice in patients with physical illness; the most common drug interactions are mediated via cytochrome p450 enzymes, and citalopram, escitalopram, and sertraline are safest in this regard.

Common side effects of particular concern in the elderly are anticholinergic effects, postural hypotension, and sedation, all of which are more common with tricyclic antidepressants than with SSRIs. 20 The risk can be minimised by starting at a low dose and slowly titrating upward. The risk of hyponatraemia induced by antidepressants increases with age and is associated with female sex, low body weight, renal failure, prescription of other drugs associated with hyponatraemia (such as diuretics), and medical comorbidity. w8 w9 Older patients prescribed SSRIs are also at increased risk of both upper and lower gastrointestinal bleeding. w10 Monitoring of serum sodium levels may be necessary, and the risk of gastrointestinal bleeding can be reduced by prescribing proton pump inhibitors.

NICE guidance recommends that antidepressant treatment is continued for at least six months for a single episode and at least two years if patients are thought to be at risk of relapse. A meta-analysis of eight double-blind placebo controlled trials of maintenance antidepressant therapy between 6 and 36 months in people over 55, published in 2011, found that the optimal duration in older adults is uncertain. 22 We suggest that a practical approach is to regularly review depressive symptoms, side effects, comorbidity, and current psychosocial stressors and to involve the patient in the decision making process about ongoing drug treatment.

What if first line drug treatment doesn’t work?

A 2011 systematic review and meta-analysis of inadequate response to treatment in older patients included 13 studies, most of which were open label. 23 The overall response rate for active treatment was 52%, and studies reporting positive results for augmentation of treatment with lithium or antipsychotics, and treatment with venlafaxine, duloxetine, selegiline, or phenelzine, were included. Lithium augmentation was the only treatment for which evidence of efficacy was replicated in more than two studies. We suggest that augmentation of treatment with antipsychotic medication should be used with particular caution in view of the susceptibility of older people to adverse drug reactions, and the paucity of data on safety.

Electroconvulsive therapy is sometimes used after inadequate response to drug treatment, although the usual indication is severe depressive illness in which life threatening refusal of food or fluid, risk of suicide, or psychotic features are present. Electroconvulsive therapy is a safe and effective treatment in the elderly despite an absence of methodologically sound evidence from randomised controlled trials. 24

Can older adults benefit from psychological therapy?

Results from a 2009 meta-regression analysis suggest that psychological therapy—particularly cognitive behavioural therapy, interpersonal therapy, and problem solving therapy—is equally effective in older and younger adults with depression. 25 Combined psychological therapy and pharmacological therapy is more effective than psychological treatment alone for older people with depression. 26

What is the outlook for older adults with depression?

A 2005 systematic review of studies comparing outcomes in depression in middle life with those in later life found that rates of remission were similar in both groups, but that late life depression was associated with higher rates of relapse. 27 A longitudinal primary care cohort study in the Netherlands reported that the median duration of a major depressive episode in late life was 18 months, with two thirds of patients taking three years to recover. 28 In the PRISM-E study, a large study of older patients with major depressive disorder, complete remission was attained in only 29% of patients at six month follow-up. 29 Factors associated with prolonged recovery in these studies included severity of depression at baseline, a family history of depression, comorbid anxiety, and general medical comorbidity.

A population based, age stratified, longitudinal study found that adults aged 70-84 years with depression have an increased risk of mortality compared with those who do not have depression, dying on average three years earlier. This risk holds beyond the effects of age, sex, and the presence of dementia, cardiovascular, and other somatic diseases, but did not persist in the oldest old—defined as those aged 85 to 101. w11

Tips for the non-specialist

Exclude physical illness as a cause for apparent depressive symptoms

Bear in mind that factors associated with ageing and the later stages of life, including physical illness, organic brain disease, pain, disability, losses (such as bereavement) , and social isolation, create vulnerability to depression

Be aware that older people with depression may minimise depressive symptoms and may present with somatic problems

Discuss options for treatment with the patient

Consider psychosocial interventions first in subsyndromal depressive states and mild depression

If medication is needed, use an SSRI at a therapeutic dose as first line treatment unless contraindications are present

Use the same criteria for referral for psychological therapy as in younger adults; older people are just as able to benefit

Evaluate risk; more people aged over 65 commit suicide than any other age group and most have major depression

Refer to specialist care if there is substantial risk of self harm, psychosis, need for complex multiprofessional care, inadequate response to treatment, or cognitive impairment

If treatment is started, evaluate response and need for ongoing treatment regularly

Points to discuss with the patient

Depression can affect people in different ways; some people may have strong feelings of sadness, but others may be more aware of feeling tired, slowed down, irritable, indecisive, that everything is an effort, or that they worry unnecessarily about small things and experience various physical problems—all these can be symptoms of depression and are not necessarily just part of “getting old”

There are many different ways to help people get well, for example taking part in social activities, attending clubs and interest groups; physical exercise; talking therapies, and medication

The beneficial effects of medication may take two to six weeks to be noticeable, but side effects may occur straight away; medication should ideally be continued for at least six months

Additional educational resources

For patients.

Depression ( www.ageuk.org.uk/health-wellbeing/conditions-illnesses/depression )—informative web page from Age UK, a charity supporting people in later life

Depression in older adults—( www.rcpsych.ac.uk/mentalhealthinfoforall/problems/depression/depressioninolderadults.aspx ) online information leaflet from the UK Royal College of Psychiatrists

CG90 Depression in adults: understanding NICE guidance ( http://guidance.nice.org.uk/CG90/PublicInfo/pdf/English )—explanation of NICE guidance for those using health services in NHS England and Wales

For healthcare professionals

Depression: the treatment and management of depression in adults (update) ( http://guidance.nice.org.uk/CG90 )—guidance from NICE

Depression ( www.cks.nhs.uk/depression/view_whole_topic )—clinical knowledge summary from NHS Evidence

GPNotebook ( www.gpnotebook.co.uk )—online medical encyclopaedia

Questions for future research

How can we differentiate between depressive syndromes in older adults, for example those overlapping with anxiety and cognitive impairment?

Does neuroimaging have a role in assessment of depression in older people?

How can we better identify and manage depression in dementia?

Are there ways of preventing depression in older adults at a population level?

What is the optimal period of maintenance treatment for depression in older adults?

Cite this as: BMJ 2011;343:d5219

Contributors: JR and JC were responsible for the planning, research, writing, and editing of the article. ZW was involved in the planning, writing and editing. JC is the guarantor.

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work ; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Provenance and peer review: Commissioned, externally peer reviewed.

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39 Depression in older people

• Published: October 2020
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Depression remains common in older people. It is strongly associated with physical illnesses and with cognitive impairment and has a complex set of relationships with dementia. Its aetiology involves a complex interplay of physical and psychosocial risk and protective factors. Its neurobiology includes a strong relationship with vascular diseases, neuroendocrine abnormalities, an increase in MRI white matter hyperintense lesions, a reduction in volume of the hippocampus and frontal and subcortical structures, and neuronal abnormalities in such structures. Management involves physical (mainly drugs but also ECT) and psychological treatments. In the acute phase, remission is the aim, and following this, continuation and maintenance stages should continue with the same treatments indefinitely. Prognosis overall is not as good as in younger adults, but this is largely due to the presence of cognitive deficits and physical ill health.

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Depression in older adults

This information is written for older adults who have or think they might have depression, and the people who care for them.

This leaflet provides information, not advice.

The content in this leaflet is provided for general information only. It is not intended to, and does not, mount to advice which you should rely on. It is not in any way an alternative to specific advice.

You must therefore obtain the relevant professional or specialist advice before taking, or refraining from, any action based on the information in this leaflet.

If you have questions about any medical matter, you should consult your doctor or other professional healthcare provider without delay.

If you think you are experiencing any medical condition you should seek immediate medical attention from a doctor or other professional healthcare provider.

Although we make reasonable efforts to compile accurate information in our leaflets and to update the information in our leaflets, we make no representations, warranties or guarantees, whether express or implied, that the content in this leaflet is accurate, complete or up to date.

Depression in older people

This information looks at:

• the challenges older adults with depression can face
• how the signs of depression can be different in older adults
• barriers to accessing care
• how to get information and support.

In this resource, when we say ‘older adults’ we are referring to people over the age of 65. However, we know that not everyone who is over 65 will find this information relevant to them.

What is depression?

Depression is a mental illness that affects the way you think and feel. It is quite common, and affects people of all ages. Around 3 in 100 people in England are diagnosed with depression every week.

What are the symptoms of depression?

Depression isn’t just feeling sad. If you have depression, you might:

• feel unhappy, hopeless or that life isn’t worth living
• feel anxious or worried
• struggle to do things
• struggle to concentrate or remember things
• lose interest in the things you once enjoyed.

In your body you might:

• feel exhausted or restless
• struggle to sleep, or sleep too much
• have physical health problems like headaches or stomach aches
• lose interest in sex
• eat less or more than usual.

Other people might notice that you:

• seem more quiet, worried, irritable or sad than usual
• struggle to focus
• sleep more or less than usual
• complain about aches and pains
• stop looking after yourself or your home
• seem more isolated or lonely.

Depression can be mild, moderate or severe, and depending on the severity of your depression you might have different symptoms. It might not be obvious straight away that you or someone else is experiencing depression. You can find out more about depression in our information resource  on the topic.

When should I get help?

Most of us have some of these feelings from time to time. However, it’s important to ask for help if:

• you experience a lot of these feelings
• the feelings go on for more than a couple of weeks
• the feelings start to affect lots of areas of your life
• you feel that life is not worth living.

Is depression a new thing?

Depression isn’t something new. However, in the past talking openly about mental health and mental illness wasn’t encouraged. There were also a lot of misconceptions and stereotypes about depression and the people who had it. Some of the words used to describe depression were stigmatising and unkind.

Over the years, we have learnt more about why depression happens and how best to treat it. While stigma around depression and other mental illnesses still exists, things are much better than they were. There is now a lot of support available to people of all ages who have depression.

Why do older people develop depression?

There are lots of reasons why people develop depression, such as difficult life experiences, physical health problems and genetic factors. You can find out more about the causes of depression in our depression resource .

There are also some things that might make older people more likely to develop depression. These include:

Physical health problems

Older people are more likely to be diagnosed with one or more long-term health conditions. Research has shown that this can make people more likely to develop depression.

Dementia is a condition that affects your memory, language and behaviour, and mostly affects older people. It’s estimated that around 3 in every 10 people living with dementia are depressed.

Parkinson’s disease

Parkinson’s disease is a condition that affects how your brain works. It causes symptoms like shaking, slow movement and stiff muscles, and is most common in people over the age of 50. Feelings of depression are common in people with Parkinson’s disease.

Loneliness is more common in people who have been widowed, have health problems or live alone. However, even people who have support from friends and family can experience loneliness. While being lonely is not the same as being depressed, older people who experience loneliness are also more likely to experience depression.

When someone you care about dies, it is normal to experience feelings of grief, especially if the person who died was very close to you. You probably won’t ever completely ‘get over’ the death of a loved one. However, if your feelings of grief continue to feel intense for a long time, or feel like they are getting worse, you might need professional help.

When someone dies, it is also common to have trouble sleeping, or to lose your appetite. Changes to your sleep and diet can also have a negative effect on your mental health.

Vascular depression

Illnesses that affect the circulation of blood to the brain can make someone more likely to develop depression. These include heart disease, strokes, and high blood pressure or cholesterol.

Alcohol use

Alcohol affects the chemistry of the brain, increasing the risk of depression. If you already have depression, alcohol can also make this worse.

Moving into care homes

Depression is more common in people who live in care homes than in people who don’t. This could be because people who live in care homes are more likely to be experiencing some of the factors we’ve already mentioned. It could also be because people who live in care homes can lose their usual familiar routines and supportive environments.

What treatments are available?

Depression is treatable. There are lots of different kinds of support available, and research has shown that these can be very effective.

The first thing you should do if you think you are experiencing depression, is to speak to your GP. They will ask you questions about how you have been feeling and what is going on in your life. They might use a questionnaire to find out whether you have depression and how severe it is.

Once you have discussed what is happening, your GP can support you to get the help you need.

Helping yourself

If your depression is mild or this is the first time you have experienced depression, your GP might recommend that you do some things to support yourself.

The NHS suggests 5 steps you can take to improve your mental health and wellbeing. These are:

• Connecting with other people – This could be a friend or family member, religious leader, or anyone you know who you trust and respect. Often when we talk to others about how we are feeling we find out that they have had similar experiences, and that we aren’t as alone as we thought.
• Being physically active – This could be anything from going for a daily walk around your local park to joining a dance class. Staying active, cutting down on alcohol, quitting smoking, eating healthily and sleeping well are good for everyone, but can be particularly helpful if you are experiencing depression.
• Learning new skills – You could try cooking a new meal, taking on new responsibilities, or signing up for a course. This can help you to improve your self-confidence and connect with others.
• Give to others – This could mean giving your time by volunteering in your local community, giving your skills by helping a neighbour or friend with a task, or just telling a friend something you appreciate about them.
• Pay attention – This is also called mindfulness, and is when you pay attention to yourself and the world around you. This can help you to feel more connected to your environment, and to become less overwhelmed by your thoughts and feelings. There are lots of different ways to practice mindfulness .

Find out more about these steps  on the NHS website .

Social prescribing

Social prescribing helps to connect people to community services and local groups to support their mental and physical health.

Your GP can refer you to a ‘link worker’ who can help you to find activities that you might be interested in. You can take part in these activities alongside other treatments like medication or talking therapies.

You can find out more about social prescribing on our website .

Psychological therapies

If you have tried helping yourself and are still struggling, or if your depression is moderate or severe, your GP might suggest a psychological therapy .

Psychological therapies, or talking therapies, are when you talk to a professional, known as a therapist, about how you are feeling. There are lots of different kinds of psychological therapy, and they work in different ways. Which you are offered will depend on your needs and your unique life circumstances.

You can find out about the different psychological therapies available on our website .

At first, it might feel uncomfortable to talk to a stranger about your life, but remember that:

• These sessions are confidential . Your therapist won’t share any information with your friends or family unless you say they can. There are some other specific situations where your information might be shared with someone else, which you can find out more about in our resource on caring for someone with a mental illness .
• Your therapist won’t judge you or be shocked by anything you tell them. It is their job to listen respectfully.
• Psychological therapies have been shown to be effective , and if you give them a chance you are more likely to get well.

Research suggests that older adults with depression are even more likely to benefit from psychological therapies than younger people are, so it is important that they are offered them. If you feel you would benefit from a psychological therapy, speak to your GP. You can find out more about the therapies available for depression in our depression resource .

Antidepressants

Antidepressants are medications that can help to improve the symptoms of depression. You normally take them as a pill once a day. Your GP might prescribe you an antidepressant at the same time as a psychological therapy.

There are lots of different kinds of antidepressants, and your GP will speak with you to understand the kind of antidepressant that might work for you. In some cases, you might need to take more than one medication. It will usually take one or two weeks before you start feeling the benefits of an antidepressant.

When taking medications, an older person may need to start on a lower dose than someone younger, and increase their dose slowly.

Can people with dementia take antidepressants?

There is no medical reason why people with dementia can’t take antidepressants.

However, research has found that antidepressants are less effective in people who have dementia than in people who don’t. People with dementia should not be offered antidepressants to manage mild to moderate depression unless they have had depression in the past.

Do antidepressants have side-effects?

Like any medication, antidepressants can cause side-effects. These can affect some people more than others, and the kinds of side-effects you have might depend on the kind of antidepressant you are taking.

The person prescribing your medication should talk to you about any possible side-effects. Ask your prescriber or pharmacist for some written information on side-effects and read this carefully.

Some antidepressants used in the past had more side-effects than more recent medications. If you were given antidepressants in the past, they might not be the same ones you will be given now. Make sure that you let your doctor know if you have taken antidepressants before.

What if I get unpleasant side-effects?

If antidepressants are giving you unpleasant side-effects or aren’t working for you, speak to your GP.

You should usually not stop taking any medication without first speaking to the person who prescribed them. However, if you start to have suicidal feelings, or any other serious side-effects, you should stop the antidepressant and get help urgently. This can be done by contacting the person who prescribed them or your GP.

If you feel you are in danger, you should call 999 or go to A&E.

You can find out more about antidepressants and side-effects on our website . We also have information on stopping antidepressants . 

What if I’m taking other medications?

If you are taking other medications, or have other health problems, you might not be able to take certain antidepressants. Or your doctor might need to monitor you more than usual. Tell your doctor about any other medication you are taking.

I’m not sure if antidepressants are right for me

It can feel like a big step to start taking antidepressants. You might be unsure about whether it’s the right decision for you.

It can be helpful to think about antidepressants in the same way you would any other medication. For example, if you had a problem with your heart and your doctor gave you medication for it, you probably wouldn’t hesitate to take it.

Finding out more about antidepressants can help you to make an informed decision.

Antipsychotics

Sometimes antipsychotics are given to people who are experiencing psychosis and depression, or people who are experiencing high levels of anxiety.

When you are given antipsychotics, your doctor will talk to you about the increased risks of falls, heart problems and circulation problems. If you are taking antipsychotics, this should be reviewed regularly.

Practical support

Your mental health might be linked to the other things in your life, even if those things don’t seem related. Problems with money, housing, care, work and retirement can all have a negative effect on your mental health. Working to fix these could be an important step in treating your depression.

There is lots of information at the end of this resource that can help you to get support with different areas of your life.

Further treatment

If your depression is very severe, you might be referred to a specialist mental health service or team. You may need to spend time in hospital if you need a lot of treatment and support, or if you are a risk to yourself or someone else. You may be offered other medication instead of or as well as antidepressants.

Sometimes, when someone is very unwell and other treatments haven’t worked, electroconvulsive therapy (ECT) might be considered. In ECT, you are given a general anaesthetic and your brain is stimulated with short electric pulses while you are asleep. ECT has been shown to be successful in treating severe cases of depression.

What are older adult mental health services?

Older adult mental health services take into account the unique needs that older people might have, and provide them with appropriate care.

When someone gets older, there are changes that happen in their lives that need to be considered if they have a mental illness. Older people might have:

• multiple health issues
• frailty , which means they find it harder to recover from illnesses or injuries
• experienced bereavements and other losses.

If an older adult has other conditions like dementia, these might be confused with anxiety or depression. Older adult mental health services have the expertise to consider this when making a diagnosis of depression.

Older adult mental health services also have the facilities to help people who need assistance with mobility.

When does someone need older adult mental health services?

The decision for you to be referred to an older adult mental health services should be based on your individual needs, and not just your age. The following things should be considered:

• the kinds of services available locally
• other health conditions you might have
• your level of frailty.

If you move from a mental health service for adults to one for older people, the people who have been treating you should make sure that the new service understands your needs, such as:

• your treatment history
• your preferences
• the support systems available to you
• your personal history.

What if I live in a care home?

People in care homes are entitled to mental health support just like everyone else. If you are in a care home, this means:

• you should be provided with activities that promote your physical and mental health
• care home staff should be trained to know if you might be experiencing a mental health problem
• any mental health problems identified should be recorded in your personal care plan.

Depression is more common in people who are in care homes. If you have depression and are in a care home, it is important that you receive the high standard of care that you are entitled to. You should have your medication reviewed regularly, and any side-effects should be carefully considered.

How can I get mental health care in a care home?

Through a gp.

If you live in a care home, you should be registered with a GP. You have the right to choose your GP practice. You might choose to remain with your previous GP practice or to move to a practice that is linked to your care home.

If you are in a care home and are experiencing a mental health problem, you should speak to your GP. Your GP should work to rule out other physical health problems that can have a negative effect on mood.

Through care home staff

Care home staff are sometimes trained to provide psychological support like counselling. If care home staff feel that you need more intense support or have a mental illness, you or your carer can speak to your GP, who can refer you to a dedicated care home liaison team.

Care home liaison teams are available at most care homes, and will be able to provide psychological therapies like cognitive behavioural therapy (CBT) or psychodynamic therapy.

The charity Age UK provides information on care homes , while the charity Carers Trust has useful information on caring for someone who is in a care home .

Why might an older person not get the help they need?

There are some things that can make it more challenging for older people to get support for depression.

Other health problems

If you have another health problem, it could be difficult for you or your doctor to work out whether you are also experiencing depression.

Depression can sometimes be confused with other mental or physical health problems. For example, memory problems that can happen with depression can be mistaken for dementia, or the other way around.

Depression might also make it difficult for you to take medications or go to appointments. As a result, your physical health might get worse, which might make your depression worse.

Stereotypes

Unfortunately, some people hold harmful stereotypes about older people. For example, some people think that it is normal for older people to feel tired all the time, or that loneliness is a normal part of getting older.

People who hold these stereotypes might be less likely to recognise that an older person they know is depressed. Feelings of depression are not a normal part of aging, and you deserve help and support whatever age you are.

Many years ago, they changed the phrase from old age pensioner to senior citizen to sort of try to change the label. But the reality is, it’s not about changing labels. It's about treating people the same.” - Bernie

In the past, mental illnesses and the people who had them were treated very differently to how they are now. If you heard negative things about people with depression in the past, you might find it hard to get help for depression now. It’s important to remember that depression is common, treatable and you deserve help. All sorts of people get depression, and it isn’t a reflection on who you are as a person.

Seeing depression as just a part of life

If you are used to feeling depressed, you might not think there’s any point in getting help. Even though it can feel difficult, the sooner you ask for help the sooner you can start getting better.

Technological barriers

Some GP appointments are now held over the phone or online. Some older people can find digital technology more challenging to use, or just prefer to do things in person. It can also be hard to talk about sensitive things over the phone or online.

It can also be hard for doctors to tell if someone is experiencing depression through a phone call. It might take a face-to-face appointment for this to be noticed.

What support can family and friends offer?

If an older person you know has depression, it can be hard to know how to help. Here are some things you can consider when you are supporting an older person with depression:

Communicating sensitively

It can be hard to know what to say to someone who is experiencing depression. Sometimes the most important thing you can do is listen and encourage someone to get help.

You should try to avoid saying things that could be taken negatively. For example, telling someone they’ll ‘get over it’ or telling them that other people have it worse than they do. This can make it harder for the person to get help.

Remember the individual

All the things that make someone unique, like their life experiences, values and interests, don’t disappear when they get older. By seeing the person you know as an individual, you will be able to support them better.

Encourage independence

While some older people might need support with certain things, such as accessing services or managing their care, it’s important to think about how the person you know can remain independent. Work with them to understand how you can both be involved in their care and help them to do things for themselves.

Consider cultural differences

There are some things to consider if the person you know grew up or spent time in another country, or speaks a different language.

• Communication barriers – If the person you know doesn’t speak English, or it isn’t the language they are most comfortable using, they might struggle to communicate with healthcare professionals. They should be offered a professional interpreter if this would help them to communicate their needs more clearly. More time should be given in appointments for this to happen.
• Stigma – Different cultures and generations have different attitudes to mental illness. If the person you know grew up in a place or time where there was stigma around mental illness, they might struggle to ask for help. Psychoeducation, where someone learns about their mental illness, can be helpful. They might also benefit from the support of a faith leader or community group.
• Peer support – Everyone can benefit from speaking to people with similar cultural experiences to them. There might be groups near you where the person you know can meet people of the same ethnicity or cultural background. You can find out about peer support near you and the kinds of services they offer on the Mind website .
• Challenges accessing records – If the person you know has lived in another country and received care there, it might be challenging to get hold of their records.

What if I'm a carer?

A carer is anyone who looks after someone else because they find it hard to look after themselves. Carers can offer practical, emotional and financial support, and might be involved in the medical care of the person they care for.

Being a carer can be very challenging, and as a carer you might experience difficult and conflicting emotions, such as anger, guilt, worry or sadness.

Being a carer can also be rewarding. Many carers have very close relationships with the people they care for, and learn important practical and emotional skills. Whatever your experiences and feelings are, they are legitimate.

As a carer, there are lots of things that you can do to support the person you care for, including:

• encouraging them to get help when they need it
• working with them to understand how much they want you to be involved in their care
• forming positive relationships with the people who provide their medical care
• making a plan for what to do in an emergency.

There are also things that you can do to support yourself, including:

• sharing your stresses and worries with a trusted friend or family member
• taking care of your physical and mental health. This is just as important as looking after the person you care for, and can be beneficial for you both
• getting a break with the help of friends or a professional caring service
• accessing support like carers assessments and workplace adjustments
• meeting with other carers for support
• planning ahead for the future
• applying for the benefits you are entitled to.

It is important to remember that it is not your responsibility to ‘fix’ the person you are caring for

You can find out more about being a carer in our resource on caring for someone with a mental illness .

“As a carer I need to plan, everything is connected. Not just the next few weeks, but the next few years.” Sofija

Further information

Information on depression.

• Depression, NHS – NHS information on depression.
• Depression, Royal College of Psychiatrists – The Royal College of Psychiatrists’ information on depression.
• Depressions and anxiety, Age UK – Information from the charity Age UK about depression and anxiety in older people.

Information for carers

• Carers UK – Carers UK is a charity offering support, information and advice to carers.
• Help and support for carers respite and support, Age UK – Information for carers from the charity Age UK.

Further information for older people

• Get help with loneliness, British Red Cross – Information on getting help with loneliness from the British Red Cross.
• Advice and support for veterans & ex-forces, Veterans' Gateway – Advice and support for veterans from the charity Veterans’ Gateway.
• Advice for LGBT older people, Age UK – Information from lesbian, gay, bisexual and transgender older people from the charity Age UK.

National Institute for Health and Care Excellence (NICE) guidance on depression

• Depression in adults: recognition and management guidance, NICE – NICE guidance on the management of depression in adults.
• Depression in adults with a chronic physical health problem: recognition and management guidance, NICE – NICE guidance on the management of depression in adults with chronic physical health problems.

This information was produced by the Royal College of Psychiatrists’ Public Engagement Editorial Board (PEEB). It reflects the best available evidence at the time of writing.

Expert authors: Dr Manoj Rajagopal, Dr Kapila Sachdev and Dr Qutub Jamali

Thank you to the people with lived experience of depression who helped to develop this resource: Bernie, Philip and Sofija Opacic. Some of their experiences have been included in this resource as quotes.

Full references available on request.

Published:  Sep 2023

Review due:  Sep 2026

© Royal College of Psychiatrists

About our information

Translations, frequently asked questions, choosing wisely.

Depression in the Elderly

Introduction, clinical depression or typical depression, forms of behavior, therapy and the consequence.

Depression can be defined as a state of anxiety, sadness, hopelessness, and worthlessness (Kail & Cavanaugh, 2011). It can affect people across all ages, who present with diverse signs and symptoms (Blatt, 2004). It has been shown that there are different types of depression, which require unique approaches with regard to diagnosis and treatment (Kail & Cavanaugh, 2011).

This paper aims at discussing how a person would know whether a relative had clinical depression or was sad due to specific changes or losses in life. It also focuses on highlighting the behaviors that could indicate that a person undergoing depression requires therapy. Finally, it offers recommendations with regard to therapy and the consequence of such a therapy in the elderly.

It would be important to determine whether a relative had clinical depression or was sad because of changes in life. This would help in determining the course of action in treatment.

Clinical depression persists in a patient longer than the other type of depression and it makes an individual not carry out his or her daily activities in a normal way. The following signs would characterize a relative suffering from clinical depression (Blatt, 2004; Kail & Cavanaugh, 2011):

• Insomnia or hypersomnia
• Lack of appetite
• Changed concentration
• Restlessness
• Worthlessness
• Considerable weight loss or gain
• Persistent suicidal thoughts

On the other hand, depression that is caused by changes or losses in life does not last long and there are no severe symptoms that could guarantee medications (Blatt, 2004). In fact, this type of depression can be resolved through the application of counselling.

Thus, it would be important to assess whether a relative encountered major changes in life. Changes could be brought by new jobs and responsibilities, among others (Blatt, 2004). Losses could be due to the death of a close family member or friend and loss of job, among others.

It is important to note the behaviors in a person undergoing depression that imply that he or she requires therapy (Kail & Cavanaugh, 2011). Most importantly, clinical depression should be treated when detected so that a person cannot result in life-threatening acts such as committing suicide. The following behaviors would indicate that a person requires therapy:

• Abrupt change of mood patterns
• Suicidal thoughts
• Hopelessness
• Prolonged anxiety
• Social withdrawal signs

A student would recommend the use of antidepressant medications aimed at curing the symptoms of a depressed patient (Kail & Cavanaugh, 2011). However, they would be selected based on behavior patterns that would be present in a patient.

Specifically, monoamine oxidase inhibitors (MAOIs), which treat depression by blocking the enzyme monoamine oxidase, would be recommended. Examples of the medications are phenelzine and isocarboxazid. The medicines would be suggested because they have fast modes of therapeutic activities (Henry et al., 2007).

The consequence of administering the drugs is that they would adversely react with other drugs and some types of food (Henry et al., 2007). In order to avoid the consequence, it would be important to tell a patient the drugs that he or she would not use while using the antidepressants. In addition, aged cheese and meats should be avoided.

Blatt, S. J. (2004). Experiences of depression: Theoretical, clinical, and research perspectives . New York, NY: American Psychological Association.

Henry, C., M’Baïlara, K., Poinsot, R., Casteret, A. A., Sorbara, F., Leboyer, M., & Vieta, E. (2007). Evidence for two types of bipolar depression using a dimensional approach. Psychotherapy and psychosomatics , 76 (6), 325-331.

Kail, R. V., & Cavanaugh, J. C. (2011). Human Development: A Life-Span View: A Life- Span View . Boston, MA: Cengage Learning.

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Essay On Depression In Older People

Type of paper: Essay

Topic: Life , Business , Psychology , Health , Depression , Family , Nursing , Services papers

Words: 2250

Published: 12/13/2019

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Depression in Older Persons

Depression is a mental disorder, which distresses mind, body and spirit of the victim. The condition significantly reduces the individual’s quality of life, productivity and own joy. Most people become depressed in their old stages, this is not an ageing process, but it is a common disorder among the older people (Hoek, 2008). At this point, older people experience a sense of loss in their existence, this disorder can be controlled with the assistance of caregivers (Baldwin, 2003). Most elderly who are depressed avoid going through diagnosis for fear of stigmatization. The depressed becomes hot tempered and disturbed; they normally experience nausea and weight reduction. Other experiences are memory lapse, be deficient in of concentration and can even engaging in reckless behaviours (Gavin & Julian, 2007). The depressed older persons would have strange thoughts of executing suicide. Regarding decision-making, depressed older people should be given the chance to make some decisions concerning his life. Such decisions can be; psychological, legal, practical, and spiritual or even medical decisions (Black Dog Institute Australia, 2012).

The elderly has a responsibility in deciding the kind of care he needs and whether the care is carried out at the health institution or home. They are also entitled to opinions, which facilitate the satisfaction of his needs and thus, assist them to overcome depression. Their decision-making and opinions reflects their preferences on matters pertaining care giving (Hoek, 2008). Every decision, preferences, and opinions they give should be considered as a step towards their satisfaction and thus part of relief from the depression (Black Dog Institute Australia, 2012). It is the responsibility of doctors and caregivers to ascertain if the victim can make a sound decision-making concerning their health before they are granted the opportunity to make. The satisfaction of the depressed older persons lies on their opinions and decision-making implementation; this will motivate the victims and consequently boosting their health (Liffe, 2009). Satisfaction in the life of older persons, with depression, is significantly affected by the status of their mood and contribution in making a decision (Hinrichsen & Clougherty, 2006). Ignoring depressed older persons in decision-making is giving them problem in coping with the situation. Letting them make a decision on their care utility placement is a vital factor on their life satisfaction (Baldwin, 2003).

There should be a good care for depressed old people to cope with the challenges associated with the disorder (McCredie, 2009). Caregivers, like family members, friends, or nurses have their own needs to execute their duties of care to the victims of depression (Tom, and Milne, 2009). With the spectacular aging and depression among older people, family members have the responsibility of taking care of them for a long time, this is a demanding responsibility, and thus the caregivers ought to be given enough support (Hinrichsen & Clougherty, 2006). There are several challenges associated with care giving; the strain of resources, exposure to health risks and more so the balance other personal or family duties and care-giving (Williamson, et al, 2007).

Families require information and their personal support facilities and services to safeguard their essential responsibility as caregivers, however habitually they are ignorant of where they can get assistance and support (Hellen, O’Connor, and Robinson, 2007). Due to their ignorance, caregivers cannot look for support from the ever-cooperating community organizations that are willing to offer sufficient supports, in terms of finance or emotional (Hellen, O’Connor, and Robinson, 2007). The centralized government can facilitate by putting effort to guarantee information to every family caregiver so as to the access support, high quality, realistic, and reasonably priced community and home -based amenities and other services (Tom, and Milne, 2009). Mental health services and community organizations offer medication, spiritual, medication and funds to the elderly. These are harsh economic moments, but funding family caregivers is among the most gainful lasting care investments that can carry out (Liffe, 2009).

Caregivers are frequently capable to delay expensive nursing home placements and decrease dependence on programs like Medicare as long as they carry their responsibilities of caring (Frazer & Griffths, 2005). Owing the many-sided responsibility that informal and family caregivers participate, they require a variety of support facilities and services to maintain their healthy, develop their care giving skilfulness and maintain their responsibility of care-giving (Gray, 2008). Support services comprise of support, counselling, information, home modification, respite, or assistive machines, family and caregiver counselling, and assistance groups (Hoek, 2008). While numerous facilities and services are accessible through local administration agencies, religious organizations, or service organizations, employers' programs also can lessen the effect of care giving on employees (Hinrichsen, et al, 2006).

Family caregivers experienced some stress on their duties; they are advised to carry bigger burdens for la long time (McCredie, 2009). In spite the more intricate care, escalating economic pressure, contradictory stress of family and jobs, and the emotional and physical needs of lasting care-giving can cause significant health effects on caregivers (Tom, and Milne, 2009). Generally, caregivers who undergo the furthermost emotional stress are mostly female (Kasper, et al, 2005). They are prone to dangers of; depression, frustration, high stress level, exhaustion, anxiety and irritation, abridged immune response, extra use of alcohol or other substances, deteriorated physical health and additional chronic conditions, abandoning their own care and have increased mortality rates (McCurren, 2002).

Furthermore, most caregivers are poorly prepared for their responsibility and offer care with modest or no assistance; nevertheless more than one-third of them keep on to offer passionate care to others whilst suffering from poor healthiness themselves (Gray, 2008). The coping strategies for caregivers entail entering into partnership with other health care experts, the partnership will enable them acquire relevant information and other support like funding and counselling (Gavin & Julian, 2007). Caregivers offer a wide variety of services, from easy assist such as shopping, to intricate medical processes (Hinrichsen, et al, 2006).

Innovations and implication of nursing care are fundamental towards prevention and identification of depression among older persons (McCurren, 2002). The campaign towards nurses' responsiveness of depression reacts to opinion-based research that depression is an unnoticed and ignored area of care. The promotion seeks to make the nurses detect depression in older people, hence drawing notice to a range of risk factors particularly to the later life. The promotion to changes to care home is a significant region for nursing involvement (Bruce, et al, 2004). The shift from the hospital of community or of other residential place to home care can be a disturbing life experience and among the greatest foundation of stress and fear for depressed older people (Kasper et al, 2005).

Nursing workers have a significant role contribution in offering the suitable social, spiritual, physical and psychological support that facilitate the development in quality of life for the depressed elderly people and their families (Rapaport et al, 2003). Physical support may entail recommendation to specialist services and facilities for the rectification of visual and hearing disabilities, which hamper the individual and stop them from coping with the new condition (Frazer, et al, 2005). The availability of written care assistance stressing the impact of transition, the possible gains and losses, is among the ways of offering substantiation that these are essential regions for supportive care (McCredie, 2009). Another innovation is the campaign for positive well-being and mental health it outlines the methods of supportive care that aid to simplicity the change and enhance the depressed older person's feelings of self-rule and control (Denby, 2004).

A completely coordinated, planned, and incorporated advance to admittance to the care home, or systematic care service is significant (McCredie, 2009). This incorporates provision of comprehensive information regarding the care service, and preferably, a pre-admission appointment to meet personnel. There is also an area for dealing with evidence around care planning and assessment (Bruce & Reynolds, 2004). Nurses are meant to be in close association with clients, and it is suggested that the first evaluation for depression starts in 48 hours of admittance and is concluded in 14 days (Sanson, 2003). Practical care planning emphasizes on the depressed older people's potencies, usual coping techniques, and their living patterns (Denby & Godfrey, 2004). Other interventions like allowing the depressed older people to access encouragement services, offering psychosocial assistance, sustaining community links, and encouraging the individual to be involved in significant activities are suggested since they contribute significantly in the deterrence of depression (McCredie, J. (2009).

Ultimately, good practice depression care necessitates the expertise of a variety of proficient other than nurses. Registered nurse ought to makes medical appointments to take gain of the specialist acquaintances (McCredie, 2009). On education and training nurses are sufficiently equipped to execute their responsibilities in caring for depressed older persons. The innovation is meant to train and educate nurses and other caregivers on depression in older persons especially for nursing workers operating in care homes (Gaugler, Mittelman, & Newcommer, 2009; Tom, and Milne, 2009). The innovation also assists the nurses to ease their work by training the caregivers and other family member involved on how to take responsibilities (Tom, and Milne, 2009).

In conclusion, Nurses are idyllically positioned to employ proactive strategies to thwart depression in elderly persons, to encourage early recognition of symptoms, and to ascertain access to efficient treatment (McCurren, 2002). Preventative strategies are founded on a consideration of danger factors for depression in elderly individuals and approval of how it feels to shift from one's residence into progressing care surroundings late in life (Frazer & Griffths, 2005). This finest practice statement has been build up to enhance development programs for national practice. (McCredie, 2009). It endeavours to depict the way nurses can work with depressed older persons and their members of their family at times of vital transformation, offering support and thwarting the usual responses to loss and misery from leading to clinical depression (Gaugler, Mittelman, & Newcommer, 2009).

Baldwin, R. (2003). Delusional depression in elderly patients: Characteristics and relationship to age at onset. Int J Geriatr Psychiatry 10:981–985.

Bruce, M., & Reynolds II. (2004). Reducing Suicidal Ideation and Depressive Symptoms in Depressed Older Primary Care Patients: A Randomized Controlled Trial. Journal of the American Medical Association, 2004, 291:1081-1091 Black Dog Institute Australia. (2012). Depression Explained: In over 65s. Retrieved from http://www.blackdoginstitute.org.au/public/depression/inover65s.cfm

Denby, T & Godfrey, M. (2004). Depression and Older People: Towards Securing Well- being in Later Life. New York: Springer.

Frazer, C & Griffths, K. (2005). Effectiveness of Treatments for Depression in Older People. The Medical Journal of Australia; 182 (12): 627-632. Gavin, A & Julian, A. (2007). Age Shall Not Weary Them: Mental Health in the Middle- Aged and the Elderly. Australian & New Zealand Journal of Psychiatry, 41 (7)

Gray, H. (2008). Work and Depression in Economic Organization: The Need for Action. Development and Learning in Organization. 10 (3).

Gaugler, J., Mittelman, M & Newcommer, R. (2009). Predictors of change in Caregivers Burden and Depressive Symptoms Following Nursing Home Admission. Psychology and Aging: 385-396. Hellen, S., O’Connor, M. and Robinson, H. (2007). “Depression in older adults: Exploring the relationship between goal setting and physical health.” International Journal of geriatric psychiatry. John Wiley and Sons, Ltd

Hoek, R. (2008). The Many Faces of Geriatric Depression. Current Opinions in Psychiatry. 6:540-545.

Hinrichsen, G. A., & Clougherty, K. F. (2006). Depression and older adults. In Interpersonal psychotherapy for depressed older adults (Ch. 2, pp. 21- 42). American Psychological Association: Washington, D.C.

Kasper S, de Swart H, Andersen HF. (2005). Escitalopram in the treatment of depressed elderly patients. Am J Geriatr Psychiatry, 13:884–891.

Lliffe, S. (2009). "Recognition and response: Approaches to late-life depression and mental health problems in primary care", Quality in Ageing and Older Adults, 10 (1), pp.9 – 15

Miller, C. (2009). Nursing for Wellness in Older Adults. London: Wiley

McCurren C.(2002). Assessment for depression among nursing home elders: Evaluation of the MDS mood assessment. Geriatr Nurse, 23(2):103–108. McCredie, J. (2009). Aged care: The Depressing Reality. ABC Health & Wellbeing. Retrieved from http://www.abc.net.au/health/features/stories/2009/08/20/2661451.htm Rapaport MH, Schneider LS, Dunner DL, Davies JT, & Pitts CD.(2003). Efficacy of controlled-release paroxetine in the treatment of late-life depression. J Clin Psychiatry 2003; 64 (9):1065–1074.

Sanson, A. (2003). Ageing: Issues for Australian Families. Family Matters. Australian Institute of Family Studies 66, p 2-5

Tom D., and Milne, A. (2009). "Depression and mental health in care homes for older people.” Quality in Ageing and Older Adults, 10 (1), pp.40 - 46 Williamson, G.M., Shaffer, D.R., & Parmelee, P.A. (2000). Physical illness and depression in older adults: A handbook of theory, research, and practice. New York: Kluwer Academic/ Plenum Publishers.

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10 of the most common signs of depression in older adults

Posted: July 27, 2023 | Last updated: July 27, 2023

Depression is not an inherent part of aging: Here are 10 of the most common signs in older adults

The American Psychiatric Association defines depression as "a common and serious medical illness that negatively affects how you feel, the way you think, and how you act," resulting in, among other symptoms, "feelings of sadness and/or a loss of interest in activities you once enjoyed."

Mental illnesses should be approached with the same seriousness and urgency as any physical disease. Unfortunately, depression in older adults is frequently misdiagnosed, undertreated, or mistaken as a natural sign of a person's "slowing down" with age or enduring chronic age-related physical ailments , of which an estimated 80% of older adults have at least one.

Stacker compiled a list of 10 of the most common signs of depression in older adults using information from the National Institute on Aging and other scientific and medical sources. Identifying these symptoms and seeking timely professional help can significantly improve the quality of life of older adults.

While depression rates among older adults are lower than among younger people, a lack of access to accurate information greatly increases the likelihood that older adults do not understand what is happening to them or how to ask for help. Depression in older people is often tied to cognitive changes, changes in sleep patterns, and a general loss of interest , all of which can contribute to a significantly higher risk of isolation. Family members, friends, caregivers, and health professionals in contact with seniors must therefore be aware of the warning signs in order to offer support and treatment options.

According to the Centers for Disease Control and Prevention, most older adults do not report feeling depressed , though living conditions and a person's degree of social interaction play a major role. While cases of depression among the elderly living within a community range from less than 1% to 5%, 11.5% of hospitalized patients and 13.5% of those who receive home health care have reported depressive symptoms.

Most elderly patients suffering from depression do respond to anti-depressive drugs, psychotherapy, or a combination thereof. Symptoms are usually different in seniors than in younger adults—they are less likely to develop cognitive-affective symptoms, such as dysphoria, worthlessness, or guilt than younger patients, while insomnia, fatigue, psychomotor lethargy, loss of interest in living, and hopelessness tend to be more prevalent.

Extended periods of feeling sad, anxious, or 'empty'

Grief and sadness due to the loss of a loved one or other life events are normal at all ages, but can become especially acute among seniors who outlive their siblings and friends. If the older adult is sad, anxious, or mentions feeling empty for a long period of time—more than a few months—they might be experiencing dysthymia or depression.

Consistent feelings of hopelessness, helplessness, worthlessness, or guilt

According to a study published by the National Library of Medicine, "self-worthlessness [or] inadequacy is a distinctive and consistent symptom of major depression across all cultures." The onset of these feelings is also a distinct reproducible predictor of a person's risk of recurrence after overcoming an initial bout of depression.

Restlessness or irritability

Seniors may show signs of being agitated, busy, or short-tempered by manifesting consistent nervous behaviors. They can repeatedly tap their fingers against a table, fidget, or repeat movements. They may also fixate on specific daily tasks such as cleaning and organizing, moving objects from one place to another, or making up excuses to try to leave the house. These and other demonstrations of restlessness, while a common symptom in Alzheimer's patients, can also be a sign of depression, especially when combined with episodes of irritability.

Loss of interest in hobbies and other pleasurable activities

Social withdrawal and a loss of interest in hobbies and other activities previously found pleasurable is called anhedonia, a core symptom of depression. Anhedonia can present as a social or physical symptom; social anhedonia is a progressive disinterest in interpersonal relationships and a lack of comfort in social situations, while physical anhedonia is the inability to feel tangible pleasures such as eating or touching.

Loss of energy or fatigue

Fatigue can make simple daily activities, such as getting out of bed or getting dressed, too hard to perform. It can be a consequence of suffering one or several other symptoms of depression, such as sleeping problems, indigestion due to bad food choices, or stress. It can also be a symptom on its own. One 2018 study found that more than 90% of patients with depression report feeling fatigued .

Sluggishness or moving and talking more slowly

While fatigue is the feeling of being exhausted even after sleeping or resting, sluggishness or lethargy can be a mental condition that compromises the capacity to move nimbly, even if the patient is physically able and healthy. It can affect speech, movement, and reflexes.

Memory and decision-making issues

In older adults, the loss of executive functions, memory, and the ability to make decisions can be symptoms of different diseases or just a normal part of the aging process. A health professional must accurately diagnose the patient to discard brain conditions such as dementia, infectious diseases, and chronic illnesses before attributing these symptoms to depression .

Sleep irregularity, including waking up too early or sleeping too late

According to the Sleep Foundation : "People with depression may find it difficult to fall asleep and stay asleep during the night or experience periods of excessive daytime sleepiness." The organization states that sleep problems and vice versa can exacerbate depression; sleep problems can bring on depression. Either way, there is an undeniable link between depression and sleeping. The sleeping habits of seniors must be closely supervised to prevent mental and physical health problems.

Change in appetite, especially with unintentional weight gain or loss

It is common for older adults to have less appetite since they have lower energy requirements due to less physical activity. There are several reasons for the elderly to lose their appetite: dental issues, difficulty chewing and swallowing, side effects of prescription medications, and depression. A mental health exam is recommended if a senior loses their appetite and weight for no apparent reason. On the other hand, if the person starts eating excessively, it might be a sign of stress or anxiety, conditions often linked to depression as well.

Suicide ideation or suicide attempts

A 2021 primer on the relationship between suicide ideation and suicide attempts pointed to, among other sources, a study by the World Health Organization that found "two‐thirds of individuals with suicidal ideation never make a suicide attempt." Mental conditions, such as depression, are strongly linked to suicidal ideation, but are not necessarily associated with suicide attempts. Constantly monitoring the elderly and providing them with adequate care and medical help is critical, especially if they have ever expressed suicidal thoughts.

Additional research by Emilia Ruzicka. Story editing by Brian Budzynski. Copy editing by Kristen Wegrzyn. Photo selection by Clarese Moller.

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Ask Amy: I'm not equipped to help my elderly mother through her depression, but she won't see a therapist

• Published: Jun. 04, 2024, 12:02 a.m.

My 83-year-old widowed mother is depressed, and I don’t know how to help. Cliff - stock.adobe.com

• Amy Dickinson

Dear Amy: My 83-year-old widowed mother is depressed, and I don’t know how to help.

She refuses to see a therapist and sees drugs as a crutch. She has always been a very private person, is generally distrustful of doctors, and would never let down her shields to a stranger.

I have told her that I am not a therapist, but she has lately begun to confide in me about things that, even as an adult, I shouldn’t be hearing.

Depression runs in the family. I have seen a therapist in the past and am on medication, so I understand and empathize, but it’s getting to the point where I dread seeing her, and yet I know that I’m her only lifeline.

How do I help her?

Stories by Amy Dickinson

• Ask Amy: Update from grieving friend who needed more than 'thoughts and prayers'
• Ask Amy: How and when do I tell people about my Alzheimer's diagnosis?
• Ask Amy: I found out my friend has been lying about mounting trouble with alcohol abuse. Should I tell her I know?

Dear Worried: People sometimes start to reveal long-repressed or suppressed trauma very late in life, when – for a variety of reasons (medical, emotional, and cognitive) – their defenses are down. Studies of WWII survivors have shown that the strong and stoic “Greatest Generation” have experienced nightmares, remembered traumatic events and suffered from depression very late in life.

Quoting from one study: “In aging individuals, the classical symptoms of posttraumatic stress disorder (PTSD) may not be manifest, yet considerable distress may occur in the face of re-awakened memories of traumatic experiences.”

Therapy helps. Medication helps. And yet many elders are resistant to the idea of treatment in the ways your mother is.

My first suggestion is that you should resume in-person (or telehealth) therapy right away, in order to process this burden, which is a trigger for you.

I urge you to seek healthy ways to be open and present for your mother, while resisting the temptation to try to provide answers or your own brand of therapy for her.

Being in the moment with her is a special and challenging kind of witnessing. You stroke her hand. You say, “Mom, I’m so sorry. I’m so very sorry.” You sit quietly, and if you’re able, you stay quietly in the moment with her, letting her speak.

I wonder if you might be able to urge your mother toward treatment by asking her if she would consider doing this “for” or with you.

A good and competent therapist helps their client transition from being a stranger – to a trusted and helpful ally.

You can email Amy Dickinson at [email protected] or send a letter to Ask Amy, P.O. Box 194, Freeville, NY 13068.

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• Open access
• Published: 01 June 2024

Factors that indicate performance on the MoCA 7.3 in healthy adults over 50 years old

• César Bugallo-Carrera 1 ,
• Carlos Dosil-Díaz 1 ,
• Arturo X. Pereiro 1 ,
• Luis Anido-Rifón 2 &
• Manuel Gandoy-Crego 3  

BMC Geriatrics volume  24 , Article number:  482 ( 2024 ) Cite this article

125 Accesses

Metrics details

Human aging is a physiological, progressive, heterogeneous global process that causes a decline of all body systems, functions, and organs. Throughout this process, cognitive function suffers an incremental decline with broad interindividual variability.

The first objective of this study was to examine the differences in the performance on the MoCA test (v. 7.3) per gender and the relationship between the performance and the variables age, years of schooling, and depressive symptoms .The second objective was to identify factors that may influence the global performance on the MoCA test (v. 7.3) and of the domains orientation, language, memory, attention/calculation, visuospatial and executive function, abstraction, and identification.

A cross-sectional study was carried out in which five hundred seventy-three (573) cognitively healthy adults ≥ 50 years old were included in the study. A sociodemographic questionnaire, the GDS-15 questionnaire to assess depression symptoms and the Spanish version of the MoCA Test (v 7.3) were administered. The evaluations were carried out between the months of January and June 2022. Differences in the MoCA test performance per gender was assessed with Student’s t-test for independent samples. The bivariate Pearson correlation was applied to examine the relationship between total scoring of the MoCA test performance and the variables age, years of schooling, and depressive symptoms. Different linear multiple regression analyses were performed to determine variables that could influence the MoCA test performance.

We found gender-related MoCA Test performance differences. An association between age, years of schooling, and severity of depressive symptoms was observed. Age, years of schooling, and severity of depressive symptoms influence the MoCA Test performance, while gender does not.

Peer Review reports

Introduction

Human aging, a physiological progressive heterogeneous global process, causes the decline of all body systems, functions, and organs. Throughout this process, progressive decline in cognitive function occurs, with large interindividual variability [ 1 ].

In normal aging, performance deceleration appears in tasks that require divided attention [ 2 ]. At the mnesic level, decline in recent episodic memory occurs, possibly due to the effect of the slowing down of speed processing and failures in the processing of information [ 3 ]; moreover, errors in working memory, executive functioning, and sensory processing arise [ 4 ].

With increasing age, executive deficits also appear, affecting planning, organization, and decision-making, accompanied by a decline in the capacity to learn new concepts; thinking becomes more concrete, with a decrease in the flexibility to perform new abstractions and categorizations [ 5 ]. Evidence shows that visuospatial abilities begin to drop from age 80, while visual and perceptual abilities do it from the age of 65 [ 6 ].

Studies have shown that age and gender are predictive factors of cognitive performance in aging [ 7 , 8 , 9 , 10 , 11 , 12 ]. Some authors report that with the passing of the years women suffer greater cognitive decline in comparison to men [ 13 , 14 ].

Depression has been receiving increasing interest with regard to cognitive functioning. There are divergences between theoretical and empirical evidences: one the one hand, some authors argue that the presence of depressive symptoms is a risk factor for the development of cognitive deterioration and later progression to dementia [ 15 , 16 , 17 , 18 , 19 ]. On the other hand, other researchers suggest that the decrease in cognitive performance could be explained by the presence of depressive symptoms [ 20 ]. More specifically, late onset depression has been more frequently associated to cognitive deterioration rather than early onset depression, late onset depression being more severe and mostly affecting cognition in terms of memory, verbal fluency, visuospatial abilities reaction times, and executive functioning [ 21 , 22 ]. A third view holds that cognitive performance decline and depression symptoms share common risk factors, which may explain the increase in prevalence of both conditions in older people and the reason of why they are frequently comorbid [ 23 , 24 , 25 ].

Cognitive deterioration is not general and homogeneous among the affected individuals; in fact, it has been shown that people with higher level of education show better cognitive performance at old age, which confirms the effect of the variables associated with cognitive reserve in the maintenance of cognitive functioning in adulthood [ 26 , 27 ]. Similarly, education has been described to be a protective element against cognitive deterioration, associated with the amount of cognitive loss required for the appearance of symptoms [ 28 ].

Initially, cognitive reserve was conceived as the brain’s ability to optimize cognitive and functional performance through compensatory mechanisms or the use of alternative cognitive strategies to cope with cerebral insults [ 29 ]. In this sense, since cognitive reserve is a theoretical construct, it cannot be measured directly but must be estimated indirectly through sociocultural indicators, such as education or occupation, through the comparison of brain state current with that expected for age, or through functional brain activity using neuroimaging techniques [ 30 ].

Besides the effects of age, level of education, mood, and other variables, cognitive functions in advanced stages of life show great interindividual variability and it is difficult to discern between normal and pathological aging; there are no clear limits between them, and sometimes it is very difficult to determine where does one start and the other end. Thus, for an adequate cognitive evaluation it is necessary to know the normal cognitive functioning in an older adult, bearing in mind that cognitive performance may be conditioned by risk factors such as gender, age, state of mind, of by protective factors such the level of education.

In a recent study [ 31 ], it has been shown that age, gender, educational level, and depressive symptomatology act as indicators of performance obtained on the Montreal Cognitive Assessment [ 32 ]. This instrument is available in multiple languages and scaled for different contexts and populations [ 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ], likewise, it has two alternative versions (7.2 and 7.3). Several studies verified the equivalence of the alternative versions with the original version [ 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. The maximum score is 30; A score equal to or greater than 26 is considered normal with a maximum of 30 points. One point is added if the subject has 12 years or less of education (if the MoCA is less than 30). However, of the alternative versions of the MoCA test, hardly any studies are available.

The purpose of this study was to widen the knowledge on the variables that may be associated with performance on the MoCA 7.3 in cognitively healthy adults ≥ 50 years old, specifically aiming at two objectives. First, to assess cognitive the performance on the MoCA test (v. 7.3) differences based on gender and the relationship between the performance and sociodemographic variables (e.g., age and years of schooling) and emotional variables (e.g., depressive symptoms) in cognitively healthy adults ≥ 50 years old. Second, to estimate the indicative ability of sociodemographic variables and depressive symptoms in the MoCA test 7.3 performance [ 47 ] and for each of the seven cognitive domains this instrument assesses (orientation, language, memory, attention/calculation, visuospatial and executive function, abstraction, and identification).

Materials and methods

A cross-sectional study was carried out in which 573 people residing in Galicia recruited from socio-cultural, professional, and civic associations. The selection of the participants has been carried out by psychologists specialized in psychogerontology through a convenience sample to obtain a sample distributed in a proportionally equivalent manner between age groups (50–59; 60–69; 70–79; and > 80), educational levels (1–4; 5–8; 9–12; and > 13), and gender. The following inclusion criteria were applied: subjects aged ≥ 50 years, without disabling psychiatric disorders, sensorial or motor function impairment, nor doing drugs or under psychoactive medication treatment. Exclusion criteria were absence of cognitive deterioration and illiteracy (participants had to at least know how to read and write). All participants signed an informed consent.

Health professionals (psychologists specialized in psychogerontology) carried out the evaluations at the participant’s home or socio-cultural centers. The following instruments were applied in a partially counterbalanced manner: a sociodemographic questionnaire [ 48 ], the Spanish version of the MoCA test (v 7.3), without the correction by education ( https://www.mocatest.org ), and the 15-item Geriatric Depression Scale (GDS-15) [ 49 ]. The evaluations were carried out between the months of January and June 2022.

Data analysis

Descriptive statistics were computed for each of the sociodemographic variables included in the study. Differences in the MoCA test performance per gender was analyzed using the Student’s t-test for independent samples, homoscedasticity has previously been analyzed through the Levène test. The association between the scoring total of the MoCA test v 7.3 and age, years of schooling, and depressive symptoms was assessed using the bivariate Pearson correlation. To determine which variables showed significant and independent contribution to explain total performance variance (MoCA test) and of each of the seven cognitive domains this test assesses (orientation, language, memory, attention/calculation, visuospatial and executive function, abstraction, and identification), we carried out different stepwise multiple regression analysis. The indicative or independent variables were gender, age, years of schooling, and severity of depressive symptoms. The MoCA test allowed us to determine the effect of each independent variable on the total performance and on the different cognitive domains it evaluates. Prior to carrying out the multiple linear regression analysis in order to guarantee the validity of the model, the assumptions of the multiple linear regression model were verified. The independence of the errors among themselves, that is, the non-self-relationship, was studied with the Durbin-Watson test. To verify the normal distribution of errors, the Kolmogorov-Smirnov test was used. Through White’s test, homoscedasticity was verified, and collinearity has been analyzed through tolerance and the variance inflation factor (FIV). The analyses were carried out with the aid of Statistical Package for Social Sciences (SPSS) statistics for Windows (version 21) (IBM, Armonk, NY).

Table  1 shows the descriptive statistics of the sociodemographic variables included in this study. We found gender-dependent differences in the total MoCA performance (t = 2.713; gl: 571; p  < .05) (Student’s t-test) and a statistically significant correlation between the total MoCA performance and the variables age, years of schooling, and severity of depressive symptoms (GDS-15) (Table  2 ) ( p  < .001). More specifically, there was a statistically significant positive association with years of schooling ( p  < .001) and significantly negative relationships for the variables age and severity of depressive symptoms ( p  < .001).

Before carrying out the multiple regression analysis, it was verified that the necessary assumptions were met in all cases to guarantee the validity of the model. Table  3 details statistically significant results for linear multiple regression analyses performed to determine the impact of independent variables on total MoCA test performance and the seven cognitive variables assessed with the MoCA test. Independent variables years of schooling, age, and severity of depressive symptoms were indicators of total MoCA performance, while the variable gender was excluded.

Regarding MoCA test domains test orientation, language, memory, attention/calculation, visuospatial and executive function, abstraction, and identification, we observed that age was the only common indicator for performance for all the domains. Years of schooling was a indicator of performance in all domains except orientation, and the independent variable severity of depressive symptoms a indicator for performance in orientation, language, attention/calculation, and abstraction.

Regarding the first aim of this study, we establish gender-related differences in total MoCA test performance, as well as a negative association between the total MoCA test performance with age and severity of depressive symptoms, and a positive relationship with years of schooling. Our findings are in line with other works that report differences based on gender [ 13 , 14 ] age [ 12 ], depression symptoms [ 17 , 18 , 20 ], and years of schooling [ 26 , 27 ].

As for our second objective (to estimate the predictive ability of sociodemographic and depression symptoms on global MoCA test performance), age and severity of depression symptoms are negative indicators and years of schooling is a positive indicator for global cognitive performance. On the other hand, gender is not a indicative factor of MoCA test performance.

When we examine the influence ability of each of the study variables on MoCA test performance, age is the only one that acts as a common negative indicator for all the domains examined.

Depressive symptoms are also negative indicators; however, age is a better indicator, as depressive symptoms are unable to explain MoCA Test performance as well as the domains memory, visuospatial/executive function, and identification.

The only positive indicative factor we identify in our study is years of schooling (associated with cognitive reserve). It works as a indicator of good MoCA Test performance in all the assessed domains, except orientation.This indicates that older people with greater cognitive reserve could have more alternative strategies and compensatory mechanisms to achieve more effective and flexible cognitive functioning, with educational level being the main indicator of cognitive reserve [ 50 , 51 ].

In this work, we identify the factors that can help explain the eventual performance on the MoCA test in healthy older adults and outline a profile of individuals with low performance, who are more vulnerable to suffer cognitive deterioration. With this in mind, designing a protocol to help detect individuals at risk of suffering cognitive deterioration will alert specialists on the need of a follow-up to detect deterioration as early as possible and establish an early treatment [ 52 , 53 ]. Achieving this would reduce the costs associated to the care of people with dementia [ 54 ].

The results obtained in the present study can serve as guidance when carrying out a cognitive evaluation. On the one hand, and prior to the cognitive evaluation, an assessment of the mood of the person we intend to evaluate should be carried out, since the existence of depressive symptoms will negatively condition the results of cognitive performance. Likewise, another factor to take into account when carrying out a cognitive evaluation is the age of the person evaluated since this will negatively condition the results obtained. On the other hand, the cognitive reserve of the person being evaluated must be taken into consideration since this will positively influence the results of the evaluation since it can function as an element that enhances the results of cognitive performance.

Taking into account the above, it would be of interest to have instruments to carry out assessments of cognitive function properly scaled by virtue of the age, depressive symptoms and educational level of the person evaluated, in order to carry out an adequate cognitive assessment.

Further longitudinal studies are needed to assess the keys of cognitive performance in the MoCA Test that help identify which variables have positive and negative effects and determine heterogeneous profiles based on these variables. Likewise, it would be advisable to extend the study to other geographical regions to check whether or not there are differences in the results.

In this original study there are limitations that are accepted by the authors and that make it difficult to generalize the results. One limitation is that referred to the composition of the sample since all the participants come from the same geographical region, another limitation is the use of a cross-sectional design and the possible existence of a cohort effect.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Geriatric Depression Scale

Montreal Cognitive Assessment

variance inflation factor

Statistical Package for Social Sciences

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This work has been partially funded by Ministerio de Ciencia e Innovación, project SAPIENS- Services and applications for a healthy ageing(PID2020-115137RB).

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The authors would like to thank all contributors participants, whose cooperation and de Authors’ contributions Conceptualization, C.B.C., and C.D.D.; methodology, C.B.C., C.D.D., M.G.C, A.X.P. and L.A.R.; formal analysis, L.A.R. and A.X.P; investigation, C.B.C., C.D.D., A.X.P., L.A.R., M.G.C.; resources, C.B.C., C.D.D., A.X.P., L.A.R., M.G.C.; data curation, C.B.C., C.D.D. ; statistical analysis, A.X.P.; writing—original draft preparation, C.D.D and C.B.C.; writing—review and editing, L.A.R and C.B.C.; visualization, C.D.D, C.B.C., L.A.R., A.X.P, and M.G.C; supervision, C.B.C., C.D.D., C.B.C, L.A.R. and A.X.P; project administration, A.X.P., L.A.R., C.D.D, C.B.C. and M.G.C; funding acquisition, L.A.R and M.G.C. All authors have read and agreed to the published version of the manuscript dedication made this study possible.

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Bugallo-Carrera, C., Dosil-Díaz, C., Pereiro, A.X. et al. Factors that indicate performance on the MoCA 7.3 in healthy adults over 50 years old. BMC Geriatr 24 , 482 (2024). https://doi.org/10.1186/s12877-024-05102-1

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Young and middle-aged adults with depression face greater dementia risk later in life

A study of more than 1.4 million Danish adults found those diagnosed with depression were more than twice as likely to get dementia later in life, a link that suggests depression may increase dementia risk, researchers said.

The study published in the Journal of the American Medical Association Neurology reported the risk of dementia more than doubled for men and women diagnosed with depression, even if diagnosed as young or middle-aged adults.

The study examined a Danish registry of nearly 250,000 citizens diagnosed with depression and nearly 1.2 million without depression. Those with depression were 2.4 times more likely to have dementia later in life compared to those without depression. The depression-dementia link held whether a person was diagnosed with depression early, middle or later in life, the study reported.

Researchers cautioned the study examines the link between depression and dementia but does not explain why such a risk might exist.

"Our study simply demonstrated the presence of a relationship, but doesn't explore mechanisms," said Holly C. Elser, a University of Pennsylvania resident neurologist and epidemiologist who led the study.

Elser said future studies could address whether early childhood experiences or genetic factors are a common cause of depression and dementia. Another unanswered question is whether chemical brain changes found in individuals with depression later increase a person's risk for dementia.

Elser said future studies could also examine whether depression triggers behavior changes that also increase a person's risk for dementia. Some examples: poor diet, decreased physical activity, tobacco or alcohol use and social isolation.

Other studies have linked dementia and depression diagnosed later in life. The JAMA Neurology study said depression has been studied as a possible "reactive or early symptom of cognitive decline."

However, past studies have reported mixed results on the link between early- and mid-life depression, the JAMA Neurology study said. Past studies did not track people as long as the Danish registry, which tracked individuals from 1977 through 2018.

The JAMA Neurology study found the dementia risk more than doubled for men and women diagnosed with depression. Men had a slightly higher risk, but the study said men are less likely to seek health care and therefore might have more severe symptoms when diagnosed.

The study also examined whether patients treated with antidepressants six months before or after depression diagnosis had a different rate of dementia later in life. However, the study didn't find much of a difference in dementia rates among those who took antidepressants.

Elser noted researchers did not know whether people received cognitive behavioral therapy, and they also did not have data on how severe a person's depression might be. She said she would like to data to see on whether cognitive therapy early in life could affect a person's dementia risk later in life.

"Our paper further underscores the importance of managing depression clinically when it arises because it may have echoes throughout the life course," Elser said.

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Guest Essay

Men Fear Me, Society Shames Me, and I Love My Life

By Glynnis MacNicol

Ms. MacNicol is a writer, a podcast host and the author of the forthcoming memoir “I’m Mostly Here to Enjoy Myself.”

I was once told that the challenge of making successful feminist porn is that the thing women desire most is freedom.

If that’s the case, one might consider my life over the past few years to be extremely pornographic — even without all the actual sex that occurred. It definitely has the makings of a fantasy, if we allowed for fantasies starring single, childless women on the brink of turning 50.

It’s not just in enjoying my age that I’m defying expectations. It’s that I’ve exempted myself from the central things we’re told give a woman’s life meaning — partnership and parenting. I’ve discovered that despite all the warnings, I regret none of those choices.

Indeed, I am enjoying them immensely. Instead of my prospects diminishing, as nearly every message that gets sent my way promises they will — fewer relationships, less excitement, less sex, less visibility — I find them widening. The world is more available to me than it’s ever been.

Saying so should not be radical in 2024, and yet, somehow it feels that way. We live in a world whose power structures continue to benefit from women staying in place. In fact, we’re currently experiencing the latest backlash against the meager feminist gains of the past half-century. My story — and those of the other women in similar shoes — shows that there are other, fulfilling ways to live.

It is disconcerting to enjoy oneself so much when there is so much to assure you to expect the opposite, just as it is strange to feel so good against a backdrop of so much terribleness in the world. But with age (hopefully) comes clarity.

Fifty is a milestone. And the fact my 50th birthday lands on or around some other significant 50ths has brought some things into focus. Last year was the 50th anniversary of Roe v. Wade. This year is the 50th of the Equal Credit Opportunity Act, which may be less well known but remains significant: It allowed women for the first time to have bank accounts and credit cards in their own name, not needing a male signature.

That my birth date landed between the passing of these two landmark laws makes it easier for me to see that the life I’m living is a result of women having authority over both their bodies and their finances. I represent a cohort of women who lead lives that do not require us to ask permission or seek approval. I have availed myself of all the choices available to me, and while the results come with their own set of risks, they have been enormously satisfying.

The timing of my birthday also helps me see the violent rollback of women’s rights happening right now as a response to the independence these legal rights afforded women. Forget about the horror of being alone and middle-aged — there is nothing more terrifying to a patriarchal society than a woman who is free. That she might be having a better time without permission or supervision is downright insufferable.

My entry into middle age certainly had the makings of an unpleasant story.

Like many, I spent the early months of the pandemic by myself. It was the type of solitary confinement that popular science, and certain men with platforms, enjoy reminding us will be the terrible future that awaits a woman who remains single for too long. I went untouched by anyone. Unsmelled, too, which you might think is a strange thing to note, but it’s an even stranger thing to experience. Unseen except by the building exterminator and the remaining doormen of the Upper West Side who gave distant friendly greetings on my evening walks around Covid-empty New York.

Alone, unmarried, childless, past my so-called prime. A caricature, culture would have it, a fringe identity; a tragedy or a punchline, depending on your preference. At the very least a cautionary tale.

By August 2021, I was desperate — not for partnership but for connection. I bought a ticket to Paris, a place where I’d spent much of my free time before the pandemic and where I had a group of friends.

Paris, I reminded myself, prioritizes pleasure. I dived in. Cheese, wine, friendships, sex — and repeat.

At first it was shocking. I was ill prepared to get what I wanted, what it seemed I had summoned. There were moments when I wondered whether I should be ashamed. I had also never felt so free and so fully myself. I felt no shame or guilt, only the thrill that came with the knowledge I was exercising my freedom.

These days, generally speaking, there is little in cinema or literature, let alone the online world, to suggest that when you are a woman alone (forget about a middle-aged woman), things will go your way, as I have often experienced.

There have been better times. In the 1980s, sitcoms were stacked with starring women for whom men were a minor-character concern — “Designing Women,” “Murphy Brown,” “The Golden Girls” — all of which, if they premiered today (and that’s a big if), would feel radical. Later there was “Girlfriends.” Even “Sex and the City,” with its often regressive marriage plotting, remains surprisingly modern in its depictions of adult friendship and sexual mores. In each case, just as it looked as if these narratives might begin to fully take root in the real world, the women largely went back inside (or into body bags, in the case of many “Law & Order” plotlines). By the early aughts we were housewives again, real and imagined.

I suspect that a lot of this backlash is connected to the terror that men experienced at discovering that they are less necessary to women’s fulfillment than centuries of laws and stories have allowed them to believe. That terror is abundantly apparent today: From Harrison Butker’s commencement speech suggesting that women may find more fulfillment in marriage and children than in having a career, to the Supreme Court once again debating access to abortion to the push to roll back no-fault divorce laws: All are efforts to return women to a place where others can manage their access to … well, just about everything.

It’s in this light that my enjoyment begins to feel radical. Come fly with me. There’s no fear here.

Glynnis MacNicol is a writer, a podcast host and the author of the forthcoming memoir “I’m Mostly Here to Enjoy Myself.”

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Biological, Psychological, and Social Determinants of Depression: A Review of Recent Literature

Olivia remes.

1 Institute for Manufacturing, University of Cambridge, Cambridge CB3 0FS, UK

João Francisco Mendes

2 NOVA Medical School, Universidade NOVA de Lisboa, 1099-085 Lisbon, Portugal; ku.ca.mac@94cfj

Peter Templeton

3 IfM Engage Limited, Institute for Manufacturing, University of Cambridge, Cambridge CB3 0FS, UK; ku.ca.mac@32twp

4 The William Templeton Foundation for Young People’s Mental Health (YPMH), Cambridge CB2 0AH, UK

Associated Data

Depression is one of the leading causes of disability, and, if left unmanaged, it can increase the risk for suicide. The evidence base on the determinants of depression is fragmented, which makes the interpretation of the results across studies difficult. The objective of this study is to conduct a thorough synthesis of the literature assessing the biological, psychological, and social determinants of depression in order to piece together the puzzle of the key factors that are related to this condition. Titles and abstracts published between 2017 and 2020 were identified in PubMed, as well as Medline, Scopus, and PsycInfo. Key words relating to biological, social, and psychological determinants as well as depression were applied to the databases, and the screening and data charting of the documents took place. We included 470 documents in this literature review. The findings showed that there are a plethora of risk and protective factors (relating to biological, psychological, and social determinants) that are related to depression; these determinants are interlinked and influence depression outcomes through a web of causation. In this paper, we describe and present the vast, fragmented, and complex literature related to this topic. This review may be used to guide practice, public health efforts, policy, and research related to mental health and, specifically, depression.

1. Introduction

Depression is one of the most common mental health issues, with an estimated prevalence of 5% among adults [ 1 , 2 ]. Symptoms may include anhedonia, feelings of worthlessness, concentration and sleep difficulties, and suicidal ideation. According to the World Health Organization, depression is a leading cause of disability; research shows that it is a burdensome condition with a negative impact on educational trajectories, work performance, and other areas of life [ 1 , 3 ]. Depression can start early in the lifecourse and, if it remains unmanaged, may increase the risk for substance abuse, chronic conditions, such as cardiovascular disease, and premature mortality [ 4 , 5 , 6 , 7 , 8 ].

Treatment for depression exists, such as pharmacotherapy, cognitive behavioural therapy, and other modalities. A meta-analysis of randomized, placebo-controlled trials of patients shows that 56–60% of people respond well to active treatment with antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants) [ 9 ]. However, pharmacotherapy may be associated with problems, such as side-effects, relapse issues, a potential duration of weeks until the medication starts working, and possible limited efficacy in mild cases [ 10 , 11 , 12 , 13 , 14 ]. Psychotherapy is also available, but access barriers can make it difficult for a number of people to get the necessary help.

Studies on depression have increased significantly over the past few decades. However, the literature remains fragmented and the interpretation of heterogeneous findings across studies and between fields is difficult. The cross-pollination of ideas between disciplines, such as genetics, neurology, immunology, and psychology, is limited. Reviews on the determinants of depression have been conducted, but they either focus exclusively on a particular set of determinants (ex. genetic risk factors [ 15 ]) or population sub-group (ex. children and adolescents [ 16 ]) or focus on characteristics measured predominantly at the individual level (ex. focus on social support, history of depression [ 17 ]) without taking the wider context (ex. area-level variables) into account. An integrated approach paying attention to key determinants from the biological, psychological, and social spheres, as well as key themes, such as the lifecourse perspective, enables clinicians and public health authorities to develop tailored, person-centred approaches.

The primary aim of this literature review: to address the aforementioned challenges, we have synthesized recent research on the biological, psychological, and social determinants of depression and we have reviewed research from fields including genetics, immunology, neurology, psychology, public health, and epidemiology, among others.

The subsidiary aim: we have paid special attention to important themes, including the lifecourse perspective and interactions between determinants, to guide further efforts by public health and medical professionals.

This literature review can be used as an evidence base by those in public health and the clinical setting and can be used to inform targeted interventions.

2. Materials and Methods

We conducted a review of the literature on the biological, psychological, and social determinants of depression in the last 4 years. We decided to focus on these determinants after discussions with academics (from the Manchester Metropolitan University, University of Cardiff, University of Colorado, Boulder, University of Cork, University of Leuven, University of Texas), charity representatives, and people with lived experience at workshops held by the University of Cambridge in 2020. In several aspects, we attempted to conduct this review according to PRISMA guidelines [ 18 ].

The inclusion and exclusion criteria are the following:

• - We included documents, such as primary studies, literature reviews, systematic reviews, meta-analyses, reports, and commentaries on the determinants of depression. The determinants refer to variables that appear to be linked to the development of depression, such as physiological factors (e.g., the nervous system, genetics), but also factors that are further away or more distal to the condition. Determinants may be risk or protective factors, and individual- or wider-area-level variables.
• - We focused on major depressive disorder, treatment-resistant depression, dysthymia, depressive symptoms, poststroke depression, perinatal depression, as well as depressive-like behaviour (common in animal studies), among others.
• - We included papers regardless of the measurement methods of depression.
• - We included papers that focused on human and/or rodent research.
• - This review focused on articles written in the English language.
• - Documents published between 2017–2020 were captured to provide an understanding of the latest research on this topic.
• - Studies that assessed depression as a comorbidity or secondary to another disorder.
• - Studies that did not focus on rodent and/or human research.
• - Studies that focused on the treatment of depression. We made this decision, because this is an in-depth topic that would warrant a separate stand-alone review.
• Next, we searched PubMed (2017–2020) using keywords related to depression and determinants. Appendix A contains the search strategy used. We also conducted focused searches in Medline, Scopus, and PsycInfo (2017–2020).
• Once the documents were identified through the databases, the inclusion and exclusion criteria were applied to the titles and abstracts. Screening of documents was conducted by O.R., and a subsample was screened by J.M.; any discrepancies were resolved through a communication process.
• The full texts of documents were retrieved, and the inclusion and exclusion criteria were again applied. A subsample of documents underwent double screening by two authors (O.R., J.M.); again, any discrepancies were resolved through communication.
• a. A data charting form was created to capture the data elements of interest, including the authors, titles, determinants (biological, psychological, social), and the type of depression assessed by the research (e.g., major depression, depressive symptoms, depressive behaviour).
• b. The data charting form was piloted on a subset of documents, and refinements to it were made. The data charting form was created with the data elements described above and tested in 20 studies to determine whether refinements in the wording or language were needed.
• c. Data charting was conducted on the documents.
• d. Narrative analysis was conducted on the data charting table to identify key themes. When a particular finding was noted more than once, it was logged as a potential theme, with a review of these notes yielding key themes that appeared on multiple occasions. When key themes were identified, one researcher (O.R.) reviewed each document pertaining to that theme and derived concepts (key determinants and related outcomes). This process (a subsample) was verified by a second author (J.M.), and the two authors resolved any discrepancies through communication. Key themes were also checked as to whether they were of major significance to public mental health and at the forefront of public health discourse according to consultations we held with stakeholders from the Manchester Metropolitan University, University of Cardiff, University of Colorado, Boulder, University of Cork, University of Leuven, University of Texas, charity representatives, and people with lived experience at workshops held by the University of Cambridge in 2020.

We condensed the extensive information gleaned through our review into short summaries (with key points boxes for ease of understanding and interpretation of the data).

Through the searches, 6335 documents, such as primary studies, literature reviews, systematic reviews, meta-analyses, reports, and commentaries, were identified. After applying the inclusion and exclusion criteria, 470 papers were included in this review ( Supplementary Table S1 ). We focused on aspects related to biological, psychological, and social determinants of depression (examples of determinants and related outcomes are provided under each of the following sections.

3.1. Biological Factors

The following aspects will be discussed in this section: physical health conditions; then specific biological factors, including genetics; the microbiome; inflammatory factors; stress and hypothalamic–pituitary–adrenal (HPA) axis dysfunction, and the kynurenine pathway. Finally, aspects related to cognition will also be discussed in the context of depression.

3.1.1. Physical Health Conditions

Studies on physical health conditions—key points:

• The presence of a physical health condition can increase the risk for depression
• Psychological evaluation in physically sick populations is needed
• There is large heterogeneity in study design and measurement; this makes the comparison of findings between and across studies difficult

A number of studies examined the links between the outcome of depression and physical health-related factors, such as bladder outlet obstruction, cerebral atrophy, cataract, stroke, epilepsy, body mass index and obesity, diabetes, urinary tract infection, forms of cancer, inflammatory bowel disorder, glaucoma, acne, urea accumulation, cerebral small vessel disease, traumatic brain injury, and disability in multiple sclerosis [ 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 ]. For example, bladder outlet obstruction has been linked to inflammation and depressive behaviour in rodent research [ 24 ]. The presence of head and neck cancer also seemed to be related to an increased risk for depressive disorder [ 45 ]. Gestational diabetes mellitus has been linked to depressive symptoms in the postpartum period (but no association has been found with depression in the third pregnancy trimester) [ 50 ], and a plethora of other such examples of relationships between depression and physical conditions exist. As such, the assessment of psychopathology and the provision of support are necessary in individuals of ill health [ 45 ]. Despite the large evidence base on physical health-related factors, differences in study methodology and design, the lack of standardization when it comes to the measurement of various physical health conditions and depression, and heterogeneity in the study populations makes it difficult to compare studies [ 50 ].

The next subsections discuss specific biological factors, including genetics; the microbiome; inflammatory factors; stress and hypothalamic–pituitary–adrenal (HPA) axis dysfunction, and the kynurenine pathway; and aspects related to cognition.

3.1.2. Genetics

Studies on genetics—key points:

There were associations between genetic factors and depression; for example:

• The brain-derived neurotrophic factor (BDNF) plays an important role in depression
• Links exist between major histocompatibility complex region genes, as well as various gene polymorphisms and depression
• Single nucleotide polymorphisms (SNPs) of genes involved in the tryptophan catabolites pathway are of interest in relation to depression

A number of genetic-related factors, genomic regions, polymorphisms, and other related aspects have been examined with respect to depression [ 61 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 ]. The influence of BDNF in relation to depression has been amply studied [ 117 , 118 , 141 , 142 , 143 ]. Research has shown associations between depression and BDNF (as well as candidate SNPs of the BDNF gene, polymorphisms of the BDNF gene, and the interaction of these polymorphisms with other determinants, such as stress) [ 129 , 144 , 145 ]. Specific findings have been reported: for example, a study reported a link between the BDNF rs6265 allele (A) and major depressive disorder [ 117 ].

Other research focused on major histocompatibility complex region genes, endocannabinoid receptor gene polymorphisms, as well as tissue-specific genes and gene co-expression networks and their links to depression [ 99 , 110 , 112 ]. The SNPs of genes involved in the tryptophan catabolites pathway have also been of interest when studying the pathogenesis of depression.

The results from genetics studies are compelling; however, the findings remain mixed. One study indicated no support for depression candidate gene findings [ 122 ]. Another study found no association between specific polymorphisms and major depressive disorder [ 132 ]. As such, further research using larger samples is needed to corroborate the statistically significant associations reported in the literature.

3.1.3. Microbiome

Studies on the microbiome—key points:

• The gut bacteria and the brain communicate via both direct and indirect pathways called the gut-microbiota-brain axis (the bidirectional communication networks between the central nervous system and the gastrointestinal tract; this axis plays an important role in maintaining homeostasis).
• A disordered microbiome can lead to inflammation, which can then lead to depression
• There are possible links between the gut microbiome, host liver metabolism, brain inflammation, and depression

The common themes of this review have focused on the microbiome/microbiota or gut metabolome [ 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 , 160 , 161 ], the microbiota-gut-brain axis, and related factors [ 152 , 162 , 163 , 164 , 165 , 166 , 167 ]. When there is an imbalance in the intestinal bacteria, this can interfere with emotional regulation and contribute to harmful inflammatory processes and mood disorders [ 148 , 151 , 153 , 155 , 157 ]. Rodent research has shown that there may be a bidirectional association between the gut microbiota and depression: a disordered gut microbiota can play a role in the onset of this mental health problem, but, at the same time, the existence of stress and depression may also lead to a lower level of richness and diversity in the microbiome [ 158 ].

Research has also attempted to disentangle the links between the gut microbiome, host liver metabolism, brain inflammation, and depression, as well as the role of the ratio of lactobacillus to clostridium [ 152 ]. The literature has also examined the links between medication, such as antibiotics, and mood and behaviour, with the findings showing that antibiotics may be related to depression [ 159 , 168 ]. The links between the microbiome and depression are complex, and further studies are needed to determine the underpinning causal mechanisms.

3.1.4. Inflammation

Studies on inflammation—key points:

• Pro-inflammatory cytokines are linked to depression
• Pro-inflammatory cytokines, such as the tumour necrosis factor (TNF)-alpha, may play an important role
• Different methods of measurement are used, making the comparison of findings across studies difficult

Inflammation has been a theme in this literature review [ 60 , 161 , 164 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 , 177 , 178 , 179 , 180 , 181 , 182 , 183 , 184 ]. The findings show that raised levels of inflammation (because of factors such as pro-inflammatory cytokines) have been associated with depression [ 60 , 161 , 174 , 175 , 178 ]. For example, pro-inflammatory cytokines, such as tumour necrosis factor (TNF)-alpha, have been linked to depression [ 185 ]. Various determinants, such as early life stress, have also been linked to systemic inflammation, and this can increase the risk for depression [ 186 ].

Nevertheless, not everyone with elevated inflammation develops depression; therefore, this is just one route out of many linked to pathogenesis. Despite the compelling evidence reported with respect to inflammation, it is difficult to compare the findings across studies because of different methods used to assess depression and its risk factors.

3.1.5. Stress and HPA Axis Dysfunction

Studies on stress and HPA axis dysfunction—key points:

• Stress is linked to the release of proinflammatory factors
• The dysregulation of the HPA axis is linked to depression
• Determinants are interlinked in a complex web of causation

Stress was studied in various forms in rodent populations and humans [ 144 , 145 , 155 , 174 , 176 , 180 , 185 , 186 , 187 , 188 , 189 , 190 , 191 , 192 , 193 , 194 , 195 , 196 , 197 , 198 , 199 , 200 , 201 , 202 , 203 , 204 , 205 , 206 , 207 , 208 , 209 , 210 , 211 ].

Although this section has some overlap with others (as is to be expected because all of these determinants and body systems are interlinked), a number of studies have focused on the impact of stress on mental health. Stress has been mentioned in the literature as a risk factor of poor mental health and has emerged as an important determinant of depression. The effects of this variable are wide-ranging, and a short discussion is warranted.

Stress has been linked to the release of inflammatory factors, as well as the development of depression [ 204 ]. When the stress is high or lasts for a long period of time, this may negatively impact the brain. Chronic stress can impact the dendrites and synapses of various neurons, and may be implicated in the pathway leading to major depressive disorder [ 114 ]. As a review by Uchida et al. indicates, stress may be associated with the “dysregulation of neuronal and synaptic plasticity” [ 114 ]. Even in rodent studies, stress has a negative impact: chronic and unpredictable stress (and other forms of tension or stress) have been linked to unusual behaviour and depression symptoms [ 114 ].

The depression process and related brain changes, however, have also been linked to the hyperactivity or dysregulation of the HPA axis [ 127 , 130 , 131 , 182 , 212 ]. One review indicates that a potential underpinning mechanism of depression relates to “HPA axis abnormalities involved in chronic stress” [ 213 ]. There is a complex relationship between the HPA axis, glucocorticoid receptors, epigenetic mechanisms, and psychiatric sequelae [ 130 , 212 ].

In terms of the relationship between the HPA axis and stress and their influence on depression, the diathesis–stress model offers an explanation: it could be that early stress plays a role in the hyperactivation of the HPA axis, thus creating a predisposition “towards a maladaptive reaction to stress”. When this predisposition then meets an acute stressor, depression may ensue; thus, in line with the diathesis–stress model, a pre-existing vulnerability and stressor can create fertile ground for a mood disorder [ 213 ]. An integrated review by Dean and Keshavan [ 213 ] suggests that HPA axis hyperactivity is, in turn, related to other determinants, such as early deprivation and insecure early attachment; this again shows the complex web of causation between the different determinants.

3.1.6. Kynurenine Pathway

Studies on the kynurenine pathway—key points:

• The kynurenine pathway is linked to depression
• Indolamine 2,3-dioxegenase (IDO) polymorphisms are linked to postpartum depression

The kynurenine pathway was another theme that emerged in this review [ 120 , 178 , 181 , 184 , 214 , 215 , 216 , 217 , 218 , 219 , 220 , 221 ]. The kynurenine pathway has been implicated not only in general depressed mood (inflammation-induced depression) [ 184 , 214 , 219 ] but also postpartum depression [ 120 ]. When the kynurenine metabolism pathway is activated, this results in metabolites, which are neurotoxic.

A review by Jeon et al. notes a link between the impairment of the kynurenine pathway and inflammation-induced depression (triggered by treatment for various physical diseases, such as malignancy). The authors note that this could represent an important opportunity for immunopharmacology [ 214 ]. Another review by Danzer et al. suggests links between the inflammation-induced activation of indolamine 2,3-dioxegenase (the enzyme that converts tryptophan to kynurenine), the kynurenine metabolism pathway, and depression, and also remarks about the “opportunities for treatment of inflammation-induced depression” [ 184 ].

3.1.7. Cognition

Studies on cognition and the brain—key points:

• Cognitive decline and cognitive deficits are linked to increased depression risk
• Cognitive reserve is important in the disability/depression relationship
• Family history of cognitive impairment is linked to depression

A number of studies have focused on the theme of cognition and the brain. The results show that factors, such as low cognitive ability/function, cognitive vulnerability, cognitive impairment or deficits, subjective cognitive decline, regression of dendritic branching and hippocampal atrophy/death of hippocampal cells, impaired neuroplasticity, and neurogenesis-related aspects, have been linked to depression [ 131 , 212 , 222 , 223 , 224 , 225 , 226 , 227 , 228 , 229 , 230 , 231 , 232 , 233 , 234 , 235 , 236 , 237 , 238 , 239 ]. The cognitive reserve appears to act as a moderator and can magnify the impact of certain determinants on poor mental health. For example, in a study in which participants with multiple sclerosis also had low cognitive reserve, disability was shown to increase the risk for depression [ 63 ]. Cognitive deficits can be both causal and resultant in depression. A study on individuals attending outpatient stroke clinics showed that lower scores in cognition were related to depression; thus, cognitive impairment appears to be associated with depressive symptomatology [ 226 ]. Further, Halahakoon et al. [ 222 ] note a meta-analysis [ 240 ] that shows that a family history of cognitive impairment (in first degree relatives) is also linked to depression.

In addition to cognitive deficits, low-level cognitive ability [ 231 ] and cognitive vulnerability [ 232 ] have also been linked to depression. While cognitive impairment may be implicated in the pathogenesis of depressive symptoms [ 222 ], negative information processing biases are also important; according to the ‘cognitive neuropsychological’ model of depression, negative affective biases play a central part in the development of depression [ 222 , 241 ]. Nevertheless, the evidence on this topic is mixed and further work is needed to determine the underpinning mechanisms between these states.

3.2. Psychological Factors

Studies on psychological factors—key points:

• There are many affective risk factors linked to depression
• Determinants of depression include negative self-concept, sensitivity to rejection, neuroticism, rumination, negative emotionality, and others

A number of studies have been undertaken on the psychological factors linked to depression (including mastery, self-esteem, optimism, negative self-image, current or past mental health conditions, and various other aspects, including neuroticism, brooding, conflict, negative thinking, insight, cognitive fusion, emotional clarity, rumination, dysfunctional attitudes, interpretation bias, and attachment style) [ 66 , 128 , 140 , 205 , 210 , 228 , 235 , 242 , 243 , 244 , 245 , 246 , 247 , 248 , 249 , 250 , 251 , 252 , 253 , 254 , 255 , 256 , 257 , 258 , 259 , 260 , 261 , 262 , 263 , 264 , 265 , 266 , 267 , 268 , 269 , 270 , 271 , 272 , 273 , 274 , 275 , 276 , 277 , 278 , 279 , 280 , 281 , 282 , 283 , 284 , 285 , 286 , 287 , 288 , 289 , 290 ]. Determinants related to this condition include low self-esteem and shame, among other factors [ 269 , 270 , 275 , 278 ]. Several emotional states and traits, such as neuroticism [ 235 , 260 , 271 , 278 ], negative self-concept (with self-perceptions of worthlessness and uselessness), and negative interpretation or attention biases have been linked to depression [ 261 , 271 , 282 , 283 , 286 ]. Moreover, low emotional clarity has been associated with depression [ 267 ]. When it comes to the severity of the disorder, it appears that meta-emotions (“emotions that occur in response to other emotions (e.g., guilt about anger)” [ 268 ]) have a role to play in depression [ 268 ].

A determinant that has received much attention in mental health research concerns rumination. Rumination has been presented as a mediator but also as a risk factor for depression [ 57 , 210 , 259 ]. When studied as a risk factor, it appears that the relationship of rumination with depression is mediated by variables that include limited problem-solving ability and insufficient social support [ 259 ]. However, rumination also appears to act as a mediator: for example, this variable (particularly brooding rumination) lies on the causal pathway between poor attention control and depression [ 265 ]. This shows that determinants may present in several forms: as moderators or mediators, risk factors or outcomes, and this is why disentangling the relationships between the various factors linked to depression is a complex task.

The psychological determinants are commonly researched variables in the mental health literature. A wide range of factors have been linked to depression, such as the aforementioned determinants, but also: (low) optimism levels, maladaptive coping (such as avoidance), body image issues, and maladaptive perfectionism, among others [ 269 , 270 , 272 , 273 , 275 , 276 , 279 , 285 , 286 ]. Various mechanisms have been proposed to explain the way these determinants increase the risk for depression. One of the underpinning mechanisms linking the determinants and depression concerns coping. For example, positive fantasy engagement, cognitive biases, or personality dispositions may lead to emotion-focused coping, such as brooding, and subsequently increase the risk for depression [ 272 , 284 , 287 ]. Knowing the causal mechanisms linking the determinants to outcomes provides insight for the development of targeted interventions.

3.3. Social Determinants

Studies on social determinants—key points:

• Social determinants are the conditions in the environments where people are born, live, learn, work, play, etc.; these influence (mental) health [ 291 ]
• There are many social determinants linked to depression, such as sociodemographics, social support, adverse childhood experiences
• Determinants can be at the individual, social network, community, and societal levels

Studies also focused on the social determinants of (mental) health; these are the conditions in which people are born, live, learn, work, play, and age, and have a significant influence on wellbeing [ 291 ]. Factors such as age, social or socioeconomic status, social support, financial strain and deprivation, food insecurity, education, employment status, living arrangements, marital status, race, childhood conflict and bullying, violent crime exposure, abuse, discrimination, (self)-stigma, ethnicity and migrant status, working conditions, adverse or significant life events, illiteracy or health literacy, environmental events, job strain, and the built environment have been linked to depression, among others [ 52 , 133 , 235 , 236 , 239 , 252 , 269 , 280 , 292 , 293 , 294 , 295 , 296 , 297 , 298 , 299 , 300 , 301 , 302 , 303 , 304 , 305 , 306 , 307 , 308 , 309 , 310 , 311 , 312 , 313 , 314 , 315 , 316 , 317 , 318 , 319 , 320 , 321 , 322 , 323 , 324 , 325 , 326 , 327 , 328 , 329 , 330 , 331 , 332 , 333 , 334 , 335 , 336 , 337 , 338 , 339 , 340 , 341 , 342 , 343 , 344 , 345 , 346 , 347 , 348 , 349 , 350 , 351 , 352 , 353 , 354 , 355 , 356 , 357 , 358 , 359 , 360 , 361 , 362 , 363 , 364 , 365 , 366 , 367 , 368 , 369 , 370 , 371 ]. Social support and cohesion, as well as structural social capital, have also been identified as determinants [ 140 , 228 , 239 , 269 , 293 , 372 , 373 , 374 , 375 , 376 , 377 , 378 , 379 ]. In a study, part of the findings showed that low levels of education have been shown to be linked to post-stroke depression (but not severe or clinical depression outcomes) [ 299 ]. A study within a systematic review indicated that having only primary education was associated with a higher risk of depression compared to having secondary or higher education (although another study contrasted this finding) [ 296 ]. Various studies on socioeconomic status-related factors have been undertaken [ 239 , 297 ]; the research has shown that a low level of education is linked to depression [ 297 ]. Low income is also related to depressive disorders [ 312 ]. By contrast, high levels of education and income are protective [ 335 ].

A group of determinants touched upon by several studies included adverse childhood or early life experiences: ex. conflict with parents, early exposure to traumatic life events, bullying and childhood trauma were found to increase the risk of depression (ex. through pathways, such as inflammation, interaction effects, or cognitive biases) [ 161 , 182 , 258 , 358 , 362 , 380 ].

Gender-related factors were also found to play an important role with respect to mental health [ 235 , 381 , 382 , 383 , 384 , 385 ]. Gender inequalities can start early on in the lifecourse, and women were found to be twice as likely to have depression as men. Gender-related factors were linked to cognitive biases, resilience and vulnerabilities [ 362 , 384 ].

Determinants can impact mental health outcomes through underpinning mechanisms. For example, harmful determinants can influence the uptake of risk behaviours. Risk behaviours, such as sedentary behaviour, substance abuse and smoking/nicotine exposure, have been linked to depression [ 226 , 335 , 355 , 385 , 386 , 387 , 388 , 389 , 390 , 391 , 392 , 393 , 394 , 395 , 396 , 397 , 398 , 399 , 400 , 401 ]. Harmful determinants can also have an impact on diet. Indeed, dietary aspects and diet components (ex. vitamin D, folate, selenium intake, iron, vitamin B12, vitamin K, fiber intake, zinc) as well as diet-related inflammatory potential have been linked to depression outcomes [ 161 , 208 , 236 , 312 , 396 , 402 , 403 , 404 , 405 , 406 , 407 , 408 , 409 , 410 , 411 , 412 , 413 , 414 , 415 , 416 , 417 , 418 , 419 , 420 , 421 , 422 , 423 , 424 , 425 , 426 , 427 , 428 ]. A poor diet has been linked to depression through mechanisms such as inflammation [ 428 ].

Again, it is difficult to constrict diet to the ‘social determinants of health’ category as it also relates to inflammation (biological determinants) and could even stand alone as its own category. Nevertheless, all of these factors are interlinked and influence one another in a complex web of causation, as mentioned elsewhere in the paper.

Supplementary Figure S1 contains a representation of key determinants acting at various levels: the individual, social network, community, and societal levels. The determinants have an influence on risk behaviours, and this, in turn, can affect the mood (i.e., depression), body processes (ex. can increase inflammation), and may negatively influence brain structure and function.

3.4. Others

Studies on ‘other’ determinants—key points:

• A number of factors are related to depression
• These may not be as easily categorized as the other determinants in this paper

A number of factors arose in this review that were related to depression; it was difficult to place these under a specific heading above, so this ‘other’ category was created. A number of these could be sorted under the ‘social determinants of depression’ category. For example, being exposed to deprivation, hardship, or adversity may increase the risk for air pollution exposure and nighttime shift work, among others, and the latter determinants have been found to increase the risk for depression. Air pollution could also be regarded as an ecologic-level (environmental) determinant of mental health.

Nevertheless, we have decided to leave these factors in a separate category (because their categorization may not be as immediately clear-cut as others), and these factors include: low-level light [ 429 ], weight cycling [ 430 ], water contaminants [ 431 ], trade [ 432 ], air pollution [ 433 , 434 ], program-level variables (ex. feedback and learning experience) [ 435 ], TV viewing [ 436 ], falls [ 437 ], various other biological factors [ 116 , 136 , 141 , 151 , 164 , 182 , 363 , 364 , 438 , 439 , 440 , 441 , 442 , 443 , 444 , 445 , 446 , 447 , 448 , 449 , 450 , 451 , 452 , 453 , 454 , 455 , 456 , 457 , 458 , 459 , 460 , 461 , 462 , 463 , 464 , 465 , 466 , 467 , 468 , 469 ], mobile phone use [ 470 ], ultrasound chronic exposure [ 471 ], nighttime shift work [ 472 ], work accidents [ 473 ], therapy enrollment [ 226 ], and exposure to light at night [ 474 ].

4. Cross-Cutting Themes

4.1. lifecourse perspective.

Studies on the lifecourse perspective—key points:

• Early life has an importance on mental health
• Stress has been linked to depression
• In old age, the decline in social capital is important

Trajectories and life events are important when it comes to the lifecourse perspective. Research has touched on the influence of prenatal or early life stress on an individual’s mental health trajectory [ 164 , 199 , 475 ]. Severe stress that occurs in the form of early-life trauma has also been associated with depressive symptoms [ 362 , 380 ]. It may be that some individuals exposed to trauma develop thoughts of personal failure, which then serve as a catalyst of depression [ 380 ].

At the other end of the life trajectory—old age—specific determinants have been linked to an increased risk for depression. Older people are at a heightened risk of losing their social networks, and structural social capital has been identified as important in relation to depression in old age [ 293 ].

4.2. Gene–Environment Interactions

Studies on gene–environment interactions—key points:

• The environment and genetics interact to increase the risk of depression
• The etiology of depression is multifactorial
• Adolescence is a time of vulnerability

A number of studies have touched on gene–environment interactions [ 72 , 77 , 82 , 119 , 381 , 476 , 477 , 478 , 479 , 480 , 481 ]. The interactions between genetic factors and determinants, such as negative life events (ex. relationship and social difficulties, serious illness, unemployment and financial crises) and stressors (ex. death of spouse, minor violations of law, neighbourhood socioeconomic status) have been studied in relation to depression [ 82 , 135 , 298 , 449 , 481 ]. A study reported an interaction of significant life events with functional variation in the serotonin-transporter-linked polymorphic region (5-HTTLPR) allele type (in the context of multiple sclerosis) and linked this to depression [ 361 ], while another reported an interaction between stress and 5-HTTLPR in relation to depression [ 480 ]. Other research reported that the genetic variation of HPA-axis genes has moderating effects on the relationship between stressors and depression [ 198 ]. Another study showed that early-life stress interacts with gene variants to increase the risk for depression [ 77 ].

Adolescence is a time of vulnerability [ 111 , 480 ]. Perceived parental support has been found to interact with genes (GABRR1, GABRR2), and this appears to be associated with depressive symptoms in adolescence [ 480 ]. It is important to pay special attention to critical periods in the lifecourse so that adequate support is provided to those who are most vulnerable.

The etiology of depression is multifactorial, and it is worthwhile to examine the interaction between multiple factors, such as epigenetic, genetic, and environmental factors, in order to truly understand this mental health condition. Finally, taking into account critical periods of life when assessing gene–environment interactions is important for developing targeted interventions.

5. Discussion

Depression is one of the most common mental health conditions, and, if left untreated, it can increase the risk for substance abuse, anxiety disorders, and suicide. In the past 20 years, a large number of studies on the risk and protective factors of depression have been undertaken in various fields, such as genetics, neurology, immunology, and epidemiology. However, there are limitations associated with the extant evidence base. The previous syntheses on depression are limited in scope and focus exclusively on social or biological factors, population sub-groups, or examine depression as a comorbidity (rather than an independent disorder). The research on the determinants and causal pathways of depression is fragmentated and heterogeneous, and this has not helped to stimulate progress when it comes to the prevention and intervention of this condition—specifically unravelling the complexity of the determinants related to this condition and thus refining the prevention and intervention methods.

The scope of this paper was to bring together the heterogeneous, vast, and fragmented literature on depression and paint a picture of the key factors that contribute to this condition. The findings from this review show that there are important themes when it comes to the determinants of depression, such as: the microbiome, dysregulation of the HPA axis, inflammatory reactions, the kynurenine pathway, as well as psychological and social factors. It may be that physical factors are proximal determinants of depression, which, in turn, are acted on by more distal social factors, such as deprivation, environmental events, and social capital.

The Marmot Report [ 291 ], the World Health Organization [ 482 ], and Compton et al. [ 483 ] highlight that the most disadvantaged segments of society are suffering (the socioeconomic context is important), and this inequality in resources has translated to inequality in mental health outcomes [ 483 ]. To tackle the issue of egalitarianism and restore equality in the health between the groups, the social determinants need to be addressed [ 483 ]. A wide range of determinants of mental health have been identified in the literature: age, gender, ethnicity, family upbringing and early attachment patterns, social support, access to food, water and proper nutrition, and community factors. People spiral downwards because of individual- and societal-level circumstances; therefore, these circumstances along with the interactions between the determinants need to be considered.

Another important theme in the mental health literature is the lifecourse perspective. This shows that the timing of events has significance when it comes to mental health. Early life is a critical period during the lifespan at which cognitive processes develop. Exposure to harmful determinants, such as stress, during this period can place an individual on a trajectory of depression in adulthood or later life. When an individual is exposed to harmful determinants during critical periods and is also genetically predisposed to depression, the risk for the disorder can be compounded. This is why aspects such as the lifecourse perspective and gene–environment interactions need to be taken into account. Insight into this can also help to refine targeted interventions.

A number of interventions for depression have been developed or recommended, addressing, for example, the physical factors described here and lifestyle modifications. Interventions targeting various factors, such as education and socioeconomic status, are needed to help prevent and reduce the burden of depression. Further research on the efficacy of various interventions is needed. Additional studies are also needed on each of the themes described in this paper, for example: the biological factors related to postpartum depression [ 134 ], and further work is needed on depression outcomes, such as chronic, recurrent depression [ 452 ]. Previous literature has shown that chronic stress (associated with depression) is also linked to glucocorticoid receptor resistance, as well as problems with the regulation of the inflammatory response [ 484 ]. Further work is needed on this and the underpinning mechanisms between the determinants and outcomes. This review highlighted the myriad ways of measuring depression and its determinants [ 66 , 85 , 281 , 298 , 451 , 485 ]. Thus, the standardization of the measurements of the outcomes (ex. a gold standard for measuring depression) and determinants is essential; this can facilitate comparisons of findings across studies.

5.1. Strengths

This paper has important strengths. It brings together the wide literature on depression and helps to bridge disciplines in relation to one of the most common mental health problems. We identified, selected, and extracted data from studies, and provided concise summaries.

5.2. Limitations

The limitations of the review include missing potentially important studies; however, this is a weakness that cannot be avoided by literature reviews. Nevertheless, the aim of the review was not to identify each study that has been conducted on the risk and protective factors of depression (which a single review is unable to capture) but rather to gain insight into the breadth of literature on this topic, highlight key biological, psychological, and social determinants, and shed light on important themes, such as the lifecourse perspective and gene–environment interactions.

6. Conclusions

We have reviewed the determinants of depression and recognize that there are a multitude of risk and protective factors at the individual and wider ecologic levels. These determinants are interlinked and influence one another. We have attempted to describe the wide literature on this topic, and we have brought to light major factors that are of public mental health significance. This review may be used as an evidence base by those in public health, clinical practice, and research.

This paper discusses key areas in depression research; however, an exhaustive discussion of all the risk factors and determinants linked to depression and their mechanisms is not possible in one journal article—which, by its very nature, a single paper cannot do. We have brought to light overarching factors linked to depression and a workable conceptual framework that may guide clinical and public health practice; however, we encourage other researchers to continue to expand on this timely and relevant work—particularly as depression is a top priority on the policy agenda now.

Acknowledgments

Thank you to Isla Kuhn for the help with the Medline, Scopus, and PsycInfo database searches.

Supplementary Materials

The following are available online at https://www.mdpi.com/article/10.3390/brainsci11121633/s1 , Figure S1: Conceptual framework: Determinants of depression, Table S1: Data charting—A selection of determinants from the literature.

Appendix A.1. Search Strategy

Search: ((((((((((((((((“Gene-Environment Interaction”[Majr]) OR (“Genetics”[Mesh])) OR (“Genome-Wide Association Study”[Majr])) OR (“Microbiota”[Mesh] OR “Gastrointestinal Microbiome”[Mesh])) OR (“Neurogenic Inflammation”[Mesh])) OR (“genetic determinant”)) OR (“gut-brain-axis”)) OR (“Kynurenine”[Majr])) OR (“Cognition”[Mesh])) OR (“Neuronal Plasticity”[Majr])) OR (“Neurogenesis”[Mesh])) OR (“Genes”[Mesh])) OR (“Neurology”[Majr])) OR (“Social Determinants of Health”[Majr])) OR (“Glucocorticoids”[Mesh])) OR (“Tryptophan”[Mesh])) AND (“Depression”[Mesh] OR “Depressive Disorder”[Mesh]) Filters: from 2017—2020.

Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions(R)

• exp *Depression/
• exp *Depressive Disorder/
• exp *”Social Determinants of Health”/
• exp *Tryptophan/
• exp *Glucocorticoids/
• exp *Neurology/
• exp *Genes/
• exp *Neurogenesis/
• exp *Neuronal Plasticity/
• exp *Kynurenine/
• exp *Genetics/
• exp *Neurogenic Inflammation/
• exp *Gastrointestinal Microbiome/
• exp *Genome-Wide Association Study/
• exp *Gene-Environment Interaction/
• exp *Depression/et [Etiology]
• exp *Depressive Disorder/et
• or/4-16   637368
• limit 22 to yr = “2017–Current”
• “cause* of depression”.mp.
• “cause* of depression”.ti.
• (cause adj3 (depression or depressive)).ti.
• (caus* adj3 (depression or depressive)).ti.

Appendix A.2. PsycInfo

(TITLE ( depression OR “ Depressive Disorder ”) AND TITLE (“ Social Determinants of Health ” OR tryptophan OR glucocorticoids OR neurology OR genes OR neurogenesis OR “ Neuronal Plasticity ” OR kynurenine OR genetics OR “ Neurogenic Inflammation ” OR “ Gastrointestinal Microbiome ” OR “ Genome-Wide Association Study ” OR “ Gene-Environment Interaction ” OR aetiology OR etiology )) OR TITLE ( cause* W/3 ( depression OR depressive )).

Author Contributions

O.R. was responsible for the design of the study and methodology undertaken. Despite P.T.’s involvement in YPMH, he had no role in the design of the study; P.T. was responsible for the conceptualization of the study. Validation was conducted by O.R. and J.F.M. Formal analysis (data charting) was undertaken by O.R. O.R. and P.T. were involved in the investigation, resource acquisition, and data presentation. The original draft preparation was undertaken by O.R. The writing was conducted by O.R., with review and editing by P.T. and J.F.M. Funding acquisition was undertaken by O.R. and P.T. All authors have read and agreed to the published version of the manuscript.

This research was funded by The William Templeton Foundation for Young People’s Mental Health, Cambridge Philosophical Society, and the Aviva Foundation.

Conflicts of Interest

The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Three-year study in farming town of Pinnaroo finds art reduces depression, improves wellbeing in the bush

ABC Rural Three-year study in farming town of Pinnaroo finds art reduces depression, improves wellbeing in the bush

Like many farmers around the country at the moment, Melissa Smyth's days are dominated by one thing.

"Seeding, seeding, seeding. Trying to keep the machines going and make sure that the seed's in the ground," she said.

But when the farmer is not out on her property on the South Australian-Victorian border, or working as a volunteer ambulance officer, she's found painting or creating mosaics in her shed, which is transforming into an arts studio.

"I'm quite an anxious person generally, so to come out into the shed and just create something and see it come together it's just a bit of a break. It does help you relax," she said.

Ms Smyth's new-found passion for art was sparked by what's known as the Pinnaroo Project.

For three years, Pinnaroo in the Murray Mallee region has been the subject of a scientific study examining whether more arts and culture can improve the mental health and wellbeing of an entire community.

The lead researcher is Professor Robyn Clark from South Australia's Flinders University.

"We have really good evidence why art in health works, but what we didn't know was how well an arts and health project would work in rural Australia," she said.

More than 120 workshops and events were held by visiting and local artists, ranging from lantern making and leather work to photography sessions and metal floral art. 

Resident Chris Jenzen has attended most of the workshops, which were funded by a range of arts, health, regional, and government bodies.

"I'm addicted to them," she said.

"I come in here and I feel a little bit flat sometimes, but always fabulous at the end."

Results speak for themselves

As well as anecdotal evidence, the university research team has returned each year to collect data using questionnaires and clinical tests like cholesterol and blood pressure measurements.

An average of 190 people took part each year, which Professor Clark said was a scientifically acceptable sample size in a town with a population of fewer than 800.

One group of participants in the study took part in arts workshops and one group did not.

And now the results are in.

"We have shown how arts and health can really improve the health and wellness of a rural Australian town," Professor Clark said.

Rates of depression dropped across the whole community, but was most noticeable in the group doing art.

The number of arts participants reporting moderate to severe depression decreased by 10 per cent between 2022 and 2023.

There were also some encouraging lifestyle findings.

"Both adults and children who were involved in the arts activities definitely were eating more healthily," Professor Clark said.

"There was also a reduction in smoking among the adults."

'Greater connectedness in the community'

Three quarters of the participants in the arts activities were women, but the project has made an impact on Pinnaroo's men too, including farmer Giles Oster.

"I feel there's been a much greater connectedness in the community," he said.

In one of the Pinnaroo Project's most ambitious storytelling events, Mr Oster worked with other farmers and a visiting artist to bring their day job to life in poetry.

He said the project had not only given him a fresh perspective on the positives of farming, it had also made it easier to talk about the tough times.

"You go to sport to watch your kids play or perform, or you're in the silo line-up at harvest time, and we still have social interactions which is fantastic," Mr Oster said.

"But because wellbeing has been a focus of the [Pinnaroo Project] study, it's easier and it's natural to go to those things and say, 'What's going on with you? How's your world? Tell me about you'."

A separate economic report found the project also made financial sense.

For every dollar invested in the Pinnaroo Project, the community got $2.30 back, with less reliance on limited health services among the cost savings.

Not every positive finding was considered statistically significant, and some health indicators like obesity levels did not improve.

But Professor Clark said overall the findings were strong enough to extend the program in Pinnaroo and beyond if funding was secured.

"The combination of the wellness indicators and health indicators, plus the economics, is a terrific model to bring to other communities," she said.

And Ms Smyth agrees.

"It would be treat for everybody to have a chance to have an arts program so that everyone can feel better," she said.

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