High Prevalence of Depression and Anxiety Symptoms among
Hospitalized Geriatric Medical Inpatients of Nepal: A study from a
Tertiary Level Hospital of Nepal.
Giri Smith1, Kumar Aditya1, Sharma Santosh Raj1, Timalsina Santosh1, Yadav Vijay1
1
Final year medical students
Institute of Medicine,
Tribhuvan University Teaching Hospital, Maharajgunj
Kathmandu, Nepal
Corresponding author:
Aditya Kumar
Final year medical student
Institute of Medicine
E-mail: Adityakumar1@hotmail.com
Postal Address: International Student’s Hostel
Institute of Medicine, Tribhuvan University Teaching Hospital
Maharajgunj, Kathmandu, Nepal
PO box: 1524
Phone number: +977 9841301666
ABSTRACT
Introduction: Depression and Anxiety are widely prevalent in the geriatric population
and the prevalence is higher in those suffering from any kind of medical illness. Although
the prevalence of anxiety and depression among elderly medical patients has been
evaluated in a few studies from developed countries like Europe and Americas, data from
a developing country like Nepal is lacking. The main aim of our study was to estimate the
burden of these psychiatric morbidities in our setting.
Materials and methods: A cross sectional analytical study was done where 42 Geriatric
inpatients admitted to the Department of Internal Medicine of Tribhuvan University
Teaching Hospital during the period of April 1st to May 20th 2009 were studied for the
prevalence of Depression and Anxiety using the Nepalese version of Beck Depression
Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI) respectively. 23 healthy
geriatric community dwellers from a senior citizen centre in Kathmandu were taken as
the control group. Data was analyzed using SPSS 14.0.
Results: Significant anxiety symptoms were present in 76.1% (N=32) of the hospitalized
geriatric patients and significant depressive symptoms in 57.1% (n=24) as compared to
21.7% (n=5) and 17.3% (n=4) of healthy community dwellers respectively. Between the
hospitalized geriatric medical inpatients and the elderly healthy community dwellers,
there was statistically significant differences in anxiety scores (F=26.06, p<0.01) and
depression scores (F=22.97, p<0.01) as measured by one way Analysis of Variance
(ANOVA).
Conclusion: There is very high prevalence of depression and anxiety among hospitalized
geriatric medical inpatients as compared to the healthy community dwellers in Nepal.
Presence of these psychiatric morbidities can further exacerbate the physical illness
slowing down recovery and adversely affecting a wide range of outcomes. Such a high
amount of psychiatric morbidity in this population needs to be addressed by appropriate
mental health interventions.
INTRODUCTION
Depression is one of the most common conditions associated with suicide in adults1and is
also a widely under-recognized and undertreated medical illness. Studies show that many
adults who die by suicide (up to 75 percent) visited a physician within a month before
death.2 All these facts highlight the urgency that must be undertaken in the detection and
treatment of depression among the geriatric age groups.
Estimates of major depression in the geriartric population living in the community range
from less than 1 percent to about 5 percent, but rises to 13.5 percent in those who require
healthcare at home and to 11.5 percent in hospitalized patients3. Health professionals may
mistakenly think that persistent depression is a normal response to other serious illnesses
and the social and financial hardships that come along with ageing4,5.This contributes to
low rates of diagnosis and treatment in the geriatric population.
Controversy still remains as to the exact prevalence of anxiety symptoms in the geriatric
population: both clinical and community samples have shown that anxiety is fairly
common in this age group6,7. Although late-life anxiety has been the focus of far less
research than depression, there is good evidence that both anxiety and depression (alone
and in combination with physical illness) are linked to poor physical and psychosocial
functioning8.
Evidence shows that mental and physical health affect each other in reciprocal ways to
have deleterious effects on a range of outcomes9. This includes decreased satisfaction
with life, increased drug dependency, and less favorable outcomes of common health
conditions9-12. This has shown that mental health interventions are very much necessary
in physical health settings in this population group13. However these interventions will
not be possible without gaining adequate knowledge about the prevalence, course and
significance of these problems.
Although the prevalence of anxiety and depression amongst geriatric medical patients has
been evaluated in a few studies from developed countries in Europe and the Americas,
data from a developing country like Nepal is lacking. Because of a different sociocultural scenario, poor health awareness and relatively underdeveloped psychiatric
medical services, the prevalence of these psychiatric morbidities could be much more in
our setting.
MATERIALS AND METHODS
This is a cross sectional analytical study taking geriatric medical inpatients admitted to
the Internal Medicine Department of Tribhuvan University Teaching Hospital.
Apparently healthy geriatric population from an elderly home will be taken as the control
group.
All the geriatric inpatients admitted to the Department of Internal Medicine of Tribhuvan
University Teaching Hospital during the period from April 1st to May 20th 2009 were
included in the study.
Criteria for inclusion were:

Age ≥ 65yrs

Suffering from any Medical Illness (Acute or Chronic)

Having good Cognitive Function (sumscore 10-12 on Mini Mental State
Examination).
Exclusion criteria were:

Terminally ill patients

Severe life events in the past 6 months (eg. Loss of a spouse or children)

Known Psychiatric Disorders including Post Traumatic Stress Disorder
Note: The last two would confound results and lead to high rates of depression and
anxiety not necessarily attributed to the current medical illness.
23 Healthy geriatric individuals were recruited from one senior citizen center (Nisahaya
Sewa Sadan) in Kathmandu as the control group. The criteria for inclusion and exclusion
were the same as the inpatients except that:
a) They should not be suffering from any acute or chronic medical illness
b) They should not be under any psychoactive drugs.
Out of 40 eligible candidates, only 23 were selected by simple random sampling
technique using a computer generated table of random numbers.
H0 (Null hypothesis): There is no difference in the prevalence of depression and anxiety
among geriatric hospitalized medical inpatients as compared to geriatric healthy
community dwellers.
H1 (Alternative hypothesis): There is a significant difference between the prevalence of
depression and anxiety among geriatric hospitalized medical inpatients as compared to
geriatric healthy community dwellers.
The prevalence of population of depression and anxiety symptoms among both the
subsets of the population were studied using the Nepalese version of Beck Depression
Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI) respectively. Nepalese version
of both these Inventories have been tested and validated in Nepalese population14,15 .
BDI-II has a total score of 63 and a score of 0-9, 10-18, 19-29, 30-63 have been classified
as having minimal, mild, moderate and severe depression respectively14. BAI also has a
total score of 63 and a score of 0-7, 8-15,16-25, 26-63 have been categorized as minimal,
mild, moderate and severe anxiety respectively15.
Analysis of the Data was done using SPSS 14.0. Test of significance of the difference of
prevalence of these psychoactive morbidities among the case and control group was done
by using one way Analysis of Variance (ANOVA) and the difference between the
inventory scores among various clinical categories was done using appropriate
significance tests.
RESULTS
Out of a total of 45 hospitalized geriatric inpatients admitted to the Department of
Internal Medicine of Tribhuvan University Teaching Hospital during the study period,
only 42 were eligible for the study. Similarly 23 healthy geriatric community dwellers
were interviewed for the study as the control group.
The mean age group for the geriatric inpatients was 69.1 with a standard deviation of 4.8.
The mean number of illness was 2.5 (S.D=1.3). The mean duration of illness was 5.8
years with a standard deviation of 5.2 years. The mean anxiety score was 21 (S.D=12.9)
and the mean depression score was 22.3 (S.D=14.4). 47% (n=20) in the patients from
Kathmandu and 53% (n=22) in the patients from outside Kathmandu.
Regarding the control population, the mean age of the patients was 69.4 years with a
standard deviation of 4.3 years. The mean anxiety score was 6.8 (S.D=3.2) and the mean
depression score was 7.6 (S.D=3.2). The difference between the mean age of the
hospitalized patients and healthy controls was not statistically significant (p value=
0.853). There was no statistical difference in terms of gender distribution among the
cases and the control group (p value=0.798)
56.1% (n=24) of the geriatric medical inpatients were having significant depressive
symptoms as compared to only 17.3% (n=4) of healthy community dwellers. Similarly
76.1% (n=32) of geriatric medical inpatients were having significant anxiety symptoms
as opposed to 21.7% (n=5) of the healthy community dwellers.
There was no significant difference in relation to the gender in the anxiety score as tested
by one way Analysis of Variance (F=0.69, p=0.41) and also for depression score (F=2.05,
p=0.15). There was poor correlation between the age of the patient and anxiety score
(Pearson correlation coefficient 0.42) and depression score (correlation coefficient 0.38).
There was however a strong correlation between number of illness and anxiety score
(Pearson correlation=0.78) and between number of illness and depression score (Pearson
correlation=0.80). Also the duration of illness showed very strong correlation with the
anxiety score (Pearson correlation=0.8) and depression score (Pearson correlation=0.79).
The anxiety and depression scores were strongly correlated with Karl Pearson correlation
coefficient calculated to be 0.91.
Between the hospitalized geriatric medical inpatients and elderly healthy community
dwellers, there were statistically significant differences in anxiety scores (F=26.06,
p<0.01) and depression scores (F=22.97, p<0.01) as measured by one way Analysis of
Variance (ANOVA).
Figure 1: Age distribution of the study population
30
25
25
20
Number of
15
Individuals
14
Cases
12
Controls
10
5
5
5
4
0
65-69 yrs
70-74
75 & above
Figure 2: Sex distribution of the study population
45
40
20
35
30
Number of 25
Individuals 20
female
22
12
15
10
11
5
0
cases
controls
male
Table 1: Distribution of the hospitalized patients according to number of illness
Number of illness
Frequency
Percent
Cumulative
percent
Single
12
28.6
28.6
Two
12
28.6
57.1
Three
8
19.0
76.2
Four
6
14.3
90.5
Five or more
4
9.5
100
Table 2: Distribution of the hospitalised patients according to the number of illnesses
Duration of illness
Frequency
Percentage
Cumulative
percentage
≤1 yr
8
19.0%
19%
>1 yr-≤5yr
16
38.1%
57.1%
>5yr-≤10yr
13
31.0%
88.1%
>10yr
5
11.9%
100%
Figure 3: BAI categories in our study population
25
20
20
18
15
Number of
Individuals
case
10
10
controls
8
4
5
4
1
0
0
Minimal (0-7)
Mild (8-15)
Moderate (1625)
Severe (26-63)
Figure 4: BDI categories in the study population
20
19
18
18
16
15
14
12
Number of
10
Individuals
8
Case
Control
6
6
4
4
3
2
0
0
Moderate (1929)
Severe (30-63)
0
Minimal (0-9)
Mild (10-18)
DISCUSSION
Out of the 42 hospitalized geriatric medical inpatients, significant depressive symptoms
were present 57.1% (n=24). This is consistent with the prevalence rate of 53% as
suggested by Khatri et al in 2006 among geriatric patients randomly selected from
psychiatry, medicine and general practice outpatient departments in a tertiary level
hospital of Nepal16. Similar study by Burns et al in UK showed that depression was
prevalent in 45% of geriatric admissions17. Addshead et al in 1992 showed that
depression was prevalent in 31.9% of medical inpatients18.
Significant anxiety symptoms were present in 76.1% (N=32). A prevalence of between
5% and 68% has been shown by many epidemiological studies7. Kvaal et al in 2000
showed that up to 41% and 47% of the female and male medical inpatients respectively
were suffering from significant anxiety disorder. Also the anxiety symptoms were
significantly higher in medical inpatients than in age and sex matched controls taken
from healthy community dwellers7
Compared to data from other international studies, our study showed very high anxiety
and depression rates. Such a high prevalence in our country could be attributed to poor
health awareness and underdeveloped psychiatric medical services in the country as well
as an inadequate social support provided by their family and the government. Another
factor could be the financial hardship that accompanies medical illness as there is no
social security as well as health insurance systems in the country. One additional factor
here is that there is very little counseling practiced so that people are uniformed about
their illness which makes them quite anxious as well as depressed.
Such a high prevalence of these psychiatric morbidities as seen in our study could also be
due to the fact that we used a screening tool for estimating the prevalence rather than a
diagnostic tool (eg. an expert psychiatrist’s assessment). Hence for further verifying the
prevalence of these psychiatric morbidities in such a population, studies using diagnostic
methods are recommended.
CONCLUSION
There is a very high prevalence of depression and anxiety among hospitalized geriatric
medical inpatients as compared to healthy community dwellers in Nepal. Presence of
these psychiatric morbidities can further exacerbate the physical illness slowing down
recovery and adversely affecting a wide range of outcomes. Such a high amount of
psychiatric morbidity in this population needs to be addressed by appropriate mental
health interventions.
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