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 symptoms 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 have been evaluated in a few studies from developed countries in Europe and the
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 where 42 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 studied for the
prevalence of depressive and anxiety symptoms using the Beck Depression Inventory and
Beck Anxiety Inventory 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 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 a very high prevalence of depressive and anxiety symptoms 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.
INTRODUCTION
Depression, one of the conditions most commonly associated with suicide in older
adults,1 is a widely under-recognized and undertreated medical illness. Studies show that
many older adults who die by suicide — up to 75 percent — visited a physician within a
month before death.2 All these facts highlight about the urgency we must take in the
detection and treatment of depression among the geriatric age groups.
Along with other physical illnesses, the risk of depression increases in the elderly
population. Estimates of major depression in older people living in the community range
from less than 1 percent to about 5 percent, but rises to 13.5 percent in those who require
home healthcare and to 11.5 percent in elderly hospital patients3. Depressive disorder is
not a normal part of aging. Health professionals may mistakenly think that persistent
depression is an acceptable response to other serious illnesses and the social and financial
hardships that often accompany aging - an attitude often shared by older people
themselves4,5.This contributes to low rates of diagnosis and treatment in older adults.
Controversy still remains as to the exact prevalence of anxiety symptoms in elderly
patients, both clinical and community samples have shown that anxiety is fairly common
in this age group6-8. 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
functioning9
Because of poor immunity, older patients are more likely to suffer from physical health
problems than the younger ones. Also they have higher rates of admission as compared to
the younger subpopulation. There is ample evidence that mental and physical health
affect each other in reciprocal ways to have deleterious effect on a range of outcomes10.
This includes decreased satisfaction with life, increased drug dependency, and less
favorable outcomes of common health conditions10-13. This has led us to believe that
mental health interventions are very much necessary in physical health settings in this
population group14. However these interventions will not be possible without gaining
adequate knowledge about the prevalence, course and significance of these mental
problems.
Although the prevalence of anxiety and depression among elderly medical patients have
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 different socio-cultural
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 various departments of Tribhuvan University Teaching Hospital. Apparently healthy
elderly individuals from an elderly home will be taken as the control group.
42 geriatric inpatients admitted to the department of medicine of Tribhuvan University
Teaching Hospital during the period from April 1st to May 20th 2009 were studied for the
prevalence of anxiety and depression. Criteria for inclusion were: age≥65yrs, suffering
from any medical illness, able to read and write, no cognitive impairment (sumscore 1012 on Mini Mental State Examination short depression), no psychosis, not in a terminal
state, no severe life events in the past 6 months (eg. Loss of a spouse or children etc.) and
no known post traumatic stress disorder.
Healthy and able elderly home dwelling control populations were recruited from one
senior citizen center (Nisahaya Sewa Sadan) in Kathmandu. (The criteria for inclusion
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.
H0 (Null hypothesis): There is no difference in the prevalence of depression and anxiety
among elderly hospitalized medical inpatients than elderly healthy community dwellers.
H1 (Alternative hypothesis): There is a significant difference between the prevalence of
depression and anxiety among elderly hospitalized medical inpatients than elderly healthy
community dwellers.
The prevalence of depression and anxiety symptoms among both the subsets of the
population were studied using the Beck Depression Inventory and Beck Anxiety
Inventory respectively. Both of these inventories are widely used and validated
inventories with good internal consistency15,16. Both these inventories are available in
Nepali in translated form and is used currently by the Department of Psychiatry of
Tribhuvan University Teaching Hospital.
Analysis of the Data was done using SPSS 14.0. Test of significance of the difference of
prevalence of these psychoactive morbidities among the cases and control group was
done by using one way Analysis of Variance (ANOVA) and the difference between the
inventory scores among various clinical categories were done using appropriate
significance tests.
RESULTS
Out of a total of 45 hospitalized geriatric inpatients admitted in 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) of the patient were
coming from Kathmandu and 53% (n=22) of the patients were coming 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
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 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).
Age distribution of hospitalized patients
Age group
Number of patients
Percentage
65-69
25
59.52%
70-74
12
28.57%
75 and above
5
11.91
Age distribution of the control group:
Age group
Number of patients
Percentage
65-69
14
60.87%
70-74
5
21.73%
75 & above
4
17.4%
Number of illness of the hospitalized patients.
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
Percentage
Cumulative
Duration of illness in year:
Duration of illness
Frequency
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%
Sex distribution of study population
Sex
Frequency (Case)
Frequency (Control)
Male
22
11
Female
20
12
BAI categories in our study population
Anxiety score
Frequency (case)
Frequency (control)
Minimal (0-7)
10
18
Mild (8-15)
8
4
Moderate (16-25)
4
1
Severe (26-63)
20
0
BDI categories in our study population.
Depression score
Frequency (case)
Frequency (control)
Minimal (0-9)
18
19
Mild (10-18)
3
4
Moderate (19-29)
6
0
Severe (30-63)
15
0
DISCUSSION
Out of the 42 hospitalized geriatric medical inpatients, significant depressive symptoms
were present 57.1% (n=24). A study done in Durham in 1988 has shown that major
depression was present in 11.5% and other depressive syndromes in 23% in hospitalized
elderly patients with medical illness17. In a similar study by Rapp et al, depression was
present in 15.3% of the elderly medical inpatients18. A study in Leeds UK in 2004
showed that depression was prevalent in 23% and anxiety in 7% of 100 medical
inpatients being studied19. Addshead et al in 1992 showed from a study in London that
depression was prevalent in 31.9% of medical inpatients20. Another study from
Middlesex, UK in 1996 showed a prevalence of 45%21. Because of a different sociocultural scenario, poor health awareness and relatively underdeveloped psychiatric
medical services, the prevalence of depression is much higher in our part of the world.
Significant depressive symptoms were present in 76.1% (N=32). A prevalence of
between 5% and 68% have been shown by many epidemiological studies7. Kvaal et al in
2000 showed that upto 41% of the female and upto 47% of the male medical inpatients
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. Such a high prevalence in our study could be attributed to poor
health awareness and underdeveloped psychiatric medical services in the country as well
as an inadequate social support given by their family as well as by the country.
One other cause for such a high prevalence of these psychiatric morbidities as seen in our
study could 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
calculating the exact prevalence of these psychiatric morbidities in such a population,
studies using diagnostic methods are required.
CONCLUSION
There is a very high prevalence of depressive and anxiety symptoms 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.
REFERENCES
1. Conwell Y, Brent D. Suicide and aging. I: patterns of psychiatric
diagnosis. International Psychogeriatrics, 1995; 7(2): 149-64.
2. Conwell Y. Suicide in later life: a review and recommendations for prevention. Suicide
and Life Threatening Behavior, 2001; 31(Suppl): 32-47.
3. Depression Guideline Panel. Depression in primary care: volume 1. Detection and
diagnosis. Clinical practice guideline, number 5. AHCPR Publication No. 93-0550.
Rockville, MD: Agency for Health Care, Policy and Research, 1993.
4. Hybels CF and Blazer DG. Epidemiology of late-life mental disorders. Clinics in
Geriatr Med ,2003; 19(4): 663-96.
5. Lebowitz BD, Pearson JL, Schneider LS, Reynolds III CF, Alexopoulos GS, Bruce
ML, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P.
Diagnosis and treatment of depression in late life. Consensus statement update. Journal
of the American Medical Association, 1997; 278(14): 1186-90.
6. Bryant C., Jackson H., Ames D. The prevalence of anxiety in older adults:
methodological issues and a review of literature. Journal of Affective Disorders, 2008;
109: 233-250.
7. Kvaal, K., Macijauskiene, J., Engedal, K. and Laake, E. High prevalence of anxiety
symptoms in hospitalised geriatric patients. International Journal of Geriatric
Psychiatry, 2001; 16: 690–693.
8. Lindesay, J. The Guy’s /Age Concern survey:physical health and psychiatric disorder
in an urban elderly sample. International Journal of Geriatric Psychiatry, 1990; 5 :171–
178.
9. Lenze, E. et al. The association of late-life depression and anxiety with physical
disability: a review of the literature and prospectus for future research. American Journal
of Geriatric Psychiatry, 2001;9 :113–135.
10. Bruce, M. Depression and disability in late life. American Journal of Geriatric
Psychiatry, 2001; 9: 102–112.
11. Kroenke, K., Jackson, J. and Chamberlin, J. Depressive and anxiety disorders in
patients presenting with physical complaints: clinical predictors and outcome. American
Journal of Medicine, 1997; 103: 339–347.
12. Shimoda, K. and Robinson, R. Effect of anxiety disorder on recovery from stroke.
Journal of Neuropsychiatry and Clinical Neuroscience,1998; 10: 34–40.
13. Bryant C., Jackson H, Ames D. Depression and anxiety in medically unwell older
aduslts: Prevalence and Short term Course. International Psychogeriatrics 2009; 21((4):
754-763.
14. Lichtenberg, P. and MacNeill, S. Streamlining assessments and treatments for
geriatric mental health in medical rehabilitation. Rehabilitation Psychology. 2003; 48:
56–60.
15. Kabacoff RI, Segal DL, Hersen M, Van Hasselt VB. "Psychometric properties and
diagnostic utility of the Beck Anxiety Inventory and the State-Trait Anxiety Inventory
with older adult psychiatric outpatients". J Anxiety Disord.1997;11 (1): 33–47.
16. Beck, A. T., and R. A. Steer. "Internal consistencies of the original and revised Beck
Depression Inventory." Journal of Clinical Psychology 1984: 40; 1365-1367.
17. Koenig HG, Meador KG, Cohen HJ, Blazer DG. Depression in elderly hospitalised
patients with medical illness. Arch Intern Med 1988; 148:1929-36.
18.Rapp SR, Parisi S, Walsh D. Psychological dysfunction and physical health among
elderly medical in-patients. J Consult Clin Psychol 1988; 56: 851-5.
19. Burn WK, Davies KN, McKenzie FR, Brothwell JA, Wattis JP. The prevalence of
psychiatric illness in acute geriatric admissions. Int J Geriatr Psychiatry 1993;8:171-4.
20. Adshead F, Day Cody D, Pitt B. BASDEC: a novel screening instrument for
depression in elderly medical inpatients. Br Med J 1992;305:397.
21. Shah A., Herbert R., Lewis S, Mahendran R, Platt J, Bhattacharyya B. Screening for
depression among acutely ill geriatric inpatients with a short geriatric depression scale.
Age and Ageing, 1997; 26: 217-221.