Transcript Desperately Seeking Depression

Eyes Wide Open: The Relationship
Between Sensory Limitations & Elderly
Depression
Presented by: William D. Cabin, PhD, JD, MSW, MA
Vision & Aging Session 3401.0, Abstract 296092,
Monday, November 17, 2014, 2:30-4:o0PM
American Public Health Association, New Orleans, LA
I. The Sociological Framework
 Social Construction of Reality orients creation
of constructs of depression (Berger &
Luckmann,1967; Bolton, 2008;Szasz,1984,
2010)
 Stigmatization of “normal sorrow” may occur
(Horwitz,Wakefield, Spitzer, 2007) (DSM
revision in progress)
 Medicalization:Over-reliance on
pharmacology to prevent, treat, and cure may
occur (Conrad, 2007; Szasz, 2007)
 On to the reality………
II. The Problem: Elderly DepressionConstructs and Nature & Prevalence
 Major Depression: 16.2% (33MM) have experienced in their
lifetime in U.S., across all ages
 Hospital outpatient visits for depression increased by 48%
between 1995-2005
 American adults’ depressive disorders estimated to generate
$36 billion in salary-equivalent lost productivity; potential for
psychological, emotional, and physical impacts
 Associated with other chronic conditions: asthma, arthritis,
cancer, cardiovascular disease, diabetes, obesity & myocardial
infraction, sensory impairment (based on literature review)
Elderly Depression
 Elderly = persons 65 years of age or older
 Wide variation in estimate & types of depression:
 1-5% all community dwelling elderly have clinically defined
major depression;
 7-36% of elderly medical outpatients have clinically defined
major depression;
 11.5-40% among hospitalized elderly are depressed;
 13.5% of elderly receiving formal home care are depressed;
&
 50% of elderly in long-term care facilities are depressed
 Often under-diagnosed & under-treated
 Estimates increase when add:
 Elderly with sub-syndromal depression (i.e. less than full
DSM-IV definition of major depression) adds another 820% community-dwelling elderly)
 Late-life depression among community dwelling elderly (820%)
 Geriatric primary care patients (37% have either clinically
or symptom-assessed depression)
 NYC estimate: 14% of elderly depressed, with 50% living
alone (NYCDFTA, 2010)
 90% US & NYC elderly are community-dwelling
 Major risk factor for functional disability
 Relationship to co-morbidities (often two-way)
III. Literature Review
 Why Necessary?
 Professional belief that individual-level
explanations of depression are insufficient;
 Interest in social inequalities and disparities in
health & mental health;
 Interest in the nature & consequences of the
aging population, including depression; and
 Need for increased knowledge to guide policy,
practice and research decisions.
Literature Review
 Found two major review articles & an updated search
 One (Mair, Diez Roux, & Galea, 2008) based on
PubMed (79 articles) & Psych Info (168) search
covering 1/90-8/07, focusing on depression across all
ages. 45 articles reviewed. Built on work of Truong &
Ma (2006) systematic review of 29 articles on
relationship of neighborhood and mental health.
 Second (Kim, 2008) based on PubMed (1966-4/1/08)
& Social Services Citation Index (1956-4/1/08).
Found only 28 articles meeting his criteria (13 were
not in Mair, et al. review). Depression across all ages.
 Cabin update- used same keywords in NYU
Bobst Library Bobcat database for 1/07-5/31/14.
Total of 1,940 articles, only 2 relevant & not in
other two reviews (Beard, Tracy, Vlahov &
Galea, 2008 and Beard, Cerda, Blaney; Ahern,
Vlahou & Galea, 2009)
 Cabin literature review on association of
depression with other physical & mental health
conditions
Major Limitations of Existing Research/Areas of
Research Improvements
 Most on adults; limited number on children and elderly
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(10 on elderly, but age definitions varied; not all in US).
Mainly cross-sectional
Over-reliance on self-report
Limited use of external validating data sources f
neighborhood variables
Variation in definition of many variables
Variation in instruments used to measure depression
Variations in neighborhood definitions
Limited number of studies on neighborhood level
variables (vs. individual), especially built environment
Major Substantive Findings
Mair, et al. (2008):
1.
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82% of studies (37 of 45) had at least one
neighborhood characteristic associated with
depression/depressive symptoms, after controlling for
individual-level characteristics, usually a combination
of age, gender, race/ethnicity, marital status, and
income;
52% of the different structural characteristics (i.e.
neighborhood socioeconomic & racial/ethnic
composition; residential stability; built environment; &
service environment) examined were significantly
associated with depression/depressive symptoms;
 Built environment measures were more consistently associated with
depression/depressive symptoms than socioeconomic composition,
racial/ethnic composition, or residential stability.
 68% of the social processes (neighborhood disorder, social
cohesiveness and ties with neighborhood, and perceived exposure
to crime, violence, drug use & graffiti) examined were significantly
associated with depression/depressive symptom.
2. Kim (2008)
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Social disorder (crime, violence, safety, illicit
drug access): higher the level, the higher the
odds of depression (6 studies)
Physical conditions/built environment (housing,
streets, walking surfaces): the worse the built
environment, the higher the level/odds of
depression (3 studies)
Neighborhood SES: limited evidence of
protective factor for depression.
Beard, et al. (2008)
3.
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Longitudinal (baseline & 6-18-30 months f/up)
NYC-based; used telephone surveys; adults
Primarily individual-level variables
Poor physical health, low income, prior family
history, high life stressors, being separated and
low social support (neighborhood-level variable)
are predictors of greater risk for late-life
depression.
4. Beard, et al. (2009)
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Longitudinal; NYC-based; persons 50 or older
Began 2005 from existing database; 2007 follow-up
Neighborhood effects: Neighborhood affluence can be
protective factor against worsening depression, adjusting
for all other individual and neighborhood factors. Neither
ethnicity nor residential stability associated with
depressive symptoms.
Individual effects: high neuroticism; high initial stressor
score; increased post-baseline stressor score (i.e.,
worsening stress level); being African American; & a
lower baseline frequency of contact with social networks
were predictors of worsening depression
IV. Using the Brookdale Demonstration
Initiative in Health Urban Aging (BDI)
 Why?
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To explore research gap regarding elderly depression and
individual and neighborhood-level predicators
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Literature reviews indicate only 5 studies on depression
for persons 65 or older in the United States
 What is BDI?
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Conducted in 2008
1,870 Respondents from more than 50 NYC senior centers
24-page survey
Administered by interviewers in 6 different languages
Done by Brookdale Center on Healthy Aging and Longevity
with NYC Department for the Aging (DFTA) funding.
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1.
Three Step Process:
The Sample Profile
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Mean Age: 70
Depression Measure (On 0-27 score range from Phq 9):
Mean: 3.6
None: 72% (0-4) ; Mild 18% (5-9); Moderate 7% (10-14)
Moderately severe: 2% (15-19); Severe: 1% (20-27)
2.Statistical significance of Selected Variables (based on
Literature Review) to Depression (PHQ-9 based):
- 48 variables identified in BDI database related to
variables in literature review (11 neighborhood; 20
demographic/activity; 17 physical health/comorbidity).
- 40 of 48 had a statistically significant relationship to
depression (p≤.05)
3. Stepwise Regression Analysis conducted using the 40
variables.
 Results:
 Eight Variables together are most predictive of elderly
depression, explaining 18% of variance in response (r
square = .18).
 Eight Variables: visual impairment (p=.000); frequent
falling (p=.000); lower income (p=.000); little leisuretime physical activity (p=.000); low neighborhood
satisfaction (p=.000); trouble hearing (p=.000);
arthritis/rheumatoid arthritis (p=.001); & being disabled
(p=.005)
 Implications
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Research & Practice
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New Emphasis on potential relationships between
physical activity, falls, and sensory impairment.
Focus future mining of BDI database by consolidating
multiple variables into key factors to analyze based
on conceptual model for mental health and old
Americans (see Fahs, Gallo, and Cabin, 2010
unpublished).
Increased mental health professional focus on early
identification of sensory impairment.
Implications (continued)
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Policy
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Medicare & Medicaid on eligibility, coverage, and
reimbursement for sensory impairment diagnosis and
treatment, including necessary equipment/devices in
home and community-based settings. Particularly
important with ACA focus on ACOs, health homes,
Medicaid expansion, clinical evidence-based practice,
and mental health and substance abuse equity coverage
and inclusion in standard benefit plans.
Role of Senior Centers (see also NYAM Report, 2010)
Senior Center- Health/Mental Health/Home Care
Provider Collaborations (link to NORCs)
Increased Case for Preventive Gerontology in policy,
building on Goldman, et al. (2009).
Presenter Disclosures
The following personal financial
relationships with commercial interests
relevant to this presentation existed during
the past 12 months:
“No relationships to disclose”