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Down & Up Show #41: Depression Among Older Women
DR. REEF KARIM:
Welcome to the Down and Up Show on depressionisreal.org. I'm your
host Dr. Reef Kareem, psychiatrist, addiction specialist and relationship
therapy. Today's guest is Dr. Lisa Berry (ph.), who is currently
at the Yale School of Public Health where she focuses her research
on the quality of life in older persons.
We'll be talking to Dr. Berry about her study higher burden of depression
among older women that was published in the February 2008 issue
of the Archives of General Psychiatry. A very good publication.
Thanks for joining us today Dr. Berry.
DR. LISA BARRY:
You're very welcome. I'm happy to be here.
DR. REEF KARIM:
Good, good, good. So let's start with the study. Can you tell us
a little bit about the study and its findings?
DR. LISA BARRY:
Sure. So the population of interest we're focusing on here today
is older persons. And that usually refers to people who are 65 years
of age and older. So just as some background the prevalence of depression,
excuse me, depressive symptoms is disproportionately higher in older
women than men.
Prior studies suggest nearly a two fold difference in the prevalence
of these symptoms in women as compared to men. However the reasons
for this gender difference are largely unknown. So our team was
interested in determining reasons for this gender difference.
Our study sample consisted of 754 people who are age 70 and older
and living in the general community in Greater New Haven, Connecticut.
All of the study participants were a part of an ongoing perspective
cohort study or longitudinal study that began in March of 98.
All the participants were evaluated by trained research nurses who
conducted face to face assessments at 18 month intervals for 72
months. So therefore we had five waves of depression data for our
study. Information regarding the depressive symptoms was determined
at these face to face assessments using a screening tool called
the Center for Epidemiologic Studies of Depression Scale, and it's
more commonly referred to as the CESD.
And scores of 20 or more on the CESD indicated depression or clinically
significant depressive symptoms. And as a caveat this instrument,
this CESD is not meant to be a diagnostic tool to indicate if major
depressive disorder is present, but rather the CESD is meant to
be a screening tool to indicate the presence of significant depressive
symptoms.
So, excuse me, while I say depression I am actually referring to
depressive symptoms versus a major depressive disorder. So we determine
the association between gender and the likelihood of six possible
transitions over time; and that's mainly from going from non-depressed
or depressed, excuse me, I have this nagging cough, so going from
non-depressed or depressed to non-depressed, depressed or death.
And using this strategy we could determine if the gender differences
in depression onset and persistence as well as gender differences
in mortality accounted for this higher burden of depression in women.
So consistent with prior work we found that the prevalence of depression
was substantially higher in the women in our study as compared to
the men at each of the five time points.
For example, at baseline approximately 17 percent of the women were
considered to be depressed as compared with about five percent of
the men. However, after controlling for other demographic characteristics
such as age, years of education, and race, using longitudinal statistical
analysis which I won't get into here, we found that women were more
than twice as likely as men to transition from a non-depressed state
to a depressed state and they were nearly 73 percent less likely
to transition from a depressed state to a non-depressed state.
Women were also 76 percent less likely to transition from depression
to death. Pardon me. So this means that once depressed the men were
more likely to, and I'm using the term loosely recover from depression
or die whereas the women were more likely to persist in a depressed
state.
So overall our primary conclusion was that this higher burden of
depression in older women in terms of the consistently higher prevalence
as compared with men really appears to be attributable to women's
greater susceptibility to depression and then once they are depressed
to more persistent depression and a lower probability of death.
So hopefully that gives you an overview of what we did and what
our study results are.
DR. REEF KARIM:
Yeah, it begs quite a few questions. I mean, one question is just
in general not in older persons, just in this demographic and middle
age demographic females tend to be more depressed than men about
two to one.
DR. LISA BARRY:
Correct.
DR. REEF KARIM:
So if you carry that over to the older persons or geriatric population
are those numbers still pretty consistent or do they actually go
up for women? Is it even higher than two to one? Or where is it
in comparison to people that are not in that age range?
DR. LISA BARRY:
Well, it depends on if you're talking about depressive symptoms
or major depressive disorders. So in terms of a major depressive
disorder I believe that the prevalence rates of a major depressive
disorder are lower in older persons as compared to younger. But
yet when it comes to depressive symptoms I believe that the rates
are higher in general. And then when we're talking about a gender
difference I believe that that holds as well in terms of women having
more depressive symptoms in all age groups really so that two to
one ratio is really kind of consistent over time.
DR. REEF KARIM:
Overall. Now when you say the difference between depressive symptoms
versus the diagnosis of major depressive disorder are you talking
about the diagnosis of major depressive disorder being a cluster
of depressive symptoms? What is your definition regards to the study
of what major depressive is versus the depressive symptoms?
DR. LISA BARRY:
Sure. Well, a study of major depressive disorder for instance or
a tool that would collect that would be a diagnostic instrument
such as the SEDS for instance, the scheduled effective disorders
and schizophrenia.
And a tool such as that would ask criteria that are specific to
DSM4, for example. So criteria listed in the DSM4 would be asked
using one of these instruments and then would provide an actual
diagnostic assessment of a major depressive disorder. In our study
we didn't have access to using one of these lengthy instruments
that really require a lot of in depth probing about the depressive
symptoms.
So instead we used we, which is common in epidemiological studies,
used a depressive symptoms screening tool, the CESD. And this CESD
cut off that we used was a cut off of 20 or more in terms of the
scoring. And to us we used that to indicate clinically significant
depressive symptoms. In prior studies this cut off of 20 and greater
in older persons has been used, has been identified to have a rather
high specificity for ruling out a major depressive disorder.
So it is a good, that using that cut off we felt was a good tool
to really indicate. We can't verify of course that these people
had a major depressive disorder but it would help us to indicate
the people that would be more likely to actually have it versus
the just classifying them.
DR. REEF KARIM:
Because if you look at the depression, the diagnostic depression
instrument, like the Hamilton or the Beck (ph.), I mean, I'm sure
a lot of the language from those instruments are utilized in regards
to the CESD, you know, just looking at what depression is and what
depressive symptoms are.
DR. LISA BARRY:
Absolutely.
DR. REEF KARIM:
I'm sure they're not like completely different in regard to that.
So it just sounds like it wasn't an instrument used, you know, precisely
for major depression indicators. But it's really more or less showcasing
the fact that people really meet potentially criteria for depression.
DR. LISA BARRY:
Absolutely, absolutely. And the types of symptoms that asked in
this CESD scale include asking people about how they've been feeling
during the past week and have they been feeling depressed, have
they felt happy, have they felt that people dislike them, have they
felt that they could not get going? So very simple questions.
DR. REEF KARIM:
We ask the CESD to everybody.
DR. LISA BARRY:
Yes, right, right.
DR. REEF KARIM:
Do people like you? (Laughter) I think out here in LA you'd get
high numbers on some of these instruments. Another question is females
outlive males, right?
DR. LISA BARRY:
Sure.
DR. REEF KARIM:
So how does that come into play? Were your demographics for age
you know consistent between men and women? Did you have women that
were a little older? For the older population if there are more
women out there than men, is it just a matter of aging? Or what's
your take on that?
DR. LISA BARRY:
That's a great question and we have been asked that before because
as you mention it's a well known fact that women tend to live longer
than men and so one of our primary findings that we were reporting
was that this higher burden of depression in women was due to women's
lower likelihood of dying once they became depressed.
And so as you are indicating the question that we were asked was
well was this just an artifact of women living longer? And we really
felt that from the numbers that we were getting, the results that
we were getting in terms of our adjusted results, again once we
controlled for those factors that I mentioned, like the demographics
etc., both among people who were non-depressed as well as depressed
we saw that gender difference in terms of deaths.
And so in any case we really felt that there wasn't a, this wasn't
an artifact of women just living longer, but that there was a true
difference in terms of once these people were depressed that's where
you really saw the affect of, the difference in terms of deaths
coming out.
I don't know if that... it's hard without having the actual table
in front of the listeners certainly, but if you can picture kind
of two groups of people, the people that are non-depressed and the
people that are depressed and then looking at the likelihood of
transitioning from those states into death. We found that that gender
difference really only existed among those people that were depressed.
And so in that case we really felt that given the high affect size
such that the odds ratio was .24, so again indicating that women
were 76 percent less likely to die once they were depressed in comparison
to men. We really felt that because there was that large affect
size as well as the lack of a gender difference among the non-depressed
that this was not due to an artifact of women living longer alone,
but was actually a true difference in terms of the depression.
DR. REEF KARIM:
So could you just explain why you think late life depression is
a significant clinical and public health problem?
DR. LISA BARRY:
Absolutely. First of all, depression or we've been talking about
clinically significant depressive symptoms in older people is common
with prevalence estimates that range between eight percent and 20
percent. Depressive symptoms have found to be associated with negative
health outcomes in older people such as worse cognitive status,
higher risk of disability and increased risk of death.
Second, depression is costly because it's associated with increased
use of medical services, and therefore this translates into greater
health care dollars being spent on those who are depressed. Finally,
depression is often undetected in older people because it can be
difficult for clinicians to disentangle depression from some of
the many other conditions that often affect older people.
Importantly, however, depression in this population is highly treatable
through both pharmacologic and non-pharmacologic methods. So although
depression is widely considered a chronic health condition it is
possible to using the word somewhat loosely to recover from depression
or transition out of depression and into a non-depressed state.
So that's why I think it really is a significant clinical and public
health problem for this population.
DR. REEF KARIM:
Okay, so what are the symptoms that depression care givers should
look for specifically in older adults to differentiate depression
versus... because also I mean if you look co-morbidities with medical
illnesses, if you've got coronary artery disease, if you've got
other medical complaints there's a carry over affect with depression.
DR. LISA BARRY:
Absolutely.
DR. REEF KARIM:
And so obviously your health and other conditions are going to be
treated better if you treat the depression. But how do you tease
out specifically depression in somebody who's older?
DR. LISA BARRY:
Exactly. Well, I think there are two different questions in terms
of the caregivers teasing things out and then the clinicians can
screen for depression amongst all these other co-morbidities. I
think caregivers may have the opportunity to notice mood changes
through symptoms such as frequent crying or tearfulness.
Caregivers might also be aware of a change in the older person's
abilities to make decisions for his or herself, so some of these
aspects that might not necessarily be due to a heart condition,
for example, but more due to the depression that's clouding their
ability to think clearly.
Caregivers also might have a heightened awareness of changes in
activity levels that may indicate depression. They may notice that
everything they do seems like an effort. Or that all of a sudden
the people that they're caring for have developed a lack of interest
in their typical social activities or things that they used to get
a lot enjoyment from.
I think it's also important to note too that depressive symptoms
are twice as common among caregivers then among non-caregivers.
So we're talking about caregivers identifying the potential depressive
symptoms of individuals that they might be caring for. I think that
it's also worthwhile just nothing that caregivers themselves because
of the high burden placed on them are often at risk for developing
depressive symptoms themselves, particularly among those who are
providing long term care giving.
But you know as you indicated it is challenging given the multitude
sometimes of other conditions that older people are dealing with
to really isolate whether or not it is depression that you're dealing
with. I think the important thing is really to recognize that these
symptoms of depression are not a common or typical part of aging.
And so I think it's very important for caregivers not to think oh,
my husband or my mother seems tearful but oh, that might just go
along with getting older, she's having some decision making trouble
in the absence of perhaps a cognitive disorder, you know, is having
some trouble making decisions all of a sudden.
Well, you know that might just come with aging. I think it's important
to question any significant mood changes or losses in interest as
potentially indicating depression and for caregivers not to be afraid
to mention something like this to the one they're caring for to
their physician.
DR. REEF KARIM:
Yeah, that I think is the biggest point of all of this. I mean,
the study obviously was great because to be able to actually state
that depression in its entirety is not a typical part of aging.
DR. LISA BARRY:
Absolutely.
DR. REEF KARIM:
That's a huge point, because I do think there's this stigma out
there that when people get older, ah, they're older, they don't
move around as well, they're probably all depressed. I mean, I think
there are some people out there that really think that.
DR. LISA BARRY:
Yeah, I agree, absolutely. And I think it's very important to change
that. And if we are saying that depression is under recognized and
under treated I think perhaps one way that we can increase recognition
is to educate caregivers and also older persons themselves that
these symptoms that they may be experiencing aren't just attributed
to older age in and of itself, but can really have either a biological
or perhaps you know some other psycho social basis.
DR. REEF KARIM:
So you know the question here in women and men is physicians examine
and treat depression differently then men?
DR. LISA BARRY:
Well, I think it's important to emphasis again that although the
overall burden of depression is higher among women as we showed
in our study and just prior studies have shown that just in terms
of the absolute prevalence rates, the negative effects of depression
really are not just limited to women.
So again that makes it very important not to just say because women
have a higher burden overall you know let's kind of forget about
the men. We certainly don't want to do that. In addition, to date
there's research that suggests that depression in older persons
does not show a gender difference in the type of depressive symptoms
experienced by women as compared with men.
So it's not that the older women are much more likely to cry and
feel lonely and the older men are much more likely to think people
dislike them. Among older persons we're really not seeing this difference
in the type of symptom reporting that exists.
So subsequently you know at this point our research doesn't advocate
for a different screening approach in women as compared with men.
I really think that more research is needed to determine whether
clinicians' approach to treating depression should differ in older
women as compared with older men.
You know, for example, it's really unknown as to whether older women
are less likely to respond to conventional treatment approaches
than are men. And I think once this has been established it will
be easier to recommendations regarding whether or not women and
men should be treated differently for depression.
DR. REEF KARIM:
Is there any difference in regards to responsiveness of pharmaco-therapy
(ph.), of medication between women and men?
DR. LISA BARRY:
At this point I think that's really a wide open research area in
older persons. And that's something that we really intend to explore
in future research. So I think that that would help us to answer
some of these questions as why the burden might be higher in older
women.
One of the findings that surprised us in our work were that women
in our study were more likely than men to have persistent depression
and that once they were depressed they were less likely to transition
out of depression. In general research suggests that women are more
likely to receive treatment both pharmacologic and non-pharmacologic
treatments.
So the question remains well, is it that women are being treated
and are not responding in the same way as men are to treatment?
We just don't know the answer to that question. And I think that's
one that really deserves exploring.
DR. REEF KARIM:
Well, could it be the numbers are skewed because you're seeing more
women in treatment than men? So many of the men out there might
be depressed? I'm just playing devil's advocate.
DR. LISA BARRY:
Sure, sure.
DR. REEF KARIM:
But if there are a lot of men who are just not reporting their depression
or under reporting their depression could that balance it out a
little bit? Or what do you think of that?
DR. LISA BARRY:
I think in terms of our study, yes, there has certainly been the
question of are men less likely to tell clinicians about their depressive
symptoms. In our particular study I mentioned that this was part
of a larger longitudinal study that had been ongoing for some time,
these people really had established a rapport with the trained nursing
assistants that were interviewing them.
So the likelihood of men and women kind of differentially reporting
their symptoms, and our study was really likely to be low, and again
with the prior research that exists, I mean, it's such a consistent
finding that women have a higher prevalence of depression than men,
it's probably rather unlikely that, you know, and constantly that
men are you know in the older population at least under reporting
their depressive symptoms, such as this.
Perhaps men, and this is more of a thought or assumption, but perhaps
men might be less likely to go into their doctor's office and report
hi, doctor, I'm feeling depressed. But in terms of asking them about
symptoms, such as you know do you feel happy, do you feel lonely,
questions such as that perhaps that aren't so, I don't know if you
want to say invasive or aggressive, if you will, might be easier
for both men and women to answer, therefore not just getting the
bulk of women to answer correctly and not the men.
So as far as the likelihood of treatment goes, and I think that
there really is a gender difference in terms of depression and women
experiencing more depression as compared to men, we're still not
completely sure of the reasons. We of course found that some of
this burden is attributed to women's greater susceptibility to depression
and greater persistence and less likely dying once depressed.
But again reasons for these transitions are really not clear, and
again will be something that we will be researching in the future.
DR. REEF KARIM:
Okay. Any closing thoughts that you'd like to add?
DR. LISA BARRY:
I think that again just to add and to say that given the growing
age of the U.S. population that depressive symptoms might become
an even greater public health problem. And as we were mentioning
before it's just so important for clinicians, care givers, and the
older people themselves to be aware that depressive symptoms are
not a usual part of the aging process, rather depression and significant
depressive symptoms are often a treatable condition and they shouldn't
be overlooked as typical aging.
So I really can't emphasize that enough. And even of course as we've
been talking about the burden of depression in older women, depression
in general can really be a problem for both older men and women,
but it is treatable. And so I really hope that both caregivers,
clinicians and the people themselves can become more educated about
depressive symptoms and helping to recognize them and treat them
in this population.
DR. REEF KARIM:
That's great. I mean, the study's obviously very important and thank
you so much for speaking with us today Doctor.
DR. LISA BARRY:
I really enjoyed speaking with you. Thank you for your interest
in the study.
DR. REEF KARIM:
Well, join us next week for another segment of the Down and Up Show
on depressionisreal.org.
