depression and disability in the elderly: reciprocal relations and changes with age

INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 3: 163-179 (1988)

DEPRESSION AND DISABILITY IN THE ELDERLY: RECIPROCAL RELATIONS AND CHANGES

WITH AGE BARRY J. CURLAND,* DAVID E. WILDER7 AND CATHY BERKMANf

*Director, 7 Deputy Director, $Research Scientist Centre for Geriatrics and Gerontology, Columbia University Faculty of Medicine, New York State Office of Mental

Health, USA

One of the less desirable features of ageing is that there is a progressively increasing chance of becoming disabled. Among all Americans age 18 and older in 1979, only 3.2% had an impairment of their ability to manage daily routines of caring for themselves and remaining mobile, but the respec- tive proportions for those age 65-74,75-84 and 85 or over were 6.9%, 16% and 43.6% (US DHHS, 1983). These sharp increases in disability rates for persons age 65 and older, and more dramatically for those age 85 and over, are found for both minor and major disabilities; they are consistent with the age trends for chronic disease.

The high prevalence of disability in old age might be expected to have a profound effect on the quality of life at this stage of life and to be accompanied by high rates of depression. This article will review evidence on the strength of the association between disability and depression in the elderly and the mechanisms that might underlie this association, not only those mechanisms that bear upon disability as a cause of depression, but also reciprocal ways in which depression can alter the risk and outcome of disability.

Particular consideration will be given to reports which suggest that, contrary to what might be expected, age variation in rates of depression may not parallel that of disability; this discordance between expected and observed patterns raises a question about the influence of age itself upon the relationship between depression and disability.

Research on the reciprocal relationship between depression and disability in the elderly has an important bearing on understanding the nature of the two conditions, and on clinical approaches to their relief. Clarifying the role of age in this relationship could shed light on the prospects and limits of the quality of life that can be achieved with advancing years.

CONCEPTS AND MEASURES

It is useful to examine a wide range of depressions and disabilities so as not to miss possible patterns of association between subtypes of the two sets of conditions, and not to overgeneralize associations restricted to subtypes. This approach has been productive in the generic field of studies on the relationship between physical and mental conditions, for example those studies which attempt to determine whether particular organs are likely to become diseased in persons with specific types of personality (Rosenman and Friedman, 197 I), whether subtypes of dementia are associated with specific patterns of decline in functional perfor- mance (Mayeux et al., 1985), which kinds of deafness increase the risk of paraphrenia (Cooper et al., 1976).

The most commonly used measure of depression reported in studies of its relationship to physical disorders, including disability, is one or other scale of depressive symptoms. The resulting data are usually treated as a continuous variable and also as a means of forming categories based upon a threshold value; the latter may be selected so that persons with scores above the threshold have a high risk of a clinically diagnosable depression. Scales frequently chosen for studies in this field include the CES-D (Radloff, 1977), Zung SDS (Zung, 1965) scales, Beck Depression Inventory or BDI (Beck, 1972), Hamilton Depression Scale or HDS (Hamilton, 1969), and the nurses’ observation of the patient’s mood, behaviour and somatic complaints (used by Feibel and Springer, 1982).

In the CARE (Comprehensive Assessment and Referral Evaluation) technique (Gurland et al., 1977), the scale of depression is developed from empirical data on the elderly and therefore reflects the way the elderly express painful affect. Latent

0885-6230/ 88/030163- 17$08.50 0 1988 by John Wiley & Sons, Ltd. Accepted 20 May 1988

164 B. J. GURLAND E T A L

class analysis (Lazarsfeld and Henry, 1968; Golden, 1982) was applied to produce a threshold score for a statistically abnormal category.

Scales can be used to predict but not make diagnoses because information on duration and other historical features, and some of the necessary specific criteria,. are missing. The category of diagnosable depression is less often considered in reports on disability in the elderly. In practice, diagnosable depression usually means a condition conforming to criteria for a depressive subtype as appearing in the professional nomenclature (e.g. the DSM-IIIR, American Psychiatric Assocation), especially adjustment reactions, dysthymic personality, and major or minor depressions including those secondary to a physical disorder (organic affective syndrome). Major depression is of special interest because it is generally more severe and its response to specific antidepressant treatment is more predictable than for other depressions; and its presence suggests that there is a disturbance of neurotransmitter pathways.

For purposes of this field of studies it is also useful to have a broad category embracing all the depressions that lead to help-seeking and help- giving behaviours. This was the sense of the term ‘pervasive depression’ as used in the CARE interview technique. The key criteria (Gurland et al., 1985) emphasize the persistence of depression and its pervasive involvement of thought, attitude and action in the day-to-day life of the patient.

The concept of disability is less familiar to the psychiatrist than that of depression. Wolcott (1981) defines impairment as an objective, quantifiable pathophysiological condition. A handicap is an extra burden following impairment. Disability is a term descriptive of subnormal activity.

The most widely reported scales of disability in the elderly are the Index of ADL (Katz et al., 1963) and the Instrumental Activities of Daily Living Scale (Lawton and Brody, 1969). The content of this domain is illustrated in the CARE technique which measures disability through a homogeneous scale of activity limitation with items on capacity for tasks of self-care, carrying out household chores, and range of movement; and a homogeneous scale of ambulation which covers problems in mobility (Golden et al., 1984; Teresi et al., 1984).

The concept of disability extends to limitations in work or social activities, exercise intolerance, and visual and communicative difficulties. Agerholm (1976) adds visceral dysfunction (digestive and excretory functions), occult or latent disorders such

as epilepsy or similar intermittent incapacities, and socially unacceptable habits and appearance such as movement disorders.

As in the case of depression, the disability data can be analysed as continuous variables or categories defined by threshold values, latent classes or criteria. CARE data have been used with opera- tional criteria to identify subjects to whom some caregiver must devote time for personal assistance (personal time dependency: PTD).

The severity of disability has been measured by Felton and Revenson (1987) using indicators of physical limitations, illness-related problems, subjective appraisal, and controllability: the latter refers to ratings on a health locus of control scale (Wallston et al., 1976) and a hierarchy of specific diagnoses arranged according to their general responsivity to treatment and threat to life. The Seriousness of Illness Scale of Wyler et al. (1968) ranks severity of physical disorders on the basis of consensus judgements. Case fatality rates have also been used as an index of seriousness (Kukull et al., 1986).

Studies on the interaction of depression and disability typically introduce measures of concepts that can act as causal, intervening or control variables: other mood states such as expressed anger, positive affect and anxiety (Viney and Westbrook, 1976), discrete life events (for example measures developed by Paykel, 1978), life strains (Pearlin et al., 1981), vulnerability or resistance to stress (Billings and Moos, 1982), social supports and confidants (Brown et al., 1975; Dimond et al., 1981), sense of mastery (Pearlin and Schooler, 1978), feelings of helplessness and hopelessness (Seligman, 1975; Janis and Rodin, 1979), intensity, frequency and induced restrictions of pain, and coping strategies covering information seeking, cognitive restructuring (seeking positive aspects of the illness experience), emotional expression, wish- fulfilling fantasy, minimization of threat, and self- blame (Folkman and Lazarus, 1980).

DIFFERENTIATION OF DEPRESSION AND DISABILITY

In studying the correlation of depression with disability, every effort has to be made to avoid confounding the measurement of one condition by the other.

The main problem in this respect has to do with distingushing somatic symptoms due to depression from those due to the disability or an accompany-

DEPRESSION AND DISABILITY IN THE ELDERLY 165

ing physical illness (Raskin, 1979; Salzman and Shader, 1978). Many of the somatic symptoms commonly reported by the elderly may be caused by either depression or disability and its accompanying physical illness, making it difficult to determine which condition generated these symptoms. Examples of these two-edged symptoms are: slowness, fatigue, weakness, anorexia, weight loss, sleep disturbance, persistent pain, shortness of breath, palpitations, dizziness, oral discomfort, urinary frequency, constipation, somatic preoccupa- tion, sexual indifference, and indecisiveness. The differential diagnosis of these somatic symptoms can be doubly difficult when a mood disturbance is not readily evident (i.e. the depression is masked) as may happen fairly often among the elderly with concomitant physical illness (Cohen-Cole and Stoudemire, 1987; Ouslander, 1982).

Cavenaugh et al. (1983) have demonstrated empirically the loss of diagnostic discrimination for depression that can affect certain symptoms such as decreased energy, when physical illness is super- imposed; while symptoms such as indecisiveness may remain discriminating. As evidence that somatic symptoms of physical disorder are difficult to distinguish from those of depression, concor- dance on the diagnosis of depression diminishes between psychiatrist and physician in cases with somatic symptoms (Goldberg and Blackwell, 1970).

Kathol and Petty (1981) point out that 33-63% of items in the BDI, HDS, and certain interviews aimed at eliciting criteria for major depression include physiological symptoms which have been shown (Stewart et al., 1965; Schwab et al., 1967) to occur frequently also in non-depressed physically ill patients.

There is an extensive body of clinical lore on making a differential diagnosis of depression in the presence of disability or physical illness (e.g. Blumenthal, 1980; Salzman and Shader, 1978). A change in the patient’s behaviour is a crucial clue to the possibility that depression has supervened in a chronically disabled patient. Unless there is a very reliable informant available, practitioners who see their patients on a regular basis are in a better position to pick up such a diagnostically significant change in the patient’s behaviour than are ad hoc consultants. Some of the warning signs when depressive complaints are not presenting include an increase in demands and hypochondriacal complaints by the patient, withdrawal from activities which is out of keeping with the degree of disability, sleep disturbance accompanied by brooding or

tense bouts of wakefulness, indecisiveness, increasing consumption of alcohol, and the development of persistent and unexplained pain. Quite often the correct diagnosis may only be revealed by the course of the ambiguous symptoms relative to the varying severity of the depression or physical condition as treatments are essayed.

On the positive side, patients with a physical condition are less likely to be suffering from a major depression if they remain capable of appreciating humour or can respond warmly to affection, or if they show an active interest in the life around them (Cohen-Cole and Stoudemire, 1987). Conversely, anhedonia can substitute for expression of depressed mood in DSM-IIIR criteria for major depression.

Unfortunately, it may be difficult to convert this clinical experience of differential diagnosis into psychometric or criterion based methods for purposes of studying the relationship between depression and disability. Moreover, biological tests for depression (e.g. the dexamethasone suppression test) may become contaminated by false positives in those with physical disorders or by the effects of ageing on the central nervous system (Katona, 1988).

Nevertheless, there are claims that certain scales of depression retain good diagnostic discrimination for depression in the elderly with physical conditions (Yesavage et al., 1983) and diagnostic criteria for depression can be modified to fit better into the context of physical illness. Cohen-Cole and Stou- demire (1987) classify the strategies for applying criteria for depression in the presence of physical illness as (1) ‘inclusive’: taking all symptoms of depression at face value and accepting the likelihood of some false positives; (2) ‘aetiological’: trying to infer (with some inevitable unreliability) which symptoms are caused by depression and which by physical illness; (3) ‘substitutive’: establi- shing criteria which are specific to depression even in the presence of physical illness; and (4) ‘exclusive’: removing the most confounding criteria such as anorexia and fatigue even though some false negatives will result. Kathol and Petty (198 1) recommend criteria for depression which emphasize change in mood with several weeks duration at least, non-physiological symptoms, and social incapacity; and anorexia, sleep disturbance, fatigue and motor retardation if accompanying the above and ‘if not easily explained by the medical illness’.

Also the indicators of disability may be mis- construed in the presence of depression: it is

166 B. J. GURLAND E T A L .

possible for a depressed person who feels helpless to report a degree of disability when no or insufficient objective physical reason for the impairment exists; depression then could be related to the subjective rather than objective aspect of disability. However, a factor analysis did not reveal objective and subjective dimensions of data on disability gathered in a community study (Gurland et al., in press), even though the items ranged from the interviewer’s observations of the subject’s range of movements to complex evaluative judgements by the subject (e.g. bothered by inability to complete chores).

RATES OF CONCURRENCE OF DEPRESSION AND DISABILITY

Studies of the prevalence of concurrent physical and psychiatric problems have a long history, stretching back over 50 years (Kinzie et al., 1986). Schwab et al. (1978) refer to a 1916 case study of Ferenczi analysing the relationship between somatic illness and neurosis, and trace the line of research on the physical-mental association through such early workers as Grodeck, Freud, Men- ninger, Doust, Brodman, Matarazzo, Hinkle and Wolff, and Langner and Michael.

Considerable effort has gone into studies on this topic, which testifies to their perceived importance: for example, in a study by Eastwood and Trevelyan (1972), random selection from a general practice register produced 1471 responders who were then given psychiatric and physical screening question- naires and clinical interviews where appropriate. Turner and Noh (1988) screened 22,000 adults in 10 counties of Ontario to produce interviews with 967 subjects who reported that they had long-term or permanent disabilities. Craig and Van Natta (1983) carried out a community survey in Kansas City, Mo. and Washington Country involving 2826 subjects representative of those 18 years or older.

The greater than chance concurrence of depression and physical disorder in the adult age range has been documented in health surveys (e.g. Downes and Simon, 1953; Hinkle and Wolff, 1957; Shepherd et al., 1966; Schwab et al., 1978), in medical wards (e.g. Maguire et al., 1974), in primary care practice (e.g. Eastwood and Trevel- yan, 1972), in a group medical practice with emphasis on long-term management of chronic disease (Kukull et al., 1986) and in various other settings (e.g. Mensh, 1984). Illness appears to be stressful in a wide variety of populations, contexts

and disorders (Cassileth et al., 1984; Revenson and Felton, 1985).

However, much of the epidemiological data which bear upon relationships between depression and physical disorders are about physical illness, with uncertain relevance to disability. Findings on physical illness include the effects of acute illness whereas physical disability is more closely identified with chronic illness (Turner and Noh, 1988). Surveys of community-residing elderly typically involve interviews which are randomly scheduled (rather than timed to coincide with a specific event) and hence are more sensitive to relationships between long-lasting situations and conditions, as in the instance of chronic disability and depression.

Depression as a symptom has been noted in a wide range of disabilities (McDaniel, 1976) and is significantly increased in the disabled elderly population in general. Gurland et al. (in press) replicated the high correlation of disability and depression among elderly community subjects in several contrasting cultural and national groups.

Rates of the recognized diagnostic types of depression (e.g. major depression) are also raised in the presence of physical disorders. The CES-D scale used in both the studies of Craig and Van Natta (1983) and Turner and Noh (1988) was analysed not only as a continuous variable but also to define a category at high risk for major depression; the results were in the same direction for both approaches. Kukull et al. (1986) used a threshold score of 60+ on the Zung SDS (because this is more predictive of major depression in the elderly than the customary 50 cut-off) and noted that ‘there was a fairly regular pattern of association between several summary measures of physical illness and depression status.’ Kinzie et al. (1986) identified 50 subjects who met research diagnostic criteria for depression (major 32, minor 11 and intermittent seven) out of a total sample of 1000 community subjects (average age 63, range 52-83): 52% were judged to have depressions definitely or probably associated with medical illness or a medication. Major depressive disorder may even be found more frequently in association with physical disorders than the less severe subtypes of depression (Hall, 1980).

The risk for clinically significant depression is about three times higher among the disabled than the non-disabled (35% vs 12%) according to Turner and Noh (1988). Gurland et al. (in press) found in a representative sample of elderly in New York City that disability was more highly associated with the


symptoms of depression than even such putatively traumatic events as widowhood, isolation, retire- ment, financial hardship, unsatisfactory environment, and intellectual deterioration.

The absolute rates of psychiatric disorder found in association with physical disorder (illness or disability) are also impressive. Maguire et al. (1974) found that almost one in four patients admitted to medical wards had psychiatric disorders, with affective disorders predominating (even though those who had taken an overdose were excluded). Morgan (1983) reported that after an acute episode of ischaemic heart disease at least half of all patients experience psychological problems. Kukull et al. (1986) using a relatively high threshold score of 60+ on the Zung SDS noted a 20% point prevalence rate of depression. Fully 20-30% of patients with terminal cancer meet the criteria for major depression (Maguire, 1984; Plumb and Holland, 1981). Kathol and Petty (1981) in a review of several studies observed that prevalence rates of depression in medical illness range from 5 to 31% and concluded that the most valid period prevalence estimate is about 18% in the severely medically ill (based upon the findings of Stewart et al., 1965).

There are admittedly potential sources of bias additional to those already mentioned which might inflate the strength of the association between depression and disability: detection bias might be a factor where somatic manifestations of depression increase the chances of a physical diagnosis; or medical illness might be more often correctly detected when depression is present because the latter leads to more frequent consultation with a physician. Kathol and Petty (1981) caution that ‘evidence for an association between medical illness exists but is based on relatively few studies of adequate research design’. Nevertheless, the weight of evidence is in favour of the two conditions being closely linked.

RECIPROCAL CAUSAL PATHWAYS

The statistical association noted between depression and disability might stem from a reciprocally causal relationship between the two conditions; either condition might precipitate the other or prolong its duration, thus raising the prevalence rate of their concurrence. The mechanisms that could serve these reciprocal causal pathways are reviewed here (other potential causes of concurrence are mentioned later).

Disability causing depression

Granville-Grossman (1983) suggested five rea- sons for the association between depression and physical disorder: (1) treatment producing physical effects and psychiatric symptoms; (2) organic mental effects; (3) psychological reaction to physical illness; (4) psychogenic physical illness; and ( 5 ) behavioural disturbance producing physical illness. The first three of these categories bear upon the way disability or its treatment could cause depression while the last two categories deal with the reverse causal direction (considered in the next section).

Additional possible pathways of this relationship lie in disability undermining the individual’s resistance to extraneous causes of depression or inhibiting recovery from extraneously induced depression (i.e. disability does not directly cause depression but increases vulnerability to, or decreases resilience in the face of, depression); also, disability could increase the likelihood of events that can precipitate depression.

Verwoerdt (1 976) and Blazer (1 982) described the specific qualities of disability or accompanying physical illness that can determine whether it is depressing to the elderly person. Expanding on their views, a summary list follows: the course of the disorder (speed of onset and progression, duration, phases of stability or recovery), its severity (a resultant of intensity of symptoms, impairment, progression and the perceived risk of decline and death); the site or organ involved, and the challenges to body image; weakness or pain; degree of disability and dependence on others; relo- cation to hospital or long-term care facility; systemic disturbance including metabolic, electrolyte or endo- crine abnormalities, and anoxia; central neurological effects; and the untoward effects of treatment.

More than 23 medications (Ouslander, 1982) have been noted to be depressogenic. Such medications may act specifically by affecting neurotransmitter pathways, through a toxic action, by affecting electrolytes, or by including hypoglycaemia (Salzman and Shader, 1978). Kinzie et al. (1986) determined that 38% of their sample of 50 elderly community subjects with major depression were on a depressogenic drug; 11 had depressions which were judged to be probably related to medications (thyroid preparations, codeine, oxyco- done, hydralazine and acetazolamide).

Certain disorders are said to be particularly prone to produce depression: Parkinson’s disease,

168 B. J. G U R L A N D E T A L

carcinoma of the head of the pancreas, uraemia, hyperparathyroidism, adrenal disturbances, hepa- titis, hypoglycaemia, and pernicious anaemia; stroke lesions of the left frontal cerebral lobe (Folstein et al., 1977; Robinson and Benson, 1981); and hypertension (Heine, 1970). Ouslander (1982) listed over 43 physical disorders that are more likely than others to cause depression in elderly patients. A recent review by House (1987) critically examines the evidence for a specific relationship between stroke and mood disorder.

However, the specificity of these relationships is not unquestioned and negative findings are reported when specific disorders are compared with those not known to be exceptionally depressogenic (Mann, 1977; Ganz et al., 1972; Evans et al., 1974). Borson et al. (1986) examined depression in relation to 30 disorders or complaints including common chronic diseases of later life such as hypertension, ischaemic heart disease, chronic obstructive pul- monary disease (COPD), stroke, arthritis, diabetes, deafness, pain, sexual dysfunction, and constipation; none of the diagnoses were significantly more often than the others associated with depression (though there was a tendency in the instance of COPD). Kukull et al. (1986) concluded that ‘illness burden may be the most generalizable factor associated with depression . . . rather than specific diagnosis’.

The list of physical conditions or their treatment reported as capable of precipitating (or mimicking) depression is very long and growing and thus of little value in suggesting what to look for as underlying a depression. New episodes of depression in an elderly patient warrant in general a thorough physical examination and investigation and a consideration of the particulars in the individual’s history that might point the way to the precipitant of the depression. Kathol and Petty (1981) suggest that specific criteria should be adopted to allow the determination that an episode of physical disorder has provoked a state of depression: (1) depression and medical illness are concurrent; (2) the depression is relieved when the medical illness resolves; (3) the depression returns when the medical illness relapses; and (4) the pathology is plausibly related.

Cohen (1985) has pointed out that there are a variety of complex physiological potential pathways between physical and mental states in the elderly, which he described in detail. In many instances of depression associated with physical

disorder, the latter is unknown to the practitioner and ‘probably’to the patient so that the accompanying psychiatric disorder was not the result of stress due to a perceived threat from the disorder (Kerr et al., 1969; Whitlock, 1982). Robinson et al. (1984) were able to locate the site of stroke cerebrovascular damage most likely to produce depression as being in the dominant hemisphere, with lesions closer to the frontal pole producing the more severe depressions.

Depression in stroke patients has been noted to be out of keeping with the accompanying disability (Folstein et al., 1977; Robinson and Benson, 1981; Ross and Rush, 1982); when patients with stroke and orthopaedic disorders were matched for disability the former group more often had depressive symptoms. Hinton (1963) found that depression in dying patients was commensurate with the severity and duration of physical discomfort. Palmore and Lukart (1974) found that in the community-residing elderly life satisfaction was influenced by health status, involvement in organized activities and internal locus of control; these determinants of life satisfaction could be affected by disability.

Some of the determinants of the extent to which disability is depressing do not arise from characteristics of the disability and its treatment alone but also from the personal and social characteristics of the individual: coping capacity and sense of mastery as influenced by personality or previous (successful or unsuccessful) experience with comparable challenges, the development of attitudes of hopelessness and helplessness, and attitudes to- wards dependence; characteristics of social networks (including size, density, geographic dis- persion, multiplicity, interaction, intensity and intimacy); restriction of social activity, impaired family and social relationships, and insufficient support from the physician. Felton et al. (1984) have shown that the coping strategy chosen by an elderly individual with a chronic disorder has an effect on the person’s emotional well-being.

Turner and Noh (1988) found that in a multiple regression analysis of cross-section data, life events and (especially) chronic strain accounted for 11% of the variance in depression among subjects with disability (compared with 41.5% accounted for by all measured psychosocial and disability factors). In a longitudinal analysis of depression at the time of a four-year follow-up, controlling for initital baseline status and demographics, chronic strain together

DEPRESSION A N D DISABILITY IN THE ELDERLY 169

with life events, social support and mastery had independent effects on depression, summating to 17% of the variance in depression.

Depression causing disability

Potential pathways for the disabling effects of depression include the following, several of which are mirror images of the pathways described for the depressing effects of disability: psychogenic onset or course of physical disorder (e.g. somatization of depressive affect, neurophysiological and neuroen- docrine mechanisms); debilitating depressive symptoms (of the vegetative kind) such as fatigue, sleep disturbance, and loss of appetite; behavioural disturbance producing or prolonging physical illness (e.g. self-neglect, inactivity, adverse health habits); reduction of the patient’s motivation to cooperate or take initiatives in the management, treatment or prevention of disability; heightening of the person’s sensitivity to pain and discomfort (with consequent inhibition of mobility); treatment of depression producing physical effects; treatment and management of disability being made more complex and less effective by concurrent depression because of the multiplication of medications and confounding of symptoms; depression undermining the individual’s resistance to extraneous causes of disability or the power to recover from extraneously induced disability; and depression increasing the likelihood of events that can precipitate disability. Turner and Noh (1988) found that the presence of depression predicted the number of life events experienced four years later.

In patients with an acute episode of ischaemic heart disease studied by Morgan (1983), it was noted that the presence of psychological problems interfered with the patient’s return to full activity: that is to say, the emotional state determined the physical function. Feibel and Springer (1982) report that in a study of recovery from stroke in 91 patients with a mean age of 72.2 years, 24 of these cases were complicated by depression: at the six- month assessment the depressed group had a significantly (p<O.Ol) reduced chance of returning to their normal social functioning (i.e. they lost 67% of their prior social activities such as work, pastimes, or visiting friends, compared with 43% in the non- depressed group), regardless of age, marital status, cognitive function or side of stroke. However, recovery of independence in activities of daily living and ambulation was not significantly related to

depression. Gurland et al. (in press) report from an analysis of a one-year follow-up of their sample of community elderly that depression predicted a higher rate of failure to recover from disability and often preceded and predicted the onset of disability; the amount of variance in disability at one-year follow-up which was predicted by depression at baseline (17.3%) was comparable to that (12.9%) for the converse prediction (i.e. depression at TZ predicated by disability at TI).

Additional support for the power of psychiatric conditions to affect health status comes from studies of death rates. Granville-Grossman (1983) concluded that ‘even when deaths associated with dementia and those due to suicide and accidental death are excluded, the mortality rate in psychiatric populations still seems to be higher than in the general population’. Partly this may be due to long- term psychiatric hospitalization with the accompanying hazards of contact with sources of infection and of poor nutrition, or to maintenance medications which may interfere with temperature regulation and immunological defences. However, death rates from natural causes (respiratory, cardiovascular and neurological) are higher also in outpatient psychiatric populations for neurotics and psy- chotics according to Sims and Prior (1978) and there is an increase in death rates in recently bereaved men, particularly from cardiovascular disease (Parkes et al., 1969). Rodin (1980) and Ostfeld (1983) have noted a relationship between depression and a shorter life expectancy. Greer (1979) found in 160 women investigated because of a lump in the breast that suppressed anger was associated with malignancy and raised IgA levels.

AGE AND THE RELATIONSHIP BETWEEN DEPRESSION AND DISABILITY

The effect of age on the relationship between depression and disability deserves special attention, partly in order to reconcile the discordance between age trends in depression and disability.

Some earlier studies had suggested that disability and depression become more closely related with advancing age. Eastwood and Trevelyan (1972) found that number of physical conditions in subjects 40-60 years was associated with greater psychiatric severity, and the number of illnesses increased with age. Maguire and Granville- Grossman ( 1968) concluded that the association

170 B. J . GURLAND E T A L .

IISA Males 7 0 60 i 0

between physical disease and functional psychiatric disorder becomes stronger with age.

Yet, despite the acknowledged increase of disability rates with ageing, there is not a corresponding rise of depression rates. Cross- sectional data (albeit confounding the effects of age and generation) suggest that prevalence rates of depression of a clinical level of severity may plateau after 65 years and then decrease with further ageing (Gurland, 1976; Myers et al., 1984; Comstock and Helsing, 1976; Eaton and Kessler, 1981; Frerichs et al., 1981). Consistent with this pattern, suicide rates also level off with advancing age, with the exception of elderly white men where high suicide rates appear to be an effect of membership of earlier generations rather than of age itself (Cross and Gurland, 1984). Thus, there are inconsistencies in the age variation rates of depression (which do not consistently show a linear rise with ageing beyond 6 5 ) and rates of chronic disability (which do).

Cross-sectional data (see Figs. 1-3) on four contrasting elderly community populations representative of London and New York cities (Gurland et al., 1983; Wilder and Gurland, in press), 'North-

NYC Males

Eastern' New York State (Stoller et al., 1981) and Los Angeles Hispanics (Lopez-Agueres et al., 1984) all showed higher rates of disability with increasing age and strong correlations between depression (as a latent class) and disability. Yet, in London, North- Eastern New York, Los Angeles Hispanics, and New York City females, depression rates were not significantly higher among the old old than the young old (New York City males were an exception). The discrepancy between age trends for disability and for depression in the majority of these samples of elderly suggests a weaker relationship between disability and depression among the old old than the young old (i.e. disability is less depressing or depression less disabling the older the person). Turner and Noh (1988) analysed their community data with respect to the age range 18-91 years in three strata (18-44, 45-64, and 65+): the oldest showed the lowest levels of depression in the disabled as well as in the non-disabled groups. Viney and Westbrooke (198 I ) interviewed in hospital and six months later 88 patients with chronic illness half of whom were 60 years or older. Content analysis was applied to descriptions of

70

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Fig. I . Proportion above cut scores on disability scale by age and sex in four community prohability samples


65-69 7 0 - 1 6 7 5 + 65-69 7 0 - 7 4 75+ 65-69 70-74 7 5 +

65-69 70-74 7 5 + 65-69 7 0 - 7 4 7 i + 65-69 70-74 7 5 +

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Fig. 2. Proportion above cut scores on homogeneous scale of depression, by age and sex in four community probability samples

65-67 70-74 75+ 65-69 70-74 7 5 + 65-69 70-74 7 %

65-69 70-74 75+ 65-69 70-74 75+

Fig. 3. Proportions above cut scores on depression scale in four probability samples by age, sex and disability

172 B. J. GURLAND E T A L .

illness-related experiences; the older patients disclosed less depression though more sense of helplessness. Felton and Revenson (1987) found a tendency for their older subjects to be less prone to self-blame regarding their disability. More muted responses to illness among older patients have also been described with regard to cancer or its possibility (Mages and Mendelsohn, 1979; Cohen, 1980).

Several explanatory hypotheses remain to be tested regarding the observation that in certain settings there is a weakening of the relationship between depression and disability as age advances. These include: (1) Effects of survivorship; Evans (1986) states that ‘it is usually difficult to establish correlates of morbidity and mortality at late ages whose distribution might be changed through selective mortality. (2) Selection bias introduced by loss from community samples of persons admitted to institutions; this could be examined by determining the relevant age correlations in both community and institutional settings or on a sample of the total elderly population regardless of location. (3) Changes in the nature of disability with advancing age, with disability becoming more stable, less acute or less symptomatic, and thus more within the patient’s capacity for adjustment. In the Turner and Noh (1988) study, duration showed a negative association with depression suggesting adaptation over time; Kukull et al. (1986) emphasize that ‘the development of a new physical illness is a stronger risk factor for depression than is the existence of one or more chronic illnesses’; Viney and Westbrook (198 1) found that severity rather than type of disability is related to depression; and changes in coping may accompany age changes in types of stressors (McCrae and Costa, 1986; McCrae, 1982). (4) Normative expectations with respect to age and disability, making it easier to accept with equani- mity the existence of disability in advanced age (Neugarten and Datan, 1973). ( 5 ) Cohort differences in coping strategies (Veroff et al., 1981; Kulka and Tamir, 1978). (6) Practice effects of previous experiences of successful coping with disability or similar challenges (or more general age- related changes in mastery and coping). (7) More willing support by families of the very old disabled elderly (or more general age-related changes in support networks). (8) Neurobiological changes with age which make the older person less vulner- able to depression with or without a stressor such as disability. (9) A reduction with age in extraneous

factors (e.g. other life events) that might precipitate depression in persons with disability: Turner and Wood (1985) found that their older subjects had fewer life events, as also reported by Chiriboga and Cutler (1980), Goldberg and Comstock (1980) and Turner and Noh (1988). Furthermore, life events may be less distressing to the elderly than for younger persons (Masuda and Holmes, 1978; Dean et al., 1980; Lieberman, 1978).

Yet paradoxes abound: Turner and Wood (1985) noted that older age was characterized by higher chronic strain, lower coping scores, and lower sense of mastery with no change in level of social support, despite finding lower depression rates among the older than younger subjects with disability. Life events are said to be more negative and uncontrol- lable with older age (Aldwin and Revenson, 1985; Folkman and Lazarus, 1980). More use of affect- ivity in response to stress has been reported among older subjects (Quayhagen and Quayhagen, 1982). Felton and Revenson (1987) studied 151 subjects aged 4 1-89 with hypertension, diabetes, rheuma- toid arthritis, or blood cancer and found that older subjects were less likely to use certain coping strategies (e.g. emotional expression and information seeking) even when numerous illness variables were controlled, the age contrast being especially marked where the illness was perceived as highly serious. The older subjects were less likely to see positive aspects in their illness situation (but were more likely to minimize the illness’s threat).

APPROACHES TO INVESTIGATION OF THE CONCURRENCE OF DEPRESSION

AND DISABILITY

Specific and non-spec@c approaches

Granville-Grossman (1983) argued that the possibilities for non-specific linkages between physical and psychiatric disorder can be reduced to three main classes: (1) individuals with psychiatric disorder are susceptible to all forms of physical disorder; (2) the converse; (3) some individuals are susceptible to all forms (i.e. physical and psychiatric) of illness. The last explanation he found appealing: ‘The concept of man having a general- ised psychophysical propensity to disease appears to be a useful and alternative model to the one which seeks only specific single cause and effect relationships’. He cites in support the findings on the clustering of illnesses of a wide variety, both

DEPRESSION A N D DISABILITY IN THE ELDERLY 173

physical and mental, in individuals and at points in time (Hinkle and Wolff, 1958) and in relation to life events (Holmes and Rahe, 1967). Schwab et al. (1978) have pointed out that ‘lower socioeconomic status is probably the most fundamental factor associated with high risk for both physical and mental illness’.

The hypothesis of non-specific vulnerability to psychiatric and physical disease does not seem to account for the differential frequency with which physical disability accompanies such psychiatric conditions as depression, dementia or schizo- phrenia; nor is the notion of a generalized propensity to all diseases sufficient to explain, for a given group of elderly, the sequence in which depression and disability appear (unless this is random and thus illusory); nor the features of one condition (e.g. the acuteness of onset of disability) which predict the likelihood of the occurrence of the other (e.g. depression).

Yet there are limits to specificity in the relationship between psychiatric and physical disorder. The evidence reviewed in this article did not clearly indicate that one specific type of depression was more likely than another to be associated with disability (other than dictated by tautological criteria) and produced only scanty or conflicting evidence that specific diseases are particularly prone to be associated with depression. A wide variety of chronic illnesses appear to lead to the same range of psychiatric states (Cassileth et al., 1984; Felton et al., 1984).

The most productive line of research would be to continue to explore both non-specific and specific hypotheses. Potentially non-specific to the disorders (either psychiatric or physical or both) are the personal characteristics of the subject including age, gender, sociodemographic status, coping strategies, sense of mastery, social supports, and experience of life events not inherent in the psychiatric or physical disorder. Specific relationships may also be found through further examination of the subtypes and surrounding characteristics of the two disorders, including onset, severity, course, site, and treatment.

Investigation by means of intervention

One strategy for specifying the causal pathways relating depression and disability is to determine whether there are one or more systematic sequences in the development of these two sets of conditions. However, there are limits to the inferences on

causality that can be drawn if data are restricted to naturalistic investigations of the concurrence of depression and disability, as in epidemiological studies. Longitudinal data do help in teasing out the relative precedence and influence of two conditions but usually cannot control all nuisance variables, nor can the findings be confidently extrapolated to practical applications in the realm of prevention and treatment. Something can be added to the body of knowledge by intervening through means of experimental designs involving treatments or other manipulations in order to determine the effects of altering some of the possible mechanisms that link the two conditions. This strategy requires that detection, classification and treatment of the two conditions be feasible, accurate and effective.

Several of the difficulties in diagnosing concurrent depression and disability have already been covered in this article; detection and intervention may also involve enlisting the cooperation of the patient and primary care physician. If only obvious or easily accessible cases of depression and disability are selected for study the results on causal links may be of unknown generality. Intervention studies in this field usually necessitate a good working partnership between psychiatry and medicine.

It is not difficult to find untreated or inadequ- ately treated cases for study of interventions. Wan and Arling (1983) noted that the disabled elderly are more likely to use physician services if they also have psychological symptoms but, as Borson et al. (1986) report, although depressives are high service utilizers in general, only one out of 99 depressives in their study had received mental health services during the previous month. Kinzie et al. (1986) drew 50 subjects with diagnosable depression from a community sample aged 52-83; only one subject was taking an antidepressive though 21 were taking a medication that might have been aimed at the depression (e.g. thyroid, oestrogen, or a sedative- hypnotic). Felton and Revenson (1987) found that those who were oldest and had the most serious illness, by their own account were less active in seeking help, tending to be most pessimistic and minimizing about the importance of their illness.

It appears that primary care practice offers ample opportunity for intervention to treat depression occurring in relation to physical disorder such as disability (German et al., 1987). However, the research environment needs to be nurtured: Mitchell (1985) has detailed some of the dissatis- factions that primary care physicians express about

174 B. J. GURLAND E T A L

their transactions with psychiatric colleagues and suggested alternative models for improving the interaction. The psychiatric services have to be willing also to take main responsibility for care of the patient under certain circumstances: when the patient with concurrent depression and disability does not respond to treatment, has a physical condition such as a recent stroke or myocardial infarction or a cardiac arrythmia that complicates pharmacological treatments, suffers a confusional state as a result of a medication side-effect, is deteriorating physically as a result of the depression, discloses suicidal impulses or delusions, or does not cooperate with treatment. Sometimes it is the distress of the caregiving family, who may become worn out by a frail elderly patient’s increased restlessness, sleeplessness and demands, or the primary care physician’s sense of being over- loaded that signals the need for intensive involvement of the psychiatric services.

A basic intervention design for examining reciprocity in the relationship between depression and disability should include: ( 1 ) the treatment of depression as the primary means of intervention in one group of elderly with depression and disability; and (2) the treatment of disability as the primary means of intervention in another like group. The design must take into account: (3) adjunctive treatments which may be relevant to both conditions.

1. Treating depression as the primary means of intervention. The critical research issue is whether the treatment of clinical levels of depression in the elderly with disability can lead not only to relief of the depression but also to improvement in the frequency, speed and extent of recovery from disability; and to the prevention of the onset, relapse or deterioration of disability.

Where major depression is diagnosed, antidepressants or electroshock therapy are indicated. Ouslander (1 982) recommends that antidepressant treatment should be considered in elderly patients whose symptoms of depression are causing; dysfunction or impairing recovery from physical illness; he claims that drug therapy can provide dramatic improvement of overall function and speed recovery from physical illness. The practice standards that pertain to the treatment of choice for major depression in general usually apply also when this condition occurs in the presence of physical illness (Cohen-Cole and Stoudemire, 1987; Maguire et al., 1985; Rifkin et al., 1985; Stoude- mire, 1985). In the experience of Sins and Rifkin

(1981), although drug treatment in the medically ill is complex it can yet be judiciously managed. Feibel and Springer (1982) gave antidepressive treatment to depressed elderly patients recovering from stroke; four out of the five improved symptomatical- ly and also showed increased activities such as returing to work or home.

Diagnosable, clinical-level depressions other than major depressions (e.g. adjustment disorder or dysthymic disorder) are treated usually by social therapies, psychotherapy or cognitive therapy; the place of antidepressants for these subtypes of depression is not settled. Clinical experience suggests that antidepressants may be helpful; for example, the sedating effect of certain antidepressants may relieve insomnia or pain (Cohen-Cole and Stoudemire, 1987). 2. Treating disability as the primary means of intervention. To the extent that the onset or course of a type or instance of depression is believed to be reactive (psychologically or biologically) to disability or its treatment, it would seem reasonable to seek to relieve the depression by treating those aspects of disability that might be provoking or maintaining the depression.

The causal pathways in the direction of disability influencing depression have been discussed in this article and implicitly suggest relevant therapeutic interventions such as physical rehabilitation, restoration of functional independence, return to activities, control of pain and other discomforts, and reducing numbers of medications. Preventive steps could also be undertaken in this approach, for example the high risk of depression from a wide range of medications used to treat physical disorder makes it seem advisable to limit the number of medications whenever possible. 3. Some types of treatment intervention straddle the targets of disability and depression and are thus adjunctive treatments for either: the bolstering of social support, increasing the participation in treatment of informal caregivers, reassuring explanations, involving the patient in decisions on treatment and management, improving the patient’s sense of mastery, and cognitive therapy for improving attitudes and coping capacity. These are apparently psychosocial approaches to treatment but their content may address both the depression and the disability; benefits may accrue to either or both conditions. The supplementation of treatments specific to depression or disability by these broad spectrum adjunctive therapies could, however, dilute the contrast in the sequence of recovery


of the two conditions under study and thus obscure the interaction between them.

C O N C L U S I O N S

The existence of a statistically significant relationship between depression and disability in the elderly is so broadly supported by the evidence and so widely acknowledged that it may be regarded more as a given than a conclusion. Yet the context, details, direction and responsivity to treatment of this relationship have been insufficiently researched and documented. Therefore, it is still not possible to confidently describe which types or characteristics of depression and disability are related, to what degree, and in which circumstances; nor the relative strength and importance of the pathways whereby such relationship is effected; nor even the effectiveness of various modalities of treatment intended to moderate the deleterious action of depression and disability on each other and to relieve either or both.

There is, however, sufficient evidence to warrant further testing of the hypotheses that disability is the most important determinant of the rates and outcomes of chronic depression of all types in old age; that the relationship between depression and disability is a reciprocal one in that the causal pathways go in either direction; that the links between depression and disability are multiple but the key links can be identified for settings, groups of patients and the individual; that treatment directed at all identified key links is more effective than treatment limited to subspecialty interests (e.g. psychiatric or medical); and that preventive and remedial treatment can make a major difference to the rates and outcomes of depression associated with disability and to disability associated with depression.

An unexpected and intriguing finding that emerges from this field of study is that there is a tendency for the relationship between depression and disability to become less marked as age advances. A plausible set of explanations was presented earlier. in this article but it is potentially productive to proceed now to the following very general speculation: that advancing age brings with it an enhanced ability to cope with adversity. That would be an hypothesis worth the proving!

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