higher burden of depression among older women

HIGHER BURDEN OF DEPRESSION AMONG OLDER WOMEN:THE EFFECT OF ONSET, PERSISTENCE AND MORTALITY OVERTIME

Lisa C. Barry, Ph.D.1, Heather G. Allore, Ph.D.1, Zhenchao Guo, Ph.D1, Martha L. Bruce, Ph.D.2, and Thomas M. Gill, M.D.1Lisa C. Barry: [email protected]; Heather G. Allore: [email protected]; Zhenchao Guo: [email protected];Martha L. Bruce: [email protected]; Thomas M. Gill: [email protected] Yale University School of Medicine, Department of Internal Medicine, New Haven, CT2 Weill Medical College of Cornell University, Department of Psychiatry

AbstractCONTEXT—The prevalence of depression is disproportionately higher in older women than men,yet the reasons for this gender difference are not clear.

OBJECTIVE—We sought to determine whether the higher burden of depression among olderwomen than men might be attributable to gender differences in the onset, i.e., first or recurrentepisodes, or persistence of depression and/or to differential mortality among those who are depressed.

DESIGN—Prospective cohort study.

SETTING—General community in greater New Haven, Connecticut from March 1998 to August2005.

PARTICIPANTS—754 persons, aged 70 years or older, who were evaluated at 18-month intervalsfor 72 months.

MAIN OUTCOME MEASURES—The three outcome states were depressed, non-depressed anddeath, with scores ≥20 and <20 on the Centers for Epidemiologic Studies-Depression scale denotingdepressed and non-depressed, respectively. The association between gender and the likelihood of sixpossible transitions, namely from non-depressed or depressed to non-depressed, depressed, or deathwas evaluated over time.

RESULTS—The prevalence of depression was substantially higher among women than men at eachof the five time points (p<0.001). In most cases, transitions between the non-depressed and depressedstates were characterized by moderate to very large absolute changes in depression scores, i.e., atleast 10 points. Adjusting for other demographic characteristics, women had a higher likelihood oftransitioning from non-depressed to depressed (odds ratio=2.02; 95% Confidence Interval 1.39, 2.94)and lower likelihood of transitioning from depressed to non-depressed (odds ratio=0.27; 95%confidence interval 0.13, 0.56) or death (odds ratio=0.24; 95% confidence interval 0.09–0.60).

Address correspondence to: Lisa C. Barry, Ph.D., M.P.H.; Yale University Program on Aging, 300 George Street; Suite 775, New Haven,CT 06511-6624, Telephone: (203) 737-2990, Fax: (203) 785-4823; [email protected] as a poster presentation at the 2006 Gerontological Society of America Meetings, Dallas, TX; November 17, 2006.Author Contributions: Dr. Gill had full access to all of the data in the study and takes responsibility for the integrity of the data and theaccuracy of the data analysis. None of the authors has any conflicts of interest including specific financial interests and relationships andaffiliations relevant to the subject matter or materials discussed in this manuscript. The specific contributions are enumerated in theauthorship, financial disclosure, and copyright transfer form.

NIH Public AccessAuthor ManuscriptArch Gen Psychiatry. Author manuscript; available in PMC 2009 December 14.

Published in final edited form as:Arch Gen Psychiatry. 2008 February ; 65(2): 172–178. doi:10.1001/archgenpsychiatry.2007.17.

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CONCLUSIONS—Among older persons, the higher burden of depression in women than menappears to be attributable to a greater susceptibility to depression and, once depressed, to morepersistent depression and a lower probability of death.

Keywordsdepression; gender differences; older persons; mortality

INTRODUCTIONWhereas major depression affects only about 1% to 2% of community-dwelling older persons,1,2 clinically significant depressive symptoms are more common. Often referred to as“depressed mood” or simply “depression,” clinically significant depressive symptoms affectbetween 8% to 20% of this population3–10 and are highly morbid.11–23 The burden ofdepression, however, is disproportionately higher among older women than men.2,24–31

Despite an expanding knowledge base about late-life depression,7,32 the reasons for this genderdifference have remained poorly defined.

Efforts to explain the gender difference in the prevalence of depression have focused largelyon evaluating associations between gender and exposure to risk factors for depression,28

comparing gender differences in the perception of symptoms,33,34 and identifyingenvironmental and personality factors that mediate the relationship between gender anddepression.35 An alternative approach, which has not yet been formally evaluated, is todetermine whether gender differences in depression onset, persistence, and mortality mightcollectively account for the higher burden of depression among older women. While priorstudies have evaluated gender differences in depression onset and persistence 9,36–40 or inmortality among those who are depressed,18,41,42 they have been limited by the availability ofdata at only two time points, often at widely spaced intervals9,18,36–38,40,42 or a short durationof follow-up.36 To our knowledge, only one study has considered the potentially fluctuatingcourse of depression over time,39 but this study had a short duration of follow-up and includedonly depressed persons in its sample.

The objective of this prospective study was to determine whether the higher burden ofdepression among older women than men is attributable to gender differences in the onset ofdepression, i.e., first or recurrent episodes, or persistence of depression over time and/or todifferential mortality among those who are depressed. To achieve our objective, we evaluatedpossible transitions between three states – not depressed, depressed, and death – at 18-monthintervals for six years among a large cohort of older men and women.

METHODSStudy Population

Participants were members of the Precipitating Events Project (PEP), a longitudinal study of754 community-dwelling persons aged 70 years or older.43 The assembly of the cohort hasbeen described in detail elsewhere.43 In brief, potential participants were identified from 3,157age-eligible members of a health plan in New Haven, Connecticut. The primary inclusioncriteria were English speaking and requiring no personal assistance with four key activities ofdaily living (i.e., bathing, dressing, transferring from a chair, and walking). The participationrate was 75.2%.43 During 6-years of follow-up occurring between March 1998 and August2005, 232 participants died after a median of 48 months, 27 dropped out of the study after amedian of 24 months, and 18 were subsequently excluded due to participation by proxy aftera median of 32 months. The Human Investigation Committee at Yale University approved thestudy.

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Data CollectionThe current study included data collected during in-home assessments that were completed atbaseline and every 18 months for up to 72 months by trained research nurses who used standardprocedures that have been described in detail elsewhere.44 Demographic data included age,gender, race, and educational level. Medical comorbidity was ascertained based on the presenceof nine self-reported, physician-diagnosed chronic conditions, including hypertension,myocardial infarction, congestive heart failure, stroke, diabetes, hip fracture, arthritis, chroniclung disease, and cancer (other than minor skin cancer). Cognitive status was assessed withthe Folstein Mini-Mental State Exam (MMSE).45 Deaths were ascertained by review of localobituaries and/or from an informant.

Assessment of Depression—The 11-item Center for Epidemiologic Studies – Depression(CES-D) scale46 was used to assess depressive symptoms in the previous week during each ofthe five time points (i.e., baseline, and 18, 36, 54, and 72 months). Prior studies of older personsreport test-retest reliability statistics of 0.82 or higher on the shortened form of the CES-D.47,48 As in several prior studies,17,18,49 scores were transformed using the procedurerecommended by Kohout et al.50 to make it compatible with the full 20-item instrument. Totalscores range from 0 to 60, with higher scores indicating more depressive symptoms. While aCES-D score of 16 is most commonly used to distinguish between depressed and non-depressedpersons in mixed-age samples, a cut point of 20 offers a more stringent approach to theclassification of depressed mood among older persons.14,17,51–53 A CES-D score of 20 orhigher has been shown to predict outcomes related to well-being and functioning as well asdiagnostic measures of depression39 and has been used in several prior epidemiologic studiesof depression in the elderly.11,17,53 Data on depression were complete for 100% of theparticipants at baseline and 95%, 93%, 91%, and 90% of the non-decedents at 18, 36, 54, and72 months, respectively.

Statistical AnalysisWe determined the association, at baseline, between depression and the characteristics of theparticipants using chi-square or t-test statistics. We then compared the prevalence of depressionbetween men and women at each time point using the chi-square statistic. For each of the 18-month intervals, we calculated rates by gender for six possible transitions, defined on the basisof the three outcome states: non-depressed, depressed and death. Chi-square or Fisher’s exactstatistics were used to evaluate the bivariate associations between gender and the six possibletransitions for each time interval. Because the number of participants was relatively small forsome of the transitions, the power to detect statistically significant differences in the transitionrates according to gender may not have been adequate for all comparisons. Furthermore, toaccount for the large number of comparisons, p-values were determined according to theHochberg method.54

To determine whether the observed transitions were clinically meaningful, we calculated thepercentage of transitions that represented absolute changes in the CES-D scores of 1 to 3(small), 4 to 9 (moderate), 10 to 19 (large), and 20 or more points (very large), respectively,for each time interval, and we subsequently determined whether the distribution of thesepercentages differed by gender using the chi-square statistic.

Lastly, we evaluated the association between gender and the likelihood of the six possibletransitions over time using longitudinal methods that optimized statistical power and accountedfor potential correlation among depression scores. Specifically, we ran generalizedmultinomial logit models for nominal outcomes that were estimated with GeneralizedEstimating Equation (GEE) and used exchangeable correlation structures.55 The firstlongitudinal model included participants who were non-depressed at the beginning of any 18-

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month time interval, with participants who were non-depressed during the entire interval (i.e.,at two consecutive 18-month time points) serving as the comparison group. The secondlongitudinal model included participants who were depressed at the beginning of any 18-monthtime interval, with participants who were depressed during the entire interval serving as thecomparison group. The magnitude of association was denoted by odds ratios, which weresubsequently adjusted for age, race (White vs. other), education, number of chronic conditions,and MMSE score.

All statistical tests were two-tailed and p-values less than .05 were considered statisticallysignificant. The longitudinal models were performed using Survey Data Analysis (SUDAAN)software version 9.0,56 and all other analyses were performed using Statistical Analysis System(SAS) software version 9.1.57

RESULTSTable 1 provides the characteristics of the study participants over the course of six years. Atbaseline, participants had a mean age of about 80 years; about two-thirds were women, andmost were white. On average, participants had a high school education, two chronic conditions,and were cognitively intact. Participants who were depressed at baseline were less educated,had more chronic conditions, had lower MMSE scores, and were more likely to be women ascompared to the non-depressed participants (p<0.05) (results not shown). The proportion ofwomen did not change appreciably over time, while the burden of chronic conditions increasedmodestly. At baseline and each subsequent time point, the prevalence of depression wassubstantially higher among women than men (p<0.001), with the greatest absolute differenceobserved at 54 months. Furthermore, of the 269 (35.7%) participants who were depressed atsome point during the 72 months of follow-up, 48 (17.8%), 30 (11.1%), 17 (6.3%) and 12(4.5%) were depressed during two, three, four, and five consecutive time points, respectively,with a greater number of women experiencing depression at subsequent time points ascompared to men (p<0.01).

Table 2 provides the transition rates between the three outcome states over the 18-monthintervals according to gender. With only a few exceptions, the rates were comparable acrossthe four intervals. Among participants who were non-depressed, women generally had higherrates of transitioning to depressed and lower rates of remaining non-depressed or transitioningto death. Among those who were depressed, women had higher rates of remaining depressedand lower rates of transitioning to non-depressed or death, with one exception. Women had ahigher rate of transitioning from depressed to death during the 54–72 month interval, althoughthis difference was not statistically significant.

As shown in the Figure (Panel A), the majority of transitions from non-depressed to depressedwere based on moderate to very large absolute changes in CES-D scores, i.e. at least 10 points;small changes in the range of 1 to 3 points were observed for no more than 15% of the transitionsduring any of the 18-month intervals. Similar results were found for transitions from depressedto non-depressed Figure 1 (Panel B). There were no significant differences in the distributionof change scores by gender for either set of transitions (results not shown).

Table 3 presents the unadjusted and adjusted odds ratios derived from the longitudinal modelsevaluating the association between gender and the likelihood of the six transitions between thethree outcome states over the course of six years. Among those who were non-depressed,women were more likely to transition to a depressed state, with an adjusted odds ratio of 2.02(95% CI: 1.39, 2.94). Among those who were depressed, women were less likely to transitionto non-depressed and to death, with adjusted odds ratios of 0.27 (95% CI: 0.13, 0.56) and 0.24

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(95% CI: 0.09, 0.60, respectively. There was no significant association between gender andtransitioning from non-depressed to death.

COMMENTIn this longitudinal study, which included multiple assessments over the course of six years,we confirmed that the prevalence of depression is substantially higher among older womenthan men. More importantly, we found that this gender difference is attributable to a greatersusceptibility to depression and, once depressed, to more persistent depression and a lowerprobability of death in older women.

Late-life depression is a significant clinical and public health problem because it is common,6–9,37 costly,58,59 and associated with disability8,15,17,19 and other adverse outcomes includingrehospitalization and death among those with chronic obstructive pulmonary disease,60

myocardial infarction,61–63 and stroke.64 Despite these negative consequences, there isconsiderable uncertainty about why the prevalence of late-life depression is disproportionatelyhigher in women than men. To our knowledge, the present study is the first to evaluate whethergender differences in depression onset, persistence, and mortality might collectively accountfor the higher burden of depression among older women.

With one exception,9 prior studies of community-living older persons have found no evidenceof a gender difference in either the onset9,36,37,40 or persistence9,36,38,39 of depression. Thesestudies, however, have generally included only one follow-up assessment of depression at aninterval no shorter than two years.9,37,39,40 The inability to account for fluctuations indepression over time (i.e., recurrent depression) may have a substantial impact on estimates ofdepression onset. In contrast, we evaluated transitions into and out of depression states at 18-month intervals for six years and used longitudinal methods that addressed potential problemsrelated to low power for any single time interval. Low self-esteem, helplessness, and low socialstatus have been shown to differentially increase the risk of depression onset in women youngerthan age 65 years as compared with men of the same age.65 Additional research is needed todetermine the etiology of gender differences in depression onset among older persons.

The consistency of our findings over four different time intervals provides strong evidence thatdepression is more likely to persist in older women than men. This gender difference in thepersistence of depression is somewhat surprising since women are more likely than men toreceive both pharmacologic and non-pharmacologic treatment for depression.66–70 Whetherwomen are treated less aggressively than men for late-life depression or are less likely torespond to conventional treatment is not known,72,73 but should be the focus of future research.In addition, nearly 40% of the depressed participants in this study were depressed during atleast two consecutive time points, highlighting the need to initiate and potentially maintainantidepressant treatment after resolution of the initial depressive episode.74

As in prior studies,18,41,42 we found that older women are less likely than men to die whendepressed, providing a third explanation for the gender difference in the prevalence ofdepression. Of course, older men generally have higher mortality rates than older womenirrespective of depression,75 as was observed in the current study. Nonetheless, the mortalitydifference we observed by gender was marked, with a nearly three-fold difference in the oddsratios for participants who were depressed as compared with those who were not.

The availability of five waves of data over a six-year period provides the best information, todate, on how depression onset, persistence, and mortality collectively influence the prevalenceof depression. Because these factors are highly inter-related, we were unable to determine theirrelative contribution to the prevalence of depression. Prevalence, for example, is a function ofincidence and duration, while duration is a function of persistence and mortality.

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Because information regarding participants’ depression status prior to the baseline interviewwas not available, we cannot determine if participants’ first transition from a non-depressed toa depressed state represents incident depression. Given the preponderance of depression amongwomen as compared with men in non-elderly samples,76–78 it is possible that our findingsrepresent the continuation of a gender-related pattern of depression established earlier in life.Future studies should evaluate whether gender differences in the onset and persistence ofdepression during youth and middle-age may help to explain reasons for gender differences indepression patterns in older age.

In the absence of a diagnostic measure, such as the Structured Clinical Interview for the DSM-IV (SCID),79 we were unable to determine the prevalence of major depression among the studyparticipants. However, we used a cut point of 20 or greater on the CES-D scale to identifydepressed participants at each time point. This cut point has previously been shown to enhancethe likelihood of detecting depressed mood among community-living older persons.14,17,51–53,80 Furthermore, the moderate to very large changes in the CES-D scores over time, regardlessof gender, indicate clinically meaningful transitions between depression states. Of note, thebaseline rate of depression in our study is somewhat higher than rates reported in other studiesof older persons that have used the more stringent cut point of 20 or greater on the CES-D.17,80 This difference may be explained by the higher mean age and more diverse racialcomposition of our sample as compared with these other studies.

Because our study participants were members of a single health plan and were non-disabledand at least 70 years of age at baseline, the generalizability of our findings to other older adultpopulations may be questioned. As previously noted, however,43 the demographiccharacteristics of our study population, including years of education, closely mirror those ofpersons aged 70 years or older in New Haven county, which, in turn, are comparable to thosein the United States as a whole, with the exception of race. New Haven county has a largerproportion of non-Hispanic whites in this age group than in the United States, 91% vs. 84%.81 Given that African-Americans have a higher prevalence of persistent depression as comparedwith non-Hispanic whites,82 future research should explore whether the relationship betweengender and transitions across depression states is modified by race using data that more closelyreflects the racial composition of older adults in the U.S. Furthermore, generalizability dependsnot only on the characteristics of the study population but also on its stability over time.83 Thehigh participation rate, completeness of data collection and low rate of attrition for reasonsother than death all enhance the generalizability of our findings,82 and at least partially offsetthe absence of a population-based sample.

In summary, the higher burden of depression in older women than men appears to beattributable to a greater susceptibility to depression, and once depressed, to more persistentdepression and lower probability of death. Additional research is needed to determine theetiology of these gender differences so that more effective strategies can be developed to detectand manage depression in this population.

AcknowledgmentsWe thank Denise Shepard, BSN, MBA, Andrea Benjamin, BSN, Paula Clark, RN, Martha Oravetz, RN, ShirleyHannan, RN, Barbara Foster, and Alice Van Wie for assistance with data collection; Evelyne Gahbauer, MD, MPHfor data management and programming; Wanda Carr and Geraldine Hawthorne for assistance with data entry andmanagement; Peter Charpentier, MPH for development of the participant tracking system; and Joanne McGloin, MDiv,MBA for leadership and advice as the Project Director.

Funding/Support: The work for this report was funded by grants from the National Institute on Aging (R37AG17560,R01AG022993, 5T32AG019134). The study was conducted at the Yale Claude D. Pepper Older AmericansIndependence Center (P30AG21342). Dr. Gill is the recipient of a Midcareer Investigator Award in Patient-Oriented

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Research (K24AG021507) from the National Institute on Aging. Dr. Barry is a 2007 Brookdale Leadership in AgingFellow.

Role of Sponsors: The organizations funding this study had no role in the design or conduct of the study; in thecollection, management, analysis, or interpretation of the data; or in the preparation, review, or approval of themanuscript.

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http://factfinder.census.gov

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Figure.Change in CES-D scores among participants who transitioned from non-depressed to depressed(Panel A) and from depressed to non-depressed (Panel B).

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Barry et al. Ta

ble

1

Cha

ract

eris

tics o

f Stu

dy P

artic

ipan

ts o

ver S

ix Y

ears

.*

Cha

ract

eris

ticB

asel

ine

(N=7

54)

18 M

onth

s (N

=675

)36

Mon

ths (

N=6

12)

54 M

onth

s (N

=538

)72

Mon

ths (

N=4

71)

Age

(yea

rs),

mea

n ±S

D78

.4 ±

5.3

79.6

± 5

.180

.9 ±

5.1

82.2

± 4

.983

.7 ±

4.8

Fem

ale,

n (%

)48

7 (6

4.6)

439

(65.

0)40

5 (6

6.2)

359

(66.

7)31

0 (6

5.8)

Non

-His

pani

c w

hite

, n (%

)68

2 (9

0.5)

609

(90.

2)55

0 (8

9.9)

483

(89.

8)42

3 (8

9.8)

Educ

atio

n (y

ears

), m

ean

±SD

12.0

± 2

.912

.0 ±

2.8

12.0

± 2

.812

.0 ±

2.8

12.1

± 2

.8C

hron

ic c

ondi

tions

,† mea

n ±S

D1.

9 ±

1.3

2.1

± 1.

32.

2 ±

1.3

2.2

± 1.

32.

4 ±

1.3

Cog

nitiv

e st

atus

scor

e, ‡ m

ean

±SD

26.8

± 2

.526

.4 ±

2.9

26.3

± 3

.425

.5 ±

4.0

25.3

± 4

.6D

epre

ssio

n, n

(%)§

M

en14

(5.2

)17

(7.2

)22

(10.

6)13

(7.3

)17

(10.

6)

Wom

en86

(17.

7)99

(22.

6)10

2 (2

5.2)

96 (2

6.7)

74 (2

3.9)

* The

cum

ulat

ive

num

ber o

f dec

eden

ts w

as 4

6 at

18

mon

ths,

98 a

t 36

mon

ths,

166

at 5

4 m

onth

s, an

d 23

2 at

72

mon

ths.

† The

9 se

lf-re

porte

d, p

hysi

cian

-dia

gnos

ed c

hron

ic c

ondi

tions

incl

uded

: hyp

erte

nsio

n, m

yoca

rdia

l inf

arct

ion,

con

gest

ive

hear

t fai

lure

, stro

ke, d

iabe

tes,

hip

frac

ture

, arth

ritis

, chr

onic

lung

dis

ease

, and

canc

er (o

ther

than

min

or sk

in c

ance

r).

‡ As a

sses

sed

by th

e M

ini-M

enta

l Sta

te E

xam

inat

ion

(MM

SE).

§ Prev

alen

ce ra

tes a

re b

ased

on

the

num

ber o

f men

and

wom

en, r

espe

ctiv

ely.

At e

ach

time

poin

t, th

e ra

tes w

ere

subs

tant

ially

hig

her a

mon

g w

omen

then

men

(p<0

.001

).


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Barry et al. Ta

ble

2

Tran

sitio

n R

ates

Bet

wee

n th

e Th

ree

Out

com

e St

ates

Ove

r Tim

e A

ccor

ding

to G

ende

r.*, †

0–18

mon

ths

18–3

6 m

onth

s36

–54

mon

ths

54–7

2 m

onth

sM

enW

omen

Men

Wom

enM

enW

omen

Men

Wom

en

Non

-Dep

ress

ed to

:N

=244

N=3

86N

=212

N=3

29N

=183

N=2

89N

=164

N=2

57N

on-D

epre

ssed

n

213

315

175

267

150

227

137

205

%

87.3

81.6

82.5

81.1

82.0

78.6

83.6

79.8

p-

valu

e0.

470.

740.

740.

74D

epre

ssed

n

1252

1948

1140

1226

%

4.9

13.5

9.0

14.6

6.0

13.8

7.3

10.1

p-

valu

e0.

006

0.47

0.08

0.74

Dea

th

n19

1918

1422

2215

26

%7.

84.

98.

54.

312

.07.

69.

110

.1

p-va

lue

0.74

0.42

0.74

0.74

Dep

ress

ed to

:N

=14

N=7

7N

=16

N=9

3N

=20

N=9

9N

=13

N=9

1N

on-D

epre

ssed

n

625

833

1533

730

%

42.9

32.5

50.0

35.5

75.0

33.3

53.8

33.0

p-

valu

e0.

990.

990.

006

0.99

Dep

ress

ed

n5

473

512

535

47

%35

.761

.018

.854

.810

.053

.538

.551

.6

p-va

lue

0.63

0.08

0.00

40.

99D

eath

n

35

59

313

113

%

21.4

6.5

31.0

9.7

15.0

13.1

7.7

14.3

p-

valu

e0.

720.

280.

990.

99

* Tran

sitio

n ra

tes w

ere

calc

ulat

ed fo

r par

ticip

ants

who

had

dat

a on

dep

ress

ion

or d

eath

at e

ach

of th

e tw

o tim

e po

ints

def

inin

g th

e re

leva

nt fo

llow

-up

inte

rval

.

† P-va

lues

wer

e de

term

ined

acc

ordi

ng to

the

Hoc

hber

g m

etho

d fo

r mul

tiple

com

paris

ons.


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Barry et al. Ta

ble

3

Long

itudi

nal A

sses

smen

t of T

rans

ition

s Ove

r the

Cou

rse

of S

ix Y

ears

Am

ong

Wom

en R

elat

ive

to M

en.

Una

djus

ted

Odd

s Rat

io95

% C

onfid

ence

Inte

rval

p-va

lue

Adj

uste

d O

dds R

atio

*95

% C

onfid

ence

Inte

rval

p-va

lue

Tran

sitio

nN

on-d

epre

ssed

to:

N

on-d

epre

ssed

1.00

--

1.00

--

D

epre

ssed

2.06

1.45

, 2.9

2<0

.001

2.02

1.39

, 2.9

4<0

.001

D

eath

0.74

0.54

, 1.0

20.

070.

790.

56, 1

.12

0.19

Dep

ress

ed to

:

Dep

ress

ed1.

00-

-1.

00-

-

Non

-dep

ress

ed0.

280.

15, 0

.51

<0.0

010.

270.

13, 0

.56

<0.0

01

Dea

th0.

250.

11, 0

.55

<0.0

010.

240.

09, 0

.60

0.00

3

* Adj

uste

d fo

r age

(yea

rs),

race

(Whi

te v

s. ot

her)

, edu

catio

n (y

ears

), nu

mbe

r of c

hron

ic c

ondi

tions

, and

MM

SE sc

ore.


higher burden of depression among older women

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