Abstract
Depression is one of the most prevalent mental disorders worldwide. Little information is available regarding association of depressive symptoms (DS) with cancer and chronic diseases among middle-aged and elderly Chinese in a population-based setting. In this study we evaluated the prevalence and examined correlates of DS in two population-based cohort studies. Included in the analyses were 103,595 people with a mean age of 61.8 years at the DS assessment. The prevalence of DS was 2.4% in men and 5.6% in women. We found elderly participants, those with lower BMI, or chronic diseases were more likely to experience DS. Having a history of stroke (odds ratio (OR) = 2.2 in men and 1.8 in women), cancer (OR = 3.3 in men and 1.9 in women), or Parkinson’s disease (OR = 3.1 in men and 2.7 in women) was associated with high DS. In women, high income and high education levels were inversely related to DS. Being a single woman, long-term or heavy female smoker was associated with high prevalence of DS. High BMI was correlated with low prevalence of depression in men. Our data suggests a low prevalence of DS among middle-aged and elderly people in Shanghai, China. Age, education, income, marital status, smoking, BMI, and certain health conditions were associated with DS.
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Introduction
Depression, characterized by symptoms of sadness, depressed mood, and loss of interest, is one of the most prevalent disorders worldwide and accounts for 5.9% of total all-cause disability-adjusted life years (DALYs)1. Depression is associated with poor quality of life, prevalence of cancer, chronic diseases and suicide, and thus may contribute to an increase in mortality2. Depression casts a heavy burden on families, communities and health services in both developed and develo** countries3,4.
The prevalence of depressive symptoms (DS) varies widely, from 1% to 16% among middle-aged and elderly people in studies conducted in Western countries5,6,7. One study reported DS prevalence of elderly Chinese people being 3.9% during 1980s and 1990s8. Two recent meta-analysis studies reported the prevalence has been increasing rapidly because of urbanization and environmental changes in China, up to 17% among people aged 55 years and above using the Center for Epidemiologic Studies Depression Scale (CES-D)9,10.
Several socio-demographic characteristics, such as age, gender, marital status, education level, and income have been associated with DS11, although the evidence is not entirely consistent7,10. Age is associated with DS in many studies12, and interestingly, this association is inverse or U-shaped in several studies13,14,43 Other factors, including geography and urbanization, are found to be important factors in DS development, especially in China because from 2012 more than half of its population live and work in urban areas and there has been massive rural-to-urban migration to Chinese cities44. In a 2011 Migration and Quality of Life Survey, Chen et al. reported highly populated cities along the eastern coast such as Shanghai illustrated potential effects of urbanization as a stressor for mental health45.
In a Hong Kong study, Li et al. found that underweight individuals had a high prevalence of DS and overweight ones a low prevalence, compared to those in the normal weight range46. Yu et al. found that thin men had a higher prevalence of DS than normal weight men in Taiwan47. In rural China, obese men were found to be less likely to suffer from DS, compared with normal weight men48. Consistent with these Chinese studies, we found that BMI was negatively associated with prevalence of DS in men and in women. However, in two meta-analysis studies, one for cohort studies and another for cross-sectional studies, mainly conducted in Western populations, reported a significantly positive association between DS and obesity49,50. A United States-based study reported that major depressive symptoms were associated with a low BMI in men but a high BMI in women22. A study in the Netherlands observed a significant U-shaped association between BMI (underweight, normal, overweight and obesity) and DS, i.e., both obesity and underweight were associated with an increased risk of DS51. The underlying mechanism for this discrepancy is not entirely clear. Among middle-aged and elderly Chinese people, the prevalence of obesity is low (3.7% in this study) and severe obesity is rare; the association pattern might be explained by the ‘happy mind and fat body’ culture because many overweight or modestly obese people tend to be more optimistic and happier than those who are thinner in China21,46. But in Western countries, obesity, particularly morbid obesity, could be related to greater stress, stigma, chronic diseases and devaluation, causing obese people to suffer lower self-esteem and have a more negative self-image, resulting in more DS49. Although several studies reported that BMI or obesity is inversely correlated with DS, some of them only observed the impact of DS on BMI and did not observe an inverse effect of BMI on DS as we did in our study. This directionality could lead to a different conclusion. Forman-Hoffman et al. reported that the effects of DS on weight differ by gender, and concluded that DS at baseline may predict both weight loss and weight gain52. However, Konttinen et al. reported that men with depressive symptoms were likely to have a higher BMI, while women with a higher BMI were likely to develop depressive symptoms53. In middle aged and elderly Asian populations, depression can lead to weight loss rather than obesity, and being underweight may elicit DS unlike among Westerners who show a positive relationship between depression and obesity. These findings have implications for public health interventions by gender in China54.
Groffen et al. reported that only current smoking, not past smoking, was associated with DS in white women in US55. Current smoking was associated with increased prevalence of DS in the Korean and Japanese female populations56,57. On the other hand, a study in Eastern Europe found that current and past smoking was associated with DS in men but not in women58. Effects of smoking on DS are complex: Nicotine has antidepressant properties, releasing dopamine in the mesolimbic reward pathway, thereby elevating mood and relieving stress59. However, evidence has also suggested that smoking increases a person’s risk of DS as a result of changes in neurophysiology60. In our study, ever smoking rate in men was 71% (50.3% for current smoking, 20.7% for past smoking), much higher than in many western countries, but the prevalence of DS was low (2.4%). We found no statistical difference in DS between smokers and non-smokers among men in our study. However, smoking rate was low in women (2.0%) in our study, and female current smokers had a high prevalence DS compared with non-smokers. It is unclear whether such association was caused by women with DS seeking stress relief via smoking. An alternative explanation is that smoking was not socially acceptable for women, especially in urban China. Thus, female smokers could have low self-esteem which led to an increase of DS57,61.
Another contribution was that our study assessed whether DS was more likely to occur in an early vs. late stage of chronic disease (i.e., within 5 years of diagnosis, or after this period) to identify when risk for depression is most elevated. Depression is a significant problem for cancer patients in particular, either as a pre-existing or co-existing condition, or as a consequence of cancer diagnosis and treatment. Several studies have reported that the associations of cancer with DS lasted for varying lengths of time depending on the type of cancer23,62. However, few studies have focused on assessing DS among long-term cancer survivors in a non-medical setting62,63. In our population-based study, we found an increased DS prevalence primarily within 5 years post-cancer diagnosis. This association persisted but was attenuated when the time interval since diagnosis increased to beyond 5 years in women. These findings suggest a need of proper intervention and care for mental health for cancer survivors, particularly during the period soon after cancer diagnosis. Consistent with previous findings24,25, we found that patients with Parkinson’s disease or stoke had an increased prevalence of DS that appeared relatively consistent both before and after 5 years post-diagnosis. These associations call for a long term management/treatment approach.
Our study has many strengths, including a large sample size, a population-based design, and adjustment for a wide range of socioeconomic characteristics, lifestyle factors, chronic diseases, and cancer. Another noticeable strength is that the measure of all physical illnesses took place prior to the CES-D measurement, minimizing the risk of reverse causation. However, several limitations of our study should also be acknowledged. (1) The relatively low participation rate of 74.0% among men in the SMHS, compared with that of women in the SWHS, could lead to selection bias in parameter estimation. Reasons for non-participation included refusal, being out of the area during enrollment and other miscellaneous reasons, including health and hearing problems. However, lower participation of men is consistent with other large psychiatric epidemiology studies64, including those conducted in China65. A study from the Danish National Birth Cohort reported that in a cohort study based on prospective data, the decision to participate cannot be based on future outcomes; this suggests a minimal risk of bias in our study given that DS outcomes were collected prospectively66. (2) We used data from two large cohort studies: the SWHS and the SMHS. However, these datasets did not allow examination of some key risk factors, including but not limited to early childhood adversity and psychosocial stress at work. (3) We only included 6 CES-D questions instead of the full 20- or 26-item measure in the study, which may not have captured all possible DS and therefore could have resulted in an underestimate of the prevalence of DS in our study population. Further, the CES-D indicates the likelihood of clinical depression, not clinical depression itself. Our study would have been strengthened if our shortened DS measure was validated by a sub-sample where clinical interviews were conducted to evaluate our shortened measure’s ability to accurately detect clinical depression. However, these concerns are at least somewhat mitigated by the psychometric analyses that we conducted above on our 6-item measure. (4) Our study was conducted among long-term urban residents in Shanghai, one of the most developed cities in China. Thus, the results of our study may not be generalizable to all Chinese, particularly those living in rural areas or those who migrated to urban areas.
In conclusion, in this large population-based study of 103,595 Chinese women and men, we found that 2.4% and 5.6% of middle-aged and elderly Chinese men and women living in Shanghai experienced DS. Age and several socio-demographic characteristics and lifestyle factors, such as education, income, smoking, cancer and several chronic diseases were associated with DS. In future studies, qualitative approaches would be quite valuable in further elucidating the nature of DS among elderly, and whether these are tied to perceived changes in aging, health status, socioeconomic status, or cultural standing in relation to modernization. Findings of our study are value for development of prevention programs in identifying elderly individuals with DS for early intervention.
References
Whiteford, H. A., Ferrari, A. J., Degenhardt, L., Feigin, V. & Vos, T. Global Burden of Mental, Neurological, and Substance Use Disorders: An Analysis from the Global Burden of Disease Study 2010. PLoS One. 10, e0116820 (2015).
Cuijpers, P. et al. Comprehensive meta-analysis of excess mortality in depression in the general community versus patients with specific illnesses. Am J Psychiatry. 171, 453–462 (2014).
World Health Organization. Depression–a global public health concern. http://hesp-news.org/2012/10/05/depression-a-global-public-health-concern/ (2012).
Walker, E. R., McGee, R. E. & Druss, B. G. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry. 72, 334–341 (2015).
Wilhelm, K., Mitchell, P., Slade, T., Brownhill, S. & Andrews, G. Prevalence and correlates of DSM-IV major depression in an Australian national survey. J Affect Disord. 75, 155–162 (2003).
Waraich, P., Goldner, E. M., Somers, J. M. & Hsu, L. Prevalence and incidence studies of mood disorders: a systematic review of the literature. Can J Psychiatry. 49, 124–138 (2004).
Djernes, J. K. Prevalence and predictors of depression in populations of elderly: a review. Acta Psychiatr Scand. 113, 372–387 (2006).
Chen, R., Copeland, J. R. & Wei, L. A meta-analysis of epidemiological studies in depression of older people in the People’s Republic of China. Int J Geriatr Psychiatry. 14, 821–830 (1999).
Li, D., Zhang, D. J., Shao, J. J., Qi, X. D. & Tian, L. A meta-analysis of the prevalence of depressive symptoms in Chinese older adults. Arch Gerontol Geriatr. 58, 1–9 (2014).
Zhang, L., Xu, Y., Nie, H., Zhang, Y. & Wu, Y. The prevalence of depressive symptoms among the older in China: a meta-analysis. Int J Geriatr Psychiatry. 27, 900–906 (2012).
Gao, S. et al. Correlates of depressive symptoms in rural elderly Chinese. Int J Geriatr Psychiatry. 24, 1358–1366 (2009).
Brault, M. C., Meuleman, B. & Bracke, P. Depressive symptoms in the Belgian population: disentangling age and cohort effects. Soc Psychiatry Psychiatr Epidemiol. 47, 903–915 (2012).
Kessler, R. C. et al. Age differences in the prevalence and co-morbidity of DSM-IV major depressive episodes: results from the WHO World Mental Health Survey Initiative. Depress Anxiety. 27, 351–364 (2010).
Pan, A. et al. Prevalence and geographic disparity of depressive symptoms among middle-aged and elderly in China. J Affect Disord. 105, 167–175 (2008).
Li, Y. et al. Prevalence and risk factors for depression in older people in **’an China: a community-based study. Int J Geriatr Psychiatry. 27, 31–39 (2012).
Lorant, V. et al. Depression and socio-economic risk factors: 7-year longitudinal population study. Br J Psychiatry. 190, 293–298 (2007).
Van, d. V., Bracke, P. & Levecque, K. Gender differences in depression in 23 European countries. Cross-national variation in the gender gap in depression. Soc Sci Med. 71, 305–313 (2010).
Zhou, X. et al. The prevalence and risk factors for depression symptoms in a rural Chinese sample population. PLoS One. 9, e99692 (2014).
Van, der, Wurff, F. B. et al. Prevalence and risk-factors for depression in elderly Turkish and Moroccan migrants in the Netherlands. J Affect Disord. 83, 33–41 (2004).
O’Donnell, K., Wardle, J., Dantzer, C. & Steptoe, A. Alcohol consumption and symptoms of depression in young adults from 20 countries. J Stud Alcohol. 67, 837–840 (2006).
Kim, E. et al. Obesity and depressive symptoms in elderly Koreans: evidence for the “Jolly Fat” hypothesis from the Ansan Geriatric (AGE) Study. Arch Gerontol Geriatr. 51, 231–234 (2010).
Carpenter, K. M., Hasin, D. S., Allison, D. B. & Faith, M. S. Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study. Am J Public Health. 90, 251–257 (2000).
Dalton, S. O., Laursen, T. M., Ross, L., Mortensen, P. B. & Johansen, C. Risk for hospitalization with depression after a cancer diagnosis: a nationwide, population-based study of cancer patients in Denmark from 1973 to 2003. J Clin Oncol. 27, 1440–1445 (2009).
Hsu, Y. T. et al. Increased Risk of Depression in Patients with Parkinson Disease: A Nationwide Cohort Study. Am J Geriatr Psychiatry. 23, 934–940 (2015).
Ayerbe, L., Ayis, S., Wolfe, C. D. & Rudd, A. G. Natural history, Predictors and outcomes of depression after stroke: systematic review and meta-analysis. Br J Psychiatry. 202, 14–21 (2013).
Polsky, D. et al. Long-term risk for depressive symptoms after a medical diagnosis. Arch Intern Med. 165, 1260–1266 (2005).
Burgess, C. et al. Depression and anxiety in women with early breast cancer: five year observational cohort study. BMJ. 330, 702 (2005).
Shu, X. O. et al. Cohort Profile: The Shanghai Men’s Health Study. Int J Epidemiol. 44, 810–818 (2015).
Zheng, W. et al. The Shanghai Women’s Health Study: rationale, study design, and baseline characteristics. Am J Epidemiol. 162, 1123–1131 (2005).
Lin, N. Measuring depressive symptomatology in China. J Nerv Ment Dis. 177, 121–123 (1989).
Radloff, L. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1, 385–401 (1977).
Yu, J., Li, J., Cuijpers, P., Wu, S. & Wu, Z. Prevalence and correlates of depressive symptoms in Chinese older adults: a population-based study. Int J Geriatr Psychiatry. 27, 305–312 (2012).
Fan, P. et al. The discussion of current mental health status and mental health management strategy in China. Journal of Practical Medical Techniques. 20, 911–12 (2013 in Chinese).
Zhou, Y. Mental health social work in America and its significance to China. Journal of Sichuan University (Social Science Edition). 3, 127–32 (2010 in Chinese).
Kessler, R. C. et al. Anxious and non-anxious major depressive disorder in the World Health Organization World Mental Health Surveys. Epidemiol Psychiatr Sci. 24, 210–226 (2015).
Tiedt, A. D. Cross-national comparisons of gender differences in late-life depressive symptoms in Japan and the United States. J Gerontol B Psychol Sci Soc Sci. 68, 443–454 (2013).
Dong, X., Chen, R., Li, C. & Simon, M. A. Understanding depressive symptoms among community-dwelling Chinese older adults in the Greater Chicago area. J Aging Health. 26, 1155–1171 (2014).
Qin, X. et al. The prevalence of depression and depressive symptoms among adults in China: Estimation based on a National Household Survey. China Economic Review, https://doi.org/10.1016/j.chieco.2016.04.001 (2016)
Bartels, M. et al. Exploring the association between well-being and psychopathology in adolescents. Behav Genet. 43, 177–90 (2013).
McEwen, B. S. & Milner, T. A. Understanding the broad influence of sex hormones and sex differences in the brain. J Neurosci Res. 95, 24–39 (2017).
Bjelland, I. et al. Does a higher educational level protect against anxiety and depression? The HUNT study. Soc Sci Med. 66, 1334–1345 (2008).
Ross, C. E. & Mirowsky, J. Sex differences in the effect of education on depression: resource multiplication or resource substitution? Soc Sci Med. 63, 1400–1413 (2006).
Lorant, V. et al. Socioeconomic inequalities in depression: a meta-analysis. Am J Epidemiol. 157, 98–112 (2003).
Juan, C. Chronic Conditions and Receipt of Treatment among Urbanized Rural Residents in China. Biomed Res Int. 2013, 568959 (2013).
Juan, C., Shuo, C. & Pierre, F. L. Urbanization and Mental Health in China: Linking the 2010 Population Census with a Cross-Sectional Survey. Int J Environ Res Public Health. 12, 9012–24 (2015).
Li, Z. B. et al. Obesity and depressive symptoms in Chinese elderly. Int J Geriatr Psychiatry. 19, 68–74 (2004).
Yu, N. W., Chen, C. Y., Liu, C. Y., Chau, Y. L. & Chang, C. M. Association of body mass index and depressive symptoms in a Chinese community population: results from the Health Promotion Knowledge, Attitudes, and Performance Survey in Taiwan. Chang Gung Med J. 34, 620–627 (2011).
Dong, Q. et al. Obesity and depressive symptoms in the elderly: a survey in the rural area of Chizhou, Anhui province. Int J Geriatr Psychiatry. 28, 227–232 (2013).
De, W. L. et al. Depression and obesity: a meta-analysis of community-based studies. Psychiatry Res. 178, 230–235 (2010).
Luppino, F. S. et al. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry. 67, 220–229 (2010).
De, Wit, L. M., van, S. A., van, H. M., Penninx, B. W. & Cuijpers, P. Depression and body mass index, a u-shaped association. BMC Public Health. 9, 14 (2009).
Forman-Hoffman, V. L., Yankey, J. W., Hillis, S. L., Wallace, R. B. & Wolinsky, F. D. Weight and depressive symptoms in older adults: direction of influence? J Gerontol B PsycholSciSocSci6 2, S43–S51 (2007).
Konttinen, H. et al. Longitudinal associations between depressive symptoms and body mass index in a 20-year follow-up. Int J Obes (Lond) 38, 668–74 (2014).
**seok, K., Noh, J. W., Jumin, P. & Young, D. K. Body Mass Index and Depressive Symptoms in Older Adults: A Cross-Lagged Panel Analysis. PLoS One. 9, e114891 (2014).
Groffen, D. A. et al. Unhealthy lifestyles do not mediate the relationship between socioeconomic status and incident depressive symptoms: the Health ABC study. Am J Geriatr Psychiatry. 21, 664–674 (2013).
Noh, J. W., Juon, H. S., Lee, S. & Kwon, Y. D. Atypical Epidemiologic Finding in Association between Depression and Alcohol Use or Smoking in Korean Male: Korean Longitudinal Study of Aging. Psychiatry Investig. 11, 272–280 (2014).
Tanaka, H., Sasazawa, Y., Suzuki, S., Nakazawa, M. & Koyama, H. Health status and lifestyle factors as predictors of depression in middle-aged and elderly Japanese adults: a seven-year follow-up of the Komo-Ise cohort study. BMC Psychiatry. 11, 20 (2011).
Sapranaviciute-Zabazlajeva, L. et al. Correlates of depressive symptoms in urban middle-aged and elderly Lithuanians. Soc Psychiatry Psychiatr Epidemiol. 49, 1199–1207 (2014).
Mendelsohn, C. Smoking and depression–a review. Aust Fam Physician. 41, 304–307 (2012).
Markou, A. & Kenny, P. J. Neuroadaptations to chronic exposure to drugs of abuse: relevance to depressive symptomatology seen across psychiatric diagnostic categories. Neurotox Res. 4, 297–313 (2002).
Benjet, C., Wagner, F. A., Borges, G. G. & Medina-Mora, M. E. The relationship of tobacco smoking with depressive symptomatology in the Third Mexican National Addictions Survey. Psychol Med. 34, 881–888 (2004).
Honda, K. & Goodwin, R. D. Cancer and mental disorders in a national community sample: findings from the national comorbidity survey. Psychother Psychosom. 73, 235–242 (2004).
Mitchell, A. J. et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncol. 12, 160–174 (2011).
Demyttenaere, K. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA. 291, 2581–90 (2004).
Phillips, M. R. et al. Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey. Lancet. 373, 2041–53 (2009).
Nohr, E. A., Frydenberg, M., Henriksen, T. B. & Olsen, J. Does low participation in cohort studies induce bias? Epidemiology. 17, 413–8 (2006).
Acknowledgements
This study was supported by grants from the US National Institutes of Health and the Intramural Research Program of the National Institutes of Health, National Cancer Institute (R37 CA070867 and UM1 CA182910 to Wei Zheng, and R01CA082729 and UM1 CA173640 to **ao-Ou Shu). The authors thank all participants and staff members of the Shanghai Men’s Health Study and Shanghai Women’s Health Study for their important contributions and Ms. Nan Kennedy for editing and preparing the manuscript.
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Q.L. and H.C. contributed to the study design, the data analysis, interpretation of the research and the manuscript writing. H.L., H.C. and G.Y. contributed to participating data collection and management. Y.X., G.Y., Y.G., L.Y., E.S., W.Z. and X.S. reviewed the manuscript and provided critical comments and suggestions.
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Liu, Q., Cai, H., Yang, L.H. et al. Depressive symptoms and their association with social determinants and chronic diseases in middle-aged and elderly Chinese people. Sci Rep 8, 3841 (2018). https://doi.org/10.1038/s41598-018-22175-2
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DOI: https://doi.org/10.1038/s41598-018-22175-2
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