A cross-sectional study on the health related quality of life of depressed Chinese older people in Shanghai

BackgroundWith an increasing life expectancy, there is a rapidly growing sector that is aging. Depression is the most prevalent functional mental disorder of older population. It is estimated that about 21% of the older population in Shanghai are
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  A cross-sectional study on the health related quality of lifeof depressed Chinese older people in Shanghai Sally Wai-chi Chan 1 *, J. I. A. Shoumei 2 , David R. Thompson 1 , H. U. Yan 2 , Helen F. K. Chiu 3 ,Wai-tong Chien 1 and Linda Lam 3 1 The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China 2 School of Nursing, Fudan University, Shanghai, China 3  Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, China SUMMARY Background  With an increasing life expectancy, there is a rapidly growing sector that is aging. Depression is the mostprevalent functional mental disorder of older population. It is estimated that about 21% of the older population in Shanghaiare suffering from depression. Aim  This study investigated the self-rated health related quality of life of community-dwelling older people diagnosedwith depression in Shanghai, and to examine the relationships between this and mental and physical health, functional statusand social support. Methods  A cross-sectional survey was conducted in two community centres with a convenience sample of 71 participants.Measures included subjective perception of health related quality of life, level of depression, cognitive function, number of medical conditions, activities of daily living, functional abilities, and social support. The majority of the participants werefemale ( n ¼ 52, 73.23%), and married ( n ¼ 51, 71.8%). Results  A higher level of depression was related to a poorer health related quality of life. Participants were least satisfiedwith their physical health. The level of depression, activities of daily living and satisfaction with social support werepredictors of health related quality of life ratings. Conclusion  The study identified how depression affects the bio-psychosocial status of Chinese older people. Findings arediscussed in light of the socio-cultural environment in Shanghai. Copyright # 2006 John Wiley & Sons, Ltd. key words —health-related quality of life; Chinese older people; depression; Shanghai INTRODUCTIONChina has a population of 1.3 billion and, like othercountries in the world, with an increasing lifeexpectancy, there is a rapidly growing sector that isaging. The demand for and importance of geriatriccare is now even greater. Shanghai, one of the mostindustrialized cities in China, has a population of 13.5million, of which 15% (over 2 million) are aged65 years or above.Depression is the most prevalent functional mentaldisorder of older populations (World Health Organ-ization, 2004). A study in Shanghai showed thatthe prevalence rate of depression in older people(age   65 years) was 21%, which is considered veryhigh (Lu  et al ., 2001). Depression imposes asubstantial personal, economic and social burden onthose afflicted as well as on their families (Pyne  et al .,1997) and this is especially problematic for olderpeople. Thus, there is a need to improve theassessment and intervention for this particularlyvulnerableand significantgroup.In the past, treatmentoutcome research on depression tended to focus onpatients’ symptoms severity. Health related quality of life (HRQoL) is now considered an importantobjective in the care of older people. To date, therehas been a relative paucity of research examining theHRQoL of older people with depression, especially inan Asian population, and the measurement of factors INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY  Int J Geriatr Psychiatry  2006;  21 : 883–889.Published online in Wiley InterScience (  DOI : 10.1002/gps.1578*Correspondence to: Prof. S. Wai-chi Chan, Room 733, Esther LeeBuilding, The Nethersole School of Nursing, The Chinese Universityof Hong Kong, Shatin, New Territories, Hong Kong SAR, China.E-mail: Copyright # 2006 John Wiley & Sons, Ltd.  Received 24 January 2006  Accepted 1 March 2006   influencing their HRQoL. Thus, the aim of thisstudy was to investigate the self-rated HRQoL of community-dwelling older people diagnosed withdepression in Shanghai, specifically: to provide aprofile of HRQoL of older people with depression;and to examine the relationships between this andtheir mental and physical health, functional status,and social support. The results of this study arediscussed in light of the socio-cultural environmentin Shanghai.METHODS Participants From May to October 2005, a cross-sectionaldescriptive survey was conducted in two communitycentres in Shanghai which serve a population of around 375,000 older people. Each centre containsactivities unit, primary health care unit and mentalhealth care unit. The participants of this study wererecruited from the mental health care unit of the twocentres.Althoughthese twocommunity centres werenot randomly selected, the sociodemgraphic charac-teristics of the populations served are comparable toother centres in Shanghai (Feng  et al ., 2005). Theinclusion criteria were: age 65 years or above,Shanghai Chinese residents, a diagnosis of majordepressive disorder according to the criteria of the  Diagnostic and Statistical Manual of Mental Disorders  (4th edition) (American PsychiatricAssociation, 1994). Those with co-morbidity of other mental disorders or with language or com-munication difficulties were excluded. The mentalhealth centres have a weekly attendance rate of 1,440. It was estimated that half of which would beeligible for this study. A convenience sample of 71depressed older people was recruited, which wasabout 10% of the eligible attendees. This sample sizewas sufficient to give a power 0.80 for bivariatecorrelation tests with an alpha of 0.05 and amoderate effect size (0.50) (Cohen, 1988).  Instruments Data were collected by face-to-face interview. Theseincluded participants’demographic data, their percep-tion of HRQoL, cognitive function, mental andphysical health, functional status and perception of social support.HRQoL was measured by the 28-item Hong KongChinese World Health Organization Quality of LifeScale-Brief Version (WHOQOL-BREF), modifiedfrom the WHOQOL-100, a multilingual assessmentfor generic quality of life, and translated into Chinese(Leung  et al ., 1997; World Health OrganizationQuality of Life Group, 1998). The items structure infour domains: physical health, psychological, socialrelationship and environment, and are rated on a five-point Likert scale, with a high score indicating betterquality of life (score range: 28–140). Psychometricproperties of the translated version were found to besound (Cronbach’s alpha coefficients ¼ 0.67 to 0.79;test–retest reliability Pearson’s  r  ¼ 0.64 to 0.90) forapplication to older Chinese people (Leung  et al .,1997).The Chinese version of the Mini-Mental StateExamination (Chinese MMSE) (Folstein  et al ., 1975;Li etal .,1988)isabrieftestforcognitivementalstatusof older people, with good reliability reported. ThisChinese version has been used in studies in Shanghaiwith good discriminant validity reported (Lin  et al .,2003)The Chinese version of the 15-item GeriatricDepression Scale (GDS) (Yesavage  et al ., 1983;Lee  et al ., 1993) is a widely used scale for detection of depression in Chinese older people, with goodsensitivity and specificity. The cut-off score of    8is recommended as an indication of depression (Lee et al ., 1993).The Chinese version of the 15-item ModifiedBarthel Index (MBI) (Granger  et al ., 1979; Woo et al ., 1994) measures functional independence. It hasa total score ranging from 0 (total dependent) to 100(independent). Good construct validity has beendemonstrated (Woo  et al ., 1994).The Chinese version of the eight-item InstrumentalActivities of Daily Living(IADL)(Lawtonand Brody,1969) is a commonly used instrument in assessing theability of older people to perform their IADLs withgood validity and reliability being reported. Higherscore indicate better functioning (possible range ¼ 8–40).The 15-item Physical Health Problems Checklist(such as hypertension, renal disease, stroke anddiabetes) assesses physical health problems. It hasbeen used extensively in medical research to assesshealth problems in older people (Yip, 2003).The Chinese version of the Social SupportQuestionnaire (SSQ-6) (Sarason  et al ., 1987; Chang,1999) is a six-item scale that measures individual’ssources of social support in their immediate socialenvironment and level of satisfaction with thissupport. The items are rated on a six-point Likertscale (from 6 ¼ very satisfied to 1 ¼ very dissatis-fied). Copyright # 2006 John Wiley & Sons, Ltd.  Int J Geriatr Psychiatry  2006;  21 : 883–889. 884  s. wai-chi chan  ET AL.  Procedure This study was approved by the study venues. Olderpeople in the community centres were assessed andthose who met the inclusion criteria were referred tothe researcher.An information sheet that described thepurpose of the study, its potential risks/benefits, andrights to confidentiality and withdrawal, was dis-tributed to all participants. A clear explanation wasgiven to ensure the participants had a full under-standing of the information presented. Those whogave their written informed consent were interviewed.  Data analysis The Statistical Product and Service Solutions (SPSS)for Windows version 13 (SPSS Inc., Chicago, IL,USA) was used for all analyses. Descriptive statisticswere used to summarise data. Pearson’s ProductMoment Correlation test was used to examinerelationships between variables (total score of measures: WHOQOL-BREF total and domain,MMSE, GDS, MBI, IADL, Physical Health ProblemsChecklists and SSQ-6). Variables that had significantcorrelations were put into the equation for stepwisemultiple linear regression analysis to investigate therelative importance of the variables in describingthe variation in the WHOQOL-BREF total score. Thelevel of significance of all statistical tests was setat 0.05.RESULTSSeventy-one participants enrolled in the study. Table 1summarises their demographic characteristics. Overthree-quarters were females, the majority weremarried and had attained a secondary level education.All of them were receiving antidepressant therapy and21% ( n ¼ 15) had a history of hospital admission.Thirty percent ( n ¼ 21) of the participants lived aloneor with their spouse. They were all retired and had apension of around RMB$1000 (  £72) a month.Table 2 shows the range, mean and standarddeviation (SD) of the scores of all the rating scales. Table 1. Demographic data ( n ¼ 71)Frequency PercentageGenderMale 19 26.8Female 52 73.2Age (years)65–70 36 50.771–75 18 25.476–80 13 18.381–85 2 2.886–90 1 1.4 > 90 1 1.4Marital statusSingle 0 0Married/Cohabiting 51 71.8Separated 3 4.3Widow/Widower 17 23.9Education levelUniversity graduate 8 11.3High school 3 4.2Secondary 29 40.8Primary 20 28.2Illiterate 11 15.5Medication: OralYes 71 100.0No 0 0No. of hospital admissionNone 56 78.91–3 13 18.3 > 3 2 2.8Table 2. Summary scores of rating scales ( n ¼ 71)Measure Possible range Actual range Mean (SD)Mini-Mental State Examination 0–30 16–30 23.76 (5.61)Modified Barthel Index 0–105 10–105 92.14 (20.60)IADL Scale 8–40 10–40 32.15 (7.32)Geriatric Depression Scale 0–15 8–15 10.06 (1.76)No. of medical conditions 0–13 0–6 2.08 (1.53)Social Support QuestionnaireNo. of social support 0–6 0–6 4.90 (2.02)Satisfaction 0–36 6–36 22.03 (7.65)WHOQOL-BREF total 28–140 48–103 78.17 (10.99)Physical 0–20 6–15 10.70 (2.10)Psychological 0–20 6–17 11.03 (2.07)Social 0–20 8–16 11.79 (2.20)Environmental 0–20 6–15 12.03 (2.16)Copyright # 2006 John Wiley & Sons, Ltd.  Int J Geriatr Psychiatry  2006;  21 : 883–889. health related quality of life of depressed chinese older people  885  The majority of participants had no cognitiveimpairment (MMSE mean ¼ 23.7, SD ¼ 5.6). TheGDS scores indicated that they demonstratedvarying levels of depression. The MBI(mean ¼ 92.14, SD ¼ 20.60) and IADL scores(mean ¼ 32.15, SD ¼ 7.32) suggested that mostcould function independently. Participants sufferedfrom an average of two medical conditions, the mostfrequent being impaired visual and auditory acuity.The mean rating of satisfaction with supportreceived was 22 (SD ¼ 7.6), indicating a moderatelevel of perceived social support, with children beingtheir main source. The WHOQOL-BREF total andall domain scores were just above the mean.Participants rated lowest in terms of their physicalhealth domain.Table 3 shows the correlations between theWHOQOL-BREF total and domain scores, andphysical, psychological and social variables. TheWHOQOL-BREF total, physical and psychologicaldomain scores had a significant correlation withparticipants’ functional abilities and abilities toperform activities of daily living, and a negativecorrelation with their level of depression. Thephysical domain scores also were negativelyassociated with and the number of medical con-ditions. The WHOQOL-BREF total, psychologicaland social domain scores had a significant corre-lation with the satisfaction of social support. Theenvironmental domain scores correlated withparticipants’ functional abilities and level of depression.Those variables that had significant correlationswith the WHOQOL-BREF were entered into theequation for multiple regression analysis. The totalscore of GDS, MBI and satisfaction of social supportwere three correlates that contributed significantly tothe variance in the WHOQOL-BREF total score,accounting for 69% of the variance (df  ¼ 3, F  ¼ 232.87,  p < 0.001) (Table 4).DISCUSSIONThe socio-demographic characteristics, such aseducational level, marital status and income, of the participants in this study are comparable toprevious studies of depressed older people inShanghai (Lu  et al ., 2001). Over three-quarters of the participants in this study were women, a findingconsistent with epidemiological studies in Cauca-sian populations, indicating that more women thanmen suffer from depression. Most participants weremarried, a finding that differs from Western studies,where the majority of depressed older people were Table 3. Correlations between WHOQOL-BREF total and domain scores and other measures ( n ¼ 71)MeasureWHOQOL-BREFTotalWHOQOLPhysicalWHOQOLPsychologicalWHOQOLSocialWHOQOLEnvironmentalMini-Mental State Examination 0.145 0.194 0.200   0.097 0.023Modified Barthel Index 0.323  0.409  0.241   0.035 0.253  IADL Scale 0.443  0.524  0.329  0.068 0.338  Geriatric Depression Scale   0.469   0.321   0.492   0.164   0.290  No. of medical conditions   0.033   0.290  0.004 0.188 0.116Social support questionnaire—No. of social support 0.083 0.030 0.072 0.092   0.006—Satisfaction 0.365  0.210 0.342  0.266  0.233  correlation is significant at the 0.05 level (two-tailed).  correlation is significant at the 0.01 level (two-tailed).Table 4. Results of stepwise multiple regression analysis—Predictor variables of WHOQOL-BREF total scores ( n ¼ 71)Variables df Beta Adjusted  R  Square  F p MBI total score 3, 70 0.17 0.69 232.87  < 0.001GDS total score   0.72  < 0.001Social support satisfaction total score 0.12  < 0.001Copyright # 2006 John Wiley & Sons, Ltd.  Int J Geriatr Psychiatry  2006;  21 : 883–889. 886  s. wai-chi chan  ET AL.  widowed (Shmuely  et al ., 2001; Naumann andByrne, 2004). However, as Shanghai is one of themost industrialized cities in China, the sociodemo-graphic characteristics of the older people living inShanghai would be different from those older peopleliving in rural areas of China.The WHOQOL-BREF scores were found to besignificantly associated with the severity of depres-sion. A higher level of depression was related to apoorer HRQoL, which is consistent with Westernstudies (Shmuely  et al ., 2001; Naumann and Byrne,2004). Though all participants received anti-depressants, some remained depressed as judgedby the GDS scores. The results may reflect theclinical features of this client group, such as lack of ability to enjoy life, difficulties in concentration andreduced energy that impacts on many aspects of theirlives, thus culminating in a poor HRQoL. It isnoteworthy that some participants had lowIADL andMBI scores and they suffered from a number of medical conditions, and limited functioning maycause an individual to become depressed (Shmuely et al ., 2001). Negative mood associated withdepression can also lead to a reporting bias in thatparticipants may report their HRQoL and function-ing in a negative light (Shmuely  et al ., 2001). Astudy with a larger sample, including depressed andnon-depressed participants, is needed to establishsuch a causal relationship.This study found that number of medicalconditions was not a predictor of the total score of the WHOQOL-BREF, a finding similar to thatreported in Western studies (Livingston  et al .,1998; Naumann and Byrne, 2004). The MBI scorehad a positive correlation with, and was also apredictor of, HRQoL. Older people who had betterfunctional abilities would have better perceivedHRQoL. Poor functional ability is likely to lead todependence, and this is particularly problematic forolder people in China, which has opened up itsmarkets during the past twenty years. China ingeneral, and Shanghai in particular, has beenundergoing enormous socio-economical changes.As a consequence, there are significant changes inthe traditional family structure and function. Nuclearfamilies have become much more widespread andgrown-up children are staying away from theirparents. Due to the highly competitive job market,people usually have very long working hours. Manyyoung people have to move to other cities to get a job, thus leaving their older parents behind. In thisstudy, 30% of the participants lived by themselves orwith the spouse only. There may not be anyone left totake care of dependent older people who may needhelp in their activities of daily living, and who mayfind it difficult to come to terms with these changes.It is not a common practice for such people to stay inan old age home as the Chinese believe that childrenare obliged to take care of their parents. Many olderpeople still hold the belief that staying in an old agehome indicates abandonment by one’s children.Also, old age homes are not readily available inShanghai. Thus, any deterioration in functioning cangenerate insecurity and worries in older people.Contrary to previous studies that depressed olderpeople were mostly dissatisfied with their psycho-logical domain (Naumann and Byrne, 2004), thisstudy shows that they are most dissatisfied with theirphysical domain. The participants suffered from anaverage of two medical conditions, the most frequentbeing impaired visual and auditory acuity. Thesesensory impairments might severely affect theindividual’s independence, thus resulting in a poorHRQoL. The findings could also reflect the uniqueaspect of the Chinese culture. Literature suggestedthat somatisation is common among Chinese.Chinese tend to report physical symptoms such asinsomnia, anorexia,poor memory andconcentration,tiredness and dizziness, rather than talking abouttheir feelings and emotions (Chan and Leung, 2002).Further studies are needed to explore the influence of culture on the participants’ perception of HRQoL.Satisfaction with social support had a positivecorrelation with the WHOQOL-BREFtotalscores andis one of the predictors of HRQoL. Most participantsregardedtheirchildrenastheir mainsourceofsupport,although they were not very satisfied with the supportthey received. Traditionally, the Chinese place greatvalues on filial responsibility and children areexpected to look after their old parents. As mentionedearlier, due to recent rapid social economic develop-ments in Shanghai, older people may not be able to getthe support that they feel they need or deserve. Thisstudy shows that participants who were more satisfiedwith their social support had higher ratings in theirperception of HRQoL, a finding similar to thatreported in the Caucasian population (Harris  et al .,2003). However, it is noteworthy that satisfaction withsupport could be influenced by the person’s mood(Harris  et al ., 2003). Future studies with larger samplesizes could investigate the causal relationship amongperception of quality of life, depression and socialsupport.The different HRQoL measures used in previousstudies did not allow ready comparison with thefindings from this study. There has been one study Copyright # 2006 John Wiley & Sons, Ltd.  Int J Geriatr Psychiatry  2006;  21 : 883–889. health related quality of life of depressed chinese older people  887
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