Lifestyle Factors In Late Onset Depression: A

Comparison Between Treatment Seeking Population And

Matched Healthy Controls.

Thesis submitted in partial fulfillment of the regulations of the

National Institute of Mental Health and Neurosciences

(Deemed university)

For the degree of

Doctor of Medicine in Psychiatry

Dr. Ramkumar G S

DEPARTMENT OF PSYCHIATRY

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEUROSCIENCES

(Deemed University)

BANGALORE-560029

INDIA

2011

DECLARATION

I, Dr. Ramkumar G S, hereby declare that the thesis titled

“Lifestyle Factors In Late Onset Depression : A Comparison Between

Treatment Seeking Population And Matched Healthy Controls”, was

carried out by me under the guidance of Dr. Srikala Bharath, Professor of

Psychiatry, Dr. P T Sivakumar, Asst. Professor of Psychiatry and Dr.

Seema Mehrotra, Assoc. Professor of Mental Health and Social Psychology

at the National Institute of Mental Health And Neurosciences (NIMHANS,

Deemed University), Bangalore.

I also declare that no part of this study has previously been

submitted as thesis for any degree or diploma of any University.

October 2010 Dr. Ramkumar G S

ACKNOWLEDGEMENTS

My sincere thanks to Prof. Srikala Bharath who has been a constant source

of encouragement and guidance over the last two years during the course of

this research work.

My sincere thanks to Dr P T Sivakumar and Dr Seema Mehrotra for their

guidance and support.

I am grateful to Dr K Thennarasu, Assoc. Prof. of Biostatistics for statistical

assistance and Mrs Beena, (Nutritionist) for assistance in developing the

scale for dietary assessment.

I express my gratitude to all the staff of the Geriatric Clinic, NIMHANS who

have always been most supportive.

Special thanks to all the research participants who patiently sat through the

interview and cooperated whole heartedly for this endeavor.

I am thankful to all my friends at Kabini Hostel who have helped me with

the statistical software, reference manager software and helping in putting

the manuscript in order.

CONTENTS

S. no Chapter Pages

1 List of Tables, Figures and Appendices i

2 Introduction 1-6

3 Review of literature 7-29

4 Aims and Objectives 30

5 Methodology 31-35

6 Results 36-43

7 Discussion 44-49

8 Conclusion and Summary 50-52

9 Bibliography 53-61

10 Appendices 62-84

List of Tables 1(a) Cross-sectional Studies on Diet and Depression……………………………….17 1(b) Cohort Studies on Diet and Depression…………………………….…………….18 2(a) Cross sectional studies in Physical Activity and Depression……….….…….20 2(b) Cohort studies in Physical Activity and Depression……………………………21 3 Studies looking at Socialization and Depression…………………….….………27 4 Socio- Demographic Data……………………………………………………..……..37 5(a) Comparison of Diet Parameters……………………………………………….…….38

5(b) Comparison of individual dietary item……………………………………….……38 6 Comparison of individual items for physical activity ……………………….…40 7 Comparison of individual items for socialization ……………………….……..41

List of Figures 1. Comparison of self reported opinion on diet………………………………………….39 2. Comparison of self reported opinion on physical activity………………..……….40

List of Appendices

1. Life style Assessment questionnaire

2. HDRS Scale (Hamilton Depression Rating Scale)

3. Hachinski Ischemic Score

4. Cumulative illness Rating scale for Geriatrics (CIRS-G)

5. Hindi Mental State Examination (HMSE)

6. MINI Screen

7. Consent form

8. Ethics committee approval letter i

This document is licensed under the Creative commons attribution license 3.0

http://creativecommons.org/licenses/by/3.0/ Contact author at ram3481@gmail.com http://twitter.com/ram3481 http://ramposters.blogspot.com/ http://www.slideshare.net/ram3481/presentations

1

INTRODUCTION

Elderly population is increasing globally due to demographic transition. As per the United

Nations estimate the global life expectancy at birth which is now at 68.9 years (India-65.2

years) is expected to increase to 75.5 years (India -73.3 years) in 2050. The proportion of

population over 60 years of age in the world is also expected to double from the current

value of 11%. In absolute numbers the population over 60 years in the world has surpassed

700 million in 2009 and it is expected to increase to 2 billion in 2050 (1).

There exist a marked difference in the number and proportion of the aged in developed and

developing regions. While in the developed countries the proportion of the elderly is

projected to increase from current level of one fifth of the population to one third of the

population in 2050, the same for the developing countries is expected to increase from

current level of 2/25th to one fifth of the population. Thus developing countries will tend to

equal the current proportion of elderly of the developed countries by 2050. However this

growth in the background of the lower levels of socio-economic development and the

continuing higher prevalence of infectious diseases is going to pose a greater challenge. In

India the population above 60 years in 2010 is 91.7 million (7.5%) and it is expected to

increase to 315.6 million (19.6%) in 2050 (2).

Though old age should not be considered as a disease the elderly are considered more

vulnerable to disabling and chronic diseases such as cardiovascular, neurological, cancer,

Diabetes, Hypertension, musculoskeletal and mental illnesses. Due to industrialization, rapid

urbanization, and increasing demographic change with smaller families, the pattern of life is

undergoing rapid change. Adult members are increasingly forced to migrate to urban areas in

2

search of livelihood. These changes are having direct impact on the health care needs of the

elderly.

Mental health in the elderly

The geriatric population is affected by the same psychiatric disorders as younger adults

however Dementia and Delirium have greater prevalence in comparison (3, 4). Depression is

the leading cause of disability when measured as Years Lost to Disability (YLD) and the

fourth leading contributor to the global burden of disease when assessed as Disability

Adjusted Life Years (DALYs). By year 2020 Depression is projected to reach the second

place in the ranking of DALYs calculated for all ages and for both sexes (5).

The lifetime incidence of depression is 26.9% for men and 45.2% for women in people up to

70 years of age (6). The prevalence of depression in the total population is generally

estimated at 5-8%. In elderly people (usually 65 years old and older), the prevalence is

generally estimated at 12-15%. The prevalence is even more higher in elderly who seek out-

patient care ranging from 18% to 36% (7).

The prevalence of Major Depressive Disorder in individuals more than 65 years was

estimated to be 1.4% in women and 0.4% in men with over all prevalence of 1% (8). A

recent study (9) also report higher prevalence rates in women -12.4% vs. 7.8% in men

however this gender gap becomes narrower in the ―oldest old‖ (10). The prevalence of sub-

syndromal depression in the elderly population in East Asia is about 8-9% (11). Other

epidemiological studies have reported prevalence rates ranging from 1%- 5% (10, 12).

The low percentages of prevalence rates in many epidemiological studies are believed to be

underestimations because of the difficulties in detecting depression in elderly. Patients and

care givers may wrongly attribute it to the ageing process and identifying the symptoms

3

when they coexist with medical illness may need skilful observation by the physician. It has

been noted that older people tend to report more physical complaints and under report

depressed mood making it difficult to use the established diagnostic criteria for the depressed

in the elderly. Very often they have combination of mild depression symptoms, ―non-

dysphoric‖ depression, dysthymia, persistent dysphoria associated with anxiety, pain in

multiple areas etc. Prevalence percentages can also vary because of population studied,

sample size, definition of depression, and method of diagnosis.

Geriatric depression in India.

In the Indian setting studies report higher prevalence rates for depression in comparison to

studies from the west. A community survey in the year 1976 (n= 1060, all age groups)

reported that the incidence of mental health disorders in the people above 60 years was

higher (75/ 1000) compared to younger age groups (13). A study done later by the same

authors in 1997 which was also a community survey of people over 60 years (n=183)

reported the prevalence of total mental morbidity as 612/1000 and depression as 522/1000

population. Depression was the most common mental disorder in this study (14). A

community survey of people more than 50 years (n= 408) in South India found that

psychiatric disorders were present in 35% (350/1000)of the elderly population out of which

the prevalence of depression was found to be much higher than any other psychiatric

disorder- 59% of the diseased (15).Another study put the prevalence rate of mental illness

at 89/1000 with depressive illness accounting for 67% of mental disease burden in a

community sample of 686 elderly (16). In a study conducted in rural population in northern

India the prevalence rate of psychiatric morbidity was 43.3% and the commonest diagnosis

was neurotic depression, Manic Depressive Psychosis (MDP) depression, and anxiety state

4

in descending order of frequency (17). A recent study from Mumbai has indicated that the

point prevalence of depressive symptoms in more than 60 years elderly is 45.9% (18).

Geriatric Depression- Characteristics

Geriatric Depression may represent a heterogeneous group of disorders that differ in

etiology, pathophysiology and prognosis, some of which may be distinct from the depressive

disorder experienced by younger adults. One example of heterogeneity is the distinction

between the late life patient with Recurrent Depressive Disorder (RDD) with onset of first

episode early in life (Early Onset Depression– EOD) and the older patient with onset of

major depressive illness after age of 50 years (Late Onset Depression– LOD).

Comparison of Late Onset Depression (LOD) and Early Onset Depression (EOD).

Patients with LOD have lower family history of depression and greater magnetic resonance

imaging abnormalities (MRI) abnormalities compatible with ischemic cerebrovascular

disease (19, 20). Vascular Factors (Hypertension, Coronary Vascular Accident, Ischemic

Heart Disease and Diabetes Mellitus) were found to increase the risk of depression in the

LOD (21-26).

In a study (unpublished thesis) it was seen that patients with LOD had more impairment in

executive functions indicating a frontal lobe involvement when compared with EOD (27) .

LOD was also seen to be associated with more neurological soft signs and cognitive deficits

than EOD. The increased association of cognitive impairment with LOD supports an

underlying organic origin (23,28) and LOD may be a possible fore runner for Alzheimer‘s

dementia (8,29).

Based on phenomenology EOD is understood to be associated with more feelings of guilt

(30, 31) and psychotic symptoms (32). It is also associated with more agitation and anxiety

5

symptoms while LOD on the other hand is associated with more somatic complaints (33).

Apathy is more prominent in LOD than in EOD (31). However some studies did not find any

difference in phenomenology between the two types (34). An Indian study reported a trend

to increased agitation and restlessness rather than retardation in the depressed elderly when

compared with younger adults(16).

The higher family history of affective disorders in EOD compared to LOD might indicate a

greater importance of genetic factors in EOD (32,33,35-38). LOD is associated with greater

life stressors and has greater chance of becoming chronic rather than recurrent (39).Two

different etiological pathways are also proposed for LOD -one through the experience of

severe life stressors and the other through biological changes in the brain (40).

In a community based longitudinal study (41) which compared women with LOD, EOD and

No MDD( Major Depressive Disorder), no difference between groups was found on marital

conflict and social support. Those with EOD scored higher than those in the LOD and No

MDD groups on neuroticism. Those with LOD reported poorer health than those with No

MDD at 10 years prior to diagnosis. The authors suggested that poor health and not

psychosocial risk factors or neuroticism predispose otherwise healthy adults to developing

depression for the first time in late-life. An earlier Indian study (42) also reported that

physical disabilities had significant association with LOD and it limits the movement of the

subject and in combination with environmental conditions lead on to a feeling of loneliness

and depression.

However conceptually the critical question remains as to whether these differences result

primarily from age associated physiological changes and a high prevalence of co-morbid

medical conditions (differences in young vs. old patients) or whether late life depression is a

disease entity distinct in its presentation, etiology, course and treatment response from

6

illness affecting the younger adults (difference in EOD vs. LOD). LOD is also being

increasingly considered as a life style disease especially because of its close association with

vascular diseases for which lifestyle influences have been strongly demonstrated. Research

by various groups internationally is active in this field and this study is being planned to

explore the same in an Indian setting.

7

REVIEW OF LITERATURE

The Concept of Life-Style

The simple sociological definition of lifestyle is ―the way a person lives‖.It includes aspects

like consumption, entertainment, diet, social interactions and so on. It can be summarised as

a conscious or unconscious choice of one set of behaviour over another. Lifestyles can be

used for making broad social classifications based upon income and occupation, spiritual and

religious preferences, traditional vs. modern, rural vs. urban etc.

Lifestyle diseases also refered to as diseases of longevity are defined as diseases that develop

as people live longer. This came from the realization that living long was good but the

quality of life was also important. Changes in diet, lifestyle and environment are thought be

behind the genesis of these disorders which affects quality of life in old age. Commonly

referred life style disorders are Diabetes Mellitus, Hypertension, Heart disease, Stroke,

Cancer, Osteoporosis, Cirrhosis and so on. Recent studies indicate that Dementia and other

late onset psychiatric disorders like depression can also result secondary to lifestyle factors.

These diseases directly influence morbidity and mortality in late life. The pattern of life style

diseases is that they develop as degenerative process which has insidious onset, take many

years to manifest and is difficult to cure. Depression however does not easily fit this pattern

as its course can be self limiting with recurrence in episodic pattern although there is a

tendency for chronicity in geriatric depression (39).But the fact that it can cause severe

morbidity and disability is not widely known .

Evidence for life-style diseases

The existance of lifesyle diseases is exemplified by the differential incidence of diseases in

different nations and cultures. The differential incidence of cancer between the western

countries and the developing countries is linked to the difference in dietary pattern and

8

physical activity (43). This study further adds weight to the said hypothesis by finding that

the incidence of cancer takes on that of the host nation in people who migrate to it thus

indicating that environmental factors are important determining risk factor rather than

genetic factors for accounting for international variation in cancer incidence.

This implies that modifiable evironmental factors can be put to advantage to reduce the

incidence of these lifestyle diseases and therefore has enormous importance in a public

health perspective. Studies have proven benefits of such interventions in various physical

illnesses like in cardiovascular diseases, stroke and more recently in cognitive impairment

(44,45).

Life style and health outcomes

The life style factors that have been found to influence genesis of physical illnesses are also

plausibly thought to influence genesis of psychiatric illness. It appears logically possible

especially in late life psychiatric illness like LOD and Dementia because of the increasing

evidence of association of vascular causes with both of them.

This area is being extensively researched by researches having affiliation to diverse

disciplines. Many aspects of lifestyle are being looked into by these researchers and their

approach has also been influenced by their disciplinary allegiance.

The Alameda country study is a land mark study of a community cohort followed up from

1965 to 1999 (46). A study published from this cohort (47) examined the relationship

between physical health status and health practices. They looked at hours of sleeping in the

night, regularity of meals, physical activity, alcohol consumption, and smoking. They found

that sleeping 7-8 hours per night, eating regular meals, participating in regular exercise,

limiting alcohol consumption, and not smoking were highly correlated with healthier

9

individuals. This study provided initial empirical support for the link between lifestyle and

health outcomes.

A 5.5 years follow up study (48) used the same parameters and additional ones of weight

and BMI to study the relationship of lifestyle to mortality. It was found that those who ate

regular meals including breakfast, received adequate sleep (7–8 hours), maintained healthy

weight for their height, did not smoke, limited alcohol consumption, and participated in

regular physical activity lived longer than those who did not practice these behaviors.

However more recent studies did not find the relationship of not eating breakfast and

snacking between meals to be associated with adverse health outcomes as previously noted.

These health habits classified as ―good‖ became a standard and were investigated in many

more studies looking at its relation to health outcomes including depression. It was found

that depression prevalence rates were higher for six of the seven ―poor‖ health habits

examined compared with the ―good‖ health habits (49). Multivariate regression analyses

done in this study showed that a simple sum of the total number of good habits to be a

significant independent predictor of depression after controlling for prior depression and

various socio-demographic factors.

Studies which have defined lifestyle as socio economic status and education have found

increased depression to be associated with low income, low socio economic status and low

education (50). Socio economic ststus and education can directly as well as indirectly

mediate dietary patterns via influencing the availability, pattern of use of food and so on.

Life style factors

This study from a mental health perspective looks into five life style factors that could be

influencing LOD by looking at a cross sectional population with depression as defined on

conventional scale.

10

Lifestyle factors that would be addressed in the present study are

1. Diet,

2. Exercise/physical activity,

3. Leisure activities including hobbies

4. Social interactions or Socialization.

5. Recreational alcohol use and tobacco use.

Review of literature focusses on studies that have studied the above mentioned five factors.

Interventional studies that look at change in depressive symptoms after its onset have been

omitted as the current study focusses only on lifestyle factors that might influence genesis of

depression in the elderly.

[I] DIET

The influence of one‘s diet on health is widely recognized in oriental culture from ancient

times. Traditional medical systems have laid a lot of importance to dietary advice not only

during time of illness but also in the healthy state. In modern medicine the importance of diet

on one‘s health is being increasingly recognized. Although the influence of dietary habits

and nutrition on physical illness is widely appreciated its influence on mental well being or

illness is not known to many (51).

Dietary pattern in general and deficiency of various nutrients like vitamins, minerals, and

omega-3 fatty acids have been implicated in genesis of depressive symptoms in various

studies. Epidemiological, co-relational studies and recent experimental studies find influence

of various nutritive factors in depression. Some of these studies are reviewed below.

11

Diet and General Nutrition

A population based study investigated social and lifestyle factors that influence depression,

anxiety disorders, sleep disorders and quality of life in men and women (age 18- 90yrs) (52).

The authors found that the prevalence of depression was more in women and it was

associated with self evaluation of nutrition as ―poor‖, low food intake and low paid jobs.

Depression was also associated with smoking, alcohol abuse and dependence. Depression

was also positively associated with vascular and gastro intestinal diseases.

In a community sample of 267 male and female it was concluded that nutritional deficit and

depression were associated after controlling for educational status, socio economic status

and smoking (53).

As found in the above mentioned studies malnutrition in general have been implicated to be

associated with depression due to decreased appetite (54). However healthy elderly are also

reported to loose weight when followed up over long period (55). Surprisingly evidence

from elderly without mental illness seem to suggest a protective effect for obesity on

depression (56). In a sample of 2406 men and women aged 70-79 years followed up after 3

years it was found that depressed mood at baseline predicted weight gain after 3 years. Also

weight loss over three years predicted depressed mood at end of the three years. The authors

attribute this effect to probable deterioration in general health associated with advancing age

(57). In fact research on the association of obesity (as measured as Body Mass Index (BMI))

and depression has produced conflicting results (58) and more studies are reporting a

protective effect of obesity for depression in elderly called popularly as the ―Jolly Fat‖

hypothesis (59, 60). In contrast other studies have reported a positive association of obesity

with depression. This can be mediated by a co-morbid metabolic syndrome (61) and also

indirectly by reduced health related quality of life from a sedentary life style (62). The

12

relationship remains unclear with many studies reporting lack of association between

depression and obesity (63).

Depression and Nutrients

The association of vascular nutritional risk factors and depression in an elderly cohort of

depression (n=196, age more than 60 years) in comparison with non depressed subjects was

studied. It was found that the depression group had higher intake of saturated fat and

cholesterol, higher body mass indices, lower alcohol intake, and higher Keys score (a

measure of the serum cholesterol-raising capacity of the diet) than the comparison group

(64). After controlling for variables like age, sex, education, race, and medical co-morbidity,

associations persisted for cholesterol, alcohol, and Keys score. Depression was found to be

positively associated with overall dietary pattern as defined by total kilocalories, saturated

fat, cholesterol, Body Mass Index, polyunsaturated fat, Sodium intake, and alcohol intake.

The study concluded that the dietary pattern considered as risk factors for vascular illness

differed between depressed and non depressed group.

Mediterranean Dietary Pattern which contains an adequate intake of fruits, nuts, vegetables,

cereals, legumes or fish ensures adequate levels of vitamin B12 and Folate have been

postulated to influence depression in various studies. In a large cohort study it was

investigated both cross-sectionally and longitudinally (65, 66). In the initial cross sectional

analysis (n= 9670) it was found that Folate intake was inversely associated with depression

prevalence among men, Vitamin B12 intake was inversely associated with depression in

women. No significant association was observed for omega-3 fatty acids intake. The

participants were reassessed after 5 years (mean follow up- 4.4 years, n= 10,094) for their

adherence to Mediterranean diet and depressive symptoms. It was found that 480 new cases

of depression were noted and adherence to Mediterranean diet was found to be protective.

13

Dose-response relationships were found inversely related to fruit and nuts intake,

monounsaturated to saturated-fatty-acids ratio, and legumes.

A prospective epidemiological cohort study followed up elderly subjects (n= 610) for 6 years

to look at the influence of dietary lipids on geriatric depression scale score (GDS) (67). In

multivariate linear regression analysis, GDS score was found to be negatively associated

with dietary intake of monounsaturated lipids (MUFA) and their main source -olive oil. GDS

score was positively associated with intake of polyunsaturated lipids (PUFA) derived from

one of the principal dietary source -seed oils. Intake of calories, total lipids, fish and seafood

or saturated lipids was not found to be associated with variation in GDS score by this group.

Depression and Consumption of Fish

Other studies have found a negative correlation between Depression and fish consumption.

A cross-sectional study with a sample of 3204 adults has found this correlation (68). In a

study which compared between the national estimate of fish consumption pattern and

prevalence of depression it was found that they were negatively associated (69). However

both the methodological aspects of this study and the tendency in general to impute dietary

explanations to any health condition has been critiqued (70).

A study assessed the serum levels of fatty acids in a community based sample of elderly

more than 60 years (71). Subjects with depressive disorders had a higher ratio of n-6 to n-3

poly unsaturated fatty acids (PUFAs) compared to healthy subjects. But difference in

individual PUFAs between the groups was small. The study controlled for potential

confounders like atherosclerosis, inflammation etc.

In a prospective study there was no association of diet-related factors with late-life

depression in a cohort of elderly men (n= 526; age 70 -89 years) (72). However a negative

relation between physical activity, moderate alcohol consumption and decline in serum

14

cholesterol level during the study period with depression was noted. The authors concluded

that physical activity and moderate alcohol consumption may be protective in ―old-old‖ men.

The study also found that a decline in serum cholesterol level may predict development of

late-life depression. An earlier review (73) has discussed this issue by looking at studies

which had similar finding and also those contesting it. They postulated that this inverse

relation between cholesterol levels and depression could be mediated by another variable in

the diet i.e. the reduced intake of dietary omega-3 poly unsaturated fatty acid (PUFA). This

has probably resulted out of the increasing proportion of omega-6 to omega-3 PUFA in the

diet over the years due to the changing dietary pattern. The inverse association between

consumption of fish and depression was further explored as to whether it was mediated

directly or indirectly (50) . Post hoc analysis of data from a large cohort study (n=10,602

men age, 50- 59 yrs) via regression analysis found that depressed mood was associated with

fish intake both directly, and also indirectly as part of other factors in the diet and also as

part of a lifestyle that was associated with depression.

General Dietary Pattern and Depression

The above studies and many other studies have looked more on the nutrients that influence

mood states and also how supplementation of these could alter health states (not discussed in

this review). A few recent studies have also look at it in a macro level i.e. quality of dietary

patterns. Food frequency questionnaires were used to gather information about diet which

were scored based on perceived quality. A study in an elderly cohort (mean age =55.6yrs)

investigated the influence of ‗whole food‘ (heavily loaded by vegetables, fruits and fish)

and

‗processed food‘ (heavily loaded by sweetened desserts, fried food, processed meat, refined

grains and high-fat dairy products) on score on standard depression scale as outcome

measure (74). The participants in the highest tertile of the whole food pattern had lower odds

15

of depression than those in the lowest tertile. High consumption

of processed food was

associated with increased odds of depression. This study concluded that whole food pattern

may be protective for depression.

Mental health outcomes in women aged 20- 93 years using similar categories in the form of

"traditional" dietary pattern ( vegetables, fruit, meat, fish, and whole grains), "western" diet

(processed or fried foods, refined grains, sugary products, and beer) and ―modern food‖

(fruits, salads, fish, tofu, beans, nuts, yogurt, red wine) were studied. It was found that

traditional dietary pattern was associated with reduced odds for depression and dysthymia.

The authors concluded that the habitual diet quality and the prevalence of mental disorders

were associated (75) .

The deficiency of omega 3 fatty acid and vitamin B12 causes impaired mood state.

Vegetarian diet has deficiency of these nutrients. 60 vegetarians were compared to 78

omnivores. It was found that vegetarians reported significantly less negative emotion than

omnivores. The authors concluded that the vegetarian diet profile does not appear to

adversely affect mood despite low intake of long-chain omega-3 fatty acids (76).

Various review articles have also summarized the research findings in this area of diet and

depression The various mechanisms of low fatty acids influencing depression like

influencing the structure of brain and modification of fluidity of neuronal cell membranes

have been comprehensively discussed in one of the review article (77). Another review has

looked at risk factors for depression along with other aspects. It reports that depression is

related to low serum Folate and vitamin B12 levels and increased serum Homocysteine

levels (11). As the evidence from randomized controlled trials (RCT) for the effect of B

vitamins and n-3 PUFAs is modest it was suggested that larger RCTs and meta-analysis

needs be done to better understand its effect (56). A better way to throw light on the

16

causality of dietary factors on mood and cognitive function would be to include them as

outcome measure in studies that look at effect of dietary patterns as markers of physical

health (78).

17

(Table -1a) Cross-sectional Studies on Diet and Depression*

Author, Year Place,

sample Age (yrs) Design Scales,

Diagnostic

criteria

Results

Tiemeier et al, 2003.

Rotterdam

study.(71)

Netherlands, 264 M&F

>60 Community, Cross-

sectional

CES, PSE- 10,DSM IV

diagnosis of

depression

Blood fatty acid composition related

to depression.

Averina et al,

2005. (52)

Russia

1968 M

&1737 F

18-90 Population

based cross-

sectional

AUDIT, QOL

& Depression

scales.

Depression

positively

associated with poor nutrition, low SES,

adverse health

behaviours (alcohol use smoking).

Sánchez-

Villegas et

al, 2006. SUN cohort.

(66)

Spain,

9670 M&F

University

graduates

Cross-

sectional

FFQ, Physician

diagnosis of

Depression.

B12 intake in

women & Folate in

men inversely associated to

depression; omega-

3 fatty acid intake not related.

Payne et al,

2006. (64)

US,

196. M&F

> 60 Cross-

sectional

FFQ, Keys

score

Depression group

had higher intake of

saturated fat, cholesterol, higher

BMI, lower alcohol

intake, and higher Keys score.

Appleton et al, 2007.

PRIME

cohort data.

(50)

Northern Ireland,

France

10,602 M

50- 59 Cross sectional

data from a

cohort study

Welsh Pure subscale for

Depression

from MMPI;

FFQ

Negative association of

depression with

dietary fish both

direct and indirect via associated life

style.

Cabrera et al, 2007. (53)

Brazil 267 M&F

>60 Community, Cross

sectional

GDS, Mini nutritional

assessment.

Depression is associated with

nutritional deficit.

*M- Men, F- women, SES- Socio Economic Status, BMI- Body Mass Index, CES-D - Centre for

Epidemiologic Studies Depression scale, PSE-10- Present State Examination, DSM-IV- Diagnostic and

statistical Manual of mental disorders edition IV, AUDIT- Alcohol Use Disorders Identification Test , QOL-

Quality Of Life, FFQ- Food Frequency Questionnaire, GDS- Geriatric Depression Scale, MMPI- The

Minnesota Multiphasic Personality Inventory. Keys score (a measure of the serum cholesterol-raising capacity of the diet)

18

(Table -1b) Cohort Studies on Diet and Depression*

Author,

Year

Place,

sample

Age

(yrs)

Design Scales Results

Timonen et

al, 2004. (79)

Finland

2721 M 2968 F

Young

adults

Follow-up

cohort from pregnancy to 31

yrs of age.

HSCL-25,

depression subscale, fish

consumption

over last 6 months.

Fish consumption

and Depression related only in

women.

Bots et al,

2007. FINE

study. (72)

Finland,

526 M

>70 Prospective

5yrs

Zung scale Dietary factors not

related to

Depression but negatively

associated with

physical activity and moderate Alcohol

use.

Kyrozis et

al, 2008. EPIC-

Greece

cohort (67)

Greece,

610 M&F

>60 Prospective

epidemiological 6 yrs

GDS, dietary

questionnaire.

Low seed oil , high

olive oil predict healthier affective

state

Sánchez-

Villegas et

al, 2009. Follow-up

of SUN

cohort. (65)

Spain,

10,094

M&F

adults Prospective 5yr FFQ,

Physician

diagnosis of depression.

Mediterranean diet

protective for

depression

Akbaraly et al, 2009.

Whitehall II

cohort. (74)

UK, 3486

M&F

Mean age=55.6

yrs

Follow up cohort 5yrs

CES-D; ―whole food‖

vs. ―processed

food‖ categories

Processed food pattern was

associated with

Depression

Jacka et al,

2010 (75)

Australia,

1,046 F

ages 20–

93 years

Cross-sectional GHQ-12, FFQ,

category of traditional,

western and

modern food.

Quality of diet

associated with mental disorders.

Western diet had

high odds for Depression.

*M- Men, F- women, HSCL-25- Hopkins Symptom Checklist Depression Scale (HSCL-D), GDS- Geriatric

Depression Scale, FFQ- Food Freq Questionnaire, CES-D - Centre for Epidemiologic Studies Depression

scale.

19

[II] PHYSICAL ACTIVITY/ EXERCISE

Physical activity is beneficial in people who are well and also on people who are unwell.

Disease outcomes that have been found to be inversely related to regular physical activity in

prospective observational studies are cardiovascular disease, thromboembolic stroke,

Hypertension, Type 2 Diabetes Mellitus, Osteoporosis, Obesity, colon cancer, breast cancer,

anxiety and depression (80). More and more of such evidence are available in recent times

especially in relation to cognitive function (81,82). However there is lack of randomized

controlled design to substantiate these findings though this evidence is considered in the

same league as the evidence in other health related behaviors and outcomes like smoking,

saturated fat intake and coronary heart diseases. Public health interventions have been

initiated in terms of lifestyle alteration in these life style diseases without need for

demonstrating the relation through randomized control trials.

The American Heart Association in 2007 has updated its original recommendation (in 1995)

about physical activity for the general public including elderly. It has stated the specific

nature, type and frequency to be followed for better physical health.

The mechanisms mediating such benefits especially the antidepressant effect which is the

focus of this review have been hypothesized; namely, a) psychological mechanisms like

increased feelings of self-efficacy, b) self perceptions of control and mastery c) reduced

physiologic responses to stress, d) and beneficial effects on neurotransmitters such as

increased serotonin and endorphins (83). Exercise and diet are also believed to mitigate the

adverse effect of stress and ageing on the functioning of neurotrophic factors (84).

The following studies are reviewed in detail.

20

A cross-sectional study in community dwelling elderly women found that depression was

inversely associated with physical exercise and directly with smoking. Non harmful alcohol

use was associated with better cognitive performance(85) .

A study examined cross-sectional and prospective association (after 5 years) between

exercise and depressed mood in community dwelling elderly (86). Regular strenuous

exercise and exercise <3 times per week were assessed and cross-sectional Beck‘s

depression inventory (BDI) score were compared at two assessment points. Higher exercise

rates corresponded with lower BDI scores. However when BDI scores of people who

attended both assessments were compared longitudinally their baseline exercise levels did

not influence their BDI score at five years. So the authors concluded that people who

exercise have better mood. However it may not ensure better mood in future in non

depressed people who also exercise.

Table 2a: Cross sectional studies in Physical Activity and Depression*

Author, Year Place, sample

Age (yrs)

Design Scales Results

Kritz-Silverstein et

al, 2001. Rancho

Bernardo Study (86)

California,

2029

M &F. 944M&F in

follow up.

50-

89

Cross sectional

and prospective

5ys

BDI Exercise associated with

better mood but not

protective longitudinally.

Cassidy et al, 2004.

(85)

Australia,

278 F only

>70 Community

cross sectional

BDI>

10

Depression negatively

associated with physical

activity & positively with smoking

*M- Men, F - women, BDI- Beck‘s Depression inventory.

21

Table 2b: Cohort studies in Physical Activity and Depression*

Author, Year place, sample

Age (yrs)

Design Scales Results

Camacho et al,

1991. Alameda

country study (87)

Californi

a,

M&F

Adults Longitudinal

cohort 20yrs

- High physical activity

related to less

depression

Strawbridge et

al, 2002. Alameda

country study

(88)

Californi

a , 1947

M&F

>50 Longitudinal,

cohort 5ys

DSM-IV

diagnosis of depression,

physical activity

scale

Physical activity

protective for depression

Frederick et al, 2004. (49)

Los Angeles,

752

M&F

adults Community longitudinal

screening

CES-D; Life style habits

Depression was associated with 6 out

of 7 poor habits.

Brown et al, 2005. (89)

Australia, 9207 F

Middle aged

Prospective cohort ,5ys

CESD-10, Mental health [MH]

subscale of the

Short Form 36 survey

Association between increasing physical

activity and decreasing

depressive symptoms

Wiles et al, 2006. Caerphilly

study (90)

UK, 1158 M

45- 69 Cohort: at 5yr and 10 yr

follow up

GHQ, Minnesota leisure time

physical activity

questionnaire

Heavy intensity leisure time activity

associated with less

odds of Depression, the effect persisted at

5ys but not at 10yrs.

Wise et al, 2006.

Black Women‘s‘ health study (91)

Boston,

US 35,224 F

21- 69 Cohort follow

up after 2yr, 4ys.

CES-D Leisure time physical

activity had reduced odds for depression.

Bots et al, 2008.

FINE study. (72)

Finland,

526 M

>70 Prospective

5yrs

Zung scale Less Depression with

physical activity and moderate alcohol use.

Dietary factors not

related.

Ku et al, 2009. (92)

Taiwan, 3778

M&F

>50 Cohort 7yr follow up

CED- D Leisure time physical activity has reduced

risk for depression.

Heesh et al,

2010. (93)

Australia,

6653 F

73- 78 Community

longitudinal

screening

GADS, Leisure

Time Physical

Activity scale(LTPA)

Depressive symptoms

on GADS score were

negatively correlated with LTPA scores.

*M- Men, F- women, CES-D - Centre for Epidemiologic Studies Depression scale, DSM-IV- Diagnostic and

statistical Manual of mental disorders edition IV, GHQ- General Health Questionnaire, GADS- Generalized

Anxiety Disorder [GAD]scale

22

The studies that have looked at mental health outcomes from a longitudinal cohort have

found that that men and women with low activity levels at baseline were at a significantly

greater risk for depression at the 20-year follow-up than those who reported high activity

levels (87). The relationship between physical activity and depression in older adults (50 to

94 years) was studied after adjusting for age, sex, ethnicity, socio-economic status, chronic

conditions, disability, body mass index, alcohol consumption, smoking, and social relations.

It was found that physical activity was protective for both prevalent and incident depression

(88). Similar inverse relation between depression and physical activity has been previously

discussed (72). A dose response relationship between self-reported Physical activity (PA)

and depressive symptoms in cross sectional analysis was investigated by a prospective

assessment in community dwelling middle aged women. Mailed questionnaire included

questions about time spent in walking, moderate- and vigorous-intensity PA. Mean

depression scores decreased with increasing levels of previous, current, and habitual activity

(89).

[III] LEISURE ACTIVITIES.

"Play is any activity that has great meaning but no purpose.” -- Mark Twain

Leisure activities are those that are freely chosen. This may be considered synonymous to

play and recreation. It implies less of serious purpose but more of enthusiasm and joy.

Leisure tends to be more associated with retirement but it occurs in all age groups. They are

enriching and rewarding experiences in life. They give purpose and satisfaction in life. The

potential physiologic benefits of leisure activities are probably derived from the exposure to

an enriched environment, defined as a combination of more opportunities for physical

activity, learning, and social interaction. It is believed that these experiences do not produce

structural changes in the brain but functional changes .It also influence the rate of

23

neurogenesis in adult and senescent animal models. Various aspects of leisure activities

have been extensively studied especially their protective effect in cognitive decline and

dementia (94) . Leisure activities may be generally divided into ingredients of social,

physical and mental (intellectual) spheres. The differential effects of these components are

well studied in literature pertaining to cognitive decline and dementia. However in studies

looking at depression it appears that only the physical aspects of leisure have been

considered.

Social and productive activities that involve little or no enhancement of fitness have the

ability to lower the risk of all cause mortality as much as fitness activities do (95). It is

believed that in addition to increased cardiopulmonary fitness, leisure activity may confer

survival benefits through psychosocial pathways.

.

The following studies have been reviewed in detail.

A cohort study found that engaging in little or no recreational activity was associated with

twofold increased odds of incident depression after 8 years in women. But no such increase

was seen in men (96).

Other epidemiological studies have however approached physical activities as part of leisure

in general. The differential influence of leisure time physical activity and occupational

physical activity with common mental disorders (CMD) as outcome in men (age 45-69) was

studied by assessing the total leisure-time activity and percentage of time spent in heavy-

intensity activity from self-reports. The leisure time physical activity was intensity scored as

light, moderate and heavy. The energy expenditure was also calculated. Men were classified

into four classes of occupational activity from least active to most active. The study found

that those who participated in any heavy-intensity leisure-time activity had reduced odds of

24

common mental disorders (CMD) 5 years later. There was little evidence that men in the

most physically demanding jobs had reduced odds of CMD after 5 years. There was no

association between physical activity and CMD at 10 year follow up (90).

Women living in the community (n=35,224, aged 21 to 69) were assessed for past and

current exercise levels at baseline. They were followed up after 2years using mailed

questionnaire. It was found that adult vigorous physical activity during leisure time was

inversely associated with depressive symptoms (91). Women who reported vigorous exercise

both in high school (≥ 5 hr per week) and adulthood (≥ 2 hr per week) had the lowest odds of

depressive symptoms relative to women who had never been physically active. Walking as

an exercise negatively affected depression symptom onset only in women having BMI > 30.

A similar study using mailed questionnaire in a community dwelling elderly women (age 73

-78 yrs) found beneficial effect of walking (93). They were assessed on their weekly minutes

of walking, moderate leisure time physical activity (LTPA) and vigorous LTPA. Association

between five levels of LTPA (none, very low, low, intermediate and high) and depression

and anxiety scores were calculated. Inverse dose–response associations were

observed between both LTPA/walking and depression

scores in concurrent and prospective models. The results supported an inverse dose–response

association between both LTPA /walking and mental health.

Another study also found that low leisure time activity was associated with greater risk of

developing depressive symptoms (92).

A Review article while looking into the relation between physical activity and mood has

evaluated the possible mechanisms that mediate it (97). The authors have dealt with

psychological theories like distraction, self efficacy, social interaction and physiological

theories that link positive mood changes to monoamine and endorphin levels. The authors

25

after a systematic review of 87 studies concluded that moderate exercise elevates mood

while heavy exercise can in fact deteriorate mood. A review article looks into basic and

clinical studies that lead to a neurotrophic hypothesis of depression according to which

stress and depression reduce neurotrophic factors and neuronal development (84).

Neurogenesis is progressively reduced in aging and could potentially put the individual at

risk for depression. Author inferred that the exercise and diet modulate antidepressant action

via positively influencing neurotrophic factors especially in the hippocampus.

All studies mentioned in this review looking at physical activity have focused on how

physical activity directly influences health outcome. Some recent research looks specifically

at the mediating variable like genetic diathesis that influence exercise behavior and health

outcome. In a twin study (98) the twin who exercised more did not display fewer anxious

and depressive symptoms than the co-twin who exercised less. The authors conclude that the

association between regular exercise and reduced depression in population at large is not due

to causal effect of exercise, but in toto a common genetic vulnerability to lack of regular

exercise and risk for anxiety and depression.

[IV] SOCIALIZATION

Social participation which is an important psychological resource is beneficial in all age

groups Studies have found that involving in social and productive activities can reduce

mortality in the elderly similar to physical activities (99). It is hypothesised that if benefits

from physical activities is due to better cardiopulmonary function, then social activities may

confer survival benefits through psychosocial pathways (95). Better health benefits in people

who do exercise have also been attributed to associated social interaction that occurs during

the process.

26

The following studies have been examined in detail.

A community level cross-sectional survey of life-style used 16 items selected from the four

factors of economic situation, physical health, social activity, and personal status(100). The

study also investigated life satisfaction, morale, and physical function and it was found that

the factors significantly related to depression in community dwelling elderly were the

number of friends and morale. An increase in the number of friends was related to a decrease

in depression. Depression in the ―old-old‖ elderly was more significantly related to many

lifestyle items compared with the ―young-old‖ elderly. The extent of influence of

socialization on depression was found more in the old-old.

Another study looked at depression in both community-dwelling and institutionalized elderly

(101). In the community study it was noted that ability to do activities of daily living and

social activities were protective for depression. In the institutionalized elderly loneliness and

poor perception of general health predicted depression. In a recent study from a cross-

sectional sample of 55 elderly from India, it was found that loneliness was positively related

to depression. However the amount of socialization was not found to be related (102). The

study also found that loneliness was not related to sociability. It appears that the concept of

loneliness appear to have more relevance in the subjective experience of depression.

27

Table 3 Studies looking at Socialization and Depression*

Author, Year

place, sample

Age (yrs)

Design Scales Results

Demura

and Sato, 2003.

(100)

Japan,

1304M&F

<75) vs.

old old (> 75)

Community

survey, cross-sectional

GDS> 10=high

D lifestyle scale,

Number of friends,

morale, social activities related to depression.

Kim et al,

2010. (59)

Korea,

295M&F

elderly Community,

Cross- sectional

GDS, scale for

ADL, hand grip

Perceived health status,

ADL, hand grip and social activities

predicted depression.

Kim et al,

2009. (101)

Korea,

Japan 184M&F

65-98 Institutionalized

elderly, comparison of

cross-sectional

assessment

Health status,

loneliness, Depression

Loneliness and

perception of general health were significant

predictors of

depression.

Singh and

Misra,

2010.

(102)

India ,

55 M&F

60-80 Cross-sectional Eysenck

sociability

scale, BDI,

UCLA loneliness scale

Loneliness related

negatively to

depression while

sociability not related to depression;

loneliness not seen as

lack of sociability,

* M- Men, F- women, GDS- Geriatric Depression Scale , ADL- Activities of Daily Living, BDI- Beck‘s

depression Inventory, UCLA- University of California Los Angeles

Many studies have investigated the benefits of religiosity/ religious beliefs and spirituality in

mental health. As the current study does not focus on this aspect but just explores it as part

of activities, only a brief mention of the literature that investigates its association in geriatric

depression is mentioned. Reciting prayers , watching television and listening to the radio ,

and participating in physical activity in community dwelling elderly correlated to lower

depression for older men, but only watching television and listening to the radio related to

lower rates of depression for women (103). Various studies have found that attending

religious activities was a protective factor for geriatric depression (104,105).

28

[V] ALCOHOL AND TOBACCO

Many of the studies discussed previously have also looked into the issue of substance use

and depression in the elderly. Direct relationship of alcohol and mood change in the form of

depression has been well documented. Substance use can mediate depressive symptoms

directly also indirectly via its influence on vascular diseases.

Long term follow up studies have found a direct relationship between substance use and

increased mortality. They have also found positive association of depression with tobacco

and alcohol use (47,52,85). However moderate alcohol consumption was also found

associated with less depression (72). Another study found that depressive subjects consumed

less alcohol than non depressed subjects (64) .

In a study among community dwelling elderly (n= 1280, 55-85 yrs) depression was assessed

both cross-sectionally and longitudinally (at the end of 6yrs). It was found that depression

was associated with smoking, a recent increase in the number of cigarettes smoked and

sedentary lifestyle. There was also a trend towards association with excessive alcohol

consumption (106).

Summary of Literature Review

Diet- Malnutrition is associated with geriatric depression as a cause and consequence.

Although studies have conflicting results obesity may have a protective influence on

depression. Dietary pattern that are associated with vascular diseases like increased intake of

calories, saturated fat, alcohol, and smoking are also found to be associated with geriatric

depression. Increased consumption of fish (omega-3 fatty acids) and mono unsaturated fatty

acids intake seem to be protective for depression. Deficiency of various nutrients like

omega-3 fatty acids, Vitamin B12 and Folate has been associated with depression. ―Whole‖

29

food and ―traditional‖ food have been found to be associated with less depression.

Vegetarian diet has not been associated with depression.

Physical activity/ Exercise- There are consensus among the studies that physical activity/

Exercise have both cross-sectional and prospective positive association with depression. A

few studies have reported that the prospective association is less clear. Physical activity is

associated with less risk for depression. Heavy intensity occupational physical activity did

not seem to protect against depression in men.

Leisure activities – Various studies have found that involvement in recreational and leisure

activities have been associated with less depression. However most studies have studied the

physically active dimension of leisure activities. Studies looking at other dimensions like

intellectual and social dimensions were lacking. Walking has been defined as a leisure time

physical activity. It has been found to be protective for depression. Many studies have found

an inverse dose- response association between leisure time physical activity and depression.

Socialization and social Interaction- Various studies have found positive association

between good social interaction and reduced depression. A few studies have reported that

feeling of loneliness may have more salience in the elderly who are depressed.

Alcohol and tobacco use- Geriatric depression has been directly associated with tobacco

use and alcohol consumption even though a few studies seem to indicate protective effect for

moderate consumption of alcohol on depression.

30

AIMS AND OBJECTIVES

1. To compare the Life Style in elderly with Late Onset Depression (LOD) subjects with age

and sex matched healthy controls .The five factors considered for the study namely-

1. Diet

2. Physical activity/ Exercise.

3. Social Interaction.

4. Leisure activity including hobbies.

5. Alcohol and tobacco use.

31

METHODOLOGY

SELECTION OF SAMPLE

INCLUSION CRITERIA

1. Subjects more than 50 years of age.

2. Availability of a relative who can corroborate the information.

3. Satisfies DSM IV-TR (107) Diagnostic criteria for Major depressive disorder

4. Gives informed consent for the study.

EXCLUSION CRITERIA

1. Onset of MDD before 50 years of age

2. Presence of other DSM IV Axis I psychiatric disorder

3. Presence of substance dependence syndrome except nicotine.

4. Presence of depression with psychotic symptoms.

5. Presence of chronic neurological conditions like Epilepsy, Multiple sclerosis, Parkinson‘s

disease

6. Presence of cancer, recent myocardial infarction or cerebrovascular accident (within 6

months), AIDS.

SELECTION OF CONTROLS

INCLUSION CRITERIA

1. Age and sex matched healthy subjects. Attempts were made to match for education and

socioeconomic factors to the extent possible.

2. Availability of a reliable relative.

3. Informed consent

EXCLUSION CRITERIA

1. Presence of DSM IV-TR Axis I diagnosis

2. 3, 5 and 6 same as for exclusion criteria of subjects

32

INSTRUMENTS FOR ASSESSMENT OF SUBJECTS AND CONTROLS

1. Socio demographic Questionnaire.

2. Hindi Mental Status Examination (HMSE) (108)

3. Mini International Neuro Psychiatric Interview (MINI) (109)

4. Hamilton Depression Rating Scale (HDRS ) (110)

5. Hachinski Ischemic Score (111).

6. Cumulative Illness Rating Scale for Geriatrics( CIRS-G) (112).

5. Life Style Questionnaire - Based on other standard questionnaires a Life Style

Questionnaire that suited the Indian population was developed addressing diet,

exercise/physical activity, alcohol and tobacco use, leisure and social activities taking into

consideration expert opinion of nutritionist and statistician.

METHOD

Forty six patients with a diagnosis of Late Onset Depression attending the Geriatric

Outpatient Services of NIMHANS and forty six healthy controls (matched for age, sex and

education) with no psychiatric conditions were studied.

DESCRIPTION OF TOOLS

1. Socio-demographic data sheet contained relevant socio demographic data, clinical

history, and mental status examination. A diagnosis of depression based on DSM IV criteria

was made.

2. Hamilton Depression Rating Scale( HDRS) (110) This is one of the most commonly

used raring scales in studies on depression. It comprises of 21 items. Items are scored 0-2

and 0-4. It has good reliability and internal consistency. It takes 15- 20 minutes to

administer.

3. Hindi Mental state examination (HMSE) (108) It is a scale that is adapted from MMSE

for purpose of interviewing Indian population.

33

5. MINI international neuropsychiatric interview- Screen (109). It is a truncated version

of the MINI questionnaire for purpose of screening people for psychiatric disorder it is used

along with schedule K of the full MINI that screens for psychotic disorder.

6. Cumulative Illness Rating Scale for Geriatrics (CIRS-G)(112) It is a modified CIRS

was operationalised with a manual of guidelines geared toward the geriatric patient. In

medically and psychiatrically impaired elderly subjects it gives reliable quantitative ratings

of chronic medical illness burden for geropsychiatric practice and research. . The score gives

an indication of the burden of vascular risk factors. It has 14 items each to be scored from 0

to 4 based on increasing severity. A total score, a severity index can be calculated from it.

7. Hachinski Ischemic Score(HIS) (111) A tool used in screening to differentiate vascular

dementia from degenerative forms of the disorder. It has got 13 items which have to be

scored either 1 or 2. Patients with a score of 7 or higher are more likely to have a vascular

dementia. A low Hachinski Ischemic Score is less likely to indicate vascular dementia.

8. Life-Style Questionnaire was developed for this study based on other standard

questionnaires from the West after consultation with the nutritionist and statistician. A

comprehensive and easy to apply scale that measured all the items of life style in the Indian

population was not available. Therefore the questionnaire developed included items which

measure frequency and type of diet, extent of physical activity, socialization, leisure

activities substance use and composite scores. The respondents were asked to reply on the

variables during the period of one to two years before onset of depressive illness.

Dietary assessments included whether the respondent was vegetarian or non vegetarian,

Adequacy of food measured on ordinal scale on categories of no of meals, snacks and

amount of water. Type of food was assessed based on broad categories like carbohydrate

(with and without fiber separately), protein (non-vegetarian and vegetation separate), fats

34

etc. Items were scored based on frequency of use from 1(never) to 3 (> 4times a week). The

dietary items were made descriptive asking the subjects about the food they commonly

consumed e.g. Anna (par-boiled rice), Mudde, idly, Dosa, Roti, Chappathi, Dhaliya, Kambu

kalzhi, Puri were categorized as carbohydrate with fibre while Akki Roti, Anna ( Raw

Polished Rice), Upma, Nan, Avalakki, Sooji, Sabudhanna Kanji were classified as

carbohydrate without fiber. For certain items based on nutritionist‘s suggestion and after

discussion with the three mental health professionals and the statistician the scoring were

reversed e.g. eating chicken more than four times a week got lesser score of 1 compared to

once a week- score of 3.

Physical activities were measured on the number of activities and the frequency of exercise

and also the number of hours spent daily in physically demanding activities. Household

activities like cooking, cleaning, washing clothes, gardening and looking after grand children

were specifically asked and scored.

Leisure activities and hobbies were assessed on the number of activities reported and each

activity got a score of one.

Social activities were measured on ordinal scale form 0-5 and it was adapted from the

Patient Version of questionnaire developed by the 10/66 Dementia Research Group (113). It

included questions which assessed how far relatives and sibling stayed away from home,

frequency of interaction with friends and children etc.

The composite scores for each factor was calculated and the max score in each are

Carbohydrate- 10, Protein- 18, Fat-6, physical activity- 15, Leisure activities- 16,

socialization- 30.

35

PROCEDURE

Patients attending the Geriatric Clinic at the Department of Psychiatry, NIMHANS

were screened for Major Depressive Disorders (DSM IV-TR codes 296.2x, 296.3 xs).

Suitable subjects were clinically examined by the investigator. The diagnosis was confirmed

by discussing with the consultant psychiatrist and cases with onset of illness after 50 years

were recruited for the study. Patients who were previously diagnosed with depression and

currently in partial or full remission were also included.

The details of study were discussed with the subjects and a reliable relative and written

informed consent was obtained. Hindi Adaptation of the Mini Mental State Examination was

administered initially to rule out any associated cognitive deficits (dementia). Hamilton

Depression Rating Scale (HDRS) was administered to assess the severity of the depression.

Subsequently the Lifestyle Questionnaire developed for this study was applied. The subjects

were asked to recall their life-style before the onset of depression and answer the questions.

Using purposive sampling, controls matched for age, gender and education and who

met the sample selection criteria were identified by ―word of mouth‖ and recruited for the

study after informed consent. MINI screening questionnaire was applied in the control

subjects to rule out psychiatric morbidity including depression. The recruited controls were

assessed with the same tools applied on the cases.

STATISTICAL METHOD

Continuous variables were tested for their normal distribution and comparison between

groups was done using Independent sample t test.

Non parametric analysis of Wilcoxon Mann- Whitney test was adopted when distribution

was not normal. Categorical variables were analyzed using Chi square test/ Fisher‘s exact

test. P < 0.05 was considered statistically significant.

36

RESULTS

The study recruited a total of 92 subjects with 46 each in the case and control groups. The

groups were comparable with respect to age, sex and educational status. (Table- 4). Two

third of the subjects were between the ages of 50 -65 years age group (33 in LOD group and

30 in control group). The groups did not differ with respect to Body Mass Index (BMI).The

groups differed significantly with respect to socio-economic status (p= 0.051).The

depressive group had less subjects n=8(7.4%) in the low socio economic status than the

control group n=18 ( 39.1%). There were significantly (p= 0.035) more subjects with

vascular risk factors (Hypertension, Diabetes Mellitus or both) in the depressive group. The

group did not differ significantly (p=0.178) in Cumulative Illnesses Rating Scale Scores

(CIRS-G) - 3.2 ± 2.5 for cases and 2. 6 ± 2.3 for controls. The mean Hachinski Ischemic in

the cases was 1.7 ± 0.8 and was significantly higher than in the control group (p<0.01).Since

many of the cases were in remission from depressive illness and on follow up their

depressive scores measure by HDRS ranged widely (5 to 35) and those who were admitted

had higher scores.

37

Table 4 Socio- Demographic Data

Item Depression (n =46) control (n= 46) P value*

Age ( mean in yrs) 62.9 ± 7.2 62.8 ± 8.3 0.947

Sex

Men 20(43.43%) 22(47.82%)

0.834 Women 26 (56.57%) 24(52.18%)

BMI 22.8 ±2.8 23.1 ±3.0 0.548

Education

Illiterate

11 (24%)

9 (19.6%)

0.49

Less than 10 std 14 (30.4%) 19 (41.35)

More than 10 std 13 (28.3%) 8 (17.4%)

Degree 6 (13%) 5(10.7%)

Post-graduation 2 (4.35%) 5 (10.7%)

Socioeconomic

Low

8 (17.4%)

18 (39.1%)

.051 Middle 33 (71.7%) 26 (56.5%)

Upper 5 (10.7%) 2 (4.35%)

Systemic illness HTN,DM or both

26 (56.5%) 15 (32.6%) .035

Others or nil 20 (43.5%) 31 (67.4%)

* Chi-square/ fisher‘s exact test, T test

Diet

The two groups did not differ significantly with respect to BMI (p=0.548). Mean BMI in

cases was 22.8 ±2.8 and in controls was 23.1 ±3.0. In detailed physical examination also

they did not show any signs of malnutrition. There was higher percentage of vegetarians

22(47.8%) in the depressive group compared to the controls 13(28.3%) but this was not

statistically significant (p=0.085). Many subjects - 9 in depressive group and 13 in control

group, who called themselves non-vegetarians, were taking non vegetarian diet less

frequently than once a month thus scoring similar to vegetarians in the diet scale

measurements on non-vegetarian items. The analysis of dietary items was done as a group

and also individually.

38

The mean composite scores for dietary factors, physical activity, socialization and leisure

activities did not differ significantly between LOD and the control groups (Table 2a).On

comparison of individual items it was found that group with depression was taking

significantly more dietary fiber(p<0.001) and dairy products ( p=0.03) (Table: 2b)

Table 5(a): Comparison of Diet Parameters

Depression (n =46)* control (n= 46) P value( T test)

Carbohydrate 6.4 ± 1.7 6.1± 1.8 0.32

Protein 8.2 ±3.7 7.7 ±3.7 0.50

Fat 6.1 1.8 6.1 2.0 0.95

* Values represent Means of composite scores ± Standard Deviation

Table 5(b) Comparison of individual dietary item.

Depression** control P Value*

Water 2.0± 0.5 2.3± 1.0 .241

Carbohydrate with Fiber 4.7± 0.8 3.9± 1.1 <.001

Carbohydrate without Fiber 1.8± 1.4 2.1± 1.2 .126

Fish 0.5± 1.0 0.6± 1.1 .412

Chicken 0.9± 1.4 0.9 ±1.3 .847

Meat 0.5± 1.1 0.6± 1.1 .647

Eggs 1.0± 1.2 1.1± 1.3 .637

Dairy products 2.5± 1.0 1.8± 1.2 .003

Veg. protein 2.7± 0.7 2.5± 0.8 .276

Fat 3.4± 1.2 3.4± 1.1 .899

Pufa 2.7± 0.8 2.0.±1.0 .752

Vegetables 4.1± 0.9 4.0± 0.6 .158

Fruits 3.2± 1.6 3.0 ±1.7 .493

*Mann- Whitney U test

** Mean scores ± Standard Deviation

39

Depressive subjects reported that they felt their diet was very healthy before the onset of

depression and this was significant when compared with control. (Fig- 1).

Fig 1 Comparison of self reported opinion on diet*

0

5

10

15

20

25

30

very good

moderate

some- what

Depression

Control

X axis= dietary pattern (very healthy, moderately healthy, somewhat healthy)

Y axis= no. of subjects.* chi square test (p= 0.03)

Physical Activity.

There was no significant difference (p = 0.64) between the LOD group and the control group

with respect to physical activity. The mean composite score in the LOD group was 5.9 ±2.4

and in control group was 5.7 ± 2.5. Comparison for individual items that measured physical

activity based on the number of hours per day and also the number of activities also showed

no significant difference (Table 6).

40

Table 6 Comparison of individual items for physical activity

Depression** control P Value*

Exercice 0.6± 1.6 1.0± 1.9 .193

House Work 2.8± 2.3 2.8± 2.0 .940

Hours Of Activity 2.6± 0.6 2.4± 0.9 .208

* Mann- Whitney test

** Mean scores ± Standard Deviation

Depressive subjects felt they were very physically active before the onset of the current

episode of depression and this was found statistically significant when compared with

control group (Fig 2)

Fig 2 Comparison of self reported opinion on physical activity *

0

5

10

15

20

25

30

35

40

very active

moderate

not active

Depression

Control

X axis= level of activity (very active, moderately active, not active).

Y axis= no. of subjects.* chi square test. (p = 0.043)

41

Socialization

Socialization was scored on the distance of close relatives from home and the frequency of

interaction with friends and children. There was no significant difference (p= 0.82) between

the two groups with respect to socialization when compared on the composite scores.

The mean composite score for LOD Group was 11.7 ±4.6 and for control group was 11.4

±4.3 However when individual items were compared it was found that the depressive group

significantly chatted less with friends/peers (p=0.024) and more with their children when

compared with the control group (p=0.001).(Table 7)

Table 7 Comparison of individual items for socialization

Depression** Control P Value*

Distance - Nearest Relative 2.2± 1.5 2.5± 1.3 .069

Distance- Sister Brother 2.8± 1.8 2.5± 1.3 .667

Distance- Nearest Child 1.8± 1.5 1.6 ±1.8 .283

Chat with Children 2.6± 6.4 1.5± 1.8 .011

Chat with Friend 1.5± 1.0 2.1± 1.8 .027

Chat with Neighbour 1.6± 1.0 1.7± 0.9 .458

* Mann- Whitney U test

** Mean scores ± Standard Deviation

Substance Use

The subjects were assessed about whether they followed religious activities like ―pooja‖at

home or visiting temple or other place of worship. The groups differed (p= 0.052) with

respect to religious activities reported. Less percentage n=34 (74.0%) of subjects in the

depressive group followed religious activities compared to control group n= 42 (91.3%).

42

Leisure Activity and Hobbies

Leisure activities were measured as scores that measured the number of leisure activities

reported. There was no significant difference (p= 0.706) between the groups with respect to

leisure activities. The mean score for LOD group was 2.2± 1.4 and for the control group was

2.3± 1.1.

There was no significant difference (p = 0.662) between groups on tobacco use (15 in

depression group and 17 in control group). Very few had a history of alcohol use in either

group (4 in LOD and 5 in control group).

Summary of Results

1. The study involves 92 subjects- 46 cases with Late Onset Depression (LOD) and 46 age,

sex and education matched controls.

2. The cases and controls differed (P=.051) with respect to socio economic status. The

control group had more number of subjects in the low socio-economic category.

3. The Groups did not differ with respect to Body Mass Index (BMI) or the Cumulative

Illnesses Rating Scale Scores (CIRS-G).

4. There were significantly (p= 0.035) more subjects with vascular risk factors (HTN, DM or

both) in the depressive group.

5. HDRS ranged widely (5 to 35) in the LOD group as many subjects were in remission.

6. Though there was higher percentage of vegetarians 22 (47.8%) in the LOD group

compared to the controls 13(28.3%) this was not statistically significant (p=0.085)

7. The mean composite scores for dietary factors, physical activity, socialization and leisure

activities did not differ significantly between the groups and substance use was found to be

43

very low. On comparison of individual items it was found that groups differed significantly

in the following items.

a. LOD group was significantly taking more of dietary fiber (p<0.001) and dairy products

(p=0.03).

b. LOD group significantly chatted less with friends/peers (p=0.024) and more with their

children when compared with the control group (p=0.001).

8. LOD subjects reported that they felt their diet was very healthy (p=.03) and that they

were very active physically (p=.043) before the onset of depression and this was significant

when compared with control group who felt they were only moderately healthy and active.

44

DISCUSSION:

Late Onset Depression (LOD) is different from Early Onset Depression (EOD) as discussed

in the review and it is associated with various parameters which have to be separately

studied rather than generalizing information from EOD. Among the various parameters,

life-style and its ramifications on health and living seem to be very relevant in the elderly.

Many studies in the Western countries have looked at it and hence formed the impetus for

the current study in the Indian population.

Life Style Factors of Diet, Physical Activity, Leisure Activities, Socialization and Substance

Use were compared between LOD group and an age and gender matched control group.

Causality was not presumed, but comparisons were made. A Descriptive and exploratory

approach has been taken in this study.

The clinic at which the study was conducted is a special clinic which serves mostly the

population from southern India. Since it is a referral Institute, there were also referrals from

the other parts of the country.

Despite attempts by the investigator to match the two groups of study on age, sex, education

and socioeconomic status cases and controls remained significantly different with respect to

socio-economic status. The control group had more subjects in the low socio-economic

status. The groups did not differ in age, gender or educational status. As it is known that Life

Style Factors are often influenced by socioeconomic factors (50) the findings of this study

need to repeated with more stringent matching of control group in future.

The subjects were also largely from an urban background thus lending more heterogeneity in

the lifestyle patterns especially diet. This might have resulted in greater individual

differences thus blunting the inter group differences. The study is also a retrospective one

with a cross- sectional design. Since most of the persons with LOD were on the road to

45

recovery, it was possible to interview them about their Life Style Pattern before the onset of

the episode. All the information gathered are pertaining to the period before the onset of the

depressive illness. This information was also corroborated to some extent with the relative

who accompanied the client. All the clients from the LOD groups were on antidepressants –

often SSRI – either Escitalopram or Mirtazapine; rarely Venlafaxine.

Body Mass Index is an objective indicator of health and indirectly life-style. The persons

with LOD in this study did not differ in their BMI from that of the controls. Biological

Functions especially appetite and food intake are affected in depression (54) with either low

or high food intake which in turn could affect the body mass index. As discussed in the

review, relation of BMI to depression is not clear though depressive individuals are prone for

malnutrition probably because of decreased appetite or associated health morbidity. The

sample studied did not show signs of malnutrition. This aspect need to be further explored

especially in view of the conflicting reports as to whether higher BMI is protective in

depression.

There was no difference between the groups in the five broad categories of life style factors.

Interesting differences emerged when individual items were scrutinized and compared. This

is discussed below.

Diet

There was no difference in the dietary intake between the two groups. BMI not being

different between the two groups corroborated this. A pervious study (72) also did not find

differences in dietary factors between LOD men and controls. However it was found in the

present study that depressed subjects were significantly taking more carbohydrate with fiber

and diary products than controls. This difference was perceived to be a reflection of the

dietary preference between the two groups – there were more vegetarians among the LOD

46

group (48%) than the control group (28%) though the difference was not statistically

significant (P= 0.08). Diary products are considered vegetarian in India and used as an

important source of protein by vegetarians. Vegetarian diets are considered to be deficient in

Vitamin B12 and Folic Acid which are associated with depression (66). But a study in adult

population reported that vegetarian diet is not associated with depression (76). The lesser

consumption of dairy products in the control group may also be explained by more

percentage of lower-socioeconomic status subjects indirectly reflecting their purchasing

power.

Interestingly the LOD opined that their diet was better before the onset of their depression

(Similar opinion voiced for physical activity also – see below). This may be due to recall

bias of the elderly who is recovering from depression who perceives as the pre-depression

days as being ‗golden‘ in comparison to the depressed period.

This study needs to be extended further if definite conclusions have to be drawn regarding

dietary habits including fiber, dairy products among others.

Socialization

Depressed subjects socialized less with their friends, but more with their own children.

Despite other research affirming the relationship between decreased socialization and

depression in the elderly (100) this finding probably needs to be understood in a varying

socio cultural context. Currently a significant proportion of the Indian elderly continue to

live in extended families especially the ‗young –old‘ (50 – 65 years) with married or

unmarried children. In this study too majority of the subjects across the group lived with

their children in the same house or within one mile as. The majority of the subjects in both

groups also reported satisfaction with the help and support they got from close friends.

However the LOD group reported significant history of less interaction with their friends and

47

peers and more interaction with their children. This probably has resulted from the pattern of

lesser interaction with peers and hence exaggerated interaction with children compared to

the control group who reported probably equal socialization with both peers and family

members. The above is only a hypothesis and needs to be validated further as one study from

India report that ‗loneliness‘ may be more related to depression in the elderly than

socialization (102). Interactions with peers/people outside the family circle could provide

opportunities for mutual disclosures with the same age peers, facilitation in problem

solving as well as positive distractions from interpersonal/other issues at home. More over

content of sharing and quality of interactions are important variables than not just the

frequency of interactions and this aspect was not specifically explored in this study. As the

specific family structure was not explored this study could not corroborate a previous Indian

study (42) which had reported that functional disorders were more common in elderly living

in nuclear family or living alone compared to joint family.

Participation in religious activities whether at home or outside was assessed as part of social

activities and it was found that the depressive group had engaged in significantly less

religious activities. This study assessed practice of religious activities as either ceremonial

prayer at home or visits to place of worship. Lesser involvement in religious activities in the

LOD may indirectly also reflect the lesser interaction patterns outside their home. This might

be possible because accessibility of social connections is considered one of the mechanism

through which religious participation may serve as a protective mechanism for health

outcome. This result seems to support previous research which seems to suggest a positive

effect of religious activities in protecting from depression (104,105).

48

Physical Activity and Exercise:

The depressive group subjectively reported more physical activity than control group. How

ever when the same was quantified as ―number of hours of activity‖ there was no difference

between the two groups. It may be due to recall bias of the depressed individuals when

asked to report on their level of physical activity before they were depressed. As many of the

subjects studied were in the ―young-old‖ (<65yrs) category they were involving themselves

in heavy occupational physical activity especially those who were involved in farming.

Many women also reported heavy house old occupational activities like washing clothes,

cleaning etc. However this study did not assess them quantitatively in metabolic equivalents

as done in some other studies. There is also a need to assess physical activities qualitatively

as whether part of occupation or leisure as in some other studies (90) that have tried to

distinguish the two with differential benefits.

Leisure Activities and Hobbies:

There was no difference in the types and numbers of leisure activities between the two study

groups. Leisure activities and hobbies were assessed as the number of activities reported.

There is a need to review the items in the tool in future work to see associations as some of

the other research have combined physical activities and leisure (90, 93). There is also need

to better understand leisure activities in culturally diverse elderly population (114).

Substance Use:

Despite detailed interviewing there were less number of elderly in both the groups who were

using alcohol. Tobacco was slightly more and there was no difference between the two

groups. Unlike the West, the current Indian elderly belong to the era where alcohol and

tobacco are a ‗social taboo and hence the low prevalence of substance use and probably the

lack of significant difference between the groups.

49

In summary this study explored the life-style pattern in a sample of elderly Indian population

and its influence on the genesis of depression. It is a retrospective study in elderly population

who developed depression compared with and age, sex and educational status matched

healthy controls. The life style patterns did not differ much between the groups studied.

When individual items were compared there appeared significant differences which require

elaboration in further studies.

50

CONCLUSION

This cross sectional study on Lifestyle Factors in Late Onset Depression (LOD) did not find

significant difference between elderly with LOD and age, sex and education matched

controls. However in this study there were certain interesting findings in relation to life-style

and LOD in the Indian socio-cultural context. Depressed elderly consumed more dietary

fiber and diary products. They perceived themselves being more physically active and

following healthier diet before the onset of depression. They socialized less with their peers,

but seemed to interact more with family, probably as a function of living with offspring.

They reported significantly less religious practices than control group. Substance use was

observed to be generally low.

LIMITATIONS

1. For want of an available questionnaire that is applicable in Indian context life style

questionnaire was devised based on available questionnaires after consultation with

experts including statistician and nutritionist.

2. The questionnaire needs to be further fine tuned to include the dimensional aspects of

leisure activities which have been used in studies done in dementia.

3. Both the study sample and control sample were derived form urban population with

heterogeneous dietary patterns. This probably blunted the differences between the

groups.

51

FUTURE DIRECTIONS

Further research both in standardization of the tool and also identification of specific life-

style factors in LOD in India need to be carried out.

Longitudinal studies need to be carried out with larger samples in more homogenous

population to better understand the effects of life-style patters in late onset depression.

Studies that can look at serum levels of fatty acids can be more informative about the

influence of specific nutrients that can influence depression.

The specific role of vegetarian diet and depression needs to be explored in a larger sample.

Further exploration into the family structure and the specifics of social interaction patterns

need to be studied in relation to geriatric depression.

IMPLICATIONS OF THIS STUDY.

Life-style factors are modifiable factors that influence health outcomes and present a

window of opportunity to intervene for primordial prevention of diseases. As has been

demonstrated for various physical illnesses if the beneficial effects of better life style could

also be proved for mental health, public at large can be educated regarding positive changes

in their life pattern. Significant differences between the depressed elderly and the matched

controls did not emerge on several life style variables examined. However, the data

highlighted interesting differences on a few items pertaining to dietary pattern and

socialization. The study findings in general and these observations in particular have

generated several hypotheses that need to be critically examined through further research.

52

SUMMARY (ABSTRACT)

Introduction.

The association of lifestyle factors and Late Onset Depression (LOD) was studied in a

treatment seeking elderly population in India.

Method

Treatment seeking population with LOD (n=46) and controls matched for age, sex and

education was cross-sectionally assessed for lifestyle pattern. Depression was diagnosed

based on DSM-IV criteria and HDRS was used for assessing severity of depression.

Depressed group reported about their lifestyle prior to onset of depressive disorder. Lifestyle

was assessed on five parameters namely diet, physical activity/exercise, leisure activities,

Socialization, alcohol and tobacco use.

Result

The mean composite scores for dietary factors, physical activity, socialization and leisure

activities did not differ significantly between the groups and substance use was found to be

low. On comparison of individual items it was found that the LOD group was significantly

taking more of dietary fiber (p<0.001) and dairy products (p=0.03). LOD group also chatted

significantly less with friends/peers (p=0.024) and more with their children when compared

with the control group (p=0.001). Less percentage n=34 (74.0%) of subjects in the

depressive group followed religious activities compared to control group n= 42 (91.3%)

(p=0.052).

Conclusion

This cross sectional study on Lifestyle Factors in Late Onset Depression (LOD) did not find

significant difference between elderly with LOD and age, sex and education matched

controls. However on comparison of individual items LOD group consumed more dietary

fiber and diary products. They socialized less with their peers, but seemed to interact more

with family, probably as a function of living with offspring. They reported significantly less

religious practices than control group. Substance use was observed to be generally low.

These findings need further elaboration in larger sample.

53

References

1. United-Nations. World Population Prospects: The 2008 Revision Population

Database. Population Division of the Department of Economic and Social Affairs of the

United Nations Secretariat 2009 [cited 2010 15 10]; Available from:

http://esa.un.org/UNPP/index.asp?panel=2.

2. United-Nations. World Population Ageing 2009. Department of Economic and Social

Affairs Population Division; 2009 [cited 2010 15 10]; Available from:

http://www.un.org/esa/population/publications/WPA2009/WPA2009_WorkingPaper.pdf.

3. Rajkumar S, Kumar S, Thara R. Prevalence of dementia in a rural setting: A report

from India. Int J Geriatr Psychiatry. 1997;12(7):702-7.

4. Khurana PS, Sharma PSVN, Avasthi A. Prevalence Of Delirium In Geriatric

Hospitalized General Medical Population2002.

5. World-Health-Organization. Mental Health. 2010 [cited 2010 15 10]; Available

from: http://www.who.int/mental_health/management/depression/definition/en/.

6. Grasbeck A. The epidemiology of anxiety and depressive syndromes. A prospective,

longitudinal study of a geographically defined, total population: the Lundby study. Doctoral

thesis.Lund. Lund Sweden: University of Lund; 1996.

7. Gottfries CG. Recognition and management of depression in the elderly. Int Clin

Psychopharmacol. 1997;12 Suppl 7:S31-6.

8. Alexopoulos GS, Meyers BS, Young RC, Kakuma T, Silbersweig D, Charlson M.

Clinically defined vascular depression. Am J Psychiatry. 1997;154(4):562-5.

9. Wang JK, Su TP, Chou P. Sex differences in prevalence and risk indicators of

geriatric depression: the Shih-Pai community-based survey. J Formos Med

Assoc;109(5):345-53.

10. Djernes JK. Prevalence and predictors of depression in populations of elderly: a

review. Acta Psychiatr Scand. 2006;113(5):372-87.

11. Heok KE, Ho R. The many faces of geriatric depression. Current Opinion in

Psychiatry. 2008;21(6):540-5 10.1097/YCO.0b013e328311cdae.

12. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive

disorder: results from the National Epidemiologic Survey on Alcoholism and Related

Conditions. Arch Gen Psychiatry. 2005;62(10):1097-106.

54

13. Nandi DN, Ajmany S, Ganguli H, Benerjee G, Boral GC, Ghosh A, et al. The

Incidence Of Mental Disorders In One Year In A Rual Community In West Bengal1976.

14. Nandi PS, Banerjee G, Mukherjee SP, Nandi S, Nandi DN. A Study Of Psychiatric

Morbidity Of The Elderly Population Of A Rural Community In West Bengal1997.

15. Ramachandran V, Sarada M, Ramamurthy B. Psychiatric Disorders In Subjects Aged

Over Fifty1979.

16. Rao VA, Madhavan T. Gerospsychiatric Morbidity Survey In A Semi-Urban Area

Near Maddurai1982.

17. Tiwari SC. Geriatric psychiatric morbidity in rural northern India: implications for

the future. Int Psychogeriatr. 2000;12(1):35-48.

18. Jain RK, Aras RY. Depression in geriatric population in urban slums of Mumbai.

Indian J Public Health. 2007;51(2):112-3.

19. Krishnan KR, Hays JC, Blazer DG. MRI-defined vascular depression. Am J

Psychiatry. 1997;154(4):497-501.

20. Steffens DC, Krishnan KR. Structural neuroimaging and mood disorders: recent

findings, implications for classification, and future directions. Biol Psychiatry.

1998;43(10):705-12.

21. Carney RM, Rich MW, Tevelde A, Saini J, Clark K, Jaffe AS. Major depressive

disorder in coronary artery disease. Am J Cardiol. 1987;60(16):1273-5.

22. Gavard JA, Lustman PJ, Clouse RE. Prevalence of depression in adults with diabetes.

An epidemiological evaluation. Diabetes Care. 1993;16(8):1167-78.

23. Greenwald BS, Kramer-Ginsberg E, Bogerts B, Ashtari M, Aupperle P, Wu H, et al.

Qualitative magnetic resonance imaging findings in geriatric depression. Possible link

between later-onset depression and Alzheimer's disease? Psychol Med. 1997;27(2):421-31.

24. Luber MP, Hollenberg JP, Williams-Russo P, DiDomenico TN, Meyers BS,

Alexopoulos GS, et al. Diagnosis, treatment, comorbidity, and resource utilization of

depressed patients in a general medical practice. Int J Psychiatry Med. 2000;30(1):1-13.

25. Rabkin JG, Charles E, Kass F. Hypertension and DSM-III depression in psychiatric

outpatients. Am J Psychiatry. 1983;140(8):1072-4.

26. Salloway S, Malloy P, Kohn R, Gillard E, Duffy J, Rogg J, et al. MRI and

neuropsychological differences in early- and late-life-onset geriatric depression. Neurology.

1996;46(6):1567-74.

27. Debbarama G. Depression- A comparitive study of Late and Early onset. Bangalore:

NIMHANS; 2002.

55

28. Alexopoulos GS, Young RC, Meyers BS, Abrams RC, Shamoian CA. Late-onset

depression. Psychiatr Clin North Am. 1988;11(1):101-15.

29. Alexopoulos GS, Young RC, Meyers BS. Geriatric depression: age of onset and

dementia. Biol Psychiatry. 1993;34(3):141-5.

30. Brown RP, Sweeney J, Loutsch E, Kocsis J, Frances A. Involutional melancholia

revisited. Am J Psychiatry. 1984;141(1):24-8.

31. Krishnan KR, McDonald WM. Arteriosclerotic depression. Med Hypotheses.

1995;44(2):111-5.

32. Burvill PW, Hall WD, Stampfer HG, Emmerson JP. A comparison of early-onset and

late-onset depressive illness in the elderly. Br J Psychiatry. 1989;155:673-9.

33. Baldwin RC, Tomenson B. Depression in later life. A comparison of symptoms and

risk factors in early and late onset cases. Br J Psychiatry. 1995;167(5):649-52.

34. Brodaty H, Luscombe G, Parker G, Wilhelm K, Hickie I, Austin MP, et al. Early and

late onset depression in old age: different aetiologies, same phenomenology. J Affect Disord.

2001;66(2-3):225-36.

35. Brodaty H, Peters K, Boyce P, Hickie I, Parker G, Mitchell P, et al. Age and

depression. J Affect Disord. 1991;23(3):137-49.

36. Conwell Y, Nelson JC, Kim KM, Mazure CM. Depression in late life: age of onset as

marker of a subtype. J Affect Disord. 1989;17(2):189-95.

37. Drevets WC. Geriatric depression: brain imaging correlates and pharmacologic

considerations. J Clin Psychiatry. 1994;55 Suppl A:71-81; discussion 2, 98-100.

38. Mendlewicz J. The age factor in depressive illness: some genetic considerations. J

Gerontol. 1976;31(3):300-3.

39. Cassano GB, Akiskal HS, Savino M, Soriani A, Musetti L, Perugi G. Single episode

of major depressive disorder. First episode of recurrent mood disorder or distinct subtype of

late-onset depression? Eur Arch Psychiatry Clin Neurosci. 1993;242(6):373-80.

40. Van den Berg MD, Oldehinkel AJ, Bouhuys AL, Brilman EI, Beekman AT, Ormel J.

Depression in later life: three etiologically different subgroups. J Affect Disord.

2001;65(1):19-26.

41. Sneed JR, Kasen S, Cohen P. Early-life risk factors for late-onset depression. Int J

Geriatr Psychiatry. 2007;22(7):663-7.

42. Ramachandran V, Menon SM, Arunagiri S. Physical Disabilities In Late Onset

Depression In The Community1982.

56

43. Key TJ, Allen NE, Spencer EA, Travis RC. The effect of diet on risk of cancer.

Lancet. 2002;360(9336):861-8.

44. Flicker L. Life style interventions to reduce the risk of dementia. Maturitas.

2009;63(4):319-22.

45. Middleton LE, Kirkland SA, Maxwell CJ, Hogan DB, Rockwood K. Exercise: a

potential contributing factor to the relationship between folate and dementia. J Am Geriatr

Soc. 2007;55(7):1095-8.

46. Housman J, Dorman S. The Alameda County Study: A Systematic, Chronological

Review. American Journal of Health Education 2005;36(5):302-8.

47. Belloc NB, Breslow L. Relationship of physical health status and health practices.

Prev Med. 1972;1(3):409-21.

48. Belloc NB. Relationship of health practices and mortality. Prev Med. 1973;2(1):67-

81.

49. Frederick T, Frerichs RR, Clark VA. Personal health habits and symptoms of

depression at the community level. Prev Med. 1988;17(2):173-82.

50. Appleton KM, Woodside JV, Yarnell JW, Arveiler D, Haas B, Amouyel P, et al.

Depressed mood and dietary fish intake: direct relationship or indirect relationship as a result

of diet and lifestyle? J Affect Disord. 2007;104(1-3):217-23.

51. Rao TS, Asha MR, Ramesh BN, Rao KS. Understanding nutrition, depression and

mental illnesses. Indian J Psychiatry. 2008;50(2):77-82.

52. Averina M, Nilssen O, Brenn T, Brox J, Arkhipovsky VL, Kalinin AG. Social and

lifestyle determinants of depression, anxiety, sleeping disorders and self-evaluated quality of

life in Russia--a population-based study in Arkhangelsk. Soc Psychiatry Psychiatr

Epidemiol. 2005;40(7):511-8.

53. Cabrera MA, Mesas AE, Garcia AR, de Andrade SM. Malnutrition and depression

among community-dwelling elderly people. J Am Med Dir Assoc. 2007;8(9):582-4.

54. Torres SJ, McCabe M, Nowson CA. Depression, nutritional risk and eating

behaviour in older caregivers. J Nutr Health Aging. 2010;14(6):442-8.

55. Woo J, Ho SC, Sham A. Longitudinal changes in body mass index and body

composition over 3 years and relationship to health outcomes in Hong Kong Chinese age 70

and older. J Am Geriatr Soc. 2001;49(6):737-46.

56. Bhat RS, Chiu E, Jeste DV. Nutrition and geriatric psychiatry: a neglected field.

Current Opinion in Psychiatry. 2005;18(6):609-14.

57

57. Koster A, van Gool CH, Kempen GI, Penninx BW, Lee JS, Rubin SM, et al. Late-life

depressed mood and weight change contribute to the risk of each other. Am J Geriatr

Psychiatry. 2010;18(3):236-44.

58. Ho RC, Niti M, Kua EH, Ng TP. Body mass index, waist circumference, waist-hip

ratio and depressive symptoms in Chinese elderly: a population-based study. Int J Geriatr

Psychiatry. 2008;23(4):401-8.

59. Kim E, Song JH, Hwang JY, Ahn K, Kim J, Koh YH, et al. Obesity and depressive

symptoms in elderly Koreans: evidence for the "Jolly Fat" hypothesis from the Ansan

Geriatric (AGE) Study. Arch Gerontol Geriatr. 2010;51(2):231-4.

60. Li ZB, Ho SY, Chan WM, Ho KS, Li MP, Leung GM, et al. Obesity and depressive

symptoms in Chinese elderly. Int J Geriatr Psychiatry. 2004;19(1):68-74.

61. Almeida OP, Calver J, Jamrozik K, Hankey GJ, Flicker L. Obesity and metabolic

syndrome increase the risk of incident depression in older men: the health in men study. Am

J Geriatr Psychiatry. 2009;17(10):889-98.

62. Kostka T, Bogus K. Independent contribution of overweight/obesity and physical

inactivity to lower health-related quality of life in community-dwelling older subjects. Z

Gerontol Geriatr. 2007;40(1):43-51.

63. Kuriyama S, Koizumi Y, Matsuda-Ohmori K, Seki T, Shimazu T, Hozawa A, et al.

Obesity and depressive symptoms in elderly Japanese: the Tsurugaya Project. J Psychosom

Res. 2006;60(3):229-35.

64. Payne ME, Hybels CF, Bales CW, Steffens DC. Vascular nutritional correlates of

late-life depression. Am J Geriatr Psychiatry. 2006;14(9):787-95.

65. Sanchez-Villegas A, Delgado-Rodriguez M, Alonso A, Schlatter J, Lahortiga F,

Serra Majem L, et al. Association of the Mediterranean dietary pattern with the incidence of

depression: the Seguimiento Universidad de Navarra/University of Navarra follow-up (SUN)

cohort. Arch Gen Psychiatry. 2009;66(10):1090-8.

66. Sanchez-Villegas A, Henriquez P, Bes-Rastrollo M, Doreste J. Mediterranean diet

and depression. Public Health Nutr. 2006;9(8A):1104-9.

67. Kyrozis A, Psaltopoulou T, Stathopoulos P, Trichopoulos D, Vassilopoulos D,

Trichopoulou A. Dietary lipids and geriatric depression scale score among elders: the EPIC-

Greece cohort. J Psychiatr Res. 2009;43(8):763-9.

68. Tanskanen A, Hibbeln JR, Tuomilehto J, Uutela A, Haukkala A, Viinamaki H, et al.

Fish consumption and depressive symptoms in the general population in Finland. Psychiatr

Serv. 2001;52(4):529-31.

58

69. Peet M. International variations in the outcome of schizophrenia and the prevalence

of depression in relation to national dietary practices: an ecological analysis. Br J Psychiatry.

2004;184:404-8.

70. McIntosh A, Lawrie S. Cross-national differences in diet, the outcome of

schizophrenia and the prevalence of depression: you are (associated with) what you eat. Br J

Psychiatry. 2004;184:381-2.

71. Tiemeier H, van Tuijl HR, Hofman A, Kiliaan AJ, Breteler MM. Plasma fatty acid

composition and depression are associated in the elderly: the Rotterdam Study. Am J Clin

Nutr. 2003;78(1):40-6.

72. Bots S, Tijhuis M, Giampaoli S, Kromhout D, Nissinen A. Lifestyle- and diet-related

factors in late-life depression—a 5-year follow-up of elderly European men: the FINE study.

International Journal of Geriatric Psychiatry. 2008;23(5):478-84.

73. Hibbeln JR, Salem N, Jr. Dietary polyunsaturated fatty acids and depression: when

cholesterol does not satisfy. Am J Clin Nutr. 1995;62(1):1-9.

74. Akbaraly TN, Brunner EJ, Ferrie JE, Marmot MG, Kivimaki M, Singh-Manoux A.

Dietary pattern and depressive symptoms in middle age. Br J Psychiatry. 2009;195(5):408-

13.

75. Jacka FN, Pasco JA, Mykletun A, Williams LJ, Hodge AM, O'Reilly SL, et al.

Association of Western and traditional diets with depression and anxiety in women. Am J

Psychiatry. 2010;167(3):305-11.

76. Beezhold BL, Johnston CS, Daigle DR. Vegetarian diets are associated with healthy

mood states: a cross-sectional study in seventh day adventist adults. Nutr J. 2010;9:26.

77. Owen C, Rees A-M, Parker G. The role of fatty acids in the development and

treatment of mood disorders. Current Opinion in Psychiatry. 2008;21(1):19-24

10.1097/YCO.0b013e3282f29841.

78. Rogers PJ. A healthy body, a healthy mind: long-term impact of diet on mood and

cognitive function. Proc Nutr Soc. 2001;60(1):135-43.

79. Timonen M, Horrobin D, Jokelainen J, Laitinen J, Herva A, Rasanen P. Fish

consumption and depression: the Northern Finland 1966 birth cohort study. J Affect Disord.

2004;82(3):447-52.

80. Kesaniemi YK, Danforth E, Jr., Jensen MD, Kopelman PG, Lefebvre P, Reeder BA.

Dose-response issues concerning physical activity and health: an evidence-based

symposium. Med Sci Sports Exerc. 2001;33(6 Suppl):S351-8.

81. Rockwood K, Middleton L. Physical activity and the maintenance of cognitive

function. Alzheimer's and Dementia. 2007;3(2, Supplement 1):S38-S44.

59

82. Lautenschlager NT, Almeida OP. Physical activity and cognition in old age. Current

Opinion in Psychiatry. 2006;19(2):190-3 10.1097/01.yco.0000214347.38787.37.

83. Paluska SA, Schwenk TL. Physical activity and mental health: current concepts.

Sports Med. 2000;29(3):167-80.

84. Duman RS. Neurotrophic factors and regulation of mood: role of exercise, diet and

metabolism. Neurobiol Aging. 2005;26 Suppl 1:88-93.

85. Cassidy K, Kotynia-English R, Acres J, Flicker L, Lautenschlager NT, Almeida OP.

Association between lifestyle factors and mental health measures among community-

dwelling older women. Australian and New Zealand Journal of Psychiatry. 2004;38(11-

12):940-7.

86. Kritz-Silverstein D, Barrett-Connor E, Corbeau C. Cross-sectional and prospective

study of exercise and depressed mood in the elderly : the Rancho Bernardo study. Am J

Epidemiol. 2001;153(6):596-603.

87. Camacho TC, Roberts RE, Lazarus NB, Kaplan GA, Cohen RD. Physical activity

and depression: evidence from the Alameda County Study. Am J Epidemiol.

1991;134(2):220-31.

88. Strawbridge W, Shema S. Impact of spouses‘ sleep problems on partners. Sleep.

2004;3(527-531).

89. Brown WJ, Ford JH, Burton NW, Marshall AL, Dobson AJ. Prospective study of

physical activity and depressive symptoms in middle-aged women. Am J Prev Med.

2005;29(4):265-72.

90. Wiles NJ, Haase AM, Gallacher J, Lawlor DA, Lewis G. Physical activity and

common mental disorder: results from the Caerphilly study. Am J Epidemiol.

2007;165(8):946-54.

91. Wise LA, Adams-Campbell LL, Palmer JR, Rosenberg L. Leisure time physical

activity in relation to depressive symptoms in the Black Women's Health Study. Ann Behav

Med. 2006;32(1):68-76.

92. Ku PW, Fox KR, Chen LJ. Physical activity and depressive symptoms in Taiwanese

older adults: a seven-year follow-up study. Prev Med. 2009;48(3):250-5.

93. Heesch KC, Burton NW, Brown WJ. Concurrent and prospective associations

between physical activity, walking and mental health in older women. Journal of

Epidemiology and Community Health. 2010.

94. Scarmeas N, Levy G, Tang MX, Manly J, Stern Y. Influence of leisure activity on

the incidence of Alzheimer's disease. Neurology. 2001;57(12):2236-42.

60

95. Glass TA, de Leon CM, Marottoli RA, Berkman LF. Population based study of social

and productive activities as predictors of survival among elderly Americans. Bmj.

1999;319(7208):478-83.

96. Farmer ME, Locke BZ, Moscicki EK, Dannenberg AL, Larson DB, Radloff LS.

Physical activity and depressive symptoms: the NHANES I Epidemiologic Follow-up Study.

Am J Epidemiol. 1988;128(6):1340-51.

97. Peluso MA, Guerra de Andrade LH. Physical activity and mental health: the

association between exercise and mood. Clinics (Sao Paulo). 2005;60(1):61-70.

98. De Moor MH, Boomsma DI, Stubbe JH, Willemsen G, de Geus EJ. Testing causality

in the association between regular exercise and symptoms of anxiety and depression. Arch

Gen Psychiatry. 2008;65(8):897-905.

99. Reynolds P, Kaplan G. . Social connections and risk for cancer: Prospective evidence

from the Alameda County Study Behav Med. 1990;31(2):101-10.

100. Demura S, Sato S. Relationships between depression, lifestyle and quality of life in

the community dwelling elderly: a comparison between gender and age groups. J Physiol

Anthropol Appl Human Sci. 2003;22(3):159-66.

101. Kim J-I, Choe M-A, Chae YR. Prevalence and Predictors of Geriatric Depression in

Community-Dwelling Elderly. Asian Nursing Research. 2009;3(3):121-9.

102. Singh A, Misra N. Loneliness, depression and sociability in old age. Industrial

psychiatry Journal. 2010;18(1):51-5.

103. Gautam R, Saito T, Kai I. Leisure and religious activity participation and mental

health: gender analysis of older adults in Nepal. BMC Public Health. 2007;7:299.

104. Hahn CY, Yang MS, Yang MJ, Shih CH, Lo HY. Religious attendance and

depressive symptoms among community dwelling elderly in Taiwan. Int J Geriatr

Psychiatry. 2004;19(12):1148-54.

105. Kennedy GJ, Kelman HR, Thomas C, Chen J. The relation of religious preference

and practice to depressive symptoms among 1,855 older adults. J Gerontol B Psychol Sci

Soc Sci. 1996;51(6):P301-8.

106. van Gool CH, Kempen GI, Penninx BW, Deeg DJ, Beekman AT, van Eijk JT.

Relationship between changes in depressive symptoms and unhealthy lifestyles in late

middle aged and older persons: results from the Longitudinal Aging Study Amsterdam. Age

Ageing. 2003;32(1):81-7.

107. American-Psychiatric-Association, editor. Diagnostic and Statistical Manual of

Mental Disorders. 4th ed Text Revision ed. Washington, DC2000.

61

108. Ganguli M, Ratcliff G, Chandra V, Sharma S, Gilby J, Pandav R, et al. A hindi

version of the MMSE: The development of a cognitive screening instrument for a largely

illiterate rural elderly population in india. International Journal of Geriatric Psychiatry.

1995;10(5):367-77.

109. Sheehan DV, Lecrubier Y, Harnett Sheehan K, Janavs J, Weiller E, Keskiner A, et al.

The validity of the Mini International Neuropsychiatric Interview (MINI) according to the

SCID-P and its reliability. European Psychiatry. 1997;12(5):232-41.

110. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry.

1960;23:56-62.

111. Hachinski VC, Iliff LD, Zilhka E, Du Boulay GH, McAllister VL, Marshall J, et al.

Cerebral blood flow in dementia. Arch Neurol. 1975;32(9):632-7.

112. Miller MD, Paradis CF, Houck PR, Mazumdar S, Stack JA, Rifai AH, et al. Rating

chronic medical illness burden in geropsychiatric practice and research: application of the

Cumulative Illness Rating Scale. Psychiatry Res. 1992;41(3):237-48.

113. Prince M, Ferri C, Acosta D, Albanese E, Arizaga R, Dewey M, et al. The protocols

for the 10/66 dementia research group population-based research programme. BMC Public

Health. 2007;7(1):165.

114. Allison MT, Geiger CW. Nature of leisure activities among the Chinese-American

elderly. Leisure Sciences: An Interdisciplinary Journal. 1993;15(4):309 - 19.

62

Appendix 1 LIFE STYLE ASSESSMENT

S. No:

NAME:

AGE :

SOCIOECONOMIC STATUS:

EDUCATION:

HEIGHT : cm

WEIGHT: Kg

Mid Arm Circumference cm

[I] DIET

We would like to know your/relatives‘ Diet Habits over the past many years.( before you

developed this disorder).

1. Are you a Vegetarian ? Y / N

Adequacy of Food and Liquids.

2. On an average how many times do you eat per day ?

Full Meals 1 – 1

2 – 2

3 - 3

Snacks (samosa, chukkli, bun) 0 – 2

1 – 1

2 – 0

3. How many cups of liquids do you drink in a day?

Water 1-2, 3-5,>5

Coffee 1-2, 3-5,>5

Tea 1-2, 3-5,>5

Others (non alcoholic ) 1-2, 3-5,>5

Total water 1- < 1L, 2- 1L to 2L , 3- > 2L.

63

III. Type of Food

1. What is the main item in your meal on a regular day 2-3 a day (it could be more than

one item)

Carbohydrates with Fibre All meals in a week - 5

(Boiled rice, red rice, wheat, ragi, Most Meals in a week - 4

corn, jowar, bajra, millets, oats) Once a day - 3

Anna, mudde, idli, dosa, roti, Sometimes in a week - 2

chappathi, dhaliya, kambu kalzhi, In a month - 1

bajra/jowar roti, puri, ragi malt) Never - 0

Carbohydrates without Fibre All meals in a week - 0

(Raw Polished Rice, Soji, Maida Most Meals in a week - 1

Rice Flour, Sabudhana) Once a day - - 2

Akki Roti, Anna, Upma, Nan, Avalakki, Sometimes in a week - 3

Sooji, Sabudhanna Kanji In a month - 4

Rarely - 5

2. Proteins

(1) NV Protein

Fish > 4 times a week – 3

2-4 times a week – 2

Once a week - 1

Never - 0

Chicken > 4 times a week -1

2-4 times a week – 2

Once a week - 3

Never - 0

Meat > 4 times a week - 1

(Lamb, Pork, Beef) 2-4 times a week – 2

Once a week - 3

Never - 0

Eggs > 4 times a week - 1

2 -4 times a week – 2

Once a week - 3

Never -0

Dairy Products > 4 times a week – 3

(Milk, Curds, Cheese) 2-4 times a week – 2

Once a week - 1

Never - 0

64

(2) Vegetable Proteins

Pulses/Legumes > 4 times a week – 3

(Thick Sambar/Saru, Dals, Usili) 2-4 times a week – 2

Once a week - 1

Never - 0

3.Fats

(1) Unsaturated Fats > 4 times a week – 1

[Butter, Ghee, vanaspathi 2 -4 times a week - 2

Coconut oil, Palmolein ] Once a week - 3

Never - 4

(2) PUFA > 4 times a week – 3

[ Sunflower oil, 2-4 times a week - 2

Til Oil, Mustard Oil Once a week - 1

Ground nut Oil , Rice Bran Oil] Never -0

4. Fruits and Vegetables.

(1) Vegetables Every meal in a week - 5

(greens, beans, potato, tomato, gourds) Most Meal in a week - 4

Once a day - 3

Sometimes in a week - 2

Rarely - 1

Never - 0

(2) Fruits Every Day - 5

(banana, apple, guava, melon, papaya) 4-6 times a week - 4

Twice a week - 3

Once a week - 2

Rarely in a month - 1

In your opinion how Healthy is your Diet over the last many years - Very healthy

( before developing the disorder) Moderately Healthy

Not Healthy

65

[II] PHYSICAL ACTIVITY

6. Are you a physically person? Yes / No

2. Do you exercise ? If yes, the number of times a week

Every day / wk – 5

4 times / wk - 4

3-4 times /wk – 3

1-2 times / wk – 2

Occasionally - 1

Never - 0

3. As an exercise do you (Give score 1 for each activity)

Walk Y / N

Yoga / Asanas Y / N

Games (Tennis) Y / N

Others Y / N

4. Do you do house work . If ‗Yes‘ specify (Give score 1 for each activity)

Cooking Y / N

Cleaning Y / N

Gardening Y / N

Sweeping Y / N

Washing Clothes Y / N

Watering Y / N

Tending to cattle Y / N

Washing Vessels Y / N

Looking after grandchildren Y / N

Others Y / N

5. According to you how many hours in a day are you moving totally?

Sedentary – 0

1-2 hours - 1

2-4 hours - 2

> 4 hours - 3

6. According to you how physically active have you been in the past many years?

Very active - 3

Moderately Active -2

Somewhat Active - 1

66

Not Active at all - 0

[III] LEISURE ACTIVITIES AND HOBBIES

1. What are/were you leisure activities

Newspaper Reading Y / N

T.V. Viewing Y / N

Listening to Music Y / N

Going to Temple Y / N

Going to movies Y / N

Visiting Friends Y / N

Others(specify) Y / N

2. Do you have any hobbies ?

Gardening Y / N

Singing (carnatic, light, bhajans) Y / N

Playing a game (Chess, cards) Y / N

Playing an instrument Y / N

Writing Poetry/story Y / N

Doing Handcrafts Y / N

Doing Painting Y / N

Social Service Y / N

Others (specify) Y / N

3. Do you follow religious activities Y / N

67

[IV] SOCIAL NETWORK

1 How far away does your nearest (in terms of distance)

relative live?

Within one mile/same home 1

1-5 miles 2

6-15 miles 3

16-50 miles 4

50+ miles 5

2 Where does your nearest sister or brother live?

No siblings 0

Within one mile/same home 1

1-5 miles 2

6-15 miles 3

16-50 miles 4

50+ miles 5

3 Do you have any children?

No 0 (goto question 6)

Yes 1

4 Where does your nearest child live?

No children 0

Within one mile/same home 1

1-5 miles 2

6-15 miles 3

16-50 miles 4

50+ miles 5

5 How often do you see any of your children or other relatives

to speak to?

Never 0

Daily 1

2-3 times a week 2

At least weekly 3

At least monthly 4

Less often 5

6 Do you have friends in this community?

No 0 ( goto question 9 )

Yes 1

7 How often do you have a chat or do something with one of

your friends?

No friends/ Never 0

Daily 1

68

2-3 times a week 2

At least weekly 3

At least monthly 4

Less often 5

8 All in all are you satisfied or dissatisfied with the help

and support you can get from your close friends?

Dissatisfied 0

Satisfied 1

9 How often do you see any of your neighbors to have a chat or

do something with?

No contact 0

Daily 1

2-3 times a week 2

At least weekly 3

At least monthly 4

Less often 5

69

[V] SMOKING

1 Has there ever been a period when you smoked or chewed

tobacco or snuff nearly every day? Y / N

2 What did you smoke?

Cigarettes Y / N

Cigars Y / N

Beedis Y / N

Chewing tobacco Y / N

Snuff Y / N

3 How many years have you been using tobacco regularly?

4 How many did you/do you have each day?

4 Do you still use tobacco regularly? Y / N

5 If yes since how long (years ) have you stopped ?

6 Pack years

[IV] ALCOHOL

1 Before you reached the age of 60, what was the most you

would drink in an average week? (in units)

2 What about after the age of 60?

(Record total consumption in units of alcohol)

3 Pattern of drinking before onset of disorder

1. daily drinking 2. regular drinking ( 3 or more times/week) 3. social drinking ( < 3times/week ) 4. none

4 Have you ever had treatment or help for drinking from a

doctor or some other agency?

70

APPENDIX 2 HDRS Scale (Hamilton Depression Rating Scale)

1. DEPRESSED MOOD (Sadness, hopeless, helpless, worthless)

0= Absent

1= These feeling states indicated only on questioning

2= These feeling states spontaneously reported verbally

3= Communicates feeling states non-verbally—i.e., through facial expression, posture,

voice, and tendency to weep

4= Patient reports VIRTUALLY ONLY these feeling states in his spontaneous verbal and

non- verbal communication

2. FEELINGS OF GUILT

0= Absent

1= Self reproach, feels he has let people down

2= Ideas of guilt or rumination over past errors or sinful deeds

3= Present illness is a punishment. Delusions of guilt

4= Hears accusatory or denunciatory voices and/or experiences threatening visual

hallucinations

3. SUICIDE

0= Absent

1= Feels life is not worth living

2= Wishes he were dead or any thoughts of possible death to self

3= Suicidal ideas or gesture

4= Attempts at suicide (any serious attempt rates 4)

4. INSOMNIA EARLY

0= No difficulty falling asleep

1= Complains of occasional difficulty falling asleep —i.e., more than 1/2 hour

2= Complains of nightly difficulty falling asleep

5. INSOMNIA MIDDLE

0= No difficulty

1= Patient complains of being restless and disturbed during the night

2= Waking during the night—any getting out of bed rates 2 (except for purposes of

voiding)

6. INSOMNIA LATE

0= No difficulty

1= Waking in early hours of the morning but goes back to sleep

2= Unable to fall asleep again if he gets out of bed

7. WORK AND ACTIVITIES

0= No difficulty

1= Thoughts and feelings of incapacity, fatigue or weakness related to activities; work or

hobbies

71

2= Loss of interest in activity; hobbies or work—either directly reported by patient, or

indirect in listlessness, indecision and vacillation (feels he has to push self to work or

activities)

3= Decrease in actual time spent in activities or decrease in productivity

4= Stopped working because of present illness

8. RETARDATION: PSYCHOMOTOR (Slowness of thought and speech; impaired ability

to concentrate; decreased motor activity)

0= Normal speech and thought

1= Slight retardation at interview

2= Obvious retardation at interview

3= Interview difficult

4= Complete stupor

9. AGITATION

0= None

1= Fidgetiness

2= Playing with hands, hair, etc.

3= Moving about, can‘t sit still

4= Hand wringing, nail biting, hair-pulling, biting of lips

10. ANXIETY (PSYCHOLOGICAL)

0= No difficulty

1= Subjective tension and irritability

2= Worrying about minor matters

3= Apprehensive attitude apparent in face or speech

4= Fears expressed without questioning

11. ANXIETY SOMATIC: Physiological concomitants of anxiety, (i.e., effects of autonomic

overactivity, ―butterflies,‖ indigestion, stomach cramps, belching, diarrhea, palpitations,

hyperventilation, paresthesia, sweating, flushing, tremor, headache, urinary frequency).

Avoid asking about possible medication side effects (i.e., dry mouth, constipation)

0= Absent

1= Mild

2= Moderate

3= Severe

4= Incapacitating

12. SOMATIC SYMPTOMS (GASTROINTESTINAL)

0= None

1= Loss of appetite but eating without encouragement from others. Food intake about

normal

2= Difficulty eating without urging from others. Marked reduction of appetite and

food intake

13. SOMATIC SYMPTOMS GENERAL

0= None

1= Heaviness in limbs, back or head. Backaches, headache, muscle aches. Loss of energy

and fatigability

72

2= Any clear-cut symptom rates 2

14. GENITAL SYMPTOMS (Symptoms such as: loss of libido; impaired sexual

performance;

menstrual disturbances)

0= Absent

1= Mild

2= Severe

15. HYPOCHONDRIASIS

0= Not present

1= Self-absorption (bodily)

2= Preoccupation with health

3= Frequent complaints, requests for help, etc.

4= Hypochondriacal delusions

16. LOSS OF WEIGHT

A. When rating by history:

0= No weight loss

1= Probably weight loss associated with present illness

2= Definite (according to patient) weight loss

3= Not assessed

7. INSIGHT

0= Acknowledges being depressed and ill

1= Acknowledges illness but attributes cause to bad food, climate, overwork, virus, need

for rest, etc.

2= Denies being ill at all

18. DIURNAL VARIATION

A. Note whether symptoms are worse in morning or evening. If NO diurnal variation,

mark none

0= No variation

1= Worse in A.M.

2= Worse in P .M.

B. When present, mark the severity of the variation. Mark ―None‖ if NO variation

0= None

1= Mild

2= Severe

19. DEPERSONALIZATION AND DEREALIZATION (Such as: Feelings of unreality;

Nihilistic ideas)

0= Absent

1= Mild

2= Moderate

3= Severe

4= Incapacitating

20. PARANOID SYMPTOMS

0= None

1= Suspicious

73

2= Ideas of reference

3= Delusions of reference and persecution

21. OBSESSIONAL AND COMPULSIVE SYMPTOMS TOTAL SCORE=

0= Absent

1= Mild

2= Severe

APPENDIX 3 HACHINSKI ISCHEMIC SCORE

FEATURE POINTS

1. Abrupt onset of symptoms 2

2. Stepwise deterioration 1

3. Fluctuating course 2

4. Nocturnal confusion 1

5. Personality relatively preserved 1

6. Depression 1

7. Somatic complaints 1

8. Emotional lability 1

9. History or presence of Hypertension 1

10. History of stroke 2

11. Evidence of coexisting atherosclerosis 1

12. Focal neurological symptoms 2

13. Focal Neurological signs 2

Total score=

74

APPENDIX 4 Cumulative illness Rating scale for Geriatrics (CIRS-G)

Rating Strategy

0- No problem

1- Current mild problem or past significant problem

2- Moderate disability or morbidity/requires ― first line‖ therapy

3- Severe/constant significant disability/ ―uncontrollable‖ chronic problems

4- Extreme Severe/ immediate treatment required/ end organ failure/ severe dysfunction

Score

Heart

Vascular

Hematopoietic

Respiratory

Eyes, Ears, nose, throat and Larynx

Upper GI

Lower GI

Liver

Renal

Genitourinary

Musculoskeletal/Integument

Neurological

Endocrine/Metabolic and Breast

Psychiatric illness

Total number of Categories endorsed

Total score

Severity index

No of categories with level 3 severity

No of categories with level 4severity

75

APPENDIX 5

HINDI MENTAL STATE EXAMINATION (HMSE)

Correct/R Wrong

1. Is it morning or afternoon or evening? 1 0

2.

What day of the week is today?

1

0

3.

What date is it today?

1

0

4.

Which month is today?

1

0

5.

What season of the year is this?

1

0

6.

Under which post office does your village come?

1

0

7.

Which district does your village fall under?

1

0

8.

Which village are you from?

1

0

9.

Which block (If village has only blocks)

1

0

OR

Which numbered area is this?

10. Which place is this? 1 0

11. (I went to Delhi and brought three things –

Mango, chair, and coin) Can you tell me what

Are the three things I brought from Delhi? 1 2 3

12. (a) Now can you tell me names of the days of

the week starting from Sunday?

(b) Now can you tell me names of the days 1 2 3 4 5

backwards?

13-15 What are the names of the three things 1 2 3

Which I told you have brought from Delhi?

76

16. (Show the subject the wrist watch and pen)

Can you tell me these objects?

(If yes, Items 17 & 18 apply)

(If No, Item 17(a) apply

17. Show him the wrist watch and say what is this 1 0

OR

17 (a). If necessary, Identification of watch by

Touching what is this?

18. Show him the pen and say – What is this? 1 0

OR

18 (a). (If necessary) Identification of pen by

Touching what is this?

19. Now I am going to say something, listen

carefully and repeat it exactly as I say

after I finish

Phrase: ―NEITHER THIS NOR THAT‖ 1 0

20. Now look at my face and do exactly what

I do. Close your eyes? 1 0

21. First you take the paper in your right hand,

then with your both hands, fold it into half

once and then give the paper back to me. 1 2 3

22. Now say a line about your house? (something

specifically about your houses) NOT

INCLUDED IN HMSE TOTAL

If given -1, Not given – 0.

23. Here is a drawing, you must copy this

drawing exactly as shown in the space

provided here.

77

Score:

Must draw two four sided figure =1

One figure should be mostly inside the other =2

Orientation of the figures should be obviously appropriate =3

Total score = /31

78

APPENDIX 6 MINI SCREEN

PATIENT NAME : DATE OF BIRTH:

DATE OF INTERVIEW: If YES, go to the corresponding M.I.N.I. module

- Have you been consistently depressed or down, most of the day, nearly every day,

for the past two weeks ? NO YES

- In the past two weeks, have you been much less interested in most things or much

less able to enjoy the things you used to enjoy most of the time ? NO YES

- Have you felt sad, low or depressed most of the time for the last two years ? NO YES

- In the past month did you think that you would be better off dead or wish you were

dead ? NO YES

- Have you ever had a period of time when you were feeling ‗up‘ or ‗high‘ or ‗hyper‘

or so full of energy or full of yourself that you got into trouble, or that other people

thought you were not your usual self ? (Do not consider times when you were NO YES

intoxicated on drugs or alcohol.)

- Have you ever been persistently irritable, for several days, so that you had arguments

or verbal or physical fights, or shouted at people outside your family ? Have you or

others noticed that you have been more irritable or over reacted, compared to other

people, even in situations that you felt were justified ? NO YES

- Have you, on more than one occasion, had spells or attacks when you suddenly felt

anxious, frightened, uncomfortable or uneasy, even in situations where most people

would not feel that way ? Did the spells surge to a peak, within 10 minutes of starting NO YES ? CODE YES ONLY IF THE SPELLS PEAK WITHIN 10 MINUTES.

- Do you feel anxious or uneasy in places or situations where you might have a panic

attack or panic-like symptoms, or where help might not be available or escape might

be difficult : like being in a crowd, standing in a line (queue), when you are away

from home or alone at home, or when crossing a bridge, traveling in a bus, train or NO YES

car ?

- In the past month were you fearful or embarrassed being watched, being the focus of

attention, or fearful of being humiliated ? This includes things like speaking in

public, eating in public or with others, writing while someone watches, or being in NO YES

social situations.

- In the past month have you been bothered by recurrent thoughts, impulses, or images

that were unwanted, distasteful, inappropriate, intrusive, or distressing ? (e.g., the

idea that you were dirty, contaminated or had germs, or fear of contaminating others,

or fear of harming someone even though you didn‘t want to, or fearing you would

act on some impulse, or fear or superstitions that you would be responsible for things

going wrong, or obsessions with sexual thoughts, images or impulses, or hoarding, NO YES

collecting, or religious obsessions.)

→ A

→ A

→ B

→ C

→ D

→ D

→ E

→ F

→ G

→ H

79

IF YES, GO T O THE CORRESPONDING M.I.N.I. MODULE

→ H

→ I

→ I

→ I → J

→ K

→ M

→ N

→ N

→ O

- In the past month, did you do something repeatedly without being able to resist doing it,

like washing or cleaning excessively, counting or checking things over and over, or

repeating, collecting, or arranging things, or other superstitious rituals ?

NO YES

- Have you ever experienced or witnessed or had to deal with an extremely traumatic event

that included actual or threatened death or serious injury to you or someone else ? EXAMPLES OF TRAUMATIC EVENTS INCLUDE SERIOUS ACCIDENTS, SEXUAL OR PHYSICAL ASSAULT, A

TERRORIST ATTACK, BEING HELD HOSTAGE, KIDNAPPING, FIRE, DISCOVERING A BODY, SUDDEN

DEATH OF SOMEONE CLOSE TO YOU, WAR, OR NATURAL DISASTER.

- Did you respond to the trauma with intense fear, helplessness, or horror ?

- During the past month, have you re-experienced the event in a distressing way (such as,

dreams, intense recollections, flashbacks or physical reactions) ?

NO YES NO YES

NO YES

- In the past 12 months, have you had 3 or more alcoholic drinks within a 3 hour period

on 3 or more occasions ?

NO YES

- Now I am going to show you / READ THE LIST BELOW of street drugs or medicines. In

the past 12 months, did you take any of these drugs more than once, to get high, to feel

better, or to change your mood ?

NO YES

amphetamines speed crystal meth Dexedrine Ritalin, diet pills, rush

cocaine crack freebase speedball heroin morphine, methadone opium Demerol codeine, Percodan, OxyContin

LSD mescaline PCP, angel dust MDA, MDMA ecstasy, ketamine

inhalants glue ether GHB steroids

THC, marijuana cannabis, hashish grass weed, reefer barbiturates, Valium, Xanax, Ativan

- How tall are you ? | | | | inches

- What was your lowest weight in the past 3 months ? | | | | lbs

IS PATIENT‘S WEIGHT LOWER THAN THE THRESHOLD CORRESPONDING TO HIS / HER HEIGHT ? NO YES

Height (ft in) 4‘9 4‘10 4‘11 5‘0 5‘1 5‘2 5‘3 5‘4 5‘5 5‘6 5‘7 Weight (lbs)

Height (ft in)

Weight (lbs)

81 84 87 89 92 96 99 102 105 108 112

5‘8 5‘9 5‘10 5‘11 6‘0 6‘1 6‘2 6‘3

115 118 122 125 129 132 136 140

- In the past three months, did you have eating binges or times when you ate a very large

amount of food within a 2-hour period ?

NO YES

- In the last 3 months, did you have eating binges as often as twice a week ? NO YES

- Have you worried excessively or been anxious about several things over the past 6

months ?

NO YES

80

BIZARR

E

YES

YES K6 YES

YES K6

YES

YES K6

YES

YES K6

YES

YES YES

YES

K8b

K. PSYCHOTIC DISORDERS AND MOOD DISORDER WITH

PSYCHOTIC FEATURES ASK FOR AN EXAMPLE OF EACH QUESTION ANSWERED POSITIVELY. CODE YES ONLY IF THE EXAMPLES CLEARLY SHOW A DISTORTION OF THOUGHT OR

OF PERCEPTION OR IF THEY ARE NOT CULTURALLY APPROPRIATE. BEFORE CODING, INVESTIGATE WHETHER DELUSIONS QUALIFY AS "BIZARRE".

DELUSIONS ARE "BIZARRE" IF: CLEARLY IMPLAUSIBLE, ABSURD, NOT UNDERSTANDABLE, AND CANNOT DERIVE FROM ORDINARY LIFE EXPERIENCE. HALLUCINATIONS ARE SCORED "BIZARRE" IF: A VOICE COMMENTS ON THE PERSON'S THOUGHTS OR BEHAVIOR, OR WHEN TWO OR MORE VOICES ARE

CONVERSING WITH EACH OTHER.

THE PURPOSE OF THIS MODULE IS TO EXCLUDE PATIENTS WITH PSYCHOTIC DISORDERS. THIS MODULE NEEDS EXPERIENCE.

K1

a

Now I am going to ask you about unusual experiences that some people have.

Have you ever believed that people were spying on you, or that someone

NO YES

NO

YE

S NO

YE

S

NO

YE

S NO

YE

S

was plotting against you, or trying to hurt you?

NOTE: ASK FOR EXAMPLES TO RULE OUT ACTUAL STALKING.

b

IF YES OR YES BIZARRE: do you currently believe these things?

K2

a

Have you ever believed that someone was reading your mind or could hear

your thoughts, or that you could actually read someone‘s mind or hear what

another person was thinking?

b

IF YES OR YES BIZARRE: do you currently believe these things?

K3

a

Have you ever believed that someone or some force outside of yourself

put thoughts in your mind that were not your own, or made you act in a

way that was not your usual self? Have you ever felt that you were

possessed?

CLINICIAN: ASK FOR EXAMPLES AND DISCOUNT ANY THAT ARE NOT PSYCHOTIC.

b

IF YES OR YES BIZARRE: do you currently believe these things?

NO

YE

S

K4

a

Have you ever believed that you were being sent special messages through

NO

YE

S the TV, radio, newspapers, books or magazines or that a person you did not personally know was particularly interested in you?

b

IF YES OR YES BIZARRE: do you currently believe these things?

NO

YE

S K5

a

Have your relatives or friends ever considered any of your beliefs odd

NO

YE

S or unusual? INTERVIEWER: ASK FOR EXAMPLES. ONLY CODE YES IF THE EXAMPLES ARE CLEARLY DELUSIONAL IDEAS NOT EXPLORED IN QUESTIONS K1 TO K4, FOR EXAMPLE, SOMATIC OR RELIGIOUS

DELUSIONS OR DELUSIONS OF GRANDIOSITY, JEALOUSY, GUILT, RUIN OR DESTITUTION, ETC.

b

IF YES OR YES BIZARRE: do they currently consider your beliefs strange?

NO

YE

S

K6

a

Have you ever heard things other people couldn't hear, such as voices?

NO

YE

S

IF YES TO VOICE HALLUCINATION: Was the voice commenting on your

NO

thoughts or behavior or did you hear two or more voices talking to each other?

81

b

IF YES OR YES BIZARRE TO K6a: have you heard sounds / voices in the past

month?

NO

YE

S

IF YES TO VOICE HALLUCINATION: Was the voice commenting on your thoughts

NO

or behavior or did you hear two or more voices talking to each other?

K7 a Have you ever had visions when you were awake or have you ever seen things NO YES other people couldn't see?

CLINICIAN: CHECK TO SEE IF THESE ARE CULTURALLY INAPPROPRIATE.

b IF YES: have you seen these things in the past month? NO YES

CLINICIAN'S JUDGMENT

K8 b IS THE PATIENT CURRENTLY EXHIBITING INCOHERENCE, DISORGANIZED NO YES

SPEECH, OR MARKED LOOSENING OF ASSOCIATIONS?

K9 b IS THE PATIENT CURRENTLY EXHIBITING DISORGANIZED OR CATATONIC NO YES

BEHAVIOR?

K10 b ARE NEGATIVE SYMPTOMS OF SCHIZOPHRENIA, E.G. SIGNIFICANT AFFECTIVE NO YES

FLATTENING, POVERTY OF SPEECH (ALOGIA) OR AN INABILITY TO INITIATE

OR PERSIST IN GOAL‐ DIRECTED ACTIVITIES (AVOLITION), PROMINENT DURING THE INTERVIEW?

K11 a ARE 1 OR MORE « a » QUESTIONS FROM K1a TO K7a CODED YES OR YES BIZARRE

AND IS EITHER:

MAJOR DEPRESSIVE EPISODE, (CURRENT, RECURRENT OR PAST) OR

MANIC OR HYPOMANIC EPISODE, (CURRENT OR PAST) CODED YES? NO YES

K13

IF NO TO K11 a, CIRCLE NO IN BOTH ‗MOOD DISORDER WITH

PSYCHOTIC FEATURES‘ DIAGNOSTIC BOXES AND MOVE TO

K13.

b You told me earlier that you had period(s) when you felt (depressed/high/persistently irritable).

Were the beliefs and experiences you just described (SYMPTOMS CODED YES FROM K1a TO K7a)

restricted exclusively to times when you were feeling depressed/high/irritable?

IF THE PATIENT EVER HAD A PERIOD OF AT LEAST 2 WEEKS OF HAVING THESE

BELIEFS OR EXPERIENCES (PSYCHOTIC SYMPTOMS) WHEN THEY WERE NOT

DEPRESSED/HIGH/IRRITABLE, CODE NO TO THIS DISORDER.

IF THE ANSWER IS NO TO THIS DISORDER, ALSO CIRCLE NO TO K12 AND MOVE TO

K13

NO YES

MOOD DISORDER

WITH

PSYCHOTIC

FEATURES

LIFETIME

82

K12 a ARE 1 OR MORE « b » QUESTIONS FROM K1b TO K7b CODED YES OR

YES BIZARRE AND IS EITHER:

MAJOR DEPRESSIVE EPISODE, (CURRENT) OR

MANIC OR HYPOMANIC EPISODE, (CURRENT) CODED YES?

IF THE ANSWER IS YES TO THIS DISORDER (LIFETIME OR CURRENT), CIRCLE NO

TO K13 AND K14 AND MOVE TO THE NEXT MODULE.

K13 ARE 1 OR MORE « b » QUESTIONS FROM K1b TO K6b, CODED YES BIZARRE?

OR

ARE 2 OR MORE « b » QUESTIONS FROM K1b TO K10b, CODED YES

(RATHER THAN YES BIZARRE)?

AND DID AT LEAST TWO OF THE PSYCHOTIC SYMPTOMS OCCUR DURING THE

SAME 1 MONTH PERIOD?

NO YES

PSYCHOTIC

DISORDER

CURRENT

NO YES

MOOD DISORDER

WITH

PSYCHOTIC

FEATURES

CURRENT

K14 IS K13 CODED YES

OR

ARE 1 OR MORE « a » QUESTIONS FROM K1a TO K6a, CODED YES BIZARRE?

OR

ARE 2 OR MORE « a » QUESTIONS FROM K1a TO K7a, CODED YES (RATHER THAN

YES BIZARRE)

AND DID AT LEAST TWO OF THE PSYCHOTIC SYMPTOMS OCCUR DURING THE

SAME 1 MONTH PERIOD?

NO YES PSYCHOTIC

DISORDER

LIFETIME

83

APPENDIX 7 CONSENT FORM

Title of the study:

LIFE STYLE FACTORS IN LATE ONSET DEPRESSION:A COMPARISON

BETWEEN TREATMENT SEEKING POPULATION AND MATCHED

HEALTHY CONTROLS

Information to the participants.

Depression is a mental illness that can occur to any human being. The

common symptoms of Depression are low mood, lack of interest, increased fatigue,

feeling of hopelessness and worthlessness, decreased appetite and sleep which last for

2 weeks or more. Studies have shown that Depression occurs due to changes in

biochemical activities in the brain which may be due to genetic or acquired causes.

Depression is the commonest psychiatric disorder in the community and its incidence

among old people is increasing. It has also been noticed that depression that occur in

old people appear different from that occurring in young adults in many ways like the

distress that the disease cause to the patient, response to the treatment and so on.

Many reasons have been proposed for this apparent difference between the two like

the various changes that may occur in the brain due to prolonged life, coexisting

diseases like increased blood pressure and sugar, stroke and so on in the elderly.

Many studies are being done world wide by researchers to find out more

about the possible factors that could lead to depression in the old age, with the

intention of understanding the disease better and thus hoping to develop new

treatment methods.

In this study we are comparing the life style factors in elderly people

having Depression with those in healthy elderly people. Life style factors would

include diet, exercise, alcohol and tobacco use, hobbies, leisure and social activities.

As part of the study we would like to interview you and your relative and record the

information. Apart from asking questions about how you lead your life with respect

to above mentioned categories no other interventions will be done for the purpose of

the study. The interview session would take approximately 30-45 minutes.

UNDERTAKING BY THE INVESTIGATOR:

Participation in the study is on voluntary basis and you will not be entitled

to any additional benefits for doing the same. It will also not be of any direct benefit

to you in the treatment which you are undergoing. However you will be able to

contribute to our research endeavor which is held solemnly in academic and scientific

interest.

You may decide not to participate in the study without citing any reason for

the same. In that case the treatment that you would continue to receive will not be

affected in any way. Any information that you provide would be kept confidential and

used only for the purpose of this study. Please feel free to clarify any doubts about the

study with Dr. Ramkumar G S, Junior Resident, NIMHANS(09880967850). This

study is being conducted under the guidance of Dr Sreekala Bharath MD, Professor of

Psychiatry, NIMHANS.

1

84

CONSENT FORM:

I/My relative have been informed about the process of the study. I have

understood that I have the right to refuse my consent or withdraw at any time during

the study without adversely affecting my treatment. I am aware that by subjecting to

this study process, I will have to give more time for assessments by the investigating

team and that these assessments do not interfere with the benefits.

I/My relative the undersigned, give consent to be a participant of this study program.

Name, Signature and address Name, signature and nature of

of the Respondent relationship of the Relative.

Signature of investigator

Dr Ramkumar G S,

Junior Resident,

Dept of Psychiatry,

NIMHANS.

Mobile Number 09880967850

GUIDE

Dr Srikala Bharath MD,

Professor of Psychiatry,

NIMHANS.

...............

2