Original Study| Volume 11, ISSUE 5, P312-319, June 2010

Descriptive Epidemiology of Undetected Depression in Institutionalized Older People


      To measure the prevalence and associated factors of undetected depression in institutionalized older people.

      Design and Setting

      Epidemiologic cross-sectional study in nursing homes and residential facilities.


      A stratified cluster sample of residents 65 years of age and older living in institutions of Madrid (Spain).


      Residents were considered to be depressed if they met at least 1 of the following 3 criteria: 10-item Geriatric Depression Scale score of 4 or higher, physician's diagnosis, or antidepressant use. Prevalence of undetected depression was defined as the proportion of depressed residents without documented diagnosis or treatment.


      A total of 255 of 579 residents had depression (weighted prevalence 46.1%, 95% confidence interval [CI] 41.0%–51.3%) and 108 depressed residents were undetected (undetection prevalence 41.5%, 95% CI 33.2%–50.2%). Undetection was lower in younger residents, private versus public facilities (sex-, age-, and size-adjusted prevalence ratio [PR] 0.59, 95% CI 0.37–0.94), and larger facilities (sex-, age-, and ownership-adjusted PR 0.94 per 50-bed increase, 95% CI 0.88–1.00). Undetected depression was higher in residents with poor self-rated health (sex- and age-adjusted PR 1.83, 95% CI 1.24–2.73), whereas the opposite came about for physician-rated health (PR 0.65, 95% CI 0.44–0.95). Undetection decreased 11% (95% CI 4%–17%) per 1-medication increase, and it was lower in patients with Alzheimer disease, anxiety, and arrhythmia.


      Number of medications and self-rated health were the main determinants of undetected depression. Physician-rated health, facility characteristics (size and ownership), and some diseases could also be considered.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Teresi J.
        • Abrams R.
        • Holmes D.
        • et al.
        Prevalence of depression and depression recognition in nursing homes.
        Soc Psychiatry Psychiatr Epidemiol. 2001; 36: 613-620
        • Jones R.N.
        • Marcantonio E.R.
        • Rabinowitz T.
        Prevalence and correlates of recognized depression in US nursing homes.
        J Am Geriatr Soc. 2003; 51: 1404-1409
        • McDougall F.A.
        • Matthews F.E.
        • Kvaal K.
        • et al.
        Prevalence and symptomatology of depression in older people living in institutions in England and Wales.
        Age Ageing. 2007; 36: 562-568
        • Jongenelis K.
        • Pot A.M.
        • Eisses A.M.
        • et al.
        Prevalence and risk indicators of depression in elderly nursing home patients: The AGED study.
        J Affect Disord. 2004; 83: 135-142
        • Fenton J.
        • Raskin A.
        • Gruber-Baldini A.L.
        • et al.
        Some predictors of psychiatric consultation in nursing home residents.
        Am J Geriatr Psychiatry. 2004; 12: 297-304
        • Weintraub D.
        • Datto C.J.
        • Streim J.E.
        • Katz I.R.
        Second-generation issues in the management of depression in nursing homes.
        J Am Geriatr Soc. 2002; 50: 2100-2101
        • Nakajima G.A.
        • Wenger N.S.
        Quality indicators for the care of depression in vulnerable elders.
        J Am Geriatr Soc. 2007; 55: S302-S311
        • D'Ath P.
        • Katona P.
        • Mullan E.
        • et al.
        Screening, detection and management of depression in elderly primary care attenders. I: The acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions.
        Fam Pract. 1994; 11: 260-266
        • Shah A.K.
        • Phongsathorn V.
        • Bielawska C.
        • Katona C.
        Screening for depression among geriatric inpatients with short versions of the Geriatric Depression Scale.
        Int J Geriatr Psychiatry. 1996; 11: 915-918
        • Jongenelis K.
        • Pot A.M.
        • Eisses A.M.
        • et al.
        Diagnostic accuracy of the original 30-item and shortened versions of the Geriatric Depression Scale in nursing home patients.
        Int J Geriatr Psychiatry. 2005; 20: 1067-1074
        • Martínez de la Iglesia J.
        • Onís-Vilches M.C.
        • Dueñas-Herrero R.
        • et al.
        Versión española del cuestionario de Yesavage abreviado (GDS) para el despistaje de depresión en mayores de 65 años: adaptación y validación.
        Medifam. 2002; 12: 620-630
        • Izal M.
        • Montorio I.
        Adaptation of the Geriatric Depression Scale: A preliminary study.
        Clin Gerontol. 1993; 13: 83-91
        • Shah S.
        • Vanclay F.
        • Cooper B.
        Improving the sensitivity of the Barthel index for stroke rehabilitation.
        J Clin Epidemiol. 1989; 42: 703-709
        • Pfeiffer E.
        A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients.
        J Am Geriatr Soc. 1975; 23: 433-441
        • Hartmaier S.L.
        • Sloane P.D.
        • Guess H.A.
        • Koch G.G.
        The MDS cognition scale: a valid instrument for identifying and staging nursing home residents with dementia using the Minimum Data Set.
        J Am Geriatr Soc. 1994; 42: 1173-1179
        • Gruber-Baldini A.L.
        • Zimmerman S.I.
        • Mortimore E.
        • Magaziner J.
        The validity of the minimum data set in measuring the cognitive impairment of persons admitted to nursing homes.
        J Am Geriatr Soc. 2000; 48: 1601-1606
        • Morris J.N.
        • Hawes C.
        • Fries B.E.
        • et al.
        Designing the national resident assessment instrument for nursing homes.
        Gerontologist. 1990; 30: 293-307
        • Barros A.J.
        • Hirakata V.N.
        Alternatives for logistic regression in cross-sectional studies: An empirical comparison of models that directly estimate the prevalence ratio.
        BMC Med Res Methodol. 2003; 3: 21
        • Skov T.
        • Deddens J.
        • Petersen M.R.
        • Endahl L.
        Prevalence proportion ratios: Estimation and hypothesis testing.
        Int J Epidemiol. 1998; 27: 91-95
        • Costa-Font J.
        • Patxot C.
        The design of the long-term care system in Spain: Policy and financial constraints.
        Soc Policy Society. 2005; 4: 11-20
      1. Sancho Castiello M, Pezuela-Pinto M, Fernández Moreno M. Social services for older people in Spain. January 2006. Institute of Older Persons and SocialServices (IMSERSO), editor. Older Persons' Portal Reports No. 77. 3/12/2007. Madrid. Available at: Accessed January 26, 2010.

        • Zimmerman S.
        • Gruber-Baldini A.L.
        • Sloane P.D.
        • et al.
        Assisted living and nursing homes: Apples and oranges?.
        Gerontologist. 2003; 43: 107-117
        • Krauss N.A.
        • Altman B.M.
        Characteristics of nursing home residents, 1996. MEPS Research findings No. 5.
        Agency for Health Care Policy and Research, US Department of Health and Human Services, Rockville (MD)1998 (AHCPR publication No. 99–0006)
        • Mitchell A.J.
        • Vaze A.
        • Rao S.
        Clinical diagnosis of depression in primary care: A meta-analysis.
        Lancet. 2009; 374: 609-619
        • Rovner B.W.
        • German P.S.
        • Brant L.J.
        • et al.
        Depression and mortality in nursing homes.
        JAMA. 1991; 265: 993-996
        • Davison T.E.
        • McCabe M.P.
        • Mellor D.
        • et al.
        The prevalence and recognition of major depression among low-level aged care residents with and without cognitive impairment.
        Aging Ment Health. 2007; 11: 82-88
        • Brown E.L.
        • McAvay G.
        • Raue P.J.
        • et al.
        Recognition of depression among elderly recipients of home care services.
        Psychiatr Serv. 2003; 54: 208-213
        • Garrard J.
        • Rolnick S.J.
        • Nitz N.M.
        • et al.
        Clinical detection of depression among community-based elderly people with self-reported symptoms of depression.
        J Gerontol A Biol Sci Med Sci. 1998; 53: M92-101
        • O'Connor D.W.
        • Rosewarne R.
        • Bruce A.
        Depression in primary care. 1: Elderly patients' disclosure of depressive symptoms to their doctors.
        Int Psychogeriatr. 2001; 13: 359-365
        • Blazer D.G.
        in: Hazzard W.R. Blass J.P. Ettinger W.P. Principles of Geriatric Medicine and Gerontology. McGraw-Hill, New York1999: 1331-1339
        • Baldwin R.C.
        Recent understandings in geriatric affective disorder.
        Curr Opin Psychiatry. 2007; 20: 539-543
        • Lyness J.M.
        • Cox C.
        • Curry J.
        • et al.
        Older age and the underreporting of depressive symptoms.
        J Am Geriatr Soc. 1995; 43: 216-221
        • Rost K.
        • Nutting P.
        • Smith J.
        • et al.
        The role of competing demands in the treatment provided primary care patients with major depression.
        Arch Fam Med. 2000; 9: 150-154
        • Kessler D.
        • Lloyd K.
        • Lewis G.
        • Gray D.P.
        Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care.
        BMJ. 1999; 318: 436-439
        • Damian J.
        • Pastor-Barriuso R.
        • Valderrama-Gama E.
        Factors associated with self-rated health in older people living in institutions.
        BMC Geriatr. 2008; 8: 5
        • Alexopoulos G.S.
        • Abrams R.C.
        • Young R.C.
        • Shamoian C.A.
        Cornell Scale for Depression in Dementia.
        Biol Psychiatry. 1988; 23: 271-284
        • Eisses A.M.
        • Kluiter H.
        • Jongenelis K.
        • et al.
        Care staff training in detection of depression in residential homes for the elderly: Randomised trial.
        Br J Psychiatry. 2005; 186: 404-409
        • Pope H.
        • Watkins K.
        • Evans A.
        • Hess P.
        The perception of depression in long-term-care residents: A qualitative study using residential journaling.
        J Appl Gerontol. 2006; 25: 153-171
        • Consensus statement on improving the quality of mental health care in US nursing homes
        Management of depression and behavioral symptoms associated with dementia.
        J Am Geriatr Soc. 2003; 51: 1287-1298