Original Study| Volume 22, ISSUE 3, P570-576.e1, March 2021

Download started.


Relationship of Frailty Markers and Socioeconomic Status to Incidence of Depressive Symptoms in a Community Cohort

  • Ying Lian
    Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University and Shandong University Center for Suicide Prevention Research, Jinan, China

    Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
    Search for articles by this author
  • Li Yang
    Jinan Municipal Center for Disease Control and Prevention, Jinan, China
    Search for articles by this author
  • Mei Gao
    Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
    Search for articles by this author
  • Cun-Xian Jia
    Address correspondence to Cun-Xian Jia, PhD, Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University and Shandong University Center for Suicide Prevention Research, No.44, Wenhuaxi Rd, Jinan 250012, China.
    Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University and Shandong University Center for Suicide Prevention Research, Jinan, China
    Search for articles by this author
Published:September 30, 2020DOI:



      This study aimed to examine the relationship between frailty markers and socioeconomic status (SES) to incidence of depressive symptoms using a nationally representative sample of middle-age and older adults.


      Cohort study with a 4-year follow-up; 89.1% of the participants were followed for 2 years and 73.4% for 4 years.

      Setting and Participants

      A total of 6641 participants from the China Health and Retirement Longitudinal Study (CHARLS) were included in the analyses.


      The outcome was incident depressive symptoms. Educational level and occupational status were used to assess SES. Physical frailty status was evaluated using 2 frailty markers, namely weakness and slowness. Two-item questionnaire was used to assess social frailty. Cox regression models were used to examine the relationship between frailty markers and SES to incidence of depressive symptoms, with sociodemographic characteristics, lifestyle information, self-rated health status, medical histories, and depressive symptoms score at baseline adjusted.


      Infrequent social activity [hazard ratio (HR) 1.09, 95% confidence interval (CI) 1.00‒1.19], weakness (HR 1.15, 95% CI 1.03‒1.28), and slowness (HR 1.19, 95% CI 1.01‒1.41) were associated with incidence of depressive symptoms. SES was associated with depressive symptoms not only through social frailty (β = 0.01, 95% CI 0.002‒0.011) and physical frailty (β = 0.01, 95% CI 0.001‒0.012) separately but also through social frailty and physical frailty sequentially. Furthermore, the effect of weakness and slowness on depressive symptoms occurred in participants with lower educational level and doing agricultural work, while the effect of infrequent social activity occurred in participants with higher educational level and doing nonagricultural work.


      SES is associated with depressive symptoms, in which frailty partly mediates the association. The effect of frailty on depressive symptoms varied across SES. Integrated and comprehensive intervention strategies, including assessing socioeconomic circumstances as well as improving frailty, are suggested in prevention of depressive symptoms.


      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


        • Walker E.R.
        • McGee R.E.
        • Druss B.G.
        Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis.
        JAMA Psychiatry. 2015; 72: 334-341
        • Malhi G.S.
        • Mann J.J.
        Lancet. 2018; 392: 2299-2312
        • WHO
        Depression and Other Common Mental Disorders.
        Global Health Estimates, Geneva, Switzerland2017
        • Huang Y.
        • Wang Y.
        • Wang H.
        • et al.
        Prevalence of mental disorders in China: A cross-sectional epidemiological study.
        Lancet Psychiatry. 2019; 6: 211-224
        • Verver D.
        • Merten H.
        • de Blok C.
        • et al.
        A cross sectional study on the different domains of frailty for independent living older adults.
        BMC Geriatr. 2019; 19: 61
        • Tsutsumimoto K.
        • Doi T.
        • Makizako H.
        • et al.
        Association of social frailty with both cognitive and physical deficits among older people.
        J Am Med Dir Assoc. 2017; 18: 603-607
        • Makizako H.
        • Shimada H.
        • Doi T.
        • et al.
        Social frailty leads to the development of physical frailty among physically non-frail adults: A four-year follow-up longitudinal cohort study.
        Int J Environ Res Public Health. 2018; 15: 490
        • Feng L.
        • Nyunt M.S.
        • Yap K.B.
        • et al.
        Frailty predicts new and persistent depressive symptoms among community-dwelling older adults: Findings from Singapore longitudinal aging study.
        J Am Med Dir Assoc. 2014; 15 (76.e7‒76.e12)
        • Collard R.M.
        • Comijs H.C.
        • Naarding P.
        • et al.
        Frailty as a predictor of the incidence and course of depressed mood.
        J Am Med Dir Assoc. 2015; 16: 509-514
        • Yamada M.
        • Arai H.
        Social frailty predicts incident disability and mortality among community-dwelling Japanese older adults.
        J Am Med Dir Assoc. 2018; 19: 1099-1103
        • Makizako H.
        • Shimada H.
        • Doi T.
        • et al.
        Physical frailty predicts incident depressive symptoms in elderly people: Prospective findings from the Obu Study of Health Promotion for the Elderly.
        J Am Med Dir Assoc. 2015; 16: 194-199
        • Tsutsumimoto K.
        • Doi T.
        • Makizako H.
        • et al.
        Social frailty has a stronger impact on the onset of depressive symptoms than physical frailty or cognitive impairment: A 4-year follow-up longitudinal cohort study.
        J Am Med Dir Assoc. 2018; 19: 504-510
        • Brunner E.J.
        • Shipley M.J.
        • Ahmadi-Abhari S.
        • et al.
        Midlife contributors to socioeconomic differences in frailty during later life: A prospective cohort study.
        Lancet Public Health. 2018; 3: e313-e322
        • Kim J.H.
        • Lee S.G.
        • Shin J.
        • et al.
        Impact of the gap between socioeconomic stratum and subjective social class on depressive symptoms: Unique insights from a longitudinal analysis.
        Soc Sci Med. 2014; 120: 49-56
        • Domenech-Abella J.
        • Mundo J.
        • Leonardi M.
        • et al.
        The association between socioeconomic status and depression among older adults in Finland, Poland and Spain: A comparative cross-sectional study of distinct measures and pathways.
        J Affect Disord. 2018; 241: 311-318
        • Stringhini S.
        • Carmeli C.
        • Jokela M.
        • et al.
        Socioeconomic status, noncommunicable disease risk factors, and walking speed in older adults: Multi-cohort population based study.
        BMJ. 2018; 360: k1046
        • Moor I.
        • Spallek J.
        • Richter M.
        Explaining socioeconomic inequalities in self-rated health: A systematic review of the relative contribution of material, psychosocial and behavioural factors.
        J Epidemiol Community Health. 2017; 71: 565-575
        • Chen E.
        • Miller G.E.
        Socioeconomic status and health: Mediating and moderating factors.
        Annu Rev Clin Psychol. 2013; 9: 723-749
        • Zhao Y.
        • Hu Y.
        • Smith J.P.
        • et al.
        Cohort profile: The China Health and Retirement Longitudinal Study (CHARLS).
        Int J Epidemiol. 2014; 43: 61-68
        • Luo Y.
        • Zhu D.
        • Shi X.
        • et al.
        Education as a moderator in the effect of diabetes on depressive symptoms in Chinese middle-aged and older adults: A population-based longitudinal study.
        J Affect Disord. 2018; 240: 41-47
        • Fried L.P.
        • Tangen C.M.
        • Walston J.
        • et al.
        Frailty in older adults: Evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156
        • Bunt S.
        • Steverink N.
        • Olthof J.
        • et al.
        Social frailty in older adults: A scoping review.
        Eur J Ageing. 2017; 14: 323-334
        • Fang M.
        • Mirutse G.
        • Guo L.
        • et al.
        Role of socioeconomic status and housing conditions in geriatric depression in rural China: A cross-sectional study.
        BMJ Open. 2019; 9: e024046
        • Pino E.C.
        • Damus K.
        • Jack B.
        • et al.
        Adolescent socioeconomic status and depressive symptoms in later life: Evidence from structural equation models.
        J Affect Disord. 2018; 225: 702-708
        • Lahelma E.
        • Martikainen P.
        • Laaksonen M.
        • et al.
        Pathways between socioeconomic determinants of health.
        J Epidemiol Community Health. 2004; 58: 327-332
        • Geyer S.
        • Hemstrom O.
        • Peter R.
        • et al.
        Education, income, and occupational class cannot be used interchangeably in social epidemiology. Empirical evidence against a common practice.
        J Epidemiol Community Health. 2006; 60: 804-810
        • Hoebel J.
        • Maske U.E.
        • Zeeb H.
        • et al.
        Social inequalities and depressive symptoms in adults: The role of objective and subjective socioeconomic status.
        PLoS One. 2017; 12: e0169764
        • Galobardes B.
        • Lynch J.
        • Smith G.D.
        Measuring socioeconomic position in health research.
        Br Med Bull. 2007; 81‒82: 21-37
        • Gong P.
        • Liang S.
        • Carlton E.J.
        • et al.
        Urbanisation and health in China.
        Lancet. 2012; 379: 843-852
        • Demakakos P.
        • Cooper R.
        • Hamer M.
        • et al.
        The bidirectional association between depressive symptoms and gait speed: Evidence from the English Longitudinal Study of Ageing (ELSA).
        PLoS One. 2013; 8: e68632
        • Han K.M.
        • Chang J.
        • Yoon H.K.
        • et al.
        Relationships between hand-grip strength, socioeconomic status, and depressive symptoms in community-dwelling older adults.
        J Affect Disord. 2019; 252: 263-270
        • Lemon B.W.
        • Bengtson V.L.
        • Peterson J.A.
        An exploration of the activity theory of aging: Activity types and life satisfaction among in-movers to a retirement community.
        J Gerontol. 1972; 27: 511-523
        • Hao Y.
        Productive activities and psychological well-being among older adults.
        J Gerontol B Psychol Sci Soc Sci. 2008; 63: S64-S72
        • Guo Q.
        • Bai X.
        • Feng N.
        Social participation and depressive symptoms among Chinese older adults: A study on rural-urban differences.
        J Affect Disord. 2018; 239: 124-130
        • Yip W.
        • Subramanian S.V.
        • Mitchell A.D.
        • et al.
        Does social capital enhance health and well-being? Evidence from rural China.
        Soc Sci Med. 2007; 64: 35-49
        • Koster A.
        • Bosma H.
        • Kempen G.I.
        • et al.
        Socioeconomic differences in incident depression in older adults: The role of psychosocial factors, physical health status, and behavioral factors.
        J Psychosom Res. 2006; 61: 619-627
        • Brown P.J.
        • Rutherford B.R.
        • Yaffe K.
        • et al.
        The depressed frail phenotype: The clinical manifestation of increased biological aging.
        Am J Geriatr Psychiatry. 2016; 24: 1084-1094
        • Belvederi Murri M.
        • Pariante C.
        • Mondelli V.
        • et al.
        HPA axis and aging in depression: Systematic review and meta-analysis.
        Psychoneuroendocrinology. 2014; 41: 46-62
        • Park H.
        • Jang I.Y.
        • Lee H.Y.
        • et al.
        Screening value of social frailty and its association with physical frailty and disability in community-dwelling older Koreans: Aging study of PyeongChang rural area.
        Int J Environ Res Public Health. 2019; 16: 2809
        • Makizako H.
        • Shimada H.
        • Tsutsumimoto K.
        • et al.
        Social frailty among community-dwelling older adults.
        J Am Med Dir Assoc. 2015; 16 (1003.e7‒1003.e11)
        • Tenenhaus M.
        • Esposito Vinzi V.
        • Chatelin Y.M.
        • et al.
        PLS path modeling. 2005; 48: 159-205
        • Abellan van Kan G.
        • Rolland Y.M.
        • Morley J.E.
        • et al.
        Frailty: Toward a clinical definition.
        J Am Med Dir Assoc. 2008; 9: 71-72
        • Bessa B.
        • Ribeiro O.
        • Coelho T.
        Assessing the social dimension of frailty in old age: A systematic review.
        Arch Gerontol Geriatr. 2018; 78: 101-113