Journal of Gerontology: MEDICAL SCIENCES
1997, Vol. 52A, No. 4, M241-M246
Copyright 1997 by The Gerontological Society of America
Characteristics of Depressive Symptoms in Elderly
Urban and Rural African Americans
Jebose O. Okwumabua,1 F. M. Baker,2 S. P. Wong,3 and Beverly O. Pilgram4
'Department of Human Movement Sciences and Education, The University of Memphis.
department of Psychiatry, The University of Maryland.
'Department of Mathematical Sciences, The University of Memphis.
4
Department of Veterans Affairs Medical Center, Memphis.
Background. Despite considerable progress in the epidemiology of late life depression, little data have been documented in the scientific literature on depressive symptoms among elderly African Americans. The present investigation
identifies characteristic symptoms of depression in African American community-resident elders.
Method. Ninety-six African American men and women aged 60 years and older, with equal representation from
urban and rural counties in west Tennessee, composed the sample. The sample was stratified in each of the two counties into three age categories; 60-69, 70-79, and 80 and older. Data from the Center for Epidemiological StudiesDepression scale were compared with the association of medical illness, medication use, social network, level of physical function in activities of daily living, and demographic characteristics.
Results. Residents screening positive for the presence of depressive symptoms showed an increased report of hypertension (p < .036), arteriosclerosis (p < .035), and circulatory problems (p < .008). There was an increased report of
symptoms of depression among those who had six or more different chronic illnesses (p < .001) and among those who
reported using four or more different prescription medications in the past month for chronic illnesses (/? < .015).
Regression analyses of data indicated that medical illness (p < .001) and social network (p < .041) were the most
important predictors of depressive symptoms among residents.
Conclusions. Considering the projected increase of African Americans reaching age 60, and because depressive illness is an important public heath concern, early identification of salient risk factors for depression is critical in instituting early intervention programs for the ethnic minority elderly population.
I
N the United States the ethnic minority elderly population is expected to increase rapidly from 13% in 1985 to
21% in 2020 and to 30% in 2050 (1,2). Depression is the
most prevalent and important mental health problem of
later life (3-5). Despite considerable progress in the epidemiology of late life depression, limited data have been
reported in the scientific literature on depressive symptoms
among elderly African Americans (6). Heretofore, empirical studies on aging minorities have primarily focused on
the disadvantages of African Americans in regard to health,
income, and housing (7). Prior to the 1970s, investigators
argued whether African Americans had rates of depression
similar to the rates reported among White Americans (8,9).
In fact, one such study advanced the hypothesis that
African Americans tend to develop a compensatory reaction to discrimination that, over time, generally provides
them with a protective social environment and mechanisms
against depression in later life (10).
Few authors have identified the presence of depression
in African American populations (11-13). Evidence suggests, for example, that depressed African Americans were
likely to report symptoms of anger, irritability, denial of illness, and to spontaneously report symptoms that did not
reflect a change in mood, but rather forbearance when facing a difficult time or somatic complaint (14,15). Medical
problems and decreased activities of daily living have also
been associated with an increased risk of depressive symptomatology among older African Americans (6,16).
Considering the rapid growth of the African American
elderly population, and given that one-third of older persons hospitalized for depressive illness die within 1 year of
discharge (3), the early identification of depressive illness
in elderly African Americans is an important public health
concern. The present investigation identifies characteristic
symptoms of depression in a sample of elderly African
American urban and rural community residents. In addition, it presents an analysis of the degree to which depressive symptoms in this sample could be predicted. The Center for Epidemiological Studies-Depression (CES-D) scale
was used to assess depressive symptoms and the association of medical illness, prescription medication use, level
of physical function in activities of daily living (ADLs),
social network, and demographic characteristics.
METHODS
A sample of 110 community-resident elders, aged 60 and
older, was drawn from a roster of clients from two home
health agencies in urban and rural counties in west Tennessee. The sample was selected based on medical diagnosis and nature of illness. For example, persons with
dementing illness were excluded from the sample to prevent the confounding of the results of the investigation. Of
M241
M242
OKWUMABUA ETAL.
this sample, 87% (n = 96) participated in the study; approximately 8% (n = 9) elected not to participate, and 5% (n =
5) did not complete the interview.
The 96 participants responded to the questionnaire via an
interview-assisted format. This format employs a face-toface interviewing procedure to provide respondents an
opportunity to interact with the interviewers, thus facilitating a better understanding and interpretation of questionnaire items. Participants resided in their own homes in the
community, but utilized senior centers for various activities
and social events. Although all participants were considered
"healthy" at the time of the interview, their health status
may not represent that of the African American elderly
clients of home health agencies in west Tennessee.
Fifty percent of the sample (n = 48) were drawn from
each of two counties representing urban and rural residents,
respectively. Each of the two groups was stratified into
equal numbers of subjects according to gender and chronological age of 60-69 years (young old), 70-79 years (middle old), and 80 years and older (old-old). Specifically, of
the 48 participants in each of the two counties, 16 were
assigned to each of the three age categories with equal distribution of males and females within each category. The
sample was stratified by chronological age because investigators have indicated that increases in reports of depressive
symptoms are most noticeable as age increases (2).
Measures. — A variety of standardized assessment instruments considered most appropriate for identifying the
characteristics of depressive symptomatology among the
elderly were used in this study. These instruments were
used in gathering information on physician-diagnosed illnesses, prescription medication use, physical and cognitive
functioning, social network, and depressive symptoms.
Demographic information descriptive of the participants
was also gathered.
In order to rule out cognitive impairment among participants, and to determine the validity of self-report, the Short
Portable Mental Status Questionnaire (SPMSQ) was used
(17). Three or more incorrect responses would indicate cognitive impairment and would cause an individual to be
eliminated from the study. This instrument was chosen
because it was validated in a southern African American
elderly population and had a correction for education of
less than 8 years.
Physical functioning was assessed by self-reports to
Katz's Index of Independence in Activities of Daily Living
(18). The survey items asked whether the participant was
able to perform a variety of basic tasks of daily living
including bathing, dressing, going to the toilet, continence,
transferring, and feeding. Information gathered from this
instrument was converted into an overall ADL grade by
using a standard definition of functional independence and
dependence. The grade classification ranged from "independent in all functions" to "dependent in all six functions."
Depressive symptomatology was measured by using the
original 20-item version of the CES-D scale (19). The scale
is designed to measure current state of depressive symptomatology and to be responsive to changes over time. As a
first-stage screening device for detecting early onset of
symptoms of depression, the CES-D scale places emphasis
on the affective component, depressive mood, rather than
on diagnosis at clinical intake and/or evaluation of severity
of depressive illness over the course of treatment (19). It
asks how often each symptom occurred during the past
week. Each response is weighted from 0 to 3 with a possible range of 0-60. A "cut-off" score of 16 or greater is used
to identify clinically significant depressive symptoms. The
CES-D scale has been the most frequently used measure
for determining depressive symptoms among communityresident populations. When compared with the 15-item
Geriatric Depression Scale, the CES-D was found to be
more reliable in detecting depressive symptoms in both
African American and White elders (20).
The Lubben Social Network Scale (LSNS) (21) is an
equally weighted sum of 10 items specific to an elderly person's social network. The possible range of scores is 0-50,
with low scores indicating a weaker social network. A score
of less than or equal to 20 is indicative of a restricted social
network. The instrument taps into three distinct factors Of
social network including family relationships, friend relationships, and interdependent-mutual support relationships.
Within the context of the LSNS, family is expressed in
terms of social interaction with relatives assessed by the
size of active family network, size of intimate family network, and frequency of contact with a family member. The
lack of a social network has been suggested in the gerontological literature as an important element associated with
depressive symptoms among the elderly population (22). In
our study, LSNS was employed to assess participants' level
of social support and its relationship to depressive symptomatology.
The interview instrument was developed to be completed
in 90 min, a time period tolerated by most community-resident elderly. Information on the total physician-diagnosed
illnesses and prescribed medication use was collected on an
intake sheet. Illnesses identified in this population included
heart attack, circulatory problems, high blood pressure
(hypertension), anemia, diabetes, emphysema or chronic
bronchitis, cataracts, stroke, ulcer, liver disease, arthritis,
Parkinson's disease, kidney disease, and emotional disorders. These conditions were believed to provide an objective measure of the individual's health status at the time of
the interview. Prescription medications used by individual
participants at the time of the interview included pain
killers, arthritis medication, high blood pressure medication, digitalis for the heart, drugs to improve circulation,
insulin injections, pills for diabetes, antibiotics, and trariquilizers or nerve pills.
Procedures. — Consenting African American elders 60
years and older were introduced to the study either in
groups in a senior citizens center or on an individual basis
in their homes. Then, a battery of screening instruments
consisting of the SPMSQ, the ADL, the CES-D, and the
LSNS were administered individually to participants.
The interview began with the completion of a background questionnaire on demographics as well as illness
and medication use. The questionnaire was administered
via an interview-assisted format either at the home of those
DEPRESSIVE SYMPTOMS IN AFRICAN AMERICANS
who were homebound or at the senior citizens center on an
individual basis by two registered nurses with professional
training in geriatric mental health. A special room in which
to administer the questionnaire was provided by the senior
center director. The questionnaire was anonymous, and
information collected was held strictly confidential. Informed consent was obtained from each participant.
Analysis of the data was based on a comparison of the
CES-D by social network, medical illness, medication use,
function in activities of daily living, and demographic characteristics of respondents. After obtaining a frequency distribution of the data, a x2 analysis was performed to compare the distribution of CES-D scores with the specified
variables. In addition, regression analyses were performed
to determine whether symptoms of depression could be predicted among participants.
RESULTS
Of the 96 African Americans who participated in the
study, 50% (n = 48) were urban residents, 50% (n = 48)
were women, 66% were unmarried, and 42% lived alone
(Table 1). Some 23% required assistance with bathing, and
more than 50% of the sample had one or more chronic diseases and had used one or more prescription medications in
the past month. Twenty percent (n = 19) of the sample
screened positive for the presence of depressive symptoms.
The group screening positive for depressive symptoms were
Table 1. Percentage Distribution of Demographical
Characteristics of Elderly Residents (N = 96)
Category
Age (Years)
60-69
70-79
80+
Sex:
Male
Female
Residence:
Urban
Rural
Marital Status:
Married
Unmarried
Education:
Grade school
Middle school
High school
College
Income ($):
< 5,000
8,000-9,999
10,000+
Living Status:
Alone
With spouse
With adult child
Other
n
32
32
32
48
48
48
48
33
63
45
14
28
9
46
30
20
40
30
10
16
33.3
33.3
33.3
50.0
50.0
50.0
50.0
34.4
65.6
46.9
14.6
29.2
9.4
47.9
31.2
20.8
41.7
31.3
10.4
16.7
M243
more likely to be female (p < .012), to be unmarried (p <
.001), and to be dependent in bathing (p < .034) (Table 2).
Residents who screened positive for the presence of
depressive symptoms showed an increased report of hypertension (p < .036), arteriosclerosis (p < .035), and circulatory problems (p < .008). There was an increased report of
Table 2. Percentage Distribution of CES-D Scores
By Demographics, Health Status and Social Network
of Residents (N = 96)
CES-D Score
Variable
CES-D Score
(N=\9)
p- value
Age:
60-69
70-79
80+
87.5
71.9
81.2
12.5
28.1
18.8
Sex:
Male
Female
91.1
70.6
8.9
29.4
Residence:
Urban
Rural
72.9
87.5
27.1
12.5
Marital Status:
Married
Unmarried
100.0
69.8
30.2
Education
Grade school
Middle school
High school
College
76.6
71.4
85.7
100.0
ADL - Bathing:
Independent
Dependent
86.2
67.7
32.3
.034
Medical Illness-Hypertension:
No
Yes
91.4
73.8
8.6
26.2
.036
Medical Illness-Arteriosclerosis:
No
89.1
Yes
72.0
10.9
28.0
.035
Medical Illness-Arthritis:
No
Yes
84.0
78.9
16.0
21.1
Medical Illness-Circulatory
Problem:
No
Yes
91.3
70.0
30.0
.008
Multiple Chronic Illnesses:
0-5
6-8
90.7
42.9
9.3
57.1
.001
Multiple Medication Use:
0-3 Medications
4-8 Medications
87.3
66.7
12.7
33.3
.015
Lubben Social Network:
Not at risk
At risk
86.8
56.0
13.2
45.0
.001
n.s. = Not statistically significant.
.012
0.0
.001
24.4
28.6
14.3
0.0
13.8
8.7
OKWUMABUA ETAL.
M244
symptoms of depression among those who had six or more
different chronic illnesses compared to those who had less
than six chronic illnesses (p < .001). Similarly, those who
screened positive for depressive symptoms reported using
four or more different prescription medications in the past
month for chronic illnesses (p < .015) (Table 2).
Twenty-one percent of the sample had scores on the
LSNS suggestive of an at-risk social network, a predisposition to clinical isolation (Table 2). Of 15 urban residents
who screened positive for an at-risk social network, 47% (7
of 15) reported symptoms of depression compared to 40%
(2 of 5) of rural residents. It is interesting to note that of
those residents who screened positive for an at-risk social
network, 55% (n = 11) did not report depressive symptoms.
To determine the extent to which positive CES-D scores
could be predicted among residents, a stepwise regression
analysis was performed on selected variables based on the
scientific literature (23,24). The variables predictive of
depressive symptoms in the elderly used in this analysis
included demographic information, medical illness, prescription medication use, functional independence in
ADL, and social network (Table 3). The overall variance
(R2 = .26) explained in this analysis was highly significant
(p < .001). Social network and medical illness were significantly associated with the likelihood of residents reporting
CES-D scores suggestive of depressive symptoms (Table
3). In contrast, age, sex, and functional independence in
ADL frequently reported in the literature as important predictors of depressive symptoms were not found to be statistically significant as predictors of positive CES-D scores
among the sample. Although education was not statistically
significant when compared with CES-D scores (Table 2), it
emerged as a predictor of scores suggestive of depressive
symptomatology among residents (Table 3). Of the 19 residents who screened positive for symptoms of depression,
approximately 79% (n =15) had grade school and middle
school education.
Further analysis of data was performed by using logistic
regression for the dichotomous dependent variable of
CES-D cut-off scores between residents screening positive
(scores > 16) or negative (scores < 16) for depressive symptomatology based on the specified independent variables
(Table 4). As indicated in Table 4, medical illness (p < .000
and social network (p < .041) were the most important predictors of depressive symptoms among residents. This suggests that residents without medical illness and who were
not at risk for social isolation were highly unlikely to screen
positive for depressive symptoms on the CES-D scale. The
prediction accuracy for this analysis was 94.7%.
DISCUSSION
Table 3. Stepwise Regression of CES-D Scores
on Demographics, Health, and Functional Characteristics
of Residents (N = 96)
Independent
Variables
Intercept*
Age
Sex
ADL-Bathing
Education
Medication use
Medical illness
Social network
b
Beta
p- value
15.90
0
-0.14
-0.10
0.02
-0.19
-0.20
0.35
-0.24
.001
.217
.312
.848
.046
.090
.004
.023
t
t
t
-1.53
-0.88
1.56
-0.22
Note: b = unstandardized, Beta = standardized.
*R2 = .26.
•("Variables not selected by stepwise regression.
Table 4. Stepwise Logistic Regression of CES-D Cut-off
Scores on Demographics, Health, and Functional
Characteristics of Residents (N = 96)
Independent Variables
b
p-value
Age
Sex
ADL-Bathing
Education
Medication use
Medical illness
Social network
**
.749
.065
.317
.359
.810
.001
.041
-1.34
**
**
**
2.35
-0.08
**Variables not selected by stepwise logistic regression.
Prediction accuracy = 94.7%.
This study was designed to provide preliminary information about the characteristics of depressive symptoms in a
sample of elderly urban and rural African American residents, a comparison relatively absent in the gerontological
literature. Using an interview-assisted format, a variety of
assessment instruments were administered to the sample.
Findings from this investigation indicated that significantly
more urban residents in the sample were at risk for clinical
isolation than rural residents. This result is consistent witji
observations by previous authors (24-26). In this sample of
older African Americans, rural area residents tended to
have stronger and more extensive social support network
with family, friends, and neighbors, which provided resourceful avenues to cope with loneliness and depression.
The reverse was generally observed among urban residents.
The social support system for rural residents in this study
consisted primarily of members of the family, neighbors,
friends, and church groups. Rarely did health care providers
assume the role of social support for these elders, because it
was considered the primary role of the family. In contrast,
the social support system for urban residents was primarily
provided by unrelated individuals, health care service
providers, and sometimes church and family members. In
essence, the observed low number of elders screening positive for social isolation among rural residents in this sample
is, in part, a reflection of the increased social support systems commonly associated with living in rural communities. Although the family has been an important source of
social support for African Americans in the past, this source
is not found among the urban resident elders.
Many of the subjects, both urban and rural residents, had
expressed major concern and a sense of isolation for not
being able to attend church services. Approximately 95% of
the subjects interviewed had very strong religious and spiri--
DEPRESSIVE SYMPTOMS IN AFRICAN AMERICANS
tual convictions. They attributed their ability to cope with
difficulties to a strong faith in God's ability to sustain them.
The African American church is a catalyst for social, economic, and political change in the African American community (7) and should provide an important source of
social support for urban resident African American elderly.
Mental health care providers and prevention practitioners
who interact regularly with African American elderly
clients should be encouraged to work with the churches in
order to design interventions that integrate spirituality into
educational and clinical modalities.
Medications are known to cause depressive symptoms
and to cause depressive illnesses (27,28). Antihypertensive
medications (propranolo, alpha-methyldopa) are frequently
cited examples. Digitalis prescribed for the treatment of
cardiac problems can produce depressive symptoms if
levels of the medication exceed the therapeutic range. Analgesics (e.g., demerol and morphine), cimetadine, and prednisone can cause depressive illnesses. The multiple problems of these African American elders and the associated
medications prescribed to treat their illnesses increase the
risk for drug-drug interactions, another cause of depressive
symptoms and cognitive impairment.
In addition to describing the patterns and characteristics
of depressive symptoms among participants, the present
study sought to determine which of the independent variables could predict positive CES-D scores. Whereas medical illness, social network, and education were associated
with the likelihood of residents reporting CES-D scores
suggestive of depressive symptoms in a stepwise regression
analysis of the data, a logistic analysis indicated that social
support and medical illness had the most important predictive relationship with positive CES-D scores in the sample.
Participants with six to eight chronic medical illnesses and
who were at risk for social isolation were more likely to
screen positive for depressive symptoms. Previous investigators have suggested that social support played a minimal
role in predicting or explaining the emergence of depression in late life (23,29). Our findings confirm those of prior
studies among African American elderly (6,20). In our sample, social support emerged as an important predictor of
depressive symptoms. The role of social support in the
occurrence of depression among African American elders
requires further investigation.
Our results may not be generalized to other African
American resident elders due to the small sample size and
the reliance on a self-report measure of depressive symptoms. Self-report measures have been known to provide
inflated assessments of depressive symptoms as a result of
subjects' response biases due to an idiosyncratic interpretation of questionnaire items. An interview-assisted format
was employed to administer the study questionnaire in an
effort to provide respondents an opportunity to interact with
the interviewers to facilitate a better understanding and
interpretation of questionnaire items. The CES-D scale has
been used in a number of community surveys and found
useful as a first-stage screening device for depressive symptoms in African American elderly (6,13,20).
Although the sample size is small, this study provides
useful preliminary data on the characteristics of depressive
M245
symptoms among African American elders who reside in
urban and rural communities. Considering the projected
increase of African Americans reaching age 60 (4), the patterns and changes in mental health occurring in this population warrant more systematic investigation. The early identification of salient risk factors for symptoms of depression
among this population and the early intervention to prevent
the development of depressive illnesses would significantly
contribute to an improved quality of life for African American elders at risk for depressive illnesses, and eliminate the
costs in medical care and psychological suffering.
ACKNOWLEDGMENT
Address correspondence to Dr. Jebose O. Okwumabua, Department of
Human Movement Sciences and Education, Elma N. Roane Field House
204, The University of Memphis, Memphis, TN 38152-6223. E-mail:
[email protected]
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Received March 29, 1996
Accepted December 13, 1996