|Year : 2019 | Volume
| Issue : 1 | Page : 182
Gender, depressive symptoms, chronic medical conditions, and time to first psychiatric diagnosis among American older adults
Shervin Assari1, Masoumeh Dejman2
1 Department of Family Medicine, Charles R Drew University of Medicine and Science; Department of Psychology, UCLA, Los Angeles, CA, USA
2 Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
|Date of Submission||10-Dec-2015|
|Date of Acceptance||11-Apr-2018|
|Date of Web Publication||09-Oct-2019|
Department of Psychiatry, University of Michigan, 4250 Plymouth Rd., Ann Arbor, MI 48109-2700
Source of Support: None, Conflict of Interest: None
Background: To test whether gender moderates the effects of baseline depressive symptoms and chronic medical conditions (CMCs) on risk of receiving subsequent psychiatric diagnosis among older adults. Methods: Data came from ten waves of the Health and Retirement Study, a nationally representative longitudinal study. We followed 9794 individuals older than 52 years without any diagnosed psychiatric disorder at baseline for up to 18 years. Baseline depressive symptoms and CMC were the predictors, time to receiving an emotional diagnosis was the outcome, baseline demographics and socioeconomics were controls, and gender was the moderator. We used Cox proportional hazards models for data analysis. Results: In the pooled sample, female gender increased the effect of baseline depressive symptoms (hazard ratio [HR], 1.58; 95% confidence interval [CI], 1.26–2.00) and reduced the effect of baseline CMC (HR, 0.78; 95% CI, 0.63–0.97) on time to receiving a psychiatric diagnosis. Among men, baseline depressive symptoms (HR, 2.36; 95% CI, 1.87–2.97) increased and baseline CMC (HR, 0.81; 95% CI, 0.69–0.95) decreased time to receiving a psychiatric diagnosis. Among women, depressive symptoms (HR, 1.49; 95% CI, 1.21–1.83) but not CMC (HR, 1.06; 95% CI, 0.91–1.23) were associated with time to receiving a psychiatric diagnosis over time. Conclusions: Men and women differ in how depressive symptoms and CMC influence their risk of receiving a psychiatric diagnosis over time. Depressive symptoms are more salient promotor for men than women while CMC is only a barrier for men.
Keywords: Chronic medical conditions, depressive symptoms, gender
|How to cite this article:|
Assari S, Dejman M. Gender, depressive symptoms, chronic medical conditions, and time to first psychiatric diagnosis among American older adults. Int J Prev Med 2019;10:182
|How to cite this URL:|
Assari S, Dejman M. Gender, depressive symptoms, chronic medical conditions, and time to first psychiatric diagnosis among American older adults. Int J Prev Med [serial online] 2019 [cited 2019 Oct 15];10:182. Available from: http://www.ijpvmjournal.net/text.asp?2019/10/1/182/268743
| Introduction|| |
Men and women differ in health-care seeking which influences risk of receiving a psychiatric diagnosis.,, Gender of the patient plays an important role in the identifying depression by physicians. Depression is more likely to be diagnosed among women compared to men, even with the same severity of the illness.,,, In the presence of emotional problems, female patients have a higher chance of receiving a diagnosis as having an emotional disorder than males.,,,,,, Green et al. showed that gender does not directly influence health service utilization but increases service utilization through perception of poorer health and emotional perception.
Given the effects of gender on how individuals use general ,,,,,, and mental ,,,,,,,,, health care services, we tested moderating effects of gender on the role of depressive symptoms and chronic medical conditions (CMCs) on time to receiving a psychiatric diagnosis over an 18-year follow-up period.
| Methods|| |
We used data from ten waves (1994–2012) of the Health and Retirement Study (HRS), a longitudinal survey of a nationally representative sample of adults over the age of 50 years in the United States. RAND HRS data file was used for this analysis. HRS is the premier source of data on health of the aging population in the United States. HRS is funded by the National Institute on Aging and housed at the University of Michigan's Institute for Social Research. All participants have provided written consent, and the study protocol has been approved by the University of Michigan, Institutional Review Board. Greater detail about the HRS protocol and data collection is provided elsewhere.
The HRS involves a multistage area probability design with geographic stratification and clustering. In addition, to ensure a large enough representation of minorities, HRS oversamples Black and Hispanic households at about twice the rate of Whites. The sample weights were applied analytically to account for the differential probability of selection into the study and differential nonresponse. The follow-up rate is around 90% at each wave.
As the first measure of depression is available at wave 2, baseline for this study is at wave 2. Thus, we began our observation at wave 2 in 1994 when the HRS cohort was 53–63 years old. Although 11,596 respondents were interviewed at wave 2 (baseline of this analysis), our analytic sample size was 9794. This was because to study incident diagnosis of any psychiatric disorders, we eliminated prevalent cases of psychiatric diagnoses. We only enrolled individuals who had data on psychiatric diagnosis in at least one other wave in the next 18 years.
Data were collected on age, race (reference: White), Hispanic ethnicity (reference: non-Hispanics), gender (reference: male), education (in years), and marital status (reference: married).
We used an 8-item version of the Center for Epidemiologic Studies Depression Scale (CES-D) for measurement of depressive symptoms. Internal consistency was good (Cronbach's alpha = 0.80). We used a cutoff score of 4 to indicate substantially elevated depressive symptoms. This cutoff score is comparable to a cutoff score of 16 on the full CES-D.,
Chronic medical conditions
At entry into the study, HRS assesses the history of seven CMCs including heart disease, hypertension, stroke, diabetes, arthritis, lung disease, and cancer. We created a CMC total score that indicated number of CMC at baseline.
Receiving a psychiatric diagnosis
In each wave, participants were asked “Has a doctor ever told you that you had emotional, nervous, or psychiatric problems?” Respondents answer yes or no.
For the purpose of this study, we used the RAND Corporation HRS data. Stata-13 (StataCorp., College Station, TX, USA) was used for data analysis. As sample weights were applied in all, the analysis, stratification, clustering, and nonresponse were accounted for in the estimation of standard errors, using Taylor series linearization method. Based on attrition analysis, individuals who were older had higher CMC, and elevated depressive symptoms at baseline were at higher risk of attrition over the follow-up period.
We used the Cox proportional hazards models for multivariable analysis. To test the proportional hazards assumption, we used estat phtest in Stata for our Schoenfeld residual analysis. In the first step, we ran our models without and with interactions in the pooled sample. Model 1 evaluated the effect of depressive symptoms and CMC with no covariate in the model. Model 2 also controlled for race, gender, and ethnicity. Model 3 also controlled for age, education, and marital status. Model 4 included two interaction terms: (1) gender × baseline depressive symptoms and (2) gender × baseline CMC. In the second step, we ran stratified models by gender to determine factors associated with receiving a psychiatric diagnosis over 18 years among men (Models 1–3) and women (Models 4–6). Hazard ratios (HRs) with 95% confidence intervals (CIs) are reported. P < 0.05 was considered significant.
| Results|| |
[Table 1] reports descriptive statistics for the total sample. From all participants, 52% were men. The average age at baseline (wave 2) was 57 years with about 12 years of education. About 33% had at least one CMC and 10.8% reported elevated depressive symptoms at baseline (wave 2). Nearly 13.9% of the participants received a psychiatric diagnosis during the 18-year follow-up period. More women had high depressive symptoms compared to men. A larger proportion of women received psychiatric diagnosis than men over the follow-up period.
|Table 1: Descriptive statistics of the sample in the pooled sample and based on gender|
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[Table 2] reports hierarchical Cox regressions in the full sample. In Models 1–3, depressive symptoms were associated with higher risk of the outcome. Model 4 which also included the gender × baseline depressive symptoms and gender × baseline CMC interaction terms showed that male gender interacted significantly with baseline depressive symptoms (HR, 1.58; 95% CI, 1.26–2.00) and baseline CMC (HR, 0.78; 95% CI, 0.63–0.97) on time to receiving psychiatric diagnosis.
|Table 2: Predictive roles of depressive symptoms and chronic medical conditions on time to receiving a psychiatric diagnosis in the pooled sample (n=9794)|
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[Table 3] provides the results of hierarchical Cox regressions in men (Models 1–3) and women (Models 4–6). According to Model 3, net of covariates, baseline depressive symptoms (HR, 2.36; 95% CI, 1.87–2.97) increased and baseline CMC (HR, 0.81; 95% CI, 0.69–0.95) decreased time to receiving a psychiatric diagnosis among men. According to Model 3 among women, while elevated depressive symptoms (HR, 1.49; 95% CI, 1.21–1.83) predicted risk of receiving a subsequent psychiatric diagnosis, CMC (HR, 1.06; 95% CI, 0.91–1.23) was not associated with time of receiving a psychiatric diagnosis among women.
|Table 3: Predictive roles of depressive symptoms and chronic medical conditions on time to receiving a psychiatric diagnosis in men (n=5100) and women (n=4694)|
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| Discussion|| |
In a nationally representative sample of older adults in the United States, baseline level of depressive symptoms was a stronger predictor of receiving a psychiatric diagnosis over time among men than women. Baseline CMC was also a stronger barrier against receiving a psychiatric diagnosis among men compared to women.
Gender alters how depressive symptoms and CMC influence time to receiving a psychiatric diagnosis. This finding may be partly due to higher depressive symptoms among women compared to men. Although elevated depressive symptoms predicted time to receiving a psychiatric diagnosis among men and women, CMC was only a barrier for men. Literature has shown that women are more likely than men to seek help for mental disorders.,,,,
Literature has shown that men and women differently perceive mental health need, express emotional symptoms, and seek help.,,,, With similar severity of emotional problem, women have higher tendency to use health-care services and are more likely to communicate about their emotional complaints and symptoms with others including health-care providers. Women better articulate their feelings and are more expressive about their subjective feelings. Such tendency increases women's chance of receiving a diagnosis of an emotional problem.,, Women perceive lower subjective health, experience more depressive symptoms, and more frequently attend primary care doctors than men. All these factors increase chance of receiving a diagnosis for an emotional problem.,,, More frequent attendance to primary health-care setting by women increases their interaction with health-care providers that raise the likelihood for evaluation of emotional problems. In addition, in the presence of minor mental health symptoms, men are more likely than women to delay visiting a doctor. However, men do seek help when their emotional problem becomes severe and interfere with their daily function and productivity.
In the absence of a severe emotional problem, recognition of symptoms, acceptance of the sickness, and help seeking without stigma shape help seeking behaviors of individuals.,,,, All these factors are more common among women compared to men.,,,, According to the WHO survey across 24 countries, low perceived need is the most common reason for not initiating treatment of mental disorders. Women have higher tendency to recognize the need for treatment in the presence of minor disorders.
Although women have a higher tendency for using health services, there are studies not showing any gender differences in the use of specialist care.,, In general population of Canada, depressed women more frequently use mental health services from primary care providers than men; however, no gender differences exist in rates of professional mental health-care use. Thus, men utilize mental health care equally as women once their mental health problem reaches a certain level.,,, In Puerto Rico, although gender does not have a main effect on mental health-care utilization, it does change the effects of predictors of use. Definite need for mental health care and poor self-rated mental health had larger effects on service use of men than women.
Gender differences in help seeking differ across ethnic groups. In a nationally representative survey, African American men with serious disorders used both psychiatrists (43.7% vs. 27.9%) and nonpsychiatrist mental health services more than women. At the same time, African American women were more likely than men to utilize general medical care. This pattern was opposite in Caribbean Blacks.
Gender bias in diagnosis may also be responsible for differential chance of receiving a psychiatric diagnosis among men and women. Gender differences in rate of diagnosis of depression among patients are at least in part due to how physicians observe and evaluate complaints of male and female clients in primary and mental health-care setting., Primary care doctors are more likely to ask regarding feelings and emotions from their female patients,, which explain higher depression diagnosis among women in primary care setting., Studies showed that while male physicians evaluate depressive symptoms and diagnose depression more frequently among female patients, physicians of both genders more frequently suggest counseling to female patients.,
Our findings suggest that CMC is a barrier against receiving a psychiatric diagnosis among men but not women. This might be that men less commonly identify and describe their feelings, are less likely to be aware of their emotional symptoms, and are less likely to attribute their feelings to a problem., Masculine gender role socialization defined as cultural values, norms, and ideologies about the role and meaning of being a man may also have a role., Data consistently show that men report better subjective health and less somatic and emotional symptoms than women.
Our findings extend the existing literature on gender differences in the pattern of general ,, and mental ,,,,,,,,, health-care utilization. The findings enhance our current understanding factors that contribute to gender disparities in mental health-care use in the US.,,,
Our study had at least four limitations. First, the validity of single-item measures of receiving a psychiatric diagnosis is unknown. Second, we did not analyze type of CMCs. Common types of medical conditions may differ among men and women. Third, we used a brief scale to measure depressive symptoms. Finally, we did not use time-varying covariates. The strength of this study is using a large nationally representative sample, which generated findings that are generalizable to the US population.
| Conclusions|| |
Elderly men and women differ in the effects of baseline depressive symptoms and CMC on time to receiving a psychiatric diagnosis over an 18-year follow-up period. Depressive symptoms are stronger risk factors, and the number of CMC is a stronger barrier for receiving a psychiatric diagnosis among older men compared to older women.
Shervin Assari is partly supported by the CMS grant 1H0CMS331621 (PI= M. Bazargan) and National Institute on Minority Health and Health Disparities (NIMHD) grant U54 MD007598 (PI = M. Bazargan).
Financial support and sponsorship
The National Institute on Aging provided funding for the Health and Retirement Study (U01 AG09740).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Albizu-Garcia CE, Alegría M, Freeman D, Vera M. Gender and health services use for a mental health problem. Soc Sci Med 2001;53:865-78.
David JL, Kaplan HB. Gender, social roles and health care utilization. Appl Behav Sci Rev 1995;3:39-64.
Afifi M. Gender differences in mental health. Singapore Med J 2007;48:385-91.
Bertakis KD, Helms LJ, Callahan EJ, Azari R, Leigh P, Robbins JA, et al.
Patient gender differences in the diagnosis of depression in primary care. J Womens Health Gend Based Med 2001;10:689-98.
Koopmans GT, Lamers LM. Gender and health care utilization: The role of mental distress and help-seeking propensity. Soc Sci Med 2007;64:1216-30.
Nolen-Hoeksema S. Gender differences in depression. Curr Dir Psychol Sci 2001;10:173-6.
Vasiliadis HM, Gagné S, Jozwiak N, Préville M. Gender differences in health service use for mental health reasons in community dwelling older adults with suicidal ideation. Int Psychogeriatr 2013;25:374-81.
Silverstein B. Gender differences in the prevalence of somatic versus pure depression: A replication. American J Psychiatry 2002;159:1051-2.
Gijsbers van Wijk CM, Huisman H, Kolk AM. Gender differences in physical symptoms and illness behavior. A health diary study. Soc Sci Med 1999;49:1061-74.
Raine R. Does gender bias exist in the use of specialist health care? J Health Serv Res Policy 2000;5:237-49.
Green CA, Polen MR, Perrin NA, Leo M, Lynch FL, Rush DP, et al.
Gender-based structural models of health care costs: Alcohol use, physical health, mental health, and functioning. J Ment Health Policy Econ 2004;7:107-25.
Song J, Chang RW, Manheim LM, Dunlop DD. Gender differences across race/ethnicity in use of health care among medicare-aged Americans. J Womens Health (Larchmt) 2006;15:1205-13.
Travassos C, Viacava F, Pinheiro R, Brito A. Utilization of health care services in Brazil: Gender, family characteristics, and social status. Rev Panam Salud Publica 2002;11:365-73.
Bertakis KD, Azari R. Patient gender differences in the prediction of medical expenditures. J Womens Health (Larchmt) 2010;19:1925-32.
Owens GM. Gender differences in health care expenditures, resource utilization, and quality of care. J Manag Care Pharm 2008;14:2-6.
Xu KT, Borders TF. Gender, health, and physician visits among adults in the united states. Am J Public Health 2003;93:1076-9.
Green CA, Pope CR. Gender, psychosocial factors and the use of medical services: A longitudinal analysis. Soc Sci Med 1999;48:1363-72.
Pattyn E, Verhaeghe M, Bracke P. The gender gap in mental health service use. Soc Psychiatry Psychiatr Epidemiol 2015;50:1089-95.
Gagné S, Vasiliadis HM, Préville M. Gender differences in general and specialty outpatient mental health service use for depression. BMC Psychiatry 2014;14:135.
Roudi-Fahimi F, Gupta Y, Swain P, Ram F, Singh A, Agrawal P, et al
. Irans family planning program: Responding to a nations needs. J Popul Res (Canberra) 2002;19:1-24.
Cabiya JJ, Canino G, Chavez L, Ramirez R, Alegría M, Shrout P, et al.
Gender disparities in mental health service use of Puerto Rican children and adolescents. J Child Psychol Psychiatry 2006;47:840-8.
Maguen S, Cohen B, Cohen G, Madden E, Bertenthal D, Seal K, et al.
Gender differences in health service utilization among Iraq and Afghanistan veterans with posttraumatic stress disorder. J Womens Health (Larchmt) 2012;21:666-73.
Maguen S, Ren L, Bosch JO, Marmar CR, Seal KH. Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in veterans affairs health care. Am J Public Health 2010;100:2450-6.
Bertakis KD, Azari R, Helms LJ, Callahan EJ, Robbins JA. Gender differences in the utilization of health care services. J Fam Pract 2000;49:147-52.
Sonnega A, Faul JD, Ofstedal MB, Langa KM, Phillips JW, Weir DR, et al.
Cohort profile: The health and retirement study (HRS). Int J Epidemiol 2014;43:576-85.
Heeringa S, Connor J. Technical Description of the Health and Retirement Study Sample Design: HRS. AHEAD Documentation Report DR-002; 1995.
Turvey CL, Wallace RB, Herzog R. A revised CES-D measure of depressive symptoms and a DSM-based measure of major depressive episodes in the elderly. Int Psychogeriatr 1999;11:139-48.
Steffick DE, Wallace RB, Herzog AR. Documentation of Affective Functioning Measures in the Health and Retirement Study; 2000.
Zivin K, Llewellyn DJ, Lang IA, Vijan S, Kabeto MU, Miller EM, et al.
Depression among older adults in the United States and England. Am J Geriatr Psychiatry 2010;18:1036-44.
Kessler RC, Brown RL, Broman CL. Sex differences in psychiatric help-seeking: Evidence from four large-scale surveys. J Health Soc Behav 1981;22:49-64.
Neighbors HW, Howard CS. Sex differences in professional help seeking among adult black Americans. Am J Community Psychol 1987;15:403-17.
Mojtabai R, Olfson M, Mechanic D. Perceived need and help-seeking in adults with mood, anxiety, or substance use disorders. Arch Gen Psychiatry 2002;59:77-84.
Nam SK, Chu HJ, Lee MK, Lee JH, Kim N, Lee SM, et al.
Ameta-analysis of gender differences in attitudes toward seeking professional psychological help. J Am Coll Health 2010;59:110-6.
Susukida R, Mojtabai R, Mendelson T. Sex Differences in Help Seeking for Mood and Anxiety Disorders in the National Comorbidity Survey-Replication. Depression and Anxiety; 2015.
ten Have M, de Graaf R, Ormel J, Vilagut G, Kovess V, Alonso J, et al.
Are attitudes towards mental health help-seeking associated with service use? Results from the European study of epidemiology of mental disorders. Soc Psychiatry Psychiatr Epidemiol 2010;45:153-63.
Mackenzie CS, Gekoski WL, Knox VJ. Age, gender, and the underutilization of mental health services: The influence of help-seeking attitudes. Aging Ment Health 2006;10:574-82.
Andrade LH, Alonso J, Mneimneh Z, Wells JE, Al-Hamzawi A, Borges G, et al.
Barriers to mental health treatment: Results from the WHO world mental health surveys. Psychol Med 2014;44:1303-17.
Benyamini Y, Leventhal EA, Leventhal H. Gender differences in processing information for making self-assessments of health. Psychosom Med 2000;62:354-64.
Möller-Leimkühler AM. Barriers to help-seeking by men: A review of sociocultural and clinical literature with particular reference to depression. J Affect Disord 2002;71:1-9.
Smith KL, Matheson FI, Moineddin R, Dunn JR, Lu H, Cairney J, et al
. Gender differences in mental health service utilization among respondents reporting depression in a national health survey. Health 2013;5:1561.
Palin JL, Goldner EM, Koehoorn M, Hertzman C. Primary mental health care visits in self-reported data versus provincial administrative records. Health Rep 2011;22:41-7.
Drapeau A, Boyer R, Lesage A. The influence of social anchorage on the gender difference in the use of mental health services. J Behav Health Serv Res 2009;36:372-84.
Leaf PJ, Bruce ML. Gender differences in the use of mental health-related services: A re-examination. J Health Soc Behav 1987;28:171-83.
Galdas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: Literature review. J Adv Nurs 2005;49:616-23.
Oliver MI, Pearson N, Coe N, Gunnell D. Help-seeking behaviour in men and women with common mental health problems: Cross-sectional study. Br J Psychiatry 2005;186:297-301.
Neighbors HW, Caldwell C, Williams DR, Nesse R, Taylor RJ, Bullard KM, et al.
Race, ethnicity, and the use of services for mental disorders: Results from the national survey of American life. Arch Gen Psychiatry 2007;64:485-94.
Badger LW, Berbaum M, Carney PA, Dietrich AJ, Owen M, Stem JT. Physician-patient gender and the recognition and treatment of depression in primary care. J Soc Serv Res 1999;25:21-39.
Brownhill S, Wilhelm K, Barclay L, Schmied V. 'Big build': Hidden depression in men. Aust N
Z J Psychiatry 2005;39:921-31.
Addis ME, Mahalik JR. Men, masculinity, and the contexts of help seeking. Am Psychol 2003;58:5-14.
Rhodes AE, Goering PN, To T, Williams JI. Gender and outpatient mental health service use. Soc Sci Med 2002;54:1-0.
[Table 1], [Table 2], [Table 3]