Mental health across the lifespan

Journal of Affective Disorders 106 (2008) 29–44 www.elsevier.com/locate/jad

Review

Risk factors for anxiety and depression in the elderly: A review

Dagmar Vink a,⁎, Marja J. Aartsen a, Robert A. Schoevers b

a Knowledge Centre of Psychiatry in the Elderly, Oude Arnhemseweg 260, 3705 BK Zeist, The Netherlands b Mentrum Mental Health Care and Department of Psychiatry, VU Medical Centre Amsterdam, The Netherlands

Received 8 March 2007; received in revised form 12 June 2007; accepted 13 June 2007 Available online 17 August 2007

Abstract

Background: Although a number of studies have examined risk factors for anxiety and depression at a later age, there have been no systematic comparisons of risk profiles across studies. Knowledge on such risk profiles may further our understanding of both the etiology and early recognition of these highly prevalent disorders. This paper gives a comprehensive overview and compares risk factors associated with anxiety and depression in the elderly. Methods: The databases MEDLINE, PsycINFO and Sociological Abstracts were systematically searched, and relevant English- language articles from January 1995 to December 2005 were reviewed. Cross-sectional and longitudinal studies on risk factors in elderly from a community or primary care setting were included. The associations between risk factors and pure anxiety or depressive symptoms or disorders were summarized and compared. Results: The abstracted risk factors from studies on anxiety (N=17) and depression (N=71) were clustered into the categories biological, psychological and social. Although risk factors for anxiety and depression showed many similarities, some differences were found. Biological factors may be more important in predicting depression, and a differential effect of social factors on depression and anxiety was found. Limitation: Due to a high heterogeneity between studies, no meta-analysis could be conducted. Conclusions: There is considerable overlap between the risk profiles for anxiety and depression in the elderly, which suggests a dimensional approach on the interrelationship between anxiety and depression is more appropriate. To improve the recognition and preventive mental health programs, a clearer understanding of differentiating etiological factors will be needed. © 2007 Elsevier B.V. All rights reserved.

Keywords: Anxiety; Depression; Risk factor; Recognition; Prevention; Elderly

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

2.1. Selection of articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 2.2. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

⁎ Corresponding author. Tel.: +31 30 6937615; fax: +31 30 6937620. E-mail address: [email protected] (D. Vink).

0165-0327/$ - see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2007.06.005

30 D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 3.1. Included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

3.1.1. Studies on risk factors for anxiety among the elderly . . . . . . . . . . . . . . . . . . . . . . . . . 32 3.1.2. Studies on risk factors for depression among the elderly. . . . . . . . . . . . . . . . . . . . . . . . 32

3.2. Biological risk factors (Table 1a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 3.2.1. Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 3.2.2. Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 3.2.3. Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

3.3. Psychological risk factors (Table 1b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.3.1. Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.3.2. Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.3.3. Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

3.4. Social risk factors (Table 1c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.4.1. Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.4.2. Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.4.3. Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Role of funding source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41 41 41 41

1. Introduction

Anxiety and depressive disorders are highly preva- lent in the elderly, often appear as comorbid disorders and both have adverse consequences such as reduced quality of life and excess mortality (de Beurs et al., 1999; Charney et al., 2003). In addition, subthreshold symptoms of anxiety and depression are common and serious, causing significant disruption in daily living. Although late-life anxiety and depression are treatable conditions (Wetherell, 1998; McCusker et al., 1998), they are often underrecognized and undertreated in pri- mary care (Mulsant and Ganguli, 1999; Olafsdottir et al., 2001; Volkers et al., 2004). Compared to elderly with a mood disorder, only a small percentage of the older adults with an anxiety disorder are referred to specialized mental health care, while this could be ap- propriate and cost-effective (de Beurs et al., 1999). For instance, a study that reviewed Medicare reimburse- ments for geriatric mental health treatment in the USA found that 55% of older mood disorder patients, but only 17% of older anxiety disorder patients, saw a mental health specialist (Ettner and Hermann, 1997). The lower prevalence of older patients with anxiety who get care from mental health specialists may be due to several factors related to the older adult or to the mental health care system. These include a tendency to somatize anxiety symptoms by the older adult or underrecogni- tion by the general practitioner.

A cost-effective way to improve detection of people who suffer from anxiety and depression is to pay special attention to elderly at risk (Smit et al., 2006; Schoevers et al., 2006; Smit et al., 2007). Proper knowledge of risk factors for anxiety and depression helps to increase the detective power. Different risk profiles may be expected among the elderly in comparison with younger adults, as both the exposure to and the impact of risk factors change with age (Beekman et al., 2000). Previous studies sug- gest that longstanding vulnerability factors, such as family and personal histories of anxiety and depression, become less important in risk profiles among the older old as the most vulnerable elderly selectively leave the population (Beekman et al., 1995; Beekman et al., 1998; Van Ojen et al., 1995). On the other hand, the prevalence of risk factors such as deteriorating physical health, cognitive decline and a diminishing social network in- creases with age. Further, the notion of ‘on-time’ versus ‘off-time’ occurrence of events may explain a change in the impact of risk factors in later life. Older adults are at a specific developmental stage where they are encounter- ing frequent losses and may be more prepared to cope effectively as compared with younger individuals (Schum et al., 2005). For example, loss of a spouse may, for an older person, be more expected and in line with the later phases of life, possibly resulting in a relatively easier adjustment and acceptation.

Early detection and treatment help to reduce symp- toms, increase quality of life and prevent an unfavorable

31D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

prognosis. However, the negative consequences of a disorder are not always averted by treatment. Data from a mental health survey show that even with perfect cov- erage and evidence based treatment, only half the bur- den of anxiety disorders and 35% of years lived with a mood disorder could be averted (Andrews et al., 2004). Therefore, in addition to proper screening of prevalent cases, early detection of people who are likely to develop an anxiety or depressive disorder in the near future is desirable. Hence, a distinction should be made between risk factors for the incidence (longitudinal studies) and prevalence (cross-sectional studies) of anxiety and de- pression. While cross-sectional studies may indicate factors that either precede or are concomitant with anx- iety or depression, or may be a consequence, risk factors for incidence derived from longitudinal studies may actually predict which older adults are at higher risk of becoming anxious or depressed in the future. However, prior research did not always find major differences between risk factors for the prevalence and incidence (Beekman et al., 2001).

Despite considerable research on risk factors for depression among elderly community subjects (Cole and Dendukuri, 2003; Djernes, 2006), limited attention has been paid to risk factors for anxiety in later life. Given the prevailing theories on the interrelationship between anxiety and depression, a dimensional ap- proach may be more appropriate than categorical mod- els (Goldberg, 1996; Goldberg, 2000). According to a dimensional model, with comorbid anxiety and de- pression on the most severe end of both the depression and the anxiety spectrum, it is likely that anxiety and depression share common risk factors (Goldberg and Huxley, 1992). Kendler (1996) however argues that these disorders may well have a common genetic basis, but environmental variables may help to determine which set of symptoms becomes predominant. For in- stance, Finlay-Jones and Brown (1981) have shown that there is a tendency for danger events to be followed by anxious symptoms, and loss by depressive symp- toms. Further, there is some evidence for a tripartite model indicating that anxiety and depression share a common distress factor referred to as negative affect (Cook et al., 2004). On the other hand, more differences than similarities were found in a study comparing risk factors associated with anxiety and depressive dis- orders in older adults, suggesting they represent useful categories with shared but distinct underpinnings (Beekman et al., 2000).

Additionally for clinical reasons, correlates that are unique to depression or anxiety may identify factors that will help improve their differential diagnosis and in

turn aid in the recognition of these disorders. As these disorders are often comorbid, it can be difficult to differentiate between anxiety and depression, while the optimal treatment is not necessarily the same.

The aim of this study is to give a comprehensive overview and compare risk factors for symptoms as well as clinically relevant levels of anxiety and depression in later life, based on cross-sectional and longitudinal stud- ies. This knowledge may provide direction for recogni- tion and preventive mental health strategies.

The research questions are:

1. Which risk factors are associated with anxiety and/or depression in the elderly?

2. Are there differences between risk factors for anxiety and depression in the elderly?

2. Methods

2.1. Selection of articles

To answer the research questions, we reviewed studies on factors associated with the prevalence and incidence of symptom or clinically relevant levels of depressive disorders (i.e. minor and major depression) and anxiety disorders (i.e. generalized anxiety dis- order (GAD), posttraumatic stress disorder (PTSD), panic disorder, phobic disorders and obsessive–com- pulsive disorder (OCD)) in the elderly. In order to improve comparability between studies and study populations, and to provide appropriate direction for possible preventive mental health interventions, only studies from Western countries with similar social circumstances and mental health care systems were included.

First, three computer databases, MEDLINE, Psy- cINFO and Sociological Abstracts, were searched for potentially relevant articles. For pragmatic reasons, ar- ticles published after January 1995 to December 2005 were selected. The names of the different levels of anxiety and mood disorders, and the words “elderly” or “older adults” were used as keywords in combination with the terms “risk factor”, “etiology”, “diathesis- stress”, “biopsychosocial”, “predictor”, “onset”, “deter- minant” and “vulnerability”. Second, relevant articles (judged on the title and abstract) were retrieved for more detailed evaluation. Additional studies were selected from reference lists of these articles. Finally, all retrieved articles were screened to determine which met the following inclusion criteria: 1) research pub- lished in English, 2) subjects age 50 years and over, 3) community or primary care setting, 4) study from

32 D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

Western country, 5) study of at least one risk factor for anxiety or depression, 6) quantitative empirical research with a cross-sectional or longitudinal study design.

2.2. Data synthesis

Information about the size of the study group, the setting, subjects' age, proportion of men, criteria for psychiatric disorder, length of follow-up in longitu- dinal studies, and associations with risk factors was abstracted from each study. A distinction was made between studies which used merely symptoms as dependent variable, and studies using clinically rele- vant levels of anxiety and depression based on either DSM or ICD criteria, or a cut-off value of ≥16 on the CES-D. Similarly, a distinction was made between studies with a cross-sectional and longitudinal study design.

Preferably, outcomes from multivariate analyses were used in this study to indicate the association be- tween a risk factor and anxiety or depression. If multi- variate outcomes were not available, bivariate outcomes were used instead. If the 95% confidence interval of Odds Ratios or Relative Risks did not include 1.0 or the p-value was below 0.05, the association was regarded to be statistically significant.

Although risk factors may work together to influence an outcome, as proxy or overlapping risk factors and as mediators and moderators (Kraemer et al., 2001), we restricted the data synthesis to main effects. Some studies examined risk factors associated with comorbid anxiety and depression. In the present study only risk factors for ‘pure’ anxiety and depression were reviewed, because it is impossible to disentangle the unique effects in comorbid disorders.

A qualitative systematic review was conducted by summarizing and comparing the abstracted data. Ab- straction of data from the articles was executed inde- pendently by the first two authors, and agreement was obtained through extensive discussion. If two or more studies used the same study population, a comparable outcome was only summarized once.

3. Results

3.1. Included studies

Based on the inclusion criteria 80 articles were considered to be relevant for this review study, including 8 studies on risk factors for anxiety, 63 on risk factors for depression and 9 on risk factors for both anxiety and depression. In these studies, almost 60 different risk

factors were studied. To improve the accessibility of the findings on risk factors, they were divided into three main categories; biological, psychological and social. This clustering was arbitrary for some factors. For example, family history of a psychiatric disorder can be interpreted both from a genetic perspective and as a qualitative aspect of family dynamics.

3.1.1. Studies on risk factors for anxiety among the elderly

Twelve cross-sectional and five longitudinal studies investigated risk factors for anxiety. These studies were based on community samples in Europe (N=13) and the USA (N=4). The numbers of subjects at baseline ranged from 70 to 4051 (median=767). The subjects' mean age, reported in 10 articles, lay between 65 and 85 years (median=71.5). Fourteen articles included gender distribution: 0% to 50% of the subjects were men (median=37.5%). The length of follow-up in the longitudinal studies ranged from 1.5 to 3 years (median=3). Most studies referred to risk factors for anxiety symptoms (N=6) or any anxiety disorder (N=5). However, some studies focused on specific anxiety symptoms or disorders, that is PTSD (Acierno et al., 2002; van Zelst et al., 2003), panic disorder (Deer and Calamari, 1998), phobic disorder (Lindesay, 1997) and GAD (Schoevers et al., 2003b, 2005).

3.1.2. Studies on risk factors for depression among the elderly

Thirty-two cross-sectional and 39 longitudinal stud- ies addressed risk factors for depression. These studies were based on samples in Europe (N=41), the USA (N=26) and Australia (N=4) and six of these studies were situated in a primary care setting. The numbers of subjects at baseline ranged from 71 to 22,570 (me- dian=767). The subjects' mean age was reported in 43 articles and ranged from 56 to 85 years (median=70). Fifty-three articles included gender distribution: 0% to 56% of the subjects were men (median=41%). The length of follow-up in the longitudinal studies ranged from 9 months to 10 years (median=3). Twen- ty-eight and 43 studies concerned risk factors for depressive symptoms, or minor/major depressive dis- order respectively.

Findings on risk factors were clustered into bio- logical (Table 1a), psychological (Table 1b) and social (Table 1c) risk factors. In Tables 1a–c, risk factors (+), protective factors (−) and non-significant associations (0) were summarized from included studies. Refer- ences printed in italics refer to studies with a cross- sectional design instead of a longitudinal design.

Table 1a Summary of biological risk factors for anxiety and depression among the elderly

Cluster Risk factors Depressive symptoms Depressive disorders Anxiety symptoms Anxiety disorders

Chronic diseases

Number of chronic health conditions

+:Adams et al. (2004) +:Beekman et al. (1995) +:Beekman et al. (2000) +:Braam et al. (2005) +:Schoevers et al. (2003b) +:Schoevers et al. (2003b) +:Gazmararian et al. (2000) +:van der Wurff et al.

(2004) 0:van Zelst et al. (2003)

+:Jang et al. (2002) 0:Beekman et al. (2000) 0:Horowitz et al. (2005)

+: Biderman et al. (2002) +: Beekman et al. (2001) 0: de Beurs et al. (2001) 0: Schoevers et al. (2005) +: Bisschop et al. (2004) +: Geerlings et al. (2000) +: Lyness et al. (2000) +: Husaini (1997) 0: Zeiss et al. (1996) +: Lyness et al. (2000)

+: Roberts et al. (1997) +: Schoevers et al. (2005) +: Strawbridge et al. (2002) 0: de Beurs et al. (2001)

Parkinsonism +:Minicuci et al. (2002) Cognitive impairment/ dementia

+:Minicuci et al. (2002) +:Beekman et al. (1995) +:Forsell and Winblad (1998)

+: Biderman et al. (2002) +: Forsell (2000) 0: de Beurs et al. (2001) 0 : Forsell (2000) +: Blazer et al. (2002) +: Roberts et al. (1997)

0: de Beurs et al. (2001) Vascular

factors Cardiovascular factors

+:Tiemeier et al. (2004)

Cerebrovascular factors

+:Azar et al. (2005) +:Copeland et al. (1999)

+: Hickie et al. (2003) 0: Lyness et al. (2000) 0: Lyness et al. (2000)

White matter +:de Groot et al. (2000) hyperintensities +:Jorm et al. (2005)

+:Nebes et al. (2001) Atherosclerosis +:Tiemeier et al. (2004) High blood pressure

0:Paterniti et al. (1999) +:Copeland et al. (1999) +:Paterniti et al. (1999)

Low blood pressure

+: Paterniti et al. (2000)

Foetal undernutrition

+: Thompson et al. (2001)

Health status

Poor health status

+:Gazmararian et al. (2000) +:Copeland et al. (1999) 0:Acierno et al. (2002) +:Lyness et al. (1998) +:Lyness et al. (1998)

0:Acierno et al. (2002) New medical illness

+: Henderson et al. (1997) +: Prince et al. (1998) 0: Schoevers et al. (2005) 0: Schoevers et al. (2005)

Sleep disturbance

+: Prince et al. (1998) +: Roberts et al. (2000)

Low exercise level/ lower number of activities

+:Adams et al. (2004) +:Gazmararian et al. (2000) +:Kritz-Silverstein et al. (2001) +: Biderman et al. (2002) +: Kivela et al. (1996b) 0: Kritz-Silverstein et al. (2001)

+: Strawbridge et al. (2002)

0: Lampinen and Heikkinen (2003)

Medicine use

Use of psychotropic and somatic medication

+:Hybels et al. (2001) +:Dhondt et al. (2002) +: Biderman et al. (2002)

Drug misuse +:Copeland et al. (1999)

(continued on next page)

33D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

Table 1a (continued )

Cluster Risk factors Depressive symptoms Depressive disorders Anxiety symptoms Anxiety disorders

Self- perceived health

Pain +:Prince et al. (1997a) +: Livingston et al. (2000) +: Prince et al. (1998)

Poor self-perceived health

+:Hybels et al. (2001) +:Almeida and Pfaff (2005)

+:van Zelst et al. (2003)

+:Minicuci et al. (2002) +:Beekman et al. (1995) +: Biderman et al. (2002) +: de Beurs et al. (2001) +: de Beurs et al. (2001)

Disability Functional limitations

+: Braam et al. (2005) +: Beekman et al. (1995) +: Beekman et al. (2000) +: Gazmararian et al. (2000)

+:Copeland et al. (1999) +: Schoevers et al. (2003b)

+: Hybels et al. (2001) +: Horowitz et al. (2005) +: Jang et al. (2002) +: Prince et al. (1997a) 0: van Zelst et al. (2003) +: Jorm et al. (2005) +: Schoevers et al.

(2003b) +: Minicuci et al. (2002) +: van der Wurff et al.

(2004) 0: Cummings et al. (2003) 0: Beekman et al. (2000) +: Biderman et al. (2002) +: Beekman et al. (2001) 0: de Beurs et al. (2001) 0: Schoevers et al. (2005) +: Blumstein et al. (2004) +: de Beurs et al. (2001) 0: Forsell (2000) +: Henderson et al. (1997) +: Geerlings et al. (2000) +: Siegel et al. (2004) +: Kivela et al. (1996b) +: Zeiss et al. (1996) +: Oldehinkel et al. (2001)

+: Prince et al. (1998) +: Roberts et al. (1997) +: Schoevers et al. (2005) +: Strawbridge et al. (2002) 0: Forsell (2000)

Vision or hearing loss

0: Horowitz et al. (2005) 0: van Zelst et al. (2003) 0: Biderman et al. (2002) +: Forsell (2000) +: de Beurs et al. (2000) 0: Forsell (2000)

0: de Beurs et al. (2001) 0: de Beurs et al. (2001) Genetic factors

APOE-E4 allele +: Nebes et al. (2001) 0: Steffens et al. (2003) 0: Blazer et al. (2002) 0: Henderson et al. (1997)

Family history of psychiatric disorder

+: Beekman et al. (1995)

Habits Alcohol problem +: Gazmararian et al. (2000)

+: Copeland et al. (1999)

Smoking +: Jorm et al. (2005) +: Almeida and Pfaff (2005) +: Strawbridge et al. (2002)

Obesity +: Strawbridge et al. (2002)

Notes: A plus sign indicates a risk factor; a zero sign indicates the factor was not significant. References printed in italics are referring to studies with a cross-sectional design, whereas normal printed references refer to studies with a longitudinal design.

34 D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

3.2. Biological risk factors (Table 1a)

3.2.1. Anxiety Studies on biological risk factors for anxiety provided

mainly cross-sectional associations. Cognitive impair- ment and high blood pressure were correlated with anxiety symptoms, and number of chronic health con- ditions, poor self-perceived health and functional limitations with anxiety disorders. Of the four studies with a longitudinal design, only de Beurs et al. (2001)

found significant associations; self-perceived health and vision or hearing loss were predictors for anxiety symptoms.

3.2.2. Depression Many risk factors from the clusters chronic diseases,

vascular factors, health status, medicine use, self- perceived health, disability and habits (such as se- vere alcohol use or smoking) were identified from cross-sectional and longitudinal studies on depressive

Table 1b Summary of psychological risk factors for anxiety and depression among the elderly

Cluster Risk factors Depressive symptoms Depressive disorders Anxiety symptoms Anxiety disorders

Personality traits

External locus of control/ lower level of mastery

+: Jang et al. (2002) +: Beekman et al. (2000) +: Beekman et al. (2000) +: Bisschop et al. (2004) +: Beekman et al. (2001) 0: de Beurs et al.

(2001) +: Beekman et al. (2004) 0: de Beurs et al. (2001)

Neuroticism +: Lyness et al. (1998) +: Lyness et al. (1998) +: Deer and Calamari (1998)

+: van Zelst et al. (2003)

+: Monopoli et al. (2000) +: Henderson et al. (1997) +: de Beurs et al. (2001) +: de Beurs et al. (2001)

+: Livingston et al. (2000) +: Oldehinkel et al. (2001) +: Ormel et al. (2001)

Lower level of extraversion

+: Livingston et al. (2000)

Impulsivity −: Monopoli et al. (2000) Coping Dysfunctional

coping +: Coolidge et al. (2000)

+: Kraaij et al. (2002) Lack of self-efficacy

+: Quinn et al. (1996) +: Horowitz et al. (2005) +: van Zelst et al. (2003) +: Bisschop et al. (2004) +: de Beurs et al. (2001) +: de Beurs et al. (2001)

Self-image Low self-esteem

+: Bisschop et al. (2004) +: Husaini (1997) +: Kivela et al. (1999)

Ego-strength −: Monopoli et al. (2000) Psychopathology More

symptoms at baseline

+: Biderman et al. (2002) +: Beekman et al. (2001) +: de Beurs et al. (2001) +: Henderson et al. (1997) +: de Beurs et al. (2001) +: Isaacowitz and Seligman (2001)

+: Roberts et al. (1997)

Psychiatric history

+: Beekman et al. (1995) +: Forsell and Winblad (1998)

+: Schoevers et al. (2003b)

+: Horowitz et al. (2005) +: Schoevers et al. (2003b) +: van Ojen et al. (1995)

+: Kraaij et al. (2002) +: Forsell (2000) +: Forsell (2000) +: Heun and Hein (2005) +: Russo et al. (1995) +: Husaini (1997) +: Schoevers et al. (2005) +: Kivela et al. (1996b) +: Russo et al. (1995) +: Schoevers et al. (2000)

Cluster C personality disorder

+: Coolidge et al. (2000)

Notes: A plus sign indicates a risk factor; a minus sign indicates a protective factor; a zero sign indicates the factor was not significant. References printed in italics are referring to studies with a cross-sectional design, whereas normal printed references refer to studies with a longitudinal design.

35D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

symptoms and disorders. Findings on genetic factors for depression were inconclusive. Whereas one study found an association between apolipoprotein E-4 (APOE) allele and depressive symptoms, three others could not find this association.

3.2.3. Differences The overall findings showed many communalities,

except for chronic diseases and functional limitations

which were associated longitudinally with depression but not anxiety. Because these differences may be the result of differences in study design, a closer look was given to studies which examined biological risk factors for pure anxiety and depression simultaneously (Acierno et al., 2002; Beekman et al., 2000; de Beurs et al., 2001; Forsell, 2000; Paterniti et al., 1999; Schoevers et al., 2003b, 2005). Within these studies the following dif- ferences between risk factors for anxiety and depression

Table 1c Summary of social risk factors for anxiety and depression among the elderly

Cluster Risk factors Depressive symptoms Depressive disorders Anxiety symptoms Anxiety disorders

Quantitative aspects of social network

Low contact frequency

+: Adams et al. (2004) +: Biderman et al. (2002) +: Prince et al. (1998) +: Forsell (2000)

0: Forsell (2000) Smaller network size

+: Jang et al. (2002) +: Beekman et al. (1995) +: Beekman et al. (1998) 0: van Zelst et al. (2003)

0: Bisschop et al. (2004) +: Beekman et al. (2001) 0: de Beurs et al. (2001) +: Beekman et al. (2004) +: de Beurs et al. (2001) +: Husaini (1997) +: Roberts et al. (1997) +: Wilson et al. (1999)

Church attendance/ religious

−: Adams et al. (2004) −: Braam et al. (2001) −: Cummings et al. (2003) −: Quinn et al. (1996)

−: Kivela et al. (1996a) Unmarried (never, divorced and widowed)

+: Hybels et al. (2001) +: Almeida and Pfaff (2005)

0: Forsell (2000)

+: Minicuci et al. (2002) +: Beekman et al. (1995) 0: Schoevers et al. (2003b)

+: Copeland et al. (1999) 0: van Zelst et al. study (2003)

+: Schoevers et al. (2003b) +: van der Wurff et al. (2004) 0: Forsell (2000)

+: Bisschop et al. (2004) +: Geerlings et al. (2000) 0: Biderman et al. (2002)

Marital status 0: Adams et al. (2004) 0: Horowitz et al. (2005) 0: Cummings et al. (2003) 0: Gazmararian et al. (2000) 0: Blazer et al. (2002) +: Kivela et al. (1996a) 0: de Beurs et al. (2001) 0: Schoevers et al. (2005)

+: Prince et al. (1998) 0: Beekman et al. (1995) 0: de Beurs et al. (2001) 0: Roberts et al. (1997) 0: Schoevers et al. (2005)

Being childless

0: Forsell (2000) +: Forsell (2000)

Qualitative aspects of social network

Lack of social support

+: Cummings et al. (2003) +: Beekman et al. (1995) +: Forsell and Winblad (1998)

+: Beekman et al. (2000)

+: Gazmararian et al. (2000)

+: Horowitz et al. (2005) 0: Schoevers et al. (2003b)

+: Hybels et al. (2001) +: Prince et al. (1997b) 0: van Zelst et al. (2003)

+: Jang et al. (2002) 0: Schoevers et al. (2003b)

+: Bisschop et al. (2004) +: Beekman et al. (2004) 0: Schoevers et al. (2005) +: Henderson et al. (1997) +: Husaini (1997)

0: Livingston et al. (2000) 0: Roberts et al. (1997) 0: Schoevers et al. (2005)

Loneliness +: Adams et al. (2004) +: Beekman et al. (1995) +: van Zelst et al. (2003) +: Prince et al. (1997b)

+: Bisschop et al. (2004) +: Prince et al. (1998) Overprotection by parents early in life

+: Stevens and Andersson (1996)

36 D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

Table 1c (continued )

Cluster Risk factors Depressive symptoms Depressive disorders Anxiety symptoms Anxiety disorders

Attachment status

+: Stevens and Andersson (1996)

Not satisfied with friendship

+: Strawbridge et al. (2002)

Problems with spouse

+: Kivela et al. (1996a)

Stressful events

Serious events WWII

+: Beekman et al. (1998) +: Beekman et al. (2004)

Negative life events in childhood

+: Kraaij and de Wilde (2001)

+: van Zelst et al. (2003)

+: Kivela et al. (1996a) Bereavement +: Adams et al. (2004) +: Beekman et al. (1995) +: Beekman et al. (1998)

+: Kraaij and de Wilde (2001)

0: Beekman et al. (2000) +: Beekman et al. (2000)

+: de Beurs et al. (2001) +: de Beurs et al. (2001) 0: Schoevers et al. (2005) +: Schoevers et al. (2005) +: Turvey et al. (1999)

Recent negative life events

+: Kraaij and de Wilde (2001)

+: Horowitz et al. (2005) +: Deer and Calamari (1998)

+: Beekman et al. (2000)

+: Prince et al. (1997b) 0: Beekman et al. (2000)

+: Glass et al. (1997) +: Brilman and Ormel (2001)

+: Isaacowitz and Seligman (2001)

+: Husaini (1997)

+: Livingston et al. (2000) +: Oldehinkel et al. (2003) +: Ormel et al. (2001) +: Roberts et al. (1997)

Caregiving status

+: Russo et al. (1995) +: Russo et al. (1995)

Depressive symptoms in spouse

+: Siegel et al. (2004)

Traumatic events

0: Acierno et al. (2002) +: Acierno et al. (2002)

Victim of crime lifetime

+: Lindesay 1997

Longterm difficulties

+: Brilman and Ormel (2001) +: Oldehinkel et al. (2003) +: Ormel et al. (2001)

Social demographics

Being older +: Adams et al. (2004) 0: Azar et al. (2005) −: Heun et al. (2000) 0: Gazmararian et al. (2000)

0: Heun et al. (2000)

0: Quinn et al. (1996) 0: Horowitz et al. (2005) −: Minicuci et al. (2002) −: Almeida and Pfaff

(2005) −: Copeland et al. (1999)

+: Lampinen and Heikkinen (2003)

+: de Beurs et al. (2001) 0: de Beurs et al. (2001) 0: Forsell (2000)

0: Biderman et al. (2002) +: Heun and Hein (2005) 0: Blazer et al. (2002) +: Strawbridge et al. (2002) 0: Henderson et al. (1997) 0: Forsell (2000) −: Siegel et al. (2004) 0: Roberts et al. (1997)

Lower level of education

+: Jang et al. (2002) +: Azar et al. (2005) +: Beekman et al. (1998) +: Minicuci et al. (2002) +: Beekman et al. (1995)

(continued on next page)

Qualitative aspects of social network

37D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

Table 1c (continued )

Cluster Risk factors Depressive symptoms Depressive disorders Anxiety symptoms Anxiety disorders

0: Gazmararian et al. (2000)

0: Horowitz et al. (2005)

+: Blazer et al. (2002) +: Beekman et al. (2001) 0: Forsell (2000) −: Siegel et al. (2004) +: Geerlings et al. (2000) 0: Schoevers et al. (2005) 0: Biderman et al. (2002) +: Strawbridge et al.

(2002) 0: Bisschop et al. (2004) 0: Forsell (2000) 0: Lampinen and Heikkinen (2003)

0: Roberts et al. (1997)

0: Schoevers et al. (2005) Female gender +: Hybels et al. (2001) +: Copeland et al. (1999) +: Forsell and

Winblad (1998) +: Beekman et al. (1998)

+: Jorm et al. (2005) +: Schoevers et al. (2003b)

+: Stevens and Andersson (1996)

+: Heun et al. (2000)

+: Minicuci et al. (2002) +: Steffens et al. (2003) +: Schoevers et al. (2003b)

0: Adams et al. (2004) +: van der Wurff et al. (2004)

+: van Zelst et al. (2003)

0: Cummings et al. (2003) 0: Azar et al. (2005) 0: Gazmararian et al. (2000) 0: Heun et al. (2000) 0: Quinn et al. (1996) 0: Horowitz et al. (2005) +: Biderman et al. (2002) +: Beekman et al. (2001) +: de Beurs et al. (2001) 0: Forsell (2000) +: Bisschop et al. (2004) +: de Beurs et al. (2001) 0: Schoevers et al. (2005) +: Blazer et al. (2002) +: Geerlings et al. (2000) +: Siegel et al. (2004) +: Heun and Hein (2005) 0: Henderson et al. (1997) +: Roberts et al. (1997) 0: Lampinen and Heikkinen (2003)

+: Strawbridge et al. (2002) 0: Forsell (2000) 0: Kivela et al. (1996b) 0: Schoevers et al. (2005)

Urbanization +: Beekman et al. (1995) 0: van Zelst et al. (2003) 0: Beekman et al. (2004) 0: de Beurs et al. (2001) 0: de Beurs et al. (2001)

Ethnic minority

0: Cummings et al. (2003) +: van der Wurff et al. (2004)

0: Quinn et al. (1996) 0: Azar et al. (2005) 0: Horowitz et al. (2005)

+: Siegel et al. (2004) 0: Strawbridge et al. (2002)

Lower income

0: Adams et al. (2004) 0: Acierno et al. (2002) +: Acierno et al. (2002)

0: van Zelst et al. (2003)

0: Cummings et al. (2003) 0: van der Wurff et al. (2004)

+: Siegel et al. (2004) +: Roberts et al. (1997) +: Strawbridge et al. (2002)

Living conditions

Living alone

+: van der Wurff et al. (2004) 0: Prince et al. (1998)

Living in a kibbutz

−: Blumstein et al. (2004)

Institutionalized +: Kivela et al. (1996a)

Notes: A plus sign indicates a risk factor; a minus sign indicates a protective factor; a zero sign indicates the factor was not significant. References printed in italics are referring to studies with a cross-sectional design, whereas normal printed references refer to studies with a longitudinal design.

Social demographics

Lower level of education

38 D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

39D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

were found. Anxiety but not depression was associated cross-sectionally with the number of chronic health conditions, high blood pressure, and functional limita- tions, whereas the number of chronic health conditions, cognitive impairment, functional limitations and visual impairment were found to be predictors for depression but not anxiety based on longitudinal associations.

3.3. Psychological risk factors (Table 1b)

3.3.1. Anxiety Personality traits (such as external locus of control

and neuroticism), dysfunctional coping strategies, and psychopathology were cross-sectionally and longitudi- nally associated with anxiety symptoms and disorders. Studies on the association between self-image and anx- iety were lacking.

3.3.2. Depression Personality traits, dysfunctional coping, negative self-

image and psychopathology were associated with de- pressive symptoms and disorders. No differences were found between studies with a cross-sectional or longi- tudinal design.

3.3.3. Differences In general the findings showed no pronounced dif-

ferences between psychological risk factors for anxiety and depression. Also, studies which examined psycho- logical risk factors for pure anxiety and depression simultaneously found no differences (Beekman et al., 2000; de Beurs et al., 2001; Schoevers et al., 2003b).

3.4. Social risk factors (Table 1c)

3.4.1. Anxiety With respect to social risk factors for anxiety, limited

evidence was found for the association with quantitative (e.g. number of friends) and qualitative aspects (e.g. social support) of social network. Further, many studies identified stressful events and a few studies found social demographic variables (mainly female gender) to be risk factors for anxiety symptoms and disorders. Studies on the association between living conditions and anxiety were lacking.

3.4.2. Depression Most cross-sectional and longitudinal studies on risk

factors for depression showed associations with quanti- tative and qualitative aspects of social network (except marital status), stressful events and living conditions. However, outcomes from studies on the association be-

tween social demographic variables and depression were not straightforward. For example, much inconsistency was found with respect to the factor ‘being older’. Al- though some studies identified being older as a risk factor for depression, others report no significant trends or even report a decline with increasing age. Only part of the studies proved lower level of education and lower income to be risk factors for depression and although not always demonstrated, female gender was often a predictor for depression. Religious practice was identified as a protective factor for depression in various study samples.

3.4.3. Differences A couple of differences between risk factors for anx-

iety and depression appeared. While being unmarried was associated with depression in most of the studies, no such association was found with anxiety. On the other hand, being childless and having experienced traumatic events were associated with anxiety but not depression. Studies on the co-occurrence of social risk factors for pure anxiety and depression (Acierno et al., 2002; Beekman et al., 2000; de Beurs et al., 2001; Forsell, 2000; Heun et al., 2000; Russo et al., 1995; Schoevers et al., 2003b, 2005) showed similarities as well as differences. Comparable associations were found with respect to marital status, lack of social support, level of education, gender and urbanization. On the other hand, low contact frequency, being childless, negative/traumatic life events and lower income were associated only with anxiety, whereas smaller network size and being unmarried were associated with depression but not anxiety. Bereavement had a cross- sectional association only with anxiety, while longitudi- nally it appeared to be a predictor for depression instead of anxiety. And being older appeared to be protective for anxiety, but a risk factor for depression.

4. Discussion

The purpose of this study was to give a compre- hensive overview and compare risk factors for anxiety and depression in the elderly. The reviewed studies show that personality traits, inadequate coping strate- gies, previous psychopathology, qualitative aspects of social network, stressful life events and female gender are risk factors associated with both prevalence and incidence of anxiety in the elderly. Chronic diseases and functional limitations showed only cross-sectional associations with anxiety, and therefore may have limited etiological relevance. With respect to depres- sion, this study showed many significant associations with biological, psychological and social factors. Sub- stantial evidence is found for the following risk

40 D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

factors for both prevalence and incidence of depres- sion; chronic diseases, poor self-perceived health, functional disability, personality traits, inadequate coping strategies, previous psychopathology, smaller network size, being unmarried, qualitative aspects of social network, stressful life events and female gender. These findings do not seem to support the on-time/off- time hypothesis, as much evidence was found for on- time events, such as chronic diseases, disability and bereavement, to be risk factors for late-life anxiety and depression.

Conclusions on the differences between risk factors for anxiety and depression are more reserved, as there are few studies on risk factors for anxiety. Overall, the current study shows many similarities between risk factors for anxiety and depression in old age, especially with regard to psychological risk factors. Still, a number of differences are found, which may help to differentiate between elderly at risk for anxiety or depression. First, the number of chronic health conditions, cognitive impairment and functional limitations (biological factors) are predictive of the incidence of depression but not anxiety. Second, the social factor being unmarried is associated with depres- sion but not with anxiety. In addition, stressful events are important predictors for both anxiety and depression, but anxiety seems better predicted by traumatic events. Further, being older seems to be protective for anxiety, but is a risk factor for depression. In conclusion, biological factors predict the onset of depression and the existence of depression and anxiety, and a differential effect of social factors on anxiety and depression is found. This appears to be in line with the idea that depression may be more strongly related to loss events, whereas anxiety may result from actual and more imminent threats (Finlay-Jones and Brown, 1981). Nevertheless, the similarities between risk factors for anxiety and depression in the elderly mostly favor a dimensional versus a categorical classification of these disorders (Goldberg and Huxley, 1992). This assumption underlines the importance of clinicians not only to focus on the categorical DSM criteria, but also on variations between the different sets of symptoms offered by older adults, in the early recognition of both anxiety and depression. Further studies with more elaborate risk profiles may however yield differentiating etiological factors.

In this review a distinction was made between studies which used symptoms or clinically relevant levels of anxiety and depression as dependent variable. While findings from studies on symptoms may be somewhat susceptible to normal fluctuations or transient levels of symptoms, studies on (subthreshold) disorders are ex- pected to depict chronic elevated levels in many cases

(Beekman et al., 2002; Schoevers et al., 2003a). The findings in Tables 1a–1c however show no clear dif- ferences between risk factors for symptoms and disorders, suggesting that these risk factors are significant for the whole continuum of severity of anxiety or depression.

Interestingly, and somewhat contrary to our expecta- tions, findings from cross-sectional and longitudinal studies were highly identical. This suggests that the risk factors that were identified in these cross-sectional studies predominantly reflect associations with onset, instead of characteristics that co-occur with, or may even be a consequence of this type of psychopathology. Still, these findings may be different for other types of risk factors, and distinguishing between cross-sectional and prospec- tive studies remains important on a theoretical basis.

The current study is an important addition to existing studies because it is the first to provide a comprehensive overview of risk factors for anxiety and depressive symptoms as well as disorders based on cross-sectional and longitudinal studies in the elderly. To accomplish this, broad inclusion criteria were used, and consequent- ly the heterogeneity between studies was high. Hence, no meta-analysis could be conducted and it was difficult to summarize the degree of evidence for each risk fac- tor. Still, the results of various studies were often in line, suggesting genuine associations. Another potential limitation of this study is that only the main effects of risk factors on anxiety and depression were reviewed. Therefore, we could not determine whether the simul- taneous presence of multiple risk factors results in a cumulative increase in the risk of anxiety or depression. In addition, the heterogeneity did not permit meaningful comparisons of the strengths of the associations between risk factors and outcome across studies. Further, this review of risk factors is based on findings from prior studies that have looked at those risk factors that appeared to be of interest at the time of study. However risk factors may exist for anxiety and depression in the elderly that have not yet been studied. Lastly, for prag- matic reasons no distinction was made between different anxiety disorders. The number of studies on anxiety was already significantly smaller than on depression, and this would have limited the possibilities of comparing overall risk profiles. Still, specific anxiety disorders may show risk profiles that differ more from that of depression than others, and further studies are needed to assess this.

This review may guide efforts to develop risk profiles for anxiety and depression in the elderly, which can improve the effectiveness of screening in primary care. Fixed (e.g. gender) and variable (e.g. age) markers play a very important role in developing cost-effective screening procedures, whereas structuring effective

41D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

treatment programs requires a focus on causal risk factors (Kraemer et al., 1997). Despite the methodological limitations of this study, our findings suggest that pre- vious psychopathology, stressful life events and female gender are fixed markers important in detecting elder- ly with anxiety, whereas personality traits, inadequate coping strategies and qualitative aspects of social network may be related to the onset of anxiety and could be addressed in preventive treatment. The same fixed and causal risk factors are found for depression, in addition to the fixed factors chronic diseases and being unmarried and self-perceived health, functional limitations and smaller network size as predictors. From a public health standpoint, the finding that many risk factors were found to be associated with both anxiety and depression is interesting as this may yield stronger associations with the onset of disorder, and thus a stronger case for preventive interventions targeted at such risk factors (Cuijpers, 2003; Schoevers et al., 2006). Still, further research is needed to establish whether manipulation of these factors may actually reduce the onset of anxiety and/or depression in the elderly.

Role of funding source The funding source had no involvement on this manuscript.

Conflict of interest None.

Acknowledgements

The Knowledge Centre of Psychiatry in the Elderly is subsidized by the Netherlands Ministry of Health, Welfare and Sport.

Rob Kok is acknowledged with many thanks for helpful comments on earlier drafts.

References

Acierno, R., Brady, K., Gray, M., Kilpatrick, D.G., Resnick, H., Best, C.L., 2002. Psychopathology following interpersonal violence: a comparison of risk factors in older and younger adults. J. Clin. Geropsychol. 8, 13–23.

Adams, K.B., Sanders, S., Auth, E.A., 2004. Loneliness and depression in independent living retirement communities: risk and resilience factors. Aging Ment. Health 8, 475–485.

Almeida, O.P., Pfaff, J.J., 2005. Depression and smoking amongst older general practice patients. J. Affect. Disord. 86, 317–321.

Andrews, G., Issakidis, C., Sanderson, K., Corry, J., Lapsley, H., 2004. Utilising survey data to inform public policy: comparison of the cost- effectiveness of treatment of ten mental disorders. Br. J. Psychiatry 184, 526–533.

Azar, A.R., Murrell, S.A., Mast, B.T., 2005. Race and vascular depression risk in community-dwelling older adults. Am. J. Geriatr. Psychiatry 13, 329–332.

Beekman, A.T., Deeg, D.J., van Tilburg, T., Smit, J.H., Hooijer, C., van Tilburg, W., 1995. Major and minor depression in later life: a study of prevalence and risk factors. J. Affect. Disord. 36, 65–75.

Beekman, A.T., Bremmer, M.A., Deeg, D.J., van Balkom, A.J., Smit, J.H., de Beurs, E., van Dyck, R., van Tilburg, W., 1998. Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam. Int. J. Geriatr. Psychiatry 13, 717–726.

Beekman, A.T., de Beurs, E., van Balkom, A.J., Deeg, D.J., van Dyck, R., van Tilburg, W., 2000. Anxiety and depression in later life: co- occurrence and communality of risk factors. Am. J. Psychiatry 157, 89–95.

Beekman, A.T.F., Deeg, D.J.H., Geerlings, S.W., Schoevers, R.A., Smit, J.H., van Tilburg, W., 2001. Emergence and persistence of late life depression: a 3-year follow-up of the Longitudinal Aging Study Amsterdam. J. Affect. Disord. 65, 131–138.

Beekman, A.T.F., Geerlings, S.W., Deeg, D.J.H., Smit, J.H., Scho- evers, R.S., de Beurs, E., Braam, A.W., Penninx, B.W.J.H., van Tilburg, W., 2002. The natural history of late-life depression: a 6- year prospective study in the community. Arch. Gen Psychiatry 59, 605–611.

Beekman, A.T.F., Deeg, D.J.H., Smit, J.H., Comijs, H.C., Braam, A.W., de Beurs, E., van Tilburg, W., 2004. Dysthymia in later life: a study in the community. J. Affect. Disord. 81, 191–199.

Biderman, A., Cwikel, J., Fried, A.V., Galinsky, D., 2002. Depression and falls among community dwelling elderly people: a search for common risk factors. J. Epidemiol. Community Health 56, 631–636.

Bisschop, M.I., Kriegsman, D.M.W., Beekman, A.T.F., Deeg, D.J.H., 2004. Chronic diseases and depression: the modifying role of psychosocial resources. Soc. Sci. Med. 59, 721–733.

Blazer, D.G., Burchett, B.B., Fillenbaum, G.G., 2002. APOE epsilon4 and low cholesterol as risks for depression in a biracial elderly community sample. Am. J. Geriatr. Psychiatry 10, 515–520.

Blumstein, T., Benyamini, Y., Fuchs, Z., Shapira, Z., Novikov, I., Walter-Ginzburg, A., Modan, B., 2004. The effect of a communal lifestyle on depressive symptoms in late life. J. Aging Health 16, 151–174.

Braam, A.W., Van den Eeden, P., Prince, M.J., Beekman, A.T.F., Kivela, S.L., Lawlor, B.A., Birkhofer, A., Fuhrer, R., Lobo, A., Magnusson, H., Mann, A.H., Meller, I., Roelands, M., Skoog, I., Turrina, C., Copeland, J.R.M., 2001. Religion as a cross-cultural determinant of depression in elderly Europeans: results from the EURODEP collaboration. Psychol. Med. 31, 803–814.

Braam, A.W., Prince, M.J., Beekman, A.T.F., Delespaul, P., Dewey, M.E., Geerlings, S.W., Kivela, S.L., Lawlor, B.A., Magnusson, H., Meller, I., Peres, K., Reischies, F.M., Roelands, M., Schoevers, R.A., Saz, P., Skoog, I., Turrina, C., Versporten, A., Copeland, J.R.M., 2005. Physical health and depressive symp- toms in older Europeans. Br. J. Psychiatry 187, 35–42.

Brilman, E.I., Ormel, J., 2001. Life events, difficulties and onset of depressive episodes in later life. Psychol. Med. 31, 859–869.

Charney, D.S., Reynolds III, C.F., Lewis, L., Lebowitz, B.D., Sunderland, T., Alexopoulos, G.S., Blazer, D.G., Katz, I.R., Meyers, B.S., Arean, P.A., Borson, S., Brown, C., Bruce, M.L., Callahan, C.M., Charlson, M.E., Conwell, Y., Cuthbert, B.N., Devanand, D.P., Gibson, M.J., Gottlieb, G.L., Krishnan, K.R., Laden, S.K., Lyketsos, C.G., Mulsant, B.H., Niederehe, G., Olin, J.T., Oslin, D.W., Pearson, J., Persky, T., Pollock, B.G., Raetzman, S., Reynolds, M., Salzman, C., Schulz, R., Schwenk, T.L., Scolnick, E., Unutzer, J., Weissman, M.M., Young, R.C., 2003. Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life. Arch. Gen. Psychiatry 60, 664–672.

42 D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

Cole, M.G., Dendukuri, N., 2003. Risk factors for depression among elderly community subjects: a systematic review and meta-analysis. Am. J. Psychiatry 160, 1147–1156.

Cook, J.M., Orvaschel, H., Simco, E., Hersen, M., Joiner, T., 2004. A test of the tripartite model of depression and anxiety in older adult psychiatric outpatients. Psychol. Aging 19, 444–451.

Coolidge, F.L., Segal, D.L., Hook, J.N., Stewart, S., 2000. Personality disorders and coping among anxious older adults. J. Anxiety Disord. 14, 157–172.

Copeland, J.R., Chen, R., Dewey, M.E., McCracken, C.F., Gilmore, C., Larkin, B., Wilson, K.C., 1999. Community-based case-control study of depression in older people. Cases and sub-cases from the MRC-ALPHA Study. Br. J. Psychiatry 175, 340–347.

Cuijpers, P., 2003. Examining the effects of prevention programs on the incidence of new cases of mental disorders: the lack of statistical power. Am. J. Psychiatry 160, 1385–1391.

Cummings, S.M., Neff, J.A., Husaini, B.A., 2003. Functional impairment as a predictor of depressive symptomatology: the role of race, religiosity, and social support. Health Soc. Work 28, 23–32.

de Beurs, E., Beekman, A.T., van Balkom, A.J., Deeg, D.J., van Dyck, R., van Tilburg, W., 1999. Consequences of anxiety in older persons: its effect on disability, well-being and use of health services. Psychol. Med. 29, 583–593.

de Beurs, E., Beekman, A.T., Deeg, D.J., van Dyck, R., van Tilburg, W., 2000. Predictors of change in anxiety symptoms of older persons: results from the Longitudinal Aging Study Amsterdam. Psychol. Med. 30, 515–527.

de Beurs, E., Beekman, A., Geerlings, S., Deeg, D., van Dyck, R., van Tilburg, W., 2001. On becoming depressed or anxious in late life: Similar vulnerability factors but different effects of stressful life events. Br. J. Psychiatry 179, 426–431.

de Groot, J.C., de Leeuw, F.E., Oudkerk, M., Hofman, A., Jolles, J., Breteler, M.M., 2000. Cerebral white matter lesions and depressive symptoms in elderly adults. Arch. Gen. Psychiatry 57, 1071–1076.

Deer, T.M., Calamari, J.E., 1998. Panic symptomatology and anx- iety sensitivity in older adults. J. Behav. Ther. Exp. Psychiatry 29, 303–316.

Dhondt, T.D., Beekman, A.T., Deeg, D.J., van Tillburg, W., 2002. Iatrogenic depression in the elderly: results from a community-based study in the Netherlands. Soc. Psychiatry Psychiatr. Epidemiol. 37, 393–398.

Djernes, J.K., 2006. Prevalence and predictors of depression in pop- ulations of elderly: a review. Acta Psychiatr. Scand. 113, 372–387.

Ettner, S.L., Hermann, R.C., 1997. Provider specialty choice among Medicare beneficiaries treated for psychiatric disorders. Health Care Financ. Rev. 18, 43–59.

Finlay-Jones, P., Brown,G.,1981. Typesofstressfullifeeventandthe onset of anxiety and depressive disorders. Psychol. Med. 11, 803–816.

Forsell, Y., 2000. Predictors for depression, anxiety and psychotic symptoms in a very elderly population: data from a 3-year follow- up study. Soc. Psychiatry Psychiatr. Epidemiol. 35, 259–263.

Forsell, Y., Winblad, B., 1998. Feelings of anxiety and associated variables in a very elderly population. Int. J. Geriatr. Psychiatry 13, 454–458.

Gazmararian, J., Baker, D., Parker, R., Blazer, D.G., 2000. A multivariate analysis of factors associated with depression: evaluating the role of health literacy as a potential contributor. Arch. Intern. Med. 160, 3307–3314.

Geerlings, S.W., Beekman, A.T.F., Deeg, D.J.H., van Tilburg, W., 2000. Physical health and the onset and persistence of depression in older adults: an eight-wave prospective community-based study. Psychol. Med. 30, 369–380.

Glass, T.A., Kasl, S.V., Berkman, L.F., 1997. Stressful life events and depressive symptoms among the elderly: evidence form a prospective community study. J. Aging Health 9, 70–89.

Goldberg, D.P., 1996. A dimensional model for common mental disorders. Br. J. Psychiatry 168, 44–49.

Goldberg, D., 2000. Plato versus Aristotle: categorical and dimensional models for common mental disorders. Compr. Psychiatry 41, 8–13.

Goldberg, D.P., Huxley, P., 1992. Common Mental Disorders: A Biosocial Model. Routledge, London.

Henderson, A.S., Korten, A.E., Jacomb, P.A., Mackinnon, A.J., 1997. The course of depression in the elderly: a longitudinal community- based study in Australia. Psychol. Med. 27, 119–129.

Heun, R., Hein, S., 2005. Risk factors of major depression in the elderly. Eur. Psychiatr.: J. Assoc. Eur. Psychiatr. 20, 199–204.

Heun, R., Papassotiropoulos, A., Ptok, U., 2000. Subthreshold depressive and anxiety disorders in the elderly. Eur. Psychiatr.: J. Assoc. Eur. Psychiatr. 15, 173–182.

Hickie, I., Simons, L., Naismith, S., Simons, J., McCallum, J., Pearson, K., 2003. Vascular risk to late-life depression: evidence from a longitudinal community study. Aust. N.Z. J. Psychiatry 37, 62–65.

Horowitz, A., Reinhardt, J.P., Kennedy, G.J., 2005. Major and subthreshold depression among older adults seeking vision rehabilitation services. Am. J. Geriatr. Psychiatry 13, 180–187.

Husaini, B.A., 1997. Predictors of depression among the elderly: racial differences over time. Am. J. Orthopsychiatr. 67, 48–58.

Hybels, C.F., Blazer, D.G., Pieper, C.F., 2001. Toward a threshold for subthreshold depression: an analysis of correlates of depression by severity of symptoms using data form an elderly community sample. Gerontologist 41, 357–365.

Isaacowitz, D.M., Seligman, M.E., 2001. Is pessimism a risk factor for depressive mood among community-dwelling older adults? Behav. Res. Ther. 39, 255–272.

Jang, Y., Haley, W.E., Small, B.J., Mortimer, J.A., 2002. The role of mastery and social resources in the associations between disability and depression in later life. Gerontologist 42, 807–813.

Jorm, A.F., Anstey, K.J., Christensen, H., de Plater, G., Kumar, R., Wen, W., Sachdev, P., 2005. MRI hyperintensities and depressive symptoms in a community sample of individuals 60–64 years old. Am. J. Psychiatry 162, 699–705.

Kendler, K.S., 1996. Major depression and generalised anxiety disorder same genes, (partly) different environments—revisited. Br. J. Psychiatry 168, 68–75.

Kivela, S.L., Kongas-Saviaro, P., Laippala, P., Pahkala, K., Kesti, E., 1996a. Social and psychosocial factors predicting depression in old age: a longitudinal study. Int. Psychogeriatr. 8, 635–644.

Kivela, S.L., Longas-Saviaro, P., Kimmo, P., Kesti, E., 1996b. Health, health behaviour and functional ability predicting depression in old age: a longitudinal study. Int. J. Geriatr. Psychiatry 11, 871–877.

Kivela, S.L., Luukinen, H., Sulkava, R., Viramo, P., Koski, K., 1999. Marital and family relations and depression in married elderly Finns. J. Affect. Disord. 54, 177–182.

Kraaij, V., de Wilde, E.J., 2001. Negative life events and depressive symptoms in the elderly: a life span perspective. Aging Ment. Health 5, 84–91.

Kraaij, V., Pruymboom, E., Garnefski, N., 2002. Cognitive coping and depressive symptoms in the elderly: a longitudinal study. Aging Ment. Health 6, 275–281.

Kraemer, H.C.P., Kazdin, A.E.P., Offord, D.R.M., Kessler, R.C.P., Jensen, P.S.M., Kupfer, D.J.M., 1997. Coming to terms with the terms of risk. Arch. Gen. Psychiatry 54, 337–343.

Kraemer, H.C.P., Stice, E.P., Kazdin, A.P., Offord, D.M.D., Kupfer, D.M.D., 2001. How do risk factors work together? Mediators,

43D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

moderators, and independent, overlapping, and proxy risk factors. Am. J. Psychiatry 158, 848–856.

Kritz-Silverstein, D., Barrett-Connor, E., Corbeau, C., 2001. Cross- sectional and prospective study of exercise and depressed mood in the elderly: the Rancho Bernardo study. Am. J. Epidemiol. 153, 596–603.

Lampinen, P., Heikkinen, E., 2003. Reduced mobility and physical activity as predictors of depressive symptoms among community- dwelling older adults: an eight-year follow-up study. Aging Clin. Exp. Res. 15, 205–211.

Lindesay, J., 1997. Phobic disorders and fear of crime in the elderly. Aging Ment. Health 1, 81–85.

Livingston, G., Watkin, V., Milne, B., Manela, M.V., Katona, C., 2000. Who becomes depressed? The Islington community study of older people. J. Affect. Disord. 58, 125–133.

Lyness, J.M.M., Duberstein, P.R.P., King, D.A.P., Cox, C.P., Caine, E.D.M., 1998. Medical illness burden, trait neuroticism, and dep- ression in older primary care patients. Am. J. Psychiatry 155, 969–971.

Lyness, J.M.M., King, D.A.P., Conwell, Y.M.D., Cox, C.P., Caine, E.D.M., 2000. Cerebrovascular risk factors and 1-year depres- sion outcome in older primary care patients. Am. J. Psychiatry 157, 1499–1501.

McCusker, J., Cole, M., Keller, E., Bellavance, F., Berard, A., 1998. Effectiveness of treatments of depression in older ambulatory patients. Arch. Intern. Med. 158, 705–712.

Minicuci, N., Maggi, S., Pavan, M., Enzi, G., Crepaldi, G., 2002. Prevalence rates and correlates of depressive symptoms in older individuals: the Veneto Study. J. Gerontol., Ser. A, Biol. Sci. Med. Sci. 57, M155–M161.

Monopoli, J., Vaccaro, F., Christmann, E., Badgett, J., 2000. Personality as a predictor of depression among the elderly. Clin. Gerontol. 21, 49–63.

Mulsant, B.H., Ganguli, M., 1999. Epidemiology and diagnosis of depression in late life. J. Clin. Psychiatry 60, 9–15.

Nebes, R.D.P., Vora, I.J.B., Meltzer, C.C.M., Fukui, M.B.M., Williams, R.L.M., Kamboh, M.I.P., Saxton, J.P., Houck, P.R.M., DeKosky, S.T.M., Reynolds, C.F.I., 2001. Relationship of deep white matter hyperintensities and apolipoprotein E genotype to depressive symptoms in older adults without clinical depression. Am. J. Psychiatry 158, 878–884.

Olafsdottir, M., Marcusson, J., Skoog, I., 2001. Mental disorders among elderly people in primary care: the Linkoping study. Acta Psychiatr. Scand. 104, 12–18.

Oldehinkel, A.J., Bouhuys, A.L., Brilman, E.I., Ormel, J., 2001. Functional disability and neuroticism as predictors of late-life depression. Am. J. Geriatr. Psychiatry 9, 241–248.

Oldehinkel, A.J., Ormel, J., Brilman, E.I., Van den Berg, M.D., 2003. Psychosocial and vascular risk factors of depression in later life. J. Affect. Disord. 74, 237–246.

Ormel, J., Oldehinkel, A.J., Brilman, E.I., 2001. The interplay and etiological continuity of neuroticism, difficulties, and life events in the etiology of major and subsyndromal, first and recurrent depressive episodes in later life. Am. J. Psychiatry 158, 885–891.

Paterniti, S., Alpérovitch, A., Ducimetière, P., Dealberto, M., Lépine, J., Bisserbe, J., 1999. Anxiety but not depression is associated with elevated blood pressure in a community group of French elderly. Psychosom. Med. 61, 77–83.

Paterniti, S., Verdier-Taillefer, M.H., Geneste, C., Bisserbe, J.C., Alperovitch, A., 2000. Low blood pressure and risk of depression in the elderly. A prospective community-based study. Br. J. Psychiatry 176, 464–467.

Prince, M.J., Harwood, R.H., Blizard, R.A., Thomas, A., Mann, A.H., 1997a. Impairment, disability and handicap as risk factors for depression in old age. The Gospel Oak Project V. Psychol. Med. 27, 311–321.

Prince, M.J., Harwood, R.H., Blizard, R.A., Thomas, A., Mann, A.H., 1997b. Social support deficits, loneliness and life events as risk factors for depression in old age. The Gospel Oak Project VI. Psychol. Med. 27, 323–332.

Prince, M.J., Harwood, R.H., Thomas, A., Mann, A.H., 1998. A prospective population-based cohort study of the effects of disablement and social milieu on the onset and maintenance of late-life depression. The Gospel Oak Project VII. Psychol. Med. 28, 337–350.

Quinn, W.H., Hazen, P.J., Martin, P., 1996. The influence of religiosity, family-of-origin, and self-efficacy on depression in older adults. J. Relig. Gerontol. 9, 57–77.

Roberts, R.E., Kaplan, G.A., Shema, S.J., Strawbridge, W.J., 1997. Does growing old increase the risk for depression? Am. J. Psychiatry 154, 1384–1390.

Roberts, R.E., Shema, S.J., Kaplan, G.A., Strawbridge, W.J., 2000. Sleep complaints and depression in an aging cohort: a prospective perspective. Am. J. Psychiatry 157, 81–88.

Russo, J., Vitaliano, P.P., Brewer, D.D., Katon, W., Becker, J., 1995. Psychiatric disorders in spouse caregivers of care recipients with Alzheimer's disease and matched controls: a diathesis-stress model of psychopathology. J. Abnorm Psychology 104, 197–204.

Schoevers, R.A., Beekman, A.T.F., Deeg, D.J.H., Geerlings, M.I., Jonker, C., van Tilburg, W., 2000. Risk factors for depression in later life: results of a prospective community based study (AMSTEL). J. Affect. Disord. 59, 127–137.

Schoevers, R.A., Beekman, A.T.F., Deeg, D.J.H., Hooijer, C., Jonker, C., van Tilburg, W., 2003a. The natural history of late life depression. J. Affect. Disord. 76, 5–14.

Schoevers, R.A., Beekman, A.T.F., Deeg, D.J.H., Jonker, C., van Tilburg, W., 2003b. Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety–depression in later life: results from the AMSTEL study. Int. J. Geriatr. Psychiatry 18, 994–1001.

Schoevers, R.A., Deeg, D.J., van Tilburg, W., Beekman, A.T., 2005. Depression and generalized anxiety disorder: co-occurrence and longitudinal patterns in elderly patients. Am. J. Geriatr. Psychiatry 13, 31–39.

Schoevers, R.A., Smit, F., Deeg, D.J., Cuijpers, P., Dekker, J., van Tilburg, W., Beekman, A.T., 2006. Prevention of late-life depression in primary care: do we know where to begin? Am. J. Psychiatry 163, 1611–1621.

Schum, J.L., Lyness, J., King, D.A., 2005. Bereavement in late life: risk factors for complicated bereavement. Geriatrics 60, 18–20.

Siegel, M.J., Bradley, E.H., Gallo, W.T., Kasl, S.V., 2004. The effect of spousal mental and physical health on husbands' and wives' de- pressive symptoms, among older adults: longitudinal evidence from the health and retirement survey. J. Aging Health 16, 398–425.

Smit, F., Ederveen, A., Cuijpers, P., Deeg, D., Beekman, A., 2006. Opportunities for cost-effective prevention of late-life depression: an epidemiological approach. Arch. Gen. Psychiatry 63, 290–296.

Smit, F., Comijs, H., Schoevers, R., Cuijpers, P., Deeg, D., Beekman, A., 2007. Target groups for the prevention of late-life anxiety. Br. J. Psychiatry 190, 428–434.

Steffens, D.C., Norton, M.C., Hart, A.D., Skoog, I., Corcoran, C., Breitner, J.C.S., 2003. Apolipoprotein E genotype and major depression in a community of older adults. The Cache County study. Psychol. Med. 33, 541–547.

44 D. Vink et al. / Journal of Affective Disorders 106 (2008) 29–44

Stevens, N.L., Andersson, L., 1996. Overprotection by parents and anxiety in later life. J. Ment. Health Aging 2, 39–50.

Strawbridge, W.J., Deleger, S., Roberts, R.E., Kaplan, G.A., 2002. Physical activity reduces the risk of subsequent depression for older adults. Am. J. Epidemiol. 156, 328–334.

Thompson, C., Syddall, H., Rodin, I., Osmond, C., Barker, D.J., 2001. Birth weight and the risk of depressive disorder in late life. Br. J. Psychiatry 179, 450–455.

Tiemeier, H., van Dijck, W., Hofman, A., Witteman, J.C.M., Stijnen, T., Breteler, M.M.B., 2004. Relationship between atherosclerosis and late-life depression: the Rotterdam Study. Arch. Gen. Psychiatry 61, 369–376.

Turvey, C.L., Carney, C., Arndt, S., Wallace, R.B., Herzog, R., 1999. Conjugal loss and syndromal depression in a sample of elders aged 70 years or older. Am. J. Psychiatry 156, 1596–1601.

van der Wurff, F.B., Beekman, A.T.F., Dijkshoorn, H., Spijker, J.A., Smits, C.H.M., Stek, M.L., Verhoeff, A., 2004. Prevalence and risk-factors for depression in elderly Turkish and Moroccan migrants in the Netherlands. J. Affect. Disord. 83, 33–41.

van Ojen, R., Hooijer, C., Jonker, C., Lindeboom, J., 1995. Late-life depressive disorder in the community, early onset and the decrease of vulnerability with increasing age. J. Affect. Disord. 33, 159–166.

van Zelst, W.H., de Beurs, E., Beekman, A.T., Deeg, D.J., van Dyck, R., 2003. Prevalence and risk factors of posttraumatic stress disorder in older adults. Psychother. Psychosom. 72, 333–342.

Volkers, A.C., Nuyen, J., Verhaak, P.F.M., Schellevis, F.G., 2004. The problem of diagnosing major depression in elderly primary care patients. J. Affect. Disord. 82, 259–263.

Wetherell, J.L., 1998. Treatment of anxiety in older adults. Psychother.: Theory, Res., Pract., Train. 35, 444–458.

Wilson, K.C.M., Chen, R., Taylor, S., McCracken, C.F.M., Copeland, J.R.M., 1999. Socio-economic deprivation and the prevalence and prediction of depression in older community residents: the MRC- ALPHA study. Br. J. Psychiatry 175, 549–553.

Zeiss, A.M., Lewinsohn, P.M., Rohde, P., Seeley, J.R., 1996. Relationship of physical disease and functional impairment to depression in older people. Psychol. Aging 11, 572–581.