INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2005; 20: 350–357.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/gps.1288

Prevalence and correlates of depression in late life:

a population based study from a rural Greek town
F. C. Papadopoulos1, E. Petridou1,2*, S. Argyropoulou1, V. Kontaxakis3,
N. Dessypris1, A. Anastasiou4, K. P. Katsiardani1, D. Trichopoulos1,2 and C. Lyketsos5
1
Department of Hygiene and Epidemiology, Athens University Medical School, Athens, Greece
2
Department of Epidemiology, Harvard School of Public Health, Boston, USA
3
Department of Psychiatry, University of Athens, Eginition Hospital, Athens, Greece
4
Health Center of Velestinos, Volos, Greece
5
Department of Psychiatry and Behavioral Sciences, Division of Geriatric Psychiatry and Neuropsychiatry,
Johns Hopkins School of Medicine, Baltimore, Maryland, USA

SUMMARY
Background Depression in late life is common and has serious consequences on function, medical co-morbidity, quality
of life, and use of medical services.
Objective To estimate the age- and gender-specific prevalence of depression among people over 60 years of age, and to
examine correlates of depression, in particular the relationship between depression and cognitive impairment.
Method From a total of 965 inhabitants, aged over 60 years, in Velestino, a rural town in central Greece, 608 were acces-
sible and constituted the target population. During a five-month period in 2000, a trained health visitor interviewed all study
participants. The interview covered socio-demographic characteristics, medical history, and administration of the 15-ques-
tion Geriatric Depression Scale (GDS-15) and the Mini Mental Scale Examination instrument (MMSE).
Results The prevalence of mild or more severe depression (GDS
7) was 27%, while the prevalence of moderate to severe
depression (GDS
11) was 12%. Increasing age, female gender, lower education, and being currently unmarried were asso-
ciated with higher risk of depression in univariate regression models, but these associations disappeared after controlling for
cognitive function, except for the association with marital status. Cognitive impairment was strongly associated with
increased risk for depression. The co-morbid presence of digestive, neurological and heart conditions was also associated
with increased risk for depression, while cancer was not.
Conclusion In a rural Greek area, the prevalence of depression in late life is high. Depression was more common among
unmarried individuals, those with significant cognitive impairment, and in association with specific medical conditions.
Copyright # 2005 John Wiley & Sons, Ltd.

key words — geriatric depression; epidemiology; correlates; cognitive decline; GDS; MMSE; medical co-morbidity

INTRODUCTION and Lopez, 1996), the identification of biological and

With rapidly increasing elderly populations in most
developed and developing countries and the recogni-
tion that mental disorders are responsible for consid-
erable losses of quality adjusted years of life (Murray
*Correspondence to: Dr E. Petridou, Department of Hygiene and
Epidemiology, Athens University Medical School, 75 Mikras Asias
str, Goudi, Athens 115-27, Greece. Tel: 0030 210 7462187. Fax:
0030 210 7462105. E-mail: epetrid@med.uoa.gr
Contract/grant sponsor: Johns Hopkins Alzheimer’s Disease
Research Center; contract/grant number: P01 AG05146.
Copyright # 2005 John Wiley & Sons, Ltd.
socio-demographic predictors of these problems has
gained prominence in the field of public health.
The prevalence of depression in late life has been
reported to range between 3% and 57% (Haller
et al., 1996; Beekman et al., 1999; Forsell and
Winblad, 1999; Mulsant and Ganguli, 1999; Steffens
et al., 2000; Abolfotouch et al., 2001; Argyriadou
et al., 2001; Wang, 2001; Osborn et al., 2002;
Parashos et al., 2002; Andrade et al., 2003; Lai,
2003; Ramos and Wilmoth, 2003; Sokoya and
Baiyewu, 2003; Sukegawa et al., 2003; Ritchie et al.,
2004) across several countries. Cultural differences,
Received 20 September 2004
Accepted 25 November 2004
 prevalence and correlates of depression in late life
expressed through various educational backgrounds,
social support networks, economic capabilities and
religious practices as variations in access and quality
of medical services available to older persons, partly
explain this wide range of prevalence estimates. Few
estimates have been derived from rural settings.
Depression in late life has serious adverse conse-
quences. It has been associated with increased health-
care costs (Unutzer et al., 1997), worse outcomes for
acute and chronic medical conditions such as myocar-
dial infarction (Penninx et al., 2001), hip fracture
(Mossey et al., 1990), stroke (Pohjasvaara et al.,
2001), diabetes mellitus (Blazer et al., 2002), digestive
conditions (Levenstein et al., 1997; Brown et al., 2004)
and cancer (Spiegel, 1996; Chochinov, 2001). It has
also been associated with decline in physical abilities
(Cronin-Stubbs et al., 2000; de Jonge et al., 2004) and
poorer survival in general (Penninx et al., 1999).
The relationship between late life depression and
cognitive dysfunction is receiving increased attention.
Poor cognitive function frequently coexists with
depression in the elderly (Green et al., 2003), and
both these risk factors are independently associated
with increased mortality in late life (Mehta et al.,
2003). Few studies have reported on the population
prevalence of depression at different levels of cogni-
tive functioning in late life.
In this paper we report findings from a cross sec-
tional study of depression among the elderly of a cir-
cumscribed population in the rural Greek town of
Velestino. There have been very few studies of the
prevalence of depression in the Greek elderly popula-
tion and none has focused exclusively on the elderly
community population of an entire town. The aims of
the study were to: (1) estimate the age- and gender-
specific prevalence of depression among people over
sixty years of age; (2) examine risk factors for depres-
sion especially exploring the relationship between
depression and co-morbid medical illnesses; and (3)
to examine the relationship between depression and
cognitive impairment.
METHOD
Velestino is a town of around 4,000 inhabitants in cen-
tral Greece (National Statistical Service of Greece,
2001). In the town registry, for the year 2000, 965
individuals were recorded to be older than 60 years
of age and constituted the target population. Attempts
were made to contact all these individuals through
house visits, visits of senior day centres, and contacts
with hospital administrators and practising physi-
cians. Of the target population, 247 were not accessi-
Copyright # 2005 John Wiley & Sons, Ltd.
351
ble, because of a permanent residence change
(moving to live with their families in other towns or
large urban centres). An additional 106 refused to par-
ticipate, and another four were not able to communi-
cate due to mental retardation. Thus, the study sample
comprised of 608 persons. This study was reviewed
and approved by the Ethics Committee of the Athens
University Medical School. Participants provided
informed consent for participation after receiving a
complete description of the study and recommenda-
tions of the physician in the local health center.
During a five-month period in 2000, a specially
trained health visitor (registered nurse) interviewed
in person, in the presence of a relative, friend or other
health professional, all study participants. The inter-
view lasted about 80 minutes and covered socio-
demographic characteristics, and medical history. In
addition, the health visitor assessed or rated all parti-
cipants on the 15-question Geriatric Depression Scale
(GDS-15) (Sheikh and Yesavage, 1986), and on the
Mini Mental Scale Examination (MMSE) (Folstein
et al., 1975), a bedside measure of cognition.
The study employed versions of the GDS-15 and
MMSE that had already been translated into Greek
and validated in a Greek population by previous
researchers. The GDS-15 takes values from zero
(absence of depression) to 15 (serious depression)
and has been validated in several populations (Sheikh
and Yesavage, 1986; Haller et al., 1996; Clement
et al., 1997; Abas et al., 1998; Fernandez-San Martin
et al., 2002; Osborn et al., 2002; De Craen et al.,
2003; Schreiner et al., 2003; Lam et al., 2004). In
Greece, a score of 6/7 was found to be the best cut-
off point for diagnosing depression in the elderly,
with high sensitivity (92%) and specificity (95%)
(Fountoulakis et al., 1999). In this study, in addition
to the cut-off point of 6/7, used to define mild or more
severe depression, a cut-off point of 10/11 was also
used to define moderate to severe depression.
The MMSE takes values from 0 to 30 with higher
scores indicative of better cognitive functioning.
MMSE has been validated in several populations
(Ylikoski et al., 1992; Law and Wolfson, 1995;
Monsch et al., 1995; Ishizaki et al., 1998; Grigoletto
et al., 1999; Ostrosky-Solis et al., 2000; Rait et al.,
2000; Espino et al., 2001; Shyu and Yip, 2001; De
Silva et al., 2002; Stewart et al., 2002). MMSE has also
been validated in Greece (Fountoulakis et al., 2000). A
cut-off point 24/23 for dementia in the Greek popula-
tion has been found to have high repeatability as well
as high sensitivity (91%) and specificity (91%).
Analyses, using the SAS statistical software (SAS
Institute Inc., 1989), initially focused on description
Int J Geriatr Psychiatry 2005; 20: 350–357.
352 f. c. papadopoulos ET AL.
of the distribution of GDS scores in the whole popula-
tion under study, and also in the younger (below median
age of 71) and older (above median age of 71) indivi-
duals. The prevalence of mild or more severe depres-
sion (GDS score
7), and moderate to severe
depression (GDS score
11) was estimated by age,
gender, other socio-demographic variables and in rela-
tionship to different medical co-morbidities. Subse-
quently, analyses, using multiple logistic regression,
focused on assessing associations between mild or
more severe depression (GDS score
7), or moderate
to severe depression (GDS score
11), and socio-
demographic characteristics, cognitive functioning, or
medical co-morbidity, by estimating adjusted odds
ratios of association and their 95% confidence intervals.
RESULTS
Figure 1 shows the distribution of GDS scores in the
population under study, and also in younger (below
median age of 71) and older (above median age of
71) age groups. The mean value of GDS score was
4.3 with an SD of 4.3 (positively skewed distribution).
Table 1 shows the prevalence of mild or more
severe depression (GDS score
7), and moderate to
severe depression (GDS score
11), across demo-
graphic groups and groups defined by selected medi-
cal conditions at examination. Depression was more
prevalent with increasing age, with 36% of peo-
ple
80 years old suffering from mild or more severe
depression and 18% from moderate to severe depres-
sion. The prevalence of depression in the younger age
groups was lower. There was an association between
Figure 1. Frequency histogram of GDS scores in the whole
population, in the younger ( 71) and older (> 71) individuals
living in a Greek rural town
Copyright # 2005 John Wiley & Sons, Ltd.
mild or more severe depression and gender, with
women having higher rates of depression (33%) com-
pared to men (20%). The latter pattern, however, was
not significant for moderate to severe depression.
Similarly, education was inversely associated only
with mild or more severe depression. Being currently
married was associated with a lower prevalence of
depression. Individuals with digestive, neurologic or
heart conditions were more likely to have depression
when compared to individuals without these co-mor-
bidities. The presence of neoplasms was not asso-
ciated with a higher frequency of depression.
Table 2 displays the prevalence of depression in
groups defined by MMSE score (< 24,
24) and
age (overall, below median, above median). Depres-
sion prevalence, especially for moderate to severe
depression, was higher among cognitively impaired
individuals; this was more pronounced in older indi-
viduals (above median age of 71 years). Almost two-
thirds of all depressed individuals were cognitively
impaired, while nearly 40% of those with cognitive
dysfunction had mild or more severe depression, half
of whom had moderate to severe depression.
Table 3 presents multiple regression-derived
adjusted odds ratios for mild or more severe depres-
sion (GDS score
7) and moderate to severe depres-
sion (GDS score
11) by demographic variables,
cognitive state and selected medical conditions at
examination. The dependent variable in these models
was depression (GDS
7 or
11), with all the other
variables in the Table serving as covariates. Age, gen-
der, or education was not significantly associated with
depression, after adjustment for MMSE score and
other variables in the Table. Being currently married
was associated with decreased risk only for mild or
more severe depression but not for moderate to severe
depression. Higher MMSE score was associated with
a lower risk of depression. The risk of mild or more
severe depression was 5% lower (7% for moderate
to severe depression) on average, for each one-point
increase in the MMSE score. The presence of co-mor-
bid digestive, neurological or cerebrovascular disease
was independently associated with a higher risk for
depression. Ischemic heart disease and arrhythmia
were associated with increased risk only for mild or
more severe depression but not for moderate to severe
depression. The presence of neoplasms was not asso-
ciated with higher risk for depression.
DISCUSSION
In a defined old age population in rural Greece the
prevalence of mild or more severe depression was
Int J Geriatr Psychiatry 2005; 20: 350–357.
 prevalence and correlates of depression in late life 353

Table 1. Distribution of the 608 study participants by GDS scores
7, or
11,a demographic variables and presence of selected medical
conditions at examination

Variable N N (%) of p-value from N (%) p-value from

GDS
7a chi square of GDS
11a chi square

Age group 0.009 0.003

60–69 257 58 (22.6%) (1)* 20 (7.8%) (1)*
70–79 236 65 (27.5%) 31 (13.1%)
80 þ 115 41 (35.7%) 21 (18.3%)
Gender 0.001 0.6
Male 283 57 (20.1%) (1)* 29 (10.3%) (1)*
Female 325 107 (32.9%) 43 (13.2%)
Education (years) 0.01 0.54
0–5 391 120 (30.7%) (1)* 48 (12.3%) (1)*
6–8 169 35 (20.7%) 19 (11.2%)
9–11 30 6 (20.0%) 4 (13.3%)
12 þ 18 3 (16.7%) 1 (5.6%)
Marital status 0.001 0.001
Currently married 438 93 (21.2%) (1)* 39 (8.9%) (1)*
Other 170 71 (41.8%) 33 (19.4%)
Neoplasmsb 0.07 0.13
No 585 154 (26.3%) (1)* 67 (11.5%) (1)*
Yes 23 10 (43.5%) 5 (21.7%)
Digestive conditionsc 0.005 0.005
No 534 134 (25.1%) (1)* 56 (10.5%) (1)*
Yes 74 30 (40.5%) 16 (21.6%)
Disease of the nervous system and 0.001 0.001
Cerebrovascular diseased (1)* (1)*
No 402 87 (21.6%) 33 (8.2%)
Yes 206 77 (37.4%) 39 (18.9%)
Ischemic heart disease and arrhythmiase 0.001 0.05
No 439 101 (23.0%) (1)* 45 (10.3%) (1)*
Yes 169 63 (37.3%) 27 (16.0%)
Total 608 164 (27.0%) 72 (11.8%)
a
Frequency and percent of participants in each category with GDS degree
7 (mild or more severe depression) and
11(moderate to
severe depression).
b
Neoplasms (ICD-9): 140–239.
c
Digestive conditions (ICD-9): Gastric ulcer (531), Duodenal ulcer (532), Gastritis and duodenitis (535), Disorders of function of stomach
(536), Functional digestive disorders (564).
d
Disease of the nervous system (ICD-9): 320–389, Cerebrovascular diseases (ICD-9): 430–438.
e
Ischemic heart disease and arrhythmias (ICD-9): 410–414 and 420–429.
*Degrees of freedom.
Bold indicates that the results are statistically significant.

27%, while the prevalence of moderate to severe

Table 2. Distribution of the 608 study participants by GDS scores
(mean,
7, or
11), by MMSE score ( < 24 and
24) and by age depression was 12%. A higher prevalence of depres-
[overall, younger (below median) and older (above median)] sion was found among older individuals (older old)
and women. However, the association between
GDS GDS
7 GDS
11
Mean (SD) N (%) N (%)
increased age or female gender and risk for depres-
sion disappeared in multivariate logistic regression
All ages 4.3 (4.3) 164 (27.0%) 72 (11.8%) models likely due to a confounding between age or
MMSE
24 3.3 (3.8) 65 (18.5%) 25 (7.1%) gender and cognitive impairment. Cognitive impair-
MMSE < 24 5.6 (4.6) 99 (38.5%) 47 (18.3%)
Younger  71 3.7 (4.1) 68 (21.8%) 28 (9.0%)
ment was significantly associated with increased risk
MMSE
24 3.0 (3.7) 33 (16.0%) 13 (6.3%) for depression and, in fact, appeared to be the major
MMSE < 24 5.0 (4.4) 35 (33.3%) 15 (14.3%) risk factor for depression in this setting. Marital status
Older > 71 4.9 (4.5) 96 (32.4%) 44 (14.7%) was associated with the risk for mild or more severe
MMSE
24 3.8 (4.0) 32 (22.2%) 12 (8.3%) depression with unmarried individuals having a 75%
MMSE < 24 6.0 (4.6) 64 (42.1%) 32 (21.1%)
higher risk of depression. As expected depression was

Copyright # 2005 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2005; 20: 350–357.
354 f. c. papadopoulos ET AL.

Table 3. Multiple logistic regression derived adjusted Odds Ratios together with 95% confidence intervals for mild or more severe
depression (GDS score
7) and moderate to severe depression (GDS score
11) by specified variables

Condition Variable Category or increment OR 95% CIs p-value

Depression GDS
7 Age

1 year more 1.005 0.98 1.03 0.73
MMSE Score
1 point more 0.95 0.91 0.99 0.02
Gender
Male Reference
Female 1.29 0.84 2.00 0.25
Education
3 years more 0.82 0.61 1.11 0.20
Marital status
Married Reference
Unmarried 1.75 1.10 2.78 0.02
a
Neoplasms
No Reference
Yes 1.80 0.72 4.51 0.21
Digestive conditionsb
No Reference
Yes 1.79 1.04 3.07 0.04
Disease of the nervous system
and Cerebrovascular diseasec
No Reference
Yes 1.65 1.10 2.49 0.02
Ischemic heart disease
and arrhythmiasd
No Reference
Yes 1.82 1.21 2.74 0.004
Severe Depression GDS
11 Age
1 year more 1.01 0.98 1.05 0.53
MMSE Score
1 point more 0.93 0.89 0.98 0.006
Gender
Male Reference
Female 0.82 0.45 1.49 0.51
Education
3 years more 1.06 0.72 1.54 0.78
Marital status
Married Reference
Unmarried 1.74 0.93 3.27 0.08
Neoplasmsa
No Reference
Yes 1.66 0.53 5.18 0.38
Digestive conditionsb
No Reference
Yes 2.04 1.05 3.96 0.03
Disease of the nervous system
and Cerebrovascular diseasec
No Reference
Yes 1.85 1.07 3.20 0.03
Ischemic heart disease
and arrhythmiasd
No Reference
Yes 1.32 0.76 2.30 0.32
a
Neoplasms (ICD-9): 140–239.
b
Digestive conditions (ICD-9): Gastric ulcer (531), Duodenal ulcer (532), Gastritis and duodenitis (535), Disorders of function of stomach
(536), Functional digestive disorders (564).
c
Disease of the nervous system (ICD-9): 320–389, Cerebrovascular diseases (ICD-9): 430–438.
d
Ischemic heart disease and arrhythmias (ICD-9): 410–414 and 420–429.
Bold indicates that the results are statistically significant.

Copyright # 2005 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2005; 20: 350–357.
 prevalence and correlates of depression in late life
also associated with selected medical co-morbid con-
ditions specifically, ischemic heart disease, arrhyth-
mia, digestive, neurological and cerebrovascular
conditions but not neoplasms.
These findings are in agreement with reports from
studies reporting that rates of depression in late life
tend to increase with age (Eaton et al., 1997; Forsell
and Winblad, 1999; Steffens et al., 2000; Palsson
et al., 2001). They suggest that the depression-age
association is primarily driven by the increasing pre-
valence of cognitive impairment and disability with
increasing age, as others have proposed (Roberts
et al., 1997).
The lack of a clear association between gender and
depression in this study is noteworthy. Female gender
has consistently been associated with increased
depression risk in later life (Eaton et al., 1997; Forsell
and Winblad, 1999; Steffens et al., 2000; Argyriadou
et al., 2001; Palsson et al., 2001; Parashos et al.,
2002; Cole and Dendukuri, 2003). Gender differences
in depression risk have been attributed to differences
in socio-economic status and physical functioning
between men and women (Takkinen et al., 2004),
and to differences in social roles with aging (Barefoot
et al., 2001). However, prior studies have not adjusted
for cognitive impairment or medical co-morbidity, as
was done here, so that earlier associations of depres-
sion and gender may well be due to the higher preva-
lence of cognitive impairment among women in the
older old (Miech et al., 2002). Moreover, earlier asso-
ciations of depression and female gender may also be
due to the fact that more women than men are
widowed in late life (Pinquart and Sorensen, 2001),
and consequently suffer from the grief of losing a
spouse and the social isolation that follows. Further
study is needed to confirm our finding that there is
no gender association with depression in late life.
It has often been reported that cognitive dysfunc-
tion is often co-morbid with depression in late life
(Abolfotouh et al., 2001; Wang, 2001; Green et al.,
2003; Mehta et al., 2003) and this association was
also observed in this study. Almost two thirds of all
depressed individuals were cognitively impaired,
and this association was stronger among older indivi-
duals and among those with more severe depression.
On the other hand, nearly 40% of those with cognitive
impairment had mild or more severe depression, and
one in five had moderate to severe depression. This
cross sectional study cannot clarify any aetiological
relationship between depression and cognitive
dysfunction. It has been proposed that depression
is a consequence of the dementing disease, such as
Alzheimer’s (Lee and Lyketsos, 2003), or that depres-
Copyright # 2005 John Wiley & Sons, Ltd.
355
sion and cognitive impairment share a common
pathophysiological mechanism, brain vascular dis-
ease (Snowdon et al., 1997; Adecola and Gorelick,
2003; Alexopoulos, 2003). These, of course, are not
mutually exclusive explanations.
A notable finding of the study is that currently
unmarried individuals (which in 92% of the cases
represent widowed individuals) are more likely to
be depressed, even after adjustment for socio-demo-
graphic factors and cognitive status. The findings with
respect to marital status have considerable public
health importance, given the high prevalence of indi-
viduals living alone in the age groups under investiga-
tion. This finding is in agreement with other studies
reporting that social isolation is a significant risk fac-
tor for depression in late life, and for its under-diag-
nosis and under-treatment (Abolfotouh et al., 2001;
Andrade et al., 2003; Mulsant and Ganguli, 1999;
Wang, 2001; Ciechanowski et al., 2004).
Many studies have reported that medical co-
morbidity affects the feeling of wellbeing in late life
and that chronic medical conditions increase risk
for depression (Penninx et al., 1999; Cole and
Dendukuri, 2003; Sokoya and Baiyewu, 2003). These
results, which are compatible with the literature, sug-
gest that co-morbid digestive, neurological and cere-
brovascular disease is strongly associated with
moderate to severe depression. Ischemic heart disease
and arrhythmias were primarily associated with
milder depression.
While cancer patients have increased rates of
depression, the possibility that depression may be a
risk factor for the development of cancer has also
been introduced (McDaniel et al., 1995; Spiegel and
Giese-Davis, 2003). In this study, there was no signif-
icant association between cancer co-morbidity and
depression. The most likely explanation is that older
cancer patients living in this rural town might have
less severe or progressive forms of cancer, while those
with disabling neoplastic disease might have moved
to live with relatives in major urban areas, where spe-
cialist care is available. Furthermore, older cancer
patients in Greece often are unaware of suffering from
a neoplastic disease, often as a result of the relatives’
pressure on physicians not to reveal the diagnosis.
Strengths of the present study include its general
population base, the limited refusal rate, and the
administration of assessment instruments specific to
old age (GDS and MMSE) by the same investigator.
Weaknesses include the limited information on perso-
nal habits and use of medication, due to the fact that
many study participants were unwilling to provide
information on these issues as they were considered
Int J Geriatr Psychiatry 2005; 20: 350–357.
356 f. c. papadopoulos ET AL.
too intimate, the absence of a clinical diagnosis made
by a medical specialist, and the weaknesses inherent
to the cross sectional study design, such as the inabil-
ity to clarify aetiological relationships.
In conclusion, in this old age population, depres-
sion was a common condition. Its prevalence was
higher among individuals with cognitive dysfunction
and co-morbid medical conditions. Currently unmar-
ried individuals also tended to be at higher risk for
depression. In terms of practical implications, our
results point to the need for more extensive socializa-
tion of the elderly population as a partial remedy for
depression manifestations. Physicians should also be
alerted to the diagnosis of depression in late life, espe-
cially in individuals with co-morbid medical condi-
tions, persistent somatic complaints, or recurrent
visits to healthcare facilities. Finally, further research
is needed to shed light on the intriguing link between
depression and cognitive impairment in older indivi-
duals, as well as on the relationship between depres-
sion and gender in late life.
ACKNOWLEDGEMENTS
Supported in part by the Johns Hopkins Alzheimer’s
Disease Research Center (P01 AG05146; Dr.
Lyketsos).
REFERENCES
Abas MA, Phillips C, Carter J, et al. 1998. Culturally sensitive vali-
dation of screening questionnaires for depression in older Afri-
can-Caribbean people living in south London. Br J Psychiatry
173: 249–254.
Abolfotouh MA, Daffallah AA, Khan MY, et al. 2001. Psychosocial
assessment of geriatric subjects in Abha City, Saudi Arabia. East
Mediterr Health J 7: 481–491.
Adecola C, Gorelick PB. 2003. Converging pathogenic mechanisms
in vascular and neurodegenerative dementia. Stroke 34: 335–
337.
Alexopoulos GS. 2003. Vascular disease, depression, and dementia.
J Am Geriatr Soc 51: 1178–1180.
Andrade L, Caraveo-Anduaga JJ, Berglund P, et al. 2003. The epi-
demiology of major depressive episodes: results from the Inter-
national Consortium of Psychiatric Epidemiology (ICPE)
Surveys. Int J Methods Psychiatr Res 12: 3–21.
Argyriadou S, Melissopoulou H, Krania E, et al. 2001. Dementia
and depression: two frequent disorders of the aged in primary
health care in Greece. Fam Pract 18: 87–91.
Barefoot JC, Mortensen EL, Helms MJ, et al. 2001. A longitudinal
study of gender differences in depressive symptoms from age 50
to 80. Psychol Aging 16: 342–345.
Beekman AT, Copeland JR, Prince MJ. 1999. Review of community
prevalence of depression in later life. Br J Psychiatry 174:
307–311.
Blazer DG, Moody-Ayers S, Craft-Morgan J, Burchett B. 2002.
Depression in diabetes and obesity: racial/ethnic/gender issues
in older adults. J Psychosom Res 53: 913–916.
Copyright # 2005 John Wiley & Sons, Ltd.
Brown ES, Varghese FP, McEwen BS. 2004. Association of depres-
sion with medical illness: does cortisol play a role? Biol Psychia-
try 55: 1–9.
Chochinov HM. 2001. Depression in cancer patients. Lancet Oncol
2: 499–505.
Ciechanowski P, Wagner E, Schmaling K, et al. 2004. Community-
integrated home-based depression treatment in older adults: a
randomized controlled trial. JAMA 291: 1569–1577.
Clement JP, Nassif RF, Leger JM, Marchan F. 1997. [Development
and contribution to the validation of a brief French version of
the Yesavage Geriatric Depression Scale.] Encephale 23:
91–99.
Cole MG, Dendukuri N. 2003. Risk factors for depression among
elderly community subjects: a systematic review and meta-
analysis. Am J Psychiatry 160: 1147–1156.
Cronin-Stubbs D, de Leon CF, Beckett LA, et al. 2000. Six-year
effect of depressive symptoms on the course of physical disabil-
ity in community-living older adults. Arch Intern Med 160:
3074–3080.
De Craen AJ, Heeren TJ, Gussekloo J. 2003. Accuracy of the 15-
item geriatric depression scale (GDS-15) in a community sample
of the oldest old. Int J Geriatr Psychiatry 18: 63–66.
De Jonge P, Ormel J, Slaets JP, et al. 2004. Depressive symptoms in
elderly patients predict poor adjustment after somatic events. Am
J Geriatr Psychiatry 12: 57–64.
De Silva HA, Gunatilake SB. 2002. Mini Mental State Examination
in Sinhalese: a sensitive test to screen for dementia in Sri Lanka.
Int J Geriatr Psychiatry 17: 134–139.
Eaton WW, Anthony JC, Gallo J, et al. 1997. Natural history of
Diagnostic Interview Schedule/DSM-IV major depression. The
Baltimore Epidemiologic Catchment Area follow-up. Arch Gen
Psychiatry 54: 993–999.
Espino DV, Lichtenstein MJ, Palmer RF, Hazuda HP. 2001. Ethnic
differences in mini-mental state examination (MMSE) scores:
where you live makes a difference. J Am Geriatr Soc 49: 538–
548.
Fernandez-San Martin MI, Andrade C, Molina J, et al. 2002. Vali-
dation of the Spanish version of the geriatric depression scale
(GDS) in primary care. Int J Geriatr Psychiatry 17: 279–287.
Folstein MF, Folstein, SE, McHugh PR. 1975. Mini-Mental State: a
practical method for grading the state of patients for the clini-
cian. J Psychiatr Res 12: 189–198.
Forsell Y, Winblad B. 1999. Incidence of major depression in a very
elderly population. Int J Geriatr Psychiatry 14: 368–372.
Fountoulakis K, Tsolaki M, Chantzi H, Kazis A. 2000. Mini-Mental
State Examination (MMSE): a validation study in Greece. Am J
Alzheimer’s Dis 15: 342–345.
Fountoulakis KN, Tsolaki M, Iacovides A, et al. 1999. The valida-
tion of the short form of the Geriatric Depression Scale (GDS) in
Greece. Aging (Milano) 11: 367–372.
Green RC, Cupples LA, Kurz A, et al. 2003. Depression as a risk
factor for Alzheimer disease: the MIRAGE Study. Arch Neurol
60: 753–759.
Grigoletto F, Zappala G, Anderson DW, Lebowitz BD. 1999. Norms
for the Mini-Mental State Examination in a healthy population.
Neurology 53: 315–320.
Haller J, Weggemans RM, Ferry M, Guigoz Y. 1996. Mental health:
minimental state examination and geriatric depression score of
elderly Europeans in the SENECA study of 1993. Eur J Clin
Nutr 50(Suppl. 2): S112–S116.
Ishizaki J, Meguro K, Ambo H, et al. 1998. A normative, commu-
nity-based study of Mini-Mental State in elderly adults: the
effect of age and educational level. J Gerontol B Psychol Sci
Soc Sci 53: 359–363.
Int J Geriatr Psychiatry 2005; 20: 350–357.
 prevalence and correlates of depression in late life
Lai DW. 2003. Measuring depression of elderly Chinese
Americans: a replication study. Home Health Care Serv Q 22:
69–85.
Lam CK, Lim PP, Low BL, et al. 2004. Depression in dementia: a
comparative and validation study of four brief scales in the
elderly Chinese. Int J Geriatr Psychiatry 19: 422–428.
Law S, Wolfson C. 1995. Validation of a French version of an infor-
mant-based questionnaire as a screening test for Alzheimer’s dis-
ease. Br J Psychiatry 167: 541–544.
Lee HB, Lyketsos CG. 2003. Depression in Alzheimer’s disease:
heterogeneity and related issues. Biol Psychiatry 54: 353–362.
Levenstein S, Kaplan GA, Smith MW. 1997. Psychological predic-
tors of peptic ulcer incidence in the Alameda County Study. J
Clin Gastroenterol 24: 140–146.
McDaniel JS, Musselman DL, Porter MR, et al. 1995. Depression
in patients with cancer. Diagnosis, biology, and treatment. Arch
Gen Psychiatry 52: 89–99.
Mehta KM, Yaffe K, Langa KM, et al. 2003. Additive effects of
cognitive function and depressive symptoms on mortality in
elderly community-living adults. J Gerontol A Biol Sci Med
Sci 58: M461–M467.
Miech RA, Breitner JCS, Zandi PP, et al. for the Cache County
Study Group. 2002. Incidence of AD May Decline in the Early
90’s for Men, Later for Women. The Cache County Study. Neu-
rology 58: 209–218.
Monsch AU, Foldi NS, Ermini-Funfschilling DE, et al. 1995.
Improving the diagnostic accuracy of the Mini-Mental State
Examination. Acta Neurol Scand 92: 145–150.
Mossey J, Knott K, Craik R. 1990. The effects of persistent depressive
symptoms on hip fracture recovery. J Gerontol 45: M163–M168.
Mulsant BH, Ganguli M. 1999. Epidemiology and diagnosis
of depression in late life. J Clin Psychiatry 60(Suppl. 20):
9–15.
Murray CJL, Lopez AD. 1996. The Global Burden of Disease.
World Health Organisation: Geneva.
National Statistical Service of Greece. Population Census 2001.
http://www.statistics.gr
Osborn DP, Fletcher AE, Smeeth L, et al. 2002. Geriatric
Depression Scale Scores in a representative sample of
14 545 people aged 75 and over in the United Kingdom:
results from the MRC Trial of Assessment and Management of
Older People in the Community. Int J Geriatr Psychiatry 17:
375–382.
Ostrosky-Solis F, Lopez-Arango G, Ardila A. 2000. Sensitivity and
specificity of the Mini-Mental State Examination in a Spanish-
speaking population. Appl Neuropsychol 7: 25–31.
Palsson SP, Ostling S, Skoog I. 2001. The incidence of first-onset
depression in a population followed from the age of 70 to 85.
Psychol Med 31: 1159–1568.
Parashos IA, Stamouli S, Rogakou E, et al. 2002. Recognition of
depressive symptoms in the elderly: what can help the patient
and the doctor. Depress Anxiety 15: 111–116.
Penninx BW, Beekman AT, Honig A, et al. 2001. Depression and
cardiac mortality: results from a community-based longitudinal
study. Arch Gen Psychiatry 58: 221–227.
Penninx BW, Geerlings SW, Deeg DJ, et al. 1999. Minor and major
depression and the risk of death in older persons. Arch Gen Psy-
chiatry 56: 889–895.
Pinquart M, Sorensen S. 2001. Gender differences in self-concept
and psychological well-being in old age: a meta-analysis. J Ger-
ontol B Psychol Sci Soc Sci 56: P195–P213.
Copyright # 2005 John Wiley & Sons, Ltd.
357
Pohjasvaara T, Vataja R, Leppavuori A, et al. 2001. Depression is
an independent predictor of poor long-term functional outcome
post-stroke. Eur J Neurol 8: 315–319.
Rait G, Burns A, Baldwin R, et al. 2000. Validating screening
instruments for cognitive impairment in older South Asians in
the United Kingdom. Int J Geriatr Psychiatry 15: 54–62.
Ramos M, Wilmoth J. 2003. Social relationships and depressive
symptoms among older adults in southern Brazil. J Gerontol B
Psychol Sci Soc Sci 58: S253–S261.
Ritchie K, Artero S, Beluche I, et al. 2004. Prevalence of DSM-IV
psychiatric disorder in the French elderly population. Br J Psy-
chiatry 184: 147–152.
Roberts RE, Kaplan GA, Shema SJ, Strawbridge WJ. 1997. Does
growing old increase the risk for depression? Am J Psychiatry
154: 1384–1390.
SAS Institute Inc. 1989. SAS/STAT User’s Guide, Version 6 Fourth
Edition Cary, NC: SAS Institute Inc.
Schreiner AS, Hayakawa H, Morimoto T, Kakuma T. 2003. Screen-
ing for late life depression: cut-off scores for the Geriatric
Depression Scale and the Cornell Scale for Depression in
Dementia among Japanese subjects. Int J Geriatr Psychiatry
18: 498–505.
Sheikh JI, Yesavage JA. 1986. Geriatric Depression Scale (GDS):
recent evidence and development of a shorter version. Clin Ger-
ontologist 5: 165–173.
Shyu YI, Yip PK. 2001. Factor structure and explanatory variables
of the Mini-Mental State Examination (MMSE) for elderly per-
sons in Taiwan. J Formos Med Assoc 100: 676–683.
Snowdon DA, Greiner LH, Mortimer JA, et al. 1997. Brain infarc-
tion and the clinical expression of Alzheimer disease: the Nun
Study. JAMA 277: 813–817.
Sokoya OO, Baiyewu O. 2003. Geriatric depression in Nigerian pri-
mary care attendees. Int J Geriatr Psychiatry 18: 506–510.
Spiegel D, Giese-Davis J. 2003. Depression and cancer: mechan-
isms and disease progression. Biol Psychiatry 54: 269–282.
Spiegel D. 1996. Cancer and depression. Br J Psychiatry Suppl:
109–116.
Steffens DC, Skoog I, Norton MC. 2000. Prevalence of depression
and its treatment in an elderly population: the Cache County
study. Arch Gen Psychiatry 57: 601–607.
Stewart R, Johnson J, Richards M, et al. 2002. Medical Council
Cognitive Function and Ageing Study. The distribution of
Mini-Mental State Examination scores in an older UK African-
Caribbean population compared to MRC CFA study norms. Int J
Geriatr Psychiatry 17: 745–751.
Sukegawa T, Itoga M, Seno H, et al. 2003. Sleep disturbances and
depression in the elderly in Japan. Psychiatry Clin Neurosci 57:
265–270.
Takkinen S, Gold C, Pedersen NL, et al. 2004. Gender differences
in depression: a study of older unlike-sex twins. Aging Ment
Health 8: 187–195.
Unutzer J, Patrick DL, Simon G, et al. 1997. Depressive symptoms
and the cost of health services in HMO patients aged 65 and
older. JAMA 277: 1618–1623.
Wang JJ. 2001. Prevalence and correlates of depressive symptoms
in the elderly of rural communities in southern Taiwan. J Nurs
Res 9: 1–12.
Ylikoski R, Erkinjuntti T, Sulkava R, et al. 1992. Correction for
age, education and other demographic variables in the use of
the Mini Mental State Examination in Finland. Acta Neurol
Scand 85: 391–396.
Int J Geriatr Psychiatry 2005; 20: 350–357.