European Psychiatry 20 (2005) 199–204

http://france.elsevier.com/direct/EURPSY/

Original article

Risk factors of major depression in the elderly

Reinhard Heun *, Sandra Hein
Department of Psychiatry, University of Bonn, Venusberg, 53105 Bonn, Germany
Received 29 March 2004; accepted 24 September 2004

Available online 19 February 2005

Abstract
Background. – Several risk factors of depression have been identified in retrospective as well as some prospective studies in the elderly.
Confirmation in independent samples is needed. The present follow-up study prospectively investigated risk factors of depression in an elderly
German sample.
Methods. – One thousand four hundred and thirty-one subjects from a family study were re-investigated after 4.7 ± 2.5 years. Bivariate and
multivariate forward logistic regression analyses were used to identify risk factors of the development of new depression in the elderly.
Results. – Risk factors of a new depressive episode in 1408 elderly without current depression were age, female gender, a previous
depression, subjective memory impairment, previous anxiety and somatoform disorders. The presence of dementia or mild cognitive impair-
ment were significant risk factors in bivariate, but not multivariate analysis controlling for possible confounding. Risk factors of a first
geriatric depressive episode were age, gender and subjective memory impairment; age remained the only significant risk factor in multivariate
analysis.
Conclusions. – This investigation confirms previous studies from other countries concerning the relevance of risk factors for depression in
the elderly. The knowledge of risk factors might help identify subjects at increased risk of depression for early intervention approaches.
Elderly with a history of previous depression carry the highest risk.
© 2005 Elsevier SAS. All rights reserved.
Keywords: Major depression; Risk factors; Elderly; Memory impairment; Dementia

1. Introduction Social factors like marital status [16,28,42,52,58], life

Previous cross-sectional as well as prospective follow-up
studies, many of them conducted in America, Great Britain
and The Netherlands, identified various risk factors of depres-
sion.
Female gender [11,26,29,41,58]—female gender is
favoured by several authors as one of the most important risk
factors of depression, but there are also some studies not con-
firming this sight [51,67].
Genetic risk factors, i.e. a positive family history of depres-
sion [27,46,50,61].
Psychiatric disorders of the individual including previous
depressive symptoms and episodes [1,9,18,29,36], cognitive
impairment [4,8,21,25], alcohol as well as nicotine abuse
[11,17,28,59,66] and insomnia [24,48].
Medical disorders, i.e. chronic diseases [14,47,58,59], per-
ceived poor health [5,40,58] and increasing disability
[40,54,58].
* Corresponding author. Tel.: +44 1325 743 779; fax: +44 1325 383 548.
E-mail address: reinhard.heun@cddps.northy.nhs.uk (R. Heun).
0924-9338/$ - see front matter © 2005 Elsevier SAS. All rights reserved.
doi:10.1016/j.eurpsy.2004.09.036
events [27,38,42,52,53] social isolation [29,35,36,46,53], low
income or financial problems [15,39,58,59] and low level of
education [16,29,58]. There were no major differences
between risk factors in younger and elderly samples
[4,8,9,14,21,25,28,29,39,40,42,48,50,52,54,55,58].
Cross-sectional studies of the prevalence of depression as
well those of associations of risk factors and depression are
usually biased by the high prevalence of chronic depression;
however, risk factor associated with prevalence are nearly
equivalent to those for the onset of depression, i.e. baseline
depression level, female sex, low educational level, presence
of physical illness, functional limitations, small social net-
work and an external locus of control [7].
Schoevers et al. [60] performed a 3 year follow-up study
in a large sample from the general population indicating that
the effect of risk factors could be influenced by social factors
such as the presence or absence of a social network.
The considerable variations of prevalence rates for depres-
sion in the different elderly populations in Europe [15] might
be explained by variations in the presence, possible effects
200 R. Heun, S. Hein / European Psychiatry 20 (2005) 199–204
and interactions of risk factors. Biological as well as cultural
risk factors might determine and influence the occurrence of
depression. Consequently, a recent consensus revealed that
further prospective studies assessing the relevance and pos-
sible interactions of risk factors on the development of new
depression in carefully diagnosed elderly in different coun-
tries are needed [13].
The present study investigated risk factors of depression
in an elderly German sample by performing a prospective
follow-up study in 1408 subjects not being currently depressed
at the time of an initial comprehensive interview (but who
might have suffered from a depressive episode at any other
time of their lives). Due to the fact that risk factors might be
different for subjects with previous depression and those who
had never suffered from depression the analysis was repeated
for all 1129 interviewed subjects who had never been de-
pressed up to the time of the initial examination. To prevent
selection bias by drop-outs with a different risk of depression
we investigated the development of new depressive episodes
using interviews as well as family-history information.
2. Materials and methods
2.1. Recruitment of subjects for initial and follow-up
examination
All participants were initially recruited for a family study
performed at the Departments of Psychiatry of the Univer-
sity of Mainz (recruitment from 1992 to 1995) and of the
University of Bonn (recruitment from 1996 to 1998). The
cross-sectional family study investigated the familial co-
aggregation of dementia, depression and other psychiatric dis-
orders in the elderly. Recruitment strategies and results of the
initial family study have already been published [31,34].
Briefly, patients with Alzheimer’s disease (AD) and/or major
depression (according to DSM-III-R criteria) aged 60 or older
were consecutively recruited. Group-matched control sub-
jects (for age, gender, and educational background) were
recruited with the support of the cities’ census agencies. The
patients and controls were asked to provide data of all first-
degree relatives and were included, if at least one aged 55 or
older was available for an interview.
The present follow-up examination to investigate the devel-
opment of depression in elderly subjects was carried out from
1999 to 2001 in Mainz and Bonn. To assess risk factors for
the development of new depression in the elderly, all subjects
older than 55 years of age who did not suffer from actual
depression or moderate to severe dementia at the initial exami-
nation (i.e. that of the family study) were selected (n = 1582).
Consequently, most of them were first-degree relatives of the
patients or member from the general population. Subjects
were contacted by mail and phone and asked for participa-
tion in a personal re-interview. The study was approved by
the local ethic committees and all participants gave written
informed consent.
Of 151 subjects (9.5%) insufficient or no follow-up infor-
mation was available. A total of 1431 elderly subjects above
the age of 55 years at the initial assessment could be included
in the present follow-up study, only 685 of these could be per-
sonally re-interviewed, but relevant family history informa-
tion was available on all others to make reasonable follow-up
assessments. The mean age of the sample at the initial exami-
nation was 61 ± 16 years (mean ± S.D.). The duration of
follow-up was 4.7 ± 2.5 years (mean ± S.D.,
range 2–10 years). 45% were male, 55% were female subjects.
Twenty-three subjects suffered depression at the initial
assessment, of 1408 subjects without current major depres-
sion at the initial examination, 331 suffered from at least one
depressive episode during follow-up. Of 1129 subjects with-
out a lifetime diagnosis of major depression up to the initial
examination 68 developed their first depressive episode dur-
ing follow-up. Detailed descriptions of the groups, i.e. non-
depressed subjects and never-depressed subjects, at initial
assessment are given in Tables 1 and 2.
2.2. Diagnostic assessment
All subjects were initially diagnosed using the Composite
International Diagnostic Interview (CIDI) [68] and/or exten-
sive family history information from several family mem-
bers, which permits DSM-III-R diagnoses for major
psychiatric disorders. The CIDI is only recommended for sub-
jects with a Mini Mental Score (MMS) of above 18 points
[23] consequently subjects with moderate to severe dementia
were excluded from the follow-up study (see above). The CIDI
was again applied once at the follow-up examination. Due to
the fact that subjects with psychiatric disorders are more often
unavailable for an interview than healthy subjects [31],
it was necessary to use the family history method [3]
to obtain more diagnostic information and to prevent selec-
tion bias for unavailable subjects. Validity and reliability of
the family history method have been described before
[30,32,33,56].
Subjects were interviewed by medical students after a
4-weeks clinical clerkship on a psychiatric ward or by junior
physicians being comprehensively trained including 10 super-
vised interviews. The final diagnoses were made using the
best-estimate procedure [43]: two experienced psychiatrists
who were not informed about the identity of the subjects had
to agree on the diagnosis. The lifetime diagnoses were made
according to DSM-III-R [2]. The lifetime diagnosis of major
depression included the DSM-III-R codes 296.20–296.36 to
get a homogeneous group of depressed subjects. Late-onset
depression was diagnosed when the age at onset was above
60 years. This threshold was chosen in accordance with recent
publications [50]. The CIDI provides detailed data on the first
and last depressive episode, but does not provide precise data
on the number or the onset of individual depressive episodes,
consequently, information on the timing of later episodes was
not available, thus preventing the use of survival analytic sta-
tistical methods. Mild cognitive impairment included sub-
 R. Heun, S. Hein / European Psychiatry 20 (2005) 199–204 201

Table 1
Risk factors of late-onset depression in subjects without current major depression at the initial examination identified by bivariate logistic regression analyses
(results, i.e. RR of multivariate analyses are given in the text)
Subjects with Subjects Group comparison Relative risks 95% CIs
new depressive remaining (Wald-statistic)
episodes non-depressed
Number 331 1077
Demographic variables
Age (years ± S.D.) 64.8 ± 14 58.5 ± 16 v2 = 37.3; df = 1; P < 0.001 1.02 per yeara,b 1.01–1.04
Gender (% female) 69% 51% v2 = 31.4; df = 1; P < 0.001 2.1a,b 1.6–2.74
Education (years in school ± S.D.) 9.9 ± 2.0 10.0 ± 2.0 v2 = 0.23; df = 1; P = 0.63 0.98 per year 0.91–1.06
Duration of follow-up (years ± S.D.) 4.8 ± 3.0 4.6 ± 2.0 v2 = 1.25; df = 1; P = 0.26 1.02 per year 0.98–1.1
Initial assessment
Previous major depression (%) 79.5% 1.5% v2 = 375; df = 1; P < 0.001 260a,b 150–450
Mini-mental status (points ± S.D.) 25.5 ± 0.5 26.2 ± 0.5 v2 = 3.66; df = 1; P = 0.056 0.97per point 0.95–1.01
Dementia (%) 18.5% 9.8% v2 = 17.9; df = 1; P < 0.001 2.1a 1.5–3.0
Mild cognitive impairment (%) 23.3% 14.1% v2 = 15.3; df = 1; P < 0.001 1.8a 1.4–2.5
Subjective memory impairment (%) 55% 45% v2 = 59,1; df = 1; P < 0.001 2.8a,b 2.1–3.6
Alcohol dependence (%) 4.8% 3.9% v2 = 0.57; df = 1; P = 0.46 1.3 0.69–2.3
Anxiety disorders (%) 19.6% 6.4% v2 = 46.8; df = 1; P < 0.001 3.6a,b 2.5–5.1
Paranoid disorders (%) 0.6% 1.4% v2 = 1.24; df = 1; P = 0.27 0.43 0.09–1.9
Somatoform disorders (%) 9.7% 3.5% v2 = 18.6; df = 1; P < 0.001 3.0a,b 1.8–4.8
a
Significant in bivariate analysis.
b
Significant in multivariate analysis.

Table 2
Risk factors of late-onset depression in subjects without a lifetime diagnosis of depression up to the initial examination identified by bivariate logistic regression
analyses (results, i.e. RR of multivariate analyses are given in the text)
Subjects with Subjects Group comparison Relative risks 95% CIs
new depressive remaining (Wald-statistic)
episodes non-depressed
Number 68 1061
Demographic variables
Age (years ± S.D.) 64 ± 15 59 ± 17 v2 = 6.89; df = 1; P = 0.009 1.02 per yeara,b 1.01–1.04
Gender (% female) 65% 51% v2 = 4.77; df = 1; P = 0.029 1.8a 1.1–3.0
Education (years in school ± S.D.) 9.6 ± 2.0 9.9 ± 2.0 v2 = 1.08; df = 1; P = 0.30 0.92 per year 0.78–1.1
Duration of follow-up (years ± S.D.) 4.8 ± 2.0 4.6 ± 2.0 v2 = 0.36; df = 1; P = 0.55 1.03 per year 0.93–1.1
Initial assessment
Mini-mental status (points ± S.D.) 26 ± 0.5 26 ± 0.5 v2 = 0.02; df = 1; P = 0.90 0.99 per point 0.95–1.1
Dementia (%) 15% 9.9% v2 = 1.57; df = 1; P = 0.21 1.6 0.77–3.2
Mild cognitive impairment (%) 19% 14% v2 = 1.45; df = 1; P = 0.23 1.5 0.78–2.8
Subjective memory impairment (%) 45% 50% v2 = 18.1; df = 1; P < 0.001 2.9a 1.8–4.8
Alcohol dependence (%) 1.5% 3.8% v2 = 0.89; df = 1; P = 0.34 0.38 0.05–2.8
Anxiety disorders (%) 8.8% 6.1% v2 = 0.78; df = 1; P = 0.38 1.5 0.62–3.6
Paranoid disorders (%) 2.9% 1.4% v2 = 0.96; df = 1; P = 0.33 2.1 0.47–9.4
Somatoform disorders (%) 4.4% 3.3% v2 = 0.24; df = 1; P = 0.63 1.4 0.40–4.5
a
Significant in bivariate analysis.
b
Significant in multivariate analysis.

jects with an MMS between 24 and 27, subjective memory
impairment was assumed when subjects indicated subjective
memory problems and gave a valid example.
2.3. Statistical analyses
To identify risk factors of depression in the elderly and geri-
atric depression, possible risk factors (see Table 1) were com-
pared between subjects having suffered at least one major
depressive episode during the time span between the initial and
the follow-up examination and subjects remaining non-
depressed using v2 statistics and t-tests for group compari-
sons. Forward logistic regression analysis was performed to
account for the simultaneous association of risk factors with
the development of depression during follow-up (inclusion of
variables in the order of effect size). To allow comparison with
the results of other authors P < 0.05 was taken as threshold for
statistical significance. This level was also applied for the inclu-
sion of variables in the forward logistic regression models.
3. Results
Bivariate logistic regression analysis revealed that age,
female gender, previous depression, dementia, mild cogni-
202 R. Heun, S. Hein / European Psychiatry 20 (2005) 199–204
tive impairment, subjective memory impairment, a lifetime
diagnosis of anxiety disorders and somatoform disorders were
risk factors of late-onset depression in subjects, who devel-
oped a new (first or recurrent) depressive episode during the
time span up to the follow-up examination. Those subjects
might have had a lifetime diagnosis of depression at the ini-
tial examination, but the depressive episode had not been
present at the initial examination (see Table 1). The forward
multivariate logistic regression analysis controlling for the
simultaneous association of risk factors revealed then a pre-
vious depressive episode (relative risk RR = 260, 95% confi-
dence interval, CI = 150–450) as the most important risk fac-
tor in subjects not suffering from present depression at the
initial examination. Age (RR = 1.03 per year, CI = 1.02–
1.04), female gender (RR = 2.1, CI = 1.6–2.7), subjective
memory impairment (RR = 2.8, CI = 2.1–3.6), and lifetime
diagnoses of anxiety disorders (RR = 3.6, CI = 2.1–5.1) and
somatoform disorders (RR = 2.9, CI = 1.8–4.8) remained sig-
nificant (P < 0.05) in the multivariate logistic regression model
thus indicating the relevance as important risk factors of
depression in the elderly. Dementia and mild cognitive impair-
ment did not remain in the model and might have been related
to the above mentioned factors.
Age, gender and subjective memory impairment were sig-
nificant risk factors of a first episode of geriatric depression
in subjects, who had never suffered from depression up to the
initial examination, in bivariate logistic regression analysis,
see Table 2. Education, duration of follow-up, mini-mental
score, alcohol dependence and paranoid disorders were no
significant risk factors of depression in the elderly in bivari-
ate logistic regression models. The forward multivariate logis-
tic regression analysis controlling for the simultaneous asso-
ciation of risk factors revealed age (RR = 1.02, CI = 1.01–
1.04) as the most important risk factor, which remained
significant in the final model; female gender and subjective
memory impairment did not remain in the multivariate logis-
tic regression model indicating they might have been less rel-
evant and might have been correlated with age.
4. Discussion
The results of our prospective study in the elderly were
mostly in agreement with previous studies, i.e. female gen-
der was found to be a risk factor of depression in the elderly,
which is in accordance with different studies [29,44,58,63].
Age is an important risk factor of depression in the elderly
in the present study, but there are controversial views of age
as risk factor of depression in previous studies. Steffens et al.
[63] investigated a sample of subjects being older than
65 years of age finding no influence of age on the prevalence
of depression. Lehtinen and Joukamaa [44] reported the high-
est prevalence rates of depression in the age group 60–
64 years, with decreasing prevalence rates till 75 years of age
and slightly increasing rates after age 75. Roberts et al. [57]
found that age effects were due to chronic health problems
and functional impairment, which cannot be proved in our
study as the necessary items were not examined. Blazer et al.
[10] found that depression was associated with increased age,
being female, lower income, physical disability, cognitive
impairment, and social support, but the association of age
and depressive symptoms reversed when the above confound-
ing variables were simultaneously controlled.
Previous depression is the most important predictor of a
new episode of depression, which has been a result of earlier
studies, too [6,49]. Maier et al. described furthermore, that
affective disorders are commonly recurrent, which is in agree-
ment with our findings of previous depressive episodes as a
risk factor of depression. Previous depression was even
revealed as the most important risk factor of depression in
the elderly in the logistic regression analysis confirming the
sight of depression as a recurrent illness.
Anxiety disorders, e.g. social phobia and generalised anxi-
ety disorder, have been identified as risk factors of depression
in previous studies [20,64], which was confirmed in our study.
Other studies described a comorbidity of anxiety disorders
and depression [22,37], but as we examined psychiatric dis-
orders preceding depressive episodes in a follow-up study,
we can be quite sure, that anxiety disorders were risk factors
and not comorbidity states of depression in the elderly. Bre-
slau et al. [12] found that prior anxiety disorders increased
the risk of depression in both women and men and in addi-
tion that the higher occurrence of prior anxiety disorders in
women might explain in part the higher female risk of depres-
sion. This hypothesis must be investigated in further studies.
Subjective memory impairment is a risk factor of depres-
sion in the elderly. This finding is in accordance with several
previous studies reporting an association of subjective
memory impairment [62] or cognitive impairment [25,65]
with depression. On the other hand some authors favour the
hypothesis, that depression causes subjective memory impair-
ment or cognitive impairment [19,45,57] or the hypothesis of
a comorbidity of cognitive impairment and depression [21].
It is difficult to determine when depression causes cognitive
impairment or vice versa.
5. Conclusions and limitations
In summary, the present prospective follow-up study sup-
ports the relevance of risk factors reported from other samples
and countries: a previous depressive episode was found to be
the most important risk factor of depression, but age, female
gender, subjective memory impairment and lifetime diag-
noses of anxiety disorders and somatoform disorders were also
important risk factors of new depression in the elderly, too. It
might be useful for clinicians to be aware of these risk factors,
especially of the relevance of previous depressive episodes, to
recognise a recurrent or new depression at its beginnings or
even to develop early intervention approaches trying to pre-
vent new depressive episodes in the elderly.
Due to the fact, that this study was based on a family-
study sample, generalising the results may be limited. The
 R. Heun, S. Hein / European Psychiatry 20 (2005) 199–204
referral patterns to our clinics, the initial family study design
and the necessary selection procedures including the ways to
approach the subjects and relatives during consultations may
have influenced the symptom presentations.
The CIDI as well as the family history method might lead
to possible misclassification, which cannot be fully excluded
in epidemiological studies including large samples. How-
ever, an adequate validity and reliability of the family history
method have been described before [30,32,33,56]. The often
unpreventable misclassification is usually prone to reduce the
power of studies, consequently, some of the risk factors found
as non-relevant in our assessment of subjects with their first
depression in late life may be found to have a predictive valid-
ity in larger samples.
Comorbidity of between different disorders might have also
led to the fact that some disorders or symptoms did not have
significant effects on the development of new depressive epi-
sodes in the elderly. Extremely larger samples would be nec-
essary to assess these as well as other possible interactions of
risk factors.
References
[1] Aalto-Setala T, Marttunen M, Tuulio-Henriksson A, Poikolainen K,
Lonnqvist J. Depressive symptoms in adolescence as predictors of
early adulthood depressive disorders and maladjustment. Am J Psy-
chiatry 2002;159(7):1235–7.
[2] American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. 3rd ed. rev. Washington DC: American Psychiat-
ric Association; 1987.
[3] Andreasen NC, Endicott J, Spitzer RL, Winokur G. The family history
method using diagnostic criteria. Reliability and validity. Arch Gen
Psychiatry 1977;34(10):1229–35.
[4] Ballard CG, Cassidy G, Bannister C, Mohan RNC. Prevalence, symp-
tom profile, and aetiology of depression in dementia sufferers. J Affect
Disord 1993;29:1–6.
[5] Barkow K, Heun R, Ustun TB, Maier W. Identification of items which
predict later development of depression in primary health care. Eur
Arch Psychiatry Clin Neurosci 2001;251(2):21–6.
[6] Barkow K, Maier W, Üstün TB, Gänsicke M, Wittchen HU, Heun R.
Risk factors for new depressive episodes in primary health care: an
international prospective 12-month follow-up study. Psychol Med
2002;32:595–607.
[7] Beekman AT, Deeg DJ, Geerlings SW, Schoevers RA, Smit JH, Van
Tilburg W. Emergence and persistence of late life depression: a 3-year
follow-up of the Longitudinal Aging Study Amsterdam. J Affect
Disord 2001;65(2):131–8.
[8] Berger AK, Small BJ, Forsell Y, Winblad B, Backman L. Preclinical
symptoms of major depression in the very old age: a prospective
longitudinal study. Am J Psychiatry 1998;155(8):1039–43.
[9] Berger AK, Fratiglioni L, Forsell Y, Winblad B, Backman L. The
occurrence of depressive symptoms in the preclinical phase of AD: a
population-based study. Neurology 1999;53(9):1998–2002.
[10] Blazer D, Burchett B, Service C, George LK. The association of age
and depression among the elderly: an epidemiologic exploration. J
Gerontol 1991;46(6):M210–M215.
[11] Breslau N, Kilbey MM, Andreski P. Nicotine dependence and major
depression. New evidence from a prospective investigation. Arch Gen
Psychiatry 1993;50(1):31–5.
203
[12] Breslau N, Schultz L, Peterson E. Sex differences in depression: a role
for preexisting anxiety. Psychiatry Res 1995;58:1–2.
[13] Charney DS, Reynolds 3rd CF, Lewis L, Lebowitz BD, Sunderland T,
Alexopoulos GS, et al. Depression and bipolar support alliance.
Depression and bipolar support alliance consensus statement on the
unmet needs in diagnosis and treatment of mood disorders in late life.
Arch Gen Psychiatry 2003;60(7):664–72.
[14] Copeland JR, Davidson IA, Dewey ME, Gilmore C, Larkin BA,
McWilliam C, et al. Alzheimer’s disease, other dementias, depression
and pseudodementia: prevalence, incidence and 3-year outcome in
Liverpool. Br J Psychiatry 1992;161:230–9.
[15] Copeland JR, Beekman AT, Dewey ME, Jordan A, Lawlor BA, Lin-
den M, et al. Cross-cultural comparison of depressive symptoms in
Europe does not support stereotypes of ageing. Br J Psychiatry 1999;
174:322–9.
[16] Coryell W, Endicott J, Keller M. Major depression in a nonclinical
sample. Demographic and clinical risk factors for first onset. Arch
Gen Psychiatry 1992;49(2):117–25.
[17] Coryell W, Winokur G, Keller M, Scheftner W, Endicott J. Alcoholism
and primary major depression: a family study approach to co-existing
disorders. J Affect Disord 1992;24(2):93–9.
[18] Crum RM, Cooper-Patrick L, Ford DE. Depressive symptoms among
general medical patients: prevalence and 1-year outcome. Psychsom
Med 1994;56(2):109–17.
[19] Dufouil C, Fuhrer R, Dartigues JF, Alperovitch A. Longitudinal analy-
sis of the association between depressive symptomatology and cogni-
tive detoriation. Am J Epidemiol 1996;144(7):634–41.
[20] Fava M, Rankin MA, Wright EC, Alpert JE, Nierenberg AA, Pava J,
et al. Anxiety disorders in major depression. Compr Psychiatry 2000;
41(2):97–102.
[21] Fichter MM, Bruce ML, Schröppel H, Meller I, Merikangas K. Cog-
nitive impairment and depression in the oldest old in a German and in
US communities. Eur Arch Psychiatry Clin Neurosci 1995;245:319–
25.
[22] Flint AJ. Epidemiology and comorbidity of anxiety disorders in the
elderly. Am J Psychiatry 1994;151:640–9.
[23] Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A prac-
tical method for grading the cognitive state of patients for the clini-
cian. J Psychiatr Res 1975;12(3):189–98.
[24] Ford DE, Cooper-Patrick L. Sleep disturbances and mood disorders:
an epidemiologic perspective. Depress Anxiety 2001;14:3–6.
[25] Fuhrer R, Antonucci M, Gagnon M, Dartigues JF, Barberger-
Gateau P, Alperovitch A. Depressive symptomatology and cognitive
functioning: an epidemiological survey in an elderly community
sample in France. Psychol Med 1992;22:159–72.
[26] Gater R, Tansella M, Korten A, Tiemens BG, Mavreas VG,
Olatawura MO. Sex differences in the prevalence and detection of
depressive and anxiety disorders in general health care settings. Arch
Gen Psychiatry 1998;55:405–13.
[27] Hammen C. Live events and depression: the plot thickens. Am J
Community Psychol 1992;20(2):179–93.
[28] Harlow BL, Cohen LS, Otto MW, Spiegelman D, Cramer DW. Preva-
lence and predictors of depressive symptoms in older premenopausal
women: the Harvard Study of Moods and Cycles. Arch Gen Psychia-
try 1999;56(5):418–24.
[29] Henderson AS, Jorm AF, Mackinnon A, Christensen H, Scott LR,
Korten AE, et al. The prevalence of depressive disorders and the
distribution of depressive symptoms in later life: a survey using Draft
ICD-10 and DSM-III-R. Psychol Med 1993;23:719–29.
[30] Heun R, Muller H. Interinformant reliability of family history infor-
mation on psychiatric disorders in relatives. Eur Arch Psychiatry Clin
Neurosci 1998;248(2):104–9.
204 R. Heun, S. Hein / European Psychiatry 20 (2005) 199–204
[31] Heun R, Burkart M, Maier W. Selection biases during recruitment of
patients and relatives for a family study in the elderly. J Psychiatry Res
1995;29(6):491–504.
[32] Heun R, Hardt J, Burkart M, Maier W. Validity of the family history
method in relatives of gerontopsychiatric patients. Psychiatry Res
1996;62(3):227–38.
[33] Heun R, Muller H, Papassotiropoulos A. Differential validity of
informant-based diagnoses of dementia and depression in index sub-
jects and in their first degree relatives. Soc Psychiatry Psychiatr
Epidemiol 1998;33(10):510–3.
[34] Heun R, Papassotiropoulos A, Jessen F, Maier W, Breitner JCS. A
family study of Alzheimer’s disease and early-onset and late-onset
depression in elderly patients. Arch Gen Psychiatry 2001;58(2):
190–6.
[35] Husaini BA. Predictors of depression among the elderly: racial differ-
ences over time. Am J Orthopsychiatr 1997;67(1):48–58.
[36] Judd LL. Social phobia: a clinical overview. J Clin Psychiatry 1994;
55:5–9.
[37] Judd LL, Akiskal HS, Paulus MP. The role and clinical significance of
subsyndromal depressive symptoms (SSD) in unipolar major depres-
sive disorder. J Affect Disord 1997;45(1–2):17–8.
[38] Kendler KS, Thornton LM, Gardner CO. Genetic risk, number of
previous depressive episodes, and stressful life events predicting onset
of major depression. Am J Psychiatry 2001;158(4):582–6.
[39] Kennedy GJ, Kelman HR, Thomas C, Wisniewski W, Metz H,
Bijur PE. Hierarchy of characteristics associated with depressive
symptoms in an urban elderly sample. Am J Psychiatry 1989;146(2):
220–5.
[40] Kennedy GJ, Kelman HR, Thomas C. The emergence of depressive
symptoms in late life: the importance of declining health and increas-
ing disability. J Community Health 1990;15(2):93–104.
[41] Kessler RC, McGonagle KA, Nelson CB, Hughes M, Swartz M,
Blazer DG. Sex and depression in the National Comorbidity Survey.
II: Cohort effects. J Affect Disord 1994;30:15–26.
[42] Kivelä SL, Kongas-Saviaro P, Laippala P, Pahkala K, Kesti E. Social
and psychosocial factors predicting depression in old age: a longitu-
dinal study. Int Psychogeriatr 1996;8(4):635–44.
[43] Leckman JF, Sholomskas D, Thompson WD, Belanger A, Weiss-
man MM. Best estimate of lifetime psychiatric diagnoses: a method-
ological study. Arch Gen Psychiatry 1982;39(8):879–83.
[44] Lehtinen V, Joukamaa M. Epidemiology of depression: prevalence,
risk factors and treatment situation. Acta Psychiatr Scand 1994;377:
7–10.
[45] Lichtenberg PA, Ross T, Millis SR, Manning CA. The relationship
between depression and cognition in older adults: a cross-validation
study. J Gerontol 1995;50(1):5–32.
[46] Lieb R, Isensee B, Hofler M, Pfister H, Wittchen HU. Parental major
depression and the risk of depression and other mental disorders in the
offspring: a prospective-longitudinal community study. Arch Gen
Psychiatry 2002;59(4):365–74.
[47] Lindeman S, Kaprio J, Isometsa E, Poikplainen K, Heikkinen M,
Hamalainen J, et al. Spousal resemblance for history of major depres-
sive episode in the previous year. Psychol Med 2002;32(2):363–7.
[48] Livingston G, Blizard B, Mann A. Does sleep disturbance predict
depression in elderly people? A study in inner London. Br J Gen Pract
1993;43(382):236.
[49] Maier W. Onset and course of affective disorders in subjects at risk: a
prospective family study. Psychiatr Annu 1996;26(6):315–9.
[50] Maier W, Lichtermann D, Minges J, Heun R, Hallmayer J, Klingler T.
Unipolar depression in the aged: determinants of familial aggregation.
J Affect Disord 1991;23(2):53–61.
[51] Meller I, Fichter MM, Schropel H. Risk factors and psychosocial
consequences in depression of octo- and nonagenerians: results of an
epidemiological study. Eur Arch Psychiatry Clin Neurosci
1997;247(5):278–87.
[52] Prigerson HG, Reynolds 3rd CF, Frank E, Kupfer DJ, George CJ,
Houck PR. Stressful life events, social rhythms, and depressive symp-
toms among the elderly: an examination of hypothesized causal link-
ages. Psychiatry Res 1994;51(1):33–49.
[53] Prince MJ, Harwood RH, Blizard RA, Thomas A, Mann AH. Social
support deficits, loneliness and life events as risk factors for depres-
sion in old age. The Gospel Oak Project VI. Psychol Med 1997;27(2):
323–32.
[54] Prince MJ, Harwood RH, Thomas A, Mann AH. 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 1998;28(2):337–50.
[55] Prince MJ, Beekman ATF, Deeg DLH, Fuhrer R, Kivela SL,
Lawlor BA, et al. Depression symptoms in late life assessed using the
EURO-D scale. Br J Psychiatry 1999;174:339–45.
[56] Ptok U, Seeher C, Jessen F, Papassotiropoulos A, Heun R. Inter-rater
reliability of family-history information on psychiatric disorders in
relatives. Eur Arch Psychiatry Clin Neurosci 2001;251(6):279–83.
[57] Roberts RE, Kaplan GA, Shema SJ, Strawbridge WJ. Does growing
old increase the risk for depression? Am J Psychiatry 1997;154:1384–
90.
[58] Roberts RE, Kaplan GA, Shema SJ, Strawbridge WJ. Prevalence and
correlates of depression in an aging cohort: The Almeda County
Study. J Gerontol 1997;52b(5):252–8.
[59] Salokangas RKR, Poutanen O. Risk factors for depression in primary
care. Findings of the TADEP project. J Affect Disord 1998;48:171–
80.
[60] Schoevers RA, Beekman AT, Deeg DJ, Geerlings MI, Jonker C, Van
Tilburg W. Risk factors for depression in later life; results of a
prospective community based study (AMSTEL). J Affect Disord
2000;59(2):127–37.
[61] Sherbourne CD, Wells KB, Hays RD, Rogers W, Burnam MA,
Judd LL. Subthreshold depression and depressive disorder: clinical
characteristics of general medical and mental health speciality outpa-
tients. Am J Psychiatry 1994;151:1777–84.
[62] Small GW, Chen ST, Komo S, Ercoli L, Miller K, Siddarth P, et al.
Memory self-appraisal and depressive symptoms in people at genetic
risk for Alzheimer’s disease. Int J Geriatr Psychiatry 2001;16(11):
1071–7.
[63] Steffens DC, Skoog I, Norton MC, Hart AD, Tschanz JT, Plass-
man BL, et al. Prevalence of depression and its treatment in an elderly
population. Arch Gen Psychiatry 2000;57:601–7.
[64] Stein MB, Fuetsch M, Muller N, Hofler M, Lieb R, Wittchen HU.
Social anxiety disorder and the risk of depression: a prospective
community study of adolescents and young adults. Arch Gen Psychia-
try 2001;58(3):251–6.
[65] Van Ojen R, Hooijer C, Bezemer D, Jonker C, Lindeboom J, Van
Tilburg W. Late-life depressive disorder in the community. Br J
Psychiatry 1995;166:311–5.
[66] Wang J, Patten SB. Prospective study of frequent heavy alcohol abuse
and the risk of major depression in the Canadian general population.
Depress Anxiety 2002;15(1):42–5.
[67] Weyerer S, Hafner H, Mann AH, Ames D, Graham N. Prevalence and
course of depression among elderly residential home admissions in
Mannheim and Camden, London. Int Psychogeriatr 1995;7(4):479–
93.
[68] World Health Organization. Composite international diagnostic inter-
view. Geneva: World Health Organization, Division of Mental Health;
1990.