Examination of the Impact of Living Arrangements and Marital Status on Depression among Older Adult Male Veterans

Project Title: Examination of the Impact of Living Arrangements and Marital Status on Depression among Older Adult Male Veterans Background: As the older adult population grows, depression rates are also on the rise. This is especially evident among American veterans, who experience a depression incidence close to 30%, making it one of the most common diagnoses treated within the Veterans Health Administration (Hankin, Spiro, Miller et al, as cited in Cully, Zimmer, Khan & Petersen, 2008). Objective: The purpose of this study is to identify key demographic variables associated with depression among older male veterans. The results could help improve patterns of care, hopefully improving the management of depression. Method: This retrospective descriptive study uses existing medical record data to identify patterns of factors commonly occurring in veterans with depression. Demographic variables, depression screening scores, and patterns of International Statistical Classification of Diseases and Related Health Problems 9th Revision (ICD9 codes) are analyzed for patterns that can improve care. Results: Descriptive findings and relevant correlations are reported with recommendations to improve care for adult older adult male veterans diagnosed with depression. DEPRESSION AMONG OLDER ADULT MALE VETERANS 3 Examination of the Impact of Living Arrangements and Marital Status on Depression among Older Adult Male Veterans: AN HONORS THESIS Introduction The older adult population is a large portion of the population of the United States, and will continue to grow in the coming years as the “baby-boomer” generation ages. According to the United States Census Bureau, 13.3% of the U.S. population was sixty-five and older in 2011. Many members of the older adult population are also veterans. According to the US Census Bureau, there were 21.8 million veterans in our nation in 2010, 20.2 million of them men (US Census Bureau, 2010). This study investigates the relationship between depression, marital status and living arrangements, in a sample of older adult veterans. The data analyzed for this research is from the medical records of veterans sixty-five years and older. In order to be medically diagnosed with depression, one must meet specific criteria. Major Depressive Disorder (MDD) is generally diagnosed as a result of a persistent low mood and lack of a positive affect. One most also meet at least 4 additional MDD criteria symptoms for at least two weeks. This study is important for maximizing the quality of care for the veteran population. Recognition of factors and measures that create improvements in depression status as veterans grow older has the potential to improve their health and well-being and reduce health care costs. DEPRESSION AMONG OLDER ADULT MALE VETERANS 4 Review of the Literature In order to be diagnosed with Major Depressive Disorder (MDD), one generally manifests a persistent low mood and lack of positive affect, along with various other symptoms. One must also manifest 4 additional MDD diagnosis criteria symptoms for at least two weeks. Examples of additional symptoms include weight or appetite changes, insomnia, decreased concentration, decreased energy and feelings of worthlessness. See Appendix A for further details of MDD diagnoses (VA, 2009). Cully, Zimmer, Khan and Petersen (2008) found that less than fifty percent of patients with newly diagnosed depression received quality care. The most likely reason for delayed follow-up care for depression is due to the vast size of the VHA health care system. Older adults with a history of anxiety or depression were more likely to participate in treatment because of their previous experience (Garrido, Kane, Kane and Kaas, 2009). These researchers also confirmed that the more experience people have with medical care, the more likely they are to recognize personal health care needs because they are more knowledgeable of and comfortable with their health care needs. The large sample size (n=1339) lends strength to this study. Zhang and Li (2011) analyzed the impact of social support systems within the older adult population. Relationships between gender and depressive symptoms and marital status and depressive symptoms were explored. Based on previous research, Zhang and Li state that the rates and severity of depression were higher among widowed people compared to their own prebereavement levels and to their married counterparts. Additionally, Zhang and Li found that the lack of social support is one of the most critical factors affecting depression in elderly people. Depression levels were significantly higher in the elderly who were widowed than those who DEPRESSION AMONG OLDER ADULT MALE VETERANS 5 were married. Furthermore, a spouse is considered the most important source of family support, providing emotional and material support. With the loss of a spouse, the older adult loses one of the most influential people in his or her life which can lead to stronger and more lasting bereavement. Liang, Brown, Krause, Ofstedal and Bennett (2005) explored the relationship between marital status, living arrangements and depression. Living arrangements tend to be very highly associated with the psychological status and overall functioning of unmarried older adults. This association is not nearly as high for married older adults. Unmarried older adults are more likely to reside with children or other loved ones compared to married older adults. Overall, unmarried older adults tend to have less support in their lives as they grow older than that of married older adults, especially in the areas of mental and physical health support. Following are examples that indicate that being in a marital relationship is one of the best ways to experience successful aging. Married people tend to be more accountable to each other for their own health and monitor their own health behaviors and those of their partner. Married people usually have a higher income and can therefore afford better health care, healthier food and a safer home. Spouses can provide effective emotional support for each other on a daily basis which can help deduce health probems that relate to poor overall health. This study showed the association between living arrangements and marital status. Marriage generally means that one is living with a spouse, while an unmarried person is much more likely than a married person to live alone. A few exceptions to this statement are if a spouse is in a long-term care facility or is unable to manage care of the spouse for another reason. Another conclusion from this data is that those who are married can better cope with poor health and uphold current living conditions than the unmarried (Liang et al., 2005). DEPRESSION AMONG OLDER ADULT MALE VETERANS 6 Ferri, James & Pruchno (2009) also researched social support in the older adult population, but in a different manner. They studied older adults’ views of successful aging. The most significant factors include: activity/exercise, physical health, social relationships, and psychological/ cognitive health. Within the sample, 27% of participants had depression scores within a clinically significant range. One drawback to this study was a small sample size; another was that the amount of missing data for total Center for Epidemiological Studies Depression Scale (CES-D) score may have impacted analysis. The researchers recommend further research on the relationship between depressive symptoms and a subjective assessment of successful aging in depressed and non-depressed older adults. Overall, the primary finding from this study is that perception of health status is more strongly related to successful aging than actual physical health status (Ferri, James & Pruchno, 2009). Research Questions Within the older adult male veteran population: • What is the relationship between marital status and depression screening scores? • What is the relationship between living arrangements and depression screening scores? Study Design and Methods Since the present study is a segment of a larger one, (Twohy, Meijer, McCue, 2011), a bit of information about the larger study can aid the reader’s understanding. The study design was a repeated measure, retrospective descriptive study. Arrangements were made for data collection with the director of research at the St. Cloud VAHCS, the Decision Support System (DSS), the DEPRESSION AMONG OLDER ADULT MALE VETERANS 7 primary investigator (required to be a VA employee), and faculty co-investigators. Beginning December 31, 2007, 1200 inpatient and outpatient records were screened for the inclusion criteria (ICD-9 codes for depression, alcohol use/abuse, and falls). On initial extraction, there were 98 inpatient cases and 645 outpatient cases. Since the study call protocol called for 200 outpatients, PAWS-20 random sample generator was used to reduce the outpatient group to 200. Preliminary data were downloaded to excel files, cleaned, formatted, and then de-identified creating a preliminary database for analysis. A number of protections are required for accessing personal health information (PHI) of veterans receiving health services from the VAHCS. The primary and co-investigators participated in the extensive research training required by the VAHCS. ‘Request to review the research proposal’ and ‘application for initial review of medical records-only research’ were submitted and approved by the St. Cloud VAHCS Research and Development (R&D) Committee and affiliate Institutional Review Board (IRB). Careful consideration was taken by the R&D and IRB to review the study for the welfare and protection of human subjects. The proposal was expedited by IRB, as the data were all retrospective and the study was considered minimal risk. Waiver of requirement for informed consent and HIPAA authorization was granted due to the retrospective nature of the study. The primary and co-investigators followed the requirem