The Relationship between Mental Health andSelf-rated Health in Older Adults
Ai Nakano

September 2014
Discussion Paper No.1423

GRADUATE SCHOOL OF ECONOMICS
KOBE UNIVERSITYROKKO, KOBE, JAPANThe Relationship between Mental Health and Self-rated Healthin Older Adults※
Ai Nakano
Research Fellow, Graduate school of economics, Kobe University

Abstract
In this study, the relationship between mental health measured by the CES-D scale andself-rated health (SRH) in older Japanese adults was examined using longitudinalmicro datasets from the National Survey of the Japanese Elderly (NLSG). Twoequations for the relationship between mental health and SRH are estimatedsimultaneously, and the results showed that SRH had an effect on mental health, andmental health had an effect on SRH. Thus, the mind and body are connected andinfluence each other. We also determine other important factors that influence health.
Age, gender, physical activity, functional abilities such as ADL and IADL, and economic
status are associated with both mental and perceived health; having a chronic illness isstrongly associated with perceived health; and interpersonal relationships have aneffect on mental health. he results suggest that older adults should work on both mind
and body to live healthy lives.
Key words: mental health, self-rated health, the mutual dependence of mind and body※

The data for this secondary analysis, "National Survey of the Japanese Elderly (NLSG),

the University of Michigan and the Tokyo Metropolitan Institute of Gerontology," wasprovided by the Social Science Japan Data Archive, Center for Social Research and Data
Archives, Institute of Social Science, The University of Tokyo. I wish to thank theparticipants for permission to use these data.

11. Introduction
It is difficult for older adults to stay healthy. Many older adults seek methods foracquiring, maintaining, and enforcing body and mental health. Considerable research
has shown that lower perceived health or poor self-rated health (SRH) predicts
long-term declines in functional ability (Wilcox et al., 1996) and poorer SRH is a robust
predictor of mortality in older adults (Kaplan & Camacho, 1983; Mulsant et al., 1997).
Therefore, many older adults are mindful of their health status.
Perceived health or SRH can be explained by many variables, such as chronic illness(Barsky et al., 1992); lifestyle, including exercise, diet, and smoking (Han, 2002; Rohrer
et al., 2004; Sargent-Cox et al., 2014); social support (Hirdes & Forbes, 1993;
Zunzunnegui et al., 2001); marital status (Hirdes & Forbes, 1993); job stress (Shimizu &Nagata, 2005); job security (Ferrie et al., 2001); effort/reward imbalance at work
(Pikhart et al., 2001); income and inequality (Franks et al., 2003; Weich et al., 2002);
and housing quality (Dunn, 2002). Importantly, SRH is related to mental health,including depression and vitality (Burns et al., 2013). Depressive symptoms also affectthe risk of fiscal disability (Bruce & Merrill, 1994), and a nursing study showed thatcritical thinking is related to perceived health status (Settersten & Lauver, 2004).
Moriyama et al. (2004) studied the relationship between physical condition and mental
health in elderly people living in Okinawa, Japan, and found that subjective well-being
was strongly affected by subjective health and ADL, and there was a correlation
between mental health and physical condition.
Mental health is also affected by physical health. A number of studies have foundthat depressive symptoms are strongly associated with illness or poorer SRH (Blazer etal., 1991; Callahan et al., 1994; Han, 2002; Kenedy et al., 1990; Terner & Beiser, 1990).
2

Physical disorders such as loss of appetite and sleeplessness are symptoms ofdepression, and older people may exhibit high rates of depressive symptoms because ofphysical problems (Davidson et al., 1994; Pijils, et al., 1993). Thus, older people in poor
physical condition have a high risk of serious depression.
Together, previous results suggest that mental health, e.g., well-being or depression,and physical health are related. In this study, we will verify the relationship between
mental health and somatic, physical health in older adults. Self-rated, perceived healthis clearly related to objective health status (Scott et al., 1999; Liang, 1986; Rodin &McAvay, 1992), and we believe that SRH is strongly related to physical health.
Therefore, in our analysis, the relationship between mental health and physical healthwill be examined by looking at the relationship between mental health and SRH.
Previous medical research has examined the correlation between mental states andphysical conditions using psychological tests. This research found that for patients in a
depressive state, psychological properties correlated with blood pressure and pulse rate,
and for patients with anxiety, psychological properties of hysterical states correlatedwith abnormal respiratory patterns (Ishikawa & Kikuchi, 1976). Naruo (2003) foundthat the growth hormone ghrelin may play an important role in the correlation between
mind and body.

2. Data
Longitudinal micro datasets from the National Survey of the Japanese Elderly(NLSG) were used in our analysis. This data were collected by the University ofMichigan and the Tokyo Metropolitan Institute of Gerontology, and it include six
datasets collected every three years between 1983 and 2002. We pooled two datasets3

from 1999 and 2002 in our analysis because these datasets addressed some particularly
fascinating questions. NLSG surveyed adults who were 60 years old and older in 1983,
and the follow-up survey added samples of older respondents. In 1999, many
individuals in the sample were 70 years old and older.
The NLSG asked respondents about their health conditions (including chronic
illness), lifestyle including exercise, diet, and smoking, social support, marital status,and socioeconomic status e.g., income. We analyzed data from two samples with a totalof 2883 respondents.

3. Measures○mental health
Mental health was assessed with twenty items from the Center for EpidemiologicalStudies Depression Scale (CES-D). Respondents were asked about their depressive
affect ( “I feel nervous,” “I have no appetite,” “I feel depressed,” “I cannot concentrate,” “Ifeel troubled,” “I feel like I failed in my life,” “I feel horrible,” “I cannot sleep well”, “I amtaciturn,” “I feel lonely,” “I feel alienated,” “I wanted to cry,” “I feel sad,” “I feel that I am
disliked,” and “I cannot get motivated”) and well-being (“I have confidence in my ability,”“I feel that the future is bright,” “I feel happy,” and “I feel gay”). Respondents wereasked how many times they experienced the feelings listed above in the past week.
Well-being items are scored as follows: 3 = 5~7 days per week, 2 = 3~4 days per week, 1= 1~2 days per week, and 0 = they hardly felt that feeling. Depressive affect items arescored negatively. Scale scores can range from 0 to 60. Mental health scores are high if
depressive symptoms are low and well-being is high.
Elderly people tend to have high rates of depressive symptoms, and Davidson et al.
4(1994) showed that CES-D is an appropriate measure of depressive symptoms in theelderly. In our analysis, higher mental health scores indicate good mental health andfewer depressive symptoms.

○self-rated health (SRH)
Subjective health status was measured by the question “Overall, how is yourcurrent health: excellent, very good, good, fair, or poor?” (5 = excellent, 4 = very good, 3 =good, 2 = fair, 1 = poor). Higher SRH scores indicate better health.

○other variables
Respondents were asked about their ability to work without help, measured by the
number of activities of daily living (ADL; take a bath, dress, eat, get up from bed andstand up from chairs, go out, and use the toilet) and number of instrumental activities
of daily living (IADL; go shopping, use telephone, take the bus and train alone, and dolight housework). Respondents are considered to have ADL ability if they do not find it
difficult to engage in all six daily living activities without help, and IADL ability if they
do not find it difficult to complete the four instrumental activities without help.
Respondents were asked if they smoked and about their drinking behavior. To
determine whether respondents could do moderate exercise, a question about physicalactivities like gardening, doing gymnastic exercises, and taking a walk was included. To
determine whether respondents had maintained their physical strength, they wereasked about their ability to move their body without the aid of sticks or tools.
Socioeconomic status was measured by the amount of public pension receipt, private
pension receipt, income, and other revenues such as property revenue and financial
support from others. Respondents were asked about their source of income in the 1999
and 2002 data.
5

Respondents chose one class value for their income level for each income source.
Mean class values were used in the analysis.
Because lack of emotional or instrumental support affects depressive symptoms andhealth, variables about the presence of social support were included. The presence of
key persons was based on whether respondents had social support including emotional
support, sending consideration, financial support, or daily support. Stress from people
who scold or complain and who are an economic burden could affect respondents’ mental
and physical health.
Separation from someone close due to death could lead to sadness, and grief caused
by death could affect depressive symptoms and health conditions.
Chronic illness could affect perceived health and depressive symptoms. Fourteen
chronic diseases were included in the analysis. Finally, socio-demographic variables(age, gender) were examined.

4. Analysis
It is possible that the equations relating mental health and SRH in older adults are
not independent, and estimation using the ordinary least squares (OLS) might beinappropriate in this case. If the error terms of the two equations are correlated, the two
equations should be estimated simultaneously. It is possible that mental health and
SRH are mutually related in older adults, such that mental health affects SRH andSRH also affects mental health. In that case, the estimated equations will be as follows:
Eq.(Mental health) = f1(SRH, age, gender, chronic illness, income…)(1)

Eq.(SRH) = f2(mental health, age, gender, chronic illness, income…)(2)

In equation (1), the SRH variable is correlated with the error term. Similarly, in
6equation (2), the mental health variable is correlated with the error term. The
estimators will be biased if the equations are estimated separately. Therefore, theequations were estimated using Three-Stage Least Squares (3SLS) to eliminate thisbias.
In addition, because data from two periods are used (the question about source ofincome was asked for three periods—1993, 1999, and 2002—and data from the latter
two were used), the two equations are estimated using both fixed and random effects
analyses, and the interaction between the two variables is checked.

5. Results
First, the two equations were estimated as follows:
Eq(Mental health) = f1(age, gender, chronic illness, income.…)(3)

Eq(SRH) = f2(age, gender, chronic illness, income……)(4)

As mentioned above, the error terms of the two equations are correlated, so the two
equations are estimated simultaneously using Seemingly Unrelated Regressions (SUR;
Zellner, 1962). The results of the Breusch-Pagan test indicated that the null hypothesisthat there is no contemporaneous correlation among error terms should be rejected(mental health:χ2=684.73, probability > χ2 ＝ .000; SRH: χ2 = 57.30, probability >χ2 =0.023).
The results for the three stage least squares are shown in Figure 2 and Figure 3.
The results in Table 2 include health condition variables, such as smoking, drinking,body mass index (BMI), ADL, and IADL, and the results in Table 3 include 14 chronic
illnesses instead of health conditions.
In both cases, there is an interdependent relationship between mental health and7

SRH, such that SRH exerts a positive effect on mental health, and mental health exerts
a positive effect on SRH. However, the effect of SRH on mental health is larger,
suggesting that perceived health has a large influence on mental condition in older
adults. This suggests that body and mind are at one and the two functions areinterdependent.
Next, we examine the factors that could influence mental health and SRH. Older
women feel more unhealthy than older men. Moreover, women live longer than men,suggesting that women remain inactive for a longer period of time. In contrast, fewer
women have depressive symptoms compared to men.
Age has a negative influence on health condition, and older people feel moreunhealthy. This suggests that getting older increases the risk for infection as bodyfunction decreases.
Physical abilities such as gardening and exercising enhance mental and perceived
health. These activities invoke a refreshing change of mood and improve physicalfunctions.
Contrary to our expectations, smoking has a positive influence on SRH. It may bethat smoking is refreshing and makes people feel healthy in the short term, eventhough it gradually harms their body and increases the risk for chronic diseases. Thissuggests that the short-term effects of smoking are good for older adults. Drinking
alcohol also has a positive influence on perceived health. Moderate drinking may
contribute to health because it is good for the blood.
Good ADL and IADL have positive effects on mental health and SRH, and arestrongly associated with mental health in older adults. Less decline in body functioning
not only increases feeling of health, but also reduces depressive symptoms in older
8adults. Inconvenience caused by the body might easily lead to feelings of dejection.
Good physical abilities have a positive effect on SRH. Older adults with physicalstrength tend to have strong, healthy bodies1.
Public pension income is strongly associated with mental health, and salary is
associated with SRH. Most elderly people live on their pension income, and some elderly
people receive employment salaries. A stable economic condition gives older adults a
feeling of security, and sufficient money enables older adults to see doctors and get
checks-up at hospitals.
Human relations are strongly associated with mental health in older adults.Having
helpful people around or having good interpersonal relationships is good for mental
health in older people2. Conversely, difficult interpersonal relationships may cause older
adults to worry, and are not good for their mental health.
Finally, suffering from chronic illness has a strong negative influence on perceived
health. In particular, cancer, kidney disease, and chronic respiratory disease werestrongly associated with SRH. Deadly diseases tend to makes older adults perceive thatthey are unhealthy.
Table 4 shows the results from pooled OLS and pooled 2SLS for mental health incolumn one and for SRH in column two. Table 5 shows the panel analysis results formental health and SRH3. Most of the results show mutually influencing relationships.
We checked whether mental and perceived health were correlated, and it is possible

1

The effects of these variables on mental health were not statistically significant, andthese variables were used as identification variables for estimation.
2

The effect of relationships on SRH was not statistically significant, and thesevariables were used as identification variables for estimation.
3Here, we estimated the equations for mental health and SRH independently.
9that the mind and body are mutually dependent in older adults.

6. Conclusion
Medical research suggests that the mind and body are mutually dependent. We
examined the relationship between mental health and SRH in older adults using
micro-data. Our results suggest that SRH affects mental health, and mental health also
affects SRH; the mind and body are connected. These results suggest that a balance
between mind and body (including psychiatric state) is important for good health, andwhen one becomes unhealthy, the other becomes unhealthy, too. This leads to a vicious
cycle in older adults. Therefore, being physically healthy leads to well-being, and ahealthy mind is good for a healthy body. Exercise and a healthy diet are important for
maintaining good health, and it is important to build environments that are good for themind.
This study suggests some future directions. First, this longitudinal analysis was
only based on data from two periods. Studying more periods may provide more accurate
results. Second, although we found many factors that affect mental health or SRH in
older adults, the effects of other psychological factors (e.g., self-efficacy, quality of thelife) should be assessed. We view these as future challenges.

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14

Table 1: Descriptive statistics
Variables
self-rated healthmental healthsexagemarital status
number of children
alcohol consumption
smoking
BMI
physical activity
gardening
gymnastic exercises
take walks
activity of daily life (ADL)
instrumental activity of daily life (IADL)
economic condition
public pension income
personal pension levelsalaryother income
separation by deathfriendspousechild
physical ability
walksquat down and kneel
muscle strength
having key person
to listen to closely
who is thoughtfulprovide financial support
daily support
attitudes of people who are close
scold and complain
financial burden
not feelig alonedisease and illness aftereffects
heart disease
Joint pain, rheumatism, neuralgia
hypertension
diabetes
cerebrovascular disordercancereye diseaseanemiakidney desease
venous inflammation
chronic respiratory diseasechronic lumbago (back) achebone fracture
liver and gallbladder disease

Description
self-rated health condition scores
CES-D score
Dummy variable, female=1
current age
Dummy variable, 1 = married (i.e., thespouse is not dead, missing, or divorced)

mean
SD
3.402
48.3190.554
74.415

0.992
5.371
0.497
6.162

1
9
0
56

5
60
1
99

0.632

0.482

0

1

2.387
0.384
0.180

1.213
0.486
0.384

0
0
0

8
1
1

0.711
0.542
0.610

0.453
0.498
0.488

0
0
0

1
1
1

0.919

0.272

0

1

0.879

0.326

0

1

amount of public pension receipt
amount of private pension receipt
amount of employment income
total amount of property revenue and help from a relative

207.300
6.469
53.07363.615142.315
30.198177.424
134.506

0
0
0
0

1344
420
1344
1434

Dummy variable, 1 = lost close friend during past year
Dummy variable, 1= lost spouse during past year
Dummy variable, 1 = lost child during past year

0.244
0.136
0.439

0.429
0.343
0.496

0
0
0

1
1
1

Dummy variable, 1 = able to walk 200–300 meters
Dummy variable, 1 = able to squat down and kneel
Dummy variable, 1 = 1 able to lift and carry about 10 kg of rice

0.886
0.883
0.767

0.318
0.318
0.423

0
0
0

1
1
1

Dummy variable, 1 = have someone who listens closely
Dummy variable, 1 = have someone who is thoughtful
Dummy variable, 1 = 1 have dependable person who provides financial
support)Dummy variable, 1 = have dependable person for daily support

0.941
0.941

0.235
0.236

0
0

1
1

0.681

0.466

0

1

0.932

0.251

0

1

Dummy variable, 1 = scold and complain
Dummy variable, 1 = financial burden
Dummy variable, 1 = not feeling alone

0.089
0.004
0.853

0.285
0.062
0.355

0
0
0

1
1
1

Dummy variable, 1 = have heart disease or illness aftereffectDummy variable, 1 = have joint pain, rheumatism, or neuralgia
Dummy variable, 1 = have hypertension
Dummy variable, 1 = 1 have diabetes
Dummy variable , 1 = have cerebrovascular disorder and illness aftereffects
Dummy variable, 1 = have cancer
Dummy variable, 1 = have glaucoma, cataract, and eye disease
Dummy variable, 1 = have anemia
Dummy variable, 1 = have kidney disease
Dummy variable, 1 = have venous inflammation
Dummy variable, 1 = have chronic respiratory disease
Dummy variable, 1 = have chronic lumbago (back) ache
Dummy variable, 1 = have bone fracture, bone crack, andaftereffects of a broken bone
Dummy variable, 1 = have a liver and gallbladder disease

0.150
0.169
0.344

0.357
0.375
0.475

0.093
0.021
0.231
0.051
0.030
0.017
0.056
0.207

0.290
0.144
0.421
0.219
0.171
0.131
0.230
0.405

0
0
0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1
1
1

0.032

0.177

0

1

0.041

0.197

0

1

Dummy variable, 1 = drink alcohol
Dummy variable, 1 = smoke cigarettes
BMI values
Dummy variable, 1 = do often or sometimes
Dummy variable, 1 = do often or sometimes
Dummy variable, 1 = do often or sometimes
Dummy variable, 1 = able to do all six activities(taking baths, putting on and taking off clothes, etc.) without difficulty.
Dummy variable, 1 = able to do all four activities(shopping, making a telephone call, etc.) without difficulty.

15

min

max

Table 2: Three stage least squares results (1)self-rated healthmental healthsex (female=1)
agemarrital status
number of children
alcohol consumption
smoking
BMI
physical activity
gardening
gymnastic exercises
take walks
activity of daily life (ADL)
instrumental activity of daily life (IADL)
economic condition
public pension income
personal pension levelsalaryother income
separation by deathfriendspousechild
physical ability
squat down and kneel
muscle strength
having key person
to listen to closely
who is thoughtfulprovide financial support
daily support
attitudes of people who are close
scold and complain
financial burden
not feelig alone
constant
Number of observation
R-squ
chi2
Prob>chi2

mental healthself-rated health
Coef.
S.E
Coef.
S.E
1.073 **
0.431
0.057 ***
0.009
-0.688 ***0.234
0.186 ***
0.043
-0.032 *0.017
0.007 **
0.003
-0.0530.229-0.013
0.042
0.036
0.077
0.012
0.014
0.243
0.217
0.160 ***
0.037
-0.2250.264
0.167 ***
0.046
0.00010.004
0.00020.001
0.411 *
0.279
0.394 *
1.031 **
0.738 *

0.234
0.202
0.216
0.482
0.440

0.104 **
0.073 **
0.107 ***
0.150 *
0.159 **

0.041
0.036
0.037
0.085
0.075

0.002 ***
0.003
-0.0002-0.0003

0.001
0.003
0.001
0.001

-0.0001-0.001 *0.0003 ***0.0001

0.000
0.001
0.000
0.000

-0.2200.144-0.061

0.210
0.258
0.188

0.014
-0.083 *-0.022

0.038
0.047
0.034

0.275 ***
0.453 ***

0.052
0.049

1.096 ***
0.639 *
0.958 ***
1.993 ***
-0.861 ***-9.968 ***2.607 ***
37.946 ***

0.395
0.388
0.197
0.366

-

0.302
1.383
0.274
1.671
2880
0.241
745.670.000-1.037 **

0.488
2880
0.257
832.4
0.000

Note: ***, **, and * indicate significance at the 1%, 5%, and 10% levels, respectively.
We performed the control by regions.

16

Table 3: Three stage least squares results (2)self-rated healthmental healthsex (female=1)
agemarrital status
number of children
physical activity
gardening
gymnastic exercises
take walks
economic condition
public pension income
personal pension levelsalaryother income
separation by deathfriendspousechild
physical ability
squat down and kneel
muscle strength
having key person
to listen to closely
who is thoughtfulprovide financial support
daily support
attitudes of people who are close
scold and complain
financial burden
not feelig alonedisease and illness aftereffects
heart disease
Joint pain, rheumatism, neuralgia
hypertension
diabetes
cerebrovascular disordercancereye diseaseanemiakidney desease
venous inflammation
chronic respiratory diseasechronic lumbago (back) achebone fracture
liver and gallbladder disease
constant
Number of observation
R-squ
chi2
Prob>chi2

mental healthself-rated health
Coef.
S.E
Coef.
S.E
1.468 ***
0.400
0.045 ***
0.009
-0.656 ***-0.6560.060 *
0.036
-0.035 **-0.0350.004
0.003-0.0570.230-0.051
0.040
0.035
0.077
0.006
0.013
0.477 **
0.271
0.408 *

0.234
0.204
0.213

0.100 ***
0.101 ***
0.090 **

0.039
0.034
0.035

0.002 ***
0.003
-0.0002-0.0004

0.001
0.003
0.001
0.001

-0.000002-0.001 *0.0003 ***0.00010.00010.001
0.00010.0001-0.1590.176-0.067

0.211
0.257
0.188

0.041
-0.066-0.016

0.036
0.045
0.033

0.228 ***
0.469 ***

0.048
0.045

1.127 ***
0.535
0.866 ***
1.965 ***

0.393
0.386
0.193
0.361

-

-0.927 ***-9.622 ***2.607 ***

0.298
1.371
0.269

-

-0.462-0.4140.005
0.009-0.560-0.107-0.475-0.8171.238 *
-0.0840.070-0.249-0.7160.719
38.828 ***

0.282
0.265
0.205
0.326
0.438
0.230
0.648
0.427
0.687
0.542
0.411
0.255
0.506
0.475
1.983
2880
0.244
791.090.000-0.258 ***-0.132 ***-0.191 ***-0.217 ***-0.231 ***-0.143 ***-0.417 **-0.179 **-0.043-0.360 ***-0.312 ***-0.218 ***0.129-0.369 ***
0.467

0.045
0.044
0.033
0.054
0.072
0.038
0.108
0.072
0.120
0.092
0.067
0.040
0.088
0.078
0.492
2880
0.33
1278.750.000

Note: ***, **, and * indicate significance at the 1%, 5%, and 10% levels, respectively.
We performed the control by regions.
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Table 4: pooling OLS and pooling 2SLS
the estimation of pooling OLS

self-rated healthmental healthmental healthself-rated health
Coef.
S.E
Coef.
S.E
1.311 ***
0.097
0.054 ***
0.003

the estimation of pooling 2SLS

self-rated healthmental healthmental healthself-rated health
Coef.
S.E
Coef.
S.E
1.081 ***
0.434
0.057 ***
0.009

Note: ***, **, and * indicate significance at the 1%, 5%, and 10% levels, respectively.
We controlled for the variables in Table 3 and region as a dummy variable.

Table 5: Fixed effect and random effect regressions
mental health
Coef.
(Fixed effect)self-rated healthmental health(Random effect)self-rated healthmental health(Fixed effect 2SLS )self-rated healthmental health(Random effect 2SLS)
self-rated healthmental healthself-rated health
Coef.

S.E

0.785 ***-

0.156

1.243 ***-

0.097

2.061 *-

1.196

1.190 ***
-

0.46

S.E

0.028 ***

0.005

0.043 ***

0.003

0.043

0.027

0.057 ***

0.010

Note:***, **, and * indicate significance at the 1%, 5%, and 10% levels, respectively.
We controlled for the variables in Table 3 and region as a dummy variable..

18