Mental health is increasingly recognized as an important component of overall health status. One of the most widely used health status assessment instruments, the Short-Form 36 (Ware and Sherbourne, 1992), contains both physical and mental health scales in recognition of the key role of emotional health in overall well-being. Quality of life, while conceptually related to mental health, addresses broader issues of life circumstances and individuals' feelings about various aspects of their lives (McDowell and Newell, 1987). The inclusion of life quality as a health and medical outcome is increasingly common, in part as a result of the increased emphasis on patient and consumer perspectives on health and health care.
The Women's Health and Aging Study (WHAS) examines selected aspects of mental health and general well-being. These include depressive symptoms as measured by the Geriatric Depression Scale (GDS; Yesavage et al., 1983), life quality assessed with the Perceived Quality of Life Scale (PQOL; Patrick et al., 1988), anxiety, and personal mastery. All indicators were administered in the baseline interview and repeated every 6 months over the 3-year followup.
Depressive symptomatology is common, affecting 12 percent to 20 percent of elderly people residing in the community (Comstock and Helsing, 1976; Eaton and Kessler, 1981; Frerichs et al., 1981; Murrell et al., 1983); the very old have higher rates (Blazer et al., 1991; Gatz and Hurwicz, 1990). There is substantial evidence that depressive symptomatology is associated with poorer physical, social, and role functioning than physical illness alone (Wells et al., 1989). Depression is associated with increased risk of cardiovascular events (Booth-Kewley and Friedman, 1987; Carney et al., 1990) and has been found to predict poorer recovery from myocardial infarction (Stern et al., 1976, 1977), stroke (Feibel and Springer, 1982), hip fracture (Magaziner et al., 1990), and disability (Gurland et al., 1988). While depressive symptoms are typically considered indicative of poor health and physical decline (Cohen-Cole and Stoudemire, 1987; Rodin and Voshart, 1986), some studies suggest that depressive symptomatology and related psychosocial factors may precipitate decline (Aneshensel et al., 1984; Gurland et al., 1988).
Prevalence of depressive symptomatology can vary with the assessment approach (Newmann, 1989). Clinical diagnostic criteria may underestimate depression among elderly people, in contrast to symptom scales, which generally yield higher prevalence estimates (Gallo et al., 1994). In the WHAS, the GDS was selected to measure depressive symptoms because it is less complicated and more sensitive than other commonly used scales and has high sensitivity and specificity for identifying depression diagnosed according to both Research Diagnostic Criteria (Spitzer et al., 1978) and DSM-III criteria (American Psychiatric Association, 1980; Norris et al., 1987). In addition, it has been found to be a valid measure of depressive symptoms in persons with mild to moderate dementia (Feher et al., 1992). Only one item in the scale is related to somatic symptoms, making it preferable for use with chronically ill and disabled persons like the women participating in the WHAS. The GDS takes 8 to 10 minutes to administer and consists of 30 items that require a yes or no response. Scores can range from 0 to 30, with higher scores indicating more depressive symptomatology. A score of 10 or below indicates no symptoms; scores of 14 or above indicate moderate to high levels of depressive symptomatology (Norris et al., 1987).
Table 8.1 presents the mean GDS score, percentage with at least mild depressive symptomatology, and the percentage with a moderate to high level of depressive symptoms for the total population, and for each age group and disability level. About one-third of these disabled older women exhibited some depressive symptomatology, but substantially fewer-17 percent-had a moderate to high level of symptoms. Prevalence of depressive symptoms declined with age. Among women age 65 to 74 years, 19 percent were in the moderate to high range, in contrast to 14 percent of women age 85 years and older. Prevalence of depressive symptoms was similar for women with moderate disability and those who reported difficulty with ADLs but did not receive help. It increased dramatically for the most severely disabled, however. Among moderately disabled women, 27 percent had at least mild symptomatology and 13 percent had a moderate to high level of symptoms. Among the most disabled women, the comparable estimates were 47 percent and 29 percent.
The PQOL scale consists of 20 items and measures satisfaction with a broad range of life domains, including physical, psychological, and social. It incorporates areas of dysfunction included in the Sickness Impact Profile, a widely used and researched instrument (Bergner et al., 1981), and validation studies are ongoing (Danis et al., 1988; Norburn et al., 1987). For 19 of the items respondents indicate their level of satisfaction on a scale ranging from 0 (extremely dissatisfied) to 10 (extremely satisfied). For 1 item, respondents indicate their level of happiness from 0 (extremely unhappy) to 10 (extremely happy). The scale may be used as a simple summary of scores across the individual items or as a mean score of the items. Three subscales, which the developers have identified as measures of physical, social, and cognitive health (Patrick et al., 1988), may also be created. The items comprising these subscales are indicated in the footnotes to Table 8.3.
To simplify presentation of the data and to provide the distribution of both low and high levels of satisfaction, the 11-point scale was categorized as follows: dissatisfied (0-3), neutral (4-6), and satisfied (7-10). Table 8.2 presents the percentage dissatisfied, neutral, and satisfied for each item for the total population and by age group and disability level. Table 8.3 provides mean full scale and subscale scores and the percentage scoring in the low, medium, and high range of the scales.
Among these older disabled women, the highest rates of dissatisfaction were observed for amount of walking, physical health, and frequency of getting outside the house (Table 8.2). All of these items are related to health and functional status. Consistent with this trend, only 50 percent fell in the high satisfaction range of the physical health subscale, compared with over 75 percent for the cognitive and social health subscales (Table 8.3). Just under one-fifth of the WHAS population was dissatisfied with the way their income meets their needs. Between 10 and 15 percent reported dissatisfaction with ability to care for themselves, contributions to their community, their retirement, their recreation or leisure activities, their level of sexual activity, the amount of variety in their lives, and sleep habits. The percentage of women in the dissatisfied range on other items was 10 percent or less. On the global question concerning happiness, three-quarters of these women fell into the happy to very happy range.
Level of satisfaction varied by age on some individual items in the PQOL. For example, higher percentages of the oldest women, compared with the others, were satisfied with their physical health and amount of walking. A higher percentage of the youngest women, on the other hand, were dissatisfied with how well they care for themselves, and neutral or dissatisfied with the way their income meets their needs. On the subscales, age differences were small. Only on the cognitive health subscale did the percentage highly satisfied decline with age.
On almost every individual item there was a gradient from dissatisfied to satisfied by disability level, with moderately disabled women expressing the most satisfaction and severely disabled women the least. Among those receiving help with ADLs, 32 percent were dissatisfied with their physical health, 30 percent with how well they care for themselves, 36 percent with how often they get outside their home, and 27 percent with their contribution to the community. Comparable percentages for moderately disabled women ranged from a high of 18 percent to a low of 5 percent. The overall scale and the physical health and social health subscales also indicate a decrease in the percentage of women in the satisfied range with increasing disability. The cognitive health subscale showed only a slight trend by disability level, however.
Fear and anxiety may have a significant effect on functional status and disability. Fear of unfamiliar places and anxiety over leaving the home, for example, can have important implications for a host of practices known to affect function, such as engaging in physical activity and maintaining social interaction. One specific fear, related to falling, has been found to contribute to limitations in physical functioning (Tinetti et al., 1994) (see Chapter 13).
Only a few brief measures of anxiety are appropriate for use in population-based surveys of community-dwelling elderly. Four of the seven items in the anxiety subscale of the Hopkins Symptom Checklist (HSCL; Derogatis et al., 1974) were used to measure symptoms of anxiety in the WHAS. The HSCL and its subscales are widely used and well studied. The four anxiety items selected were chosen on the basis of their face validity. The three that were excluded are largely somatic. Respondents were asked, in the past week, how frequently (not at all, a little, quite a bit, and extremely) they felt nervous or shaky inside; had to avoid certain things, places, or activities because they frightened them; felt tense or keyed up; or felt fearful.
Table 8.4 presents the percentage distribution of responses to each of the anxiety symptoms for the total population and for the age and disability subgroups. The percentage with none, one, or two or more symptoms is also provided. Women expressing considerable anxiety (quite a bit or extreme frequency of symptoms in the past week) represented a small percentage of the overall population, ranging from a little over 10 percent who felt nervous or shaky inside or tense or keyed up, to 5 percent who felt fearful and 3 percent who avoided things, places, or activities out of fear. About one-fifth of these women experienced at least one symptom, however, and another fifth reported experiencing two or more symptoms. There were few differences by age on individual items or the percentage experiencing one or more symptoms. The most disabled women were more likely to report at least one symptom, about half compared with 37 percent of moderately disabled women. For the individual symptoms, among women receiving help in ADLs, about one-third reported feeling nervous or shaky inside, or tense or keyed up. About one-quarter of moderately disabled women reported these symptoms.
Sense of personal control over health outcomes has emerged as a potentially important factor in the maintenance of physical function (Rodin, 1986). To minimize respondent burden, only the two items most representative of the personal mastery dimension were selected from Pearlin and Schooler's (1978) work on the structure of coping. The two items are "I can do just about anything I really set my mind to" and "I often feel helpless in dealing with the problems of life." For each item there are four response options, ranging from strongly agree to strongly disagree.
Table 8.5 lists the response distribution for each of the mastery items. In this population of disabled women, 46 percent agreed strongly that they can do what they set their minds to, and 37 percent disagreed strongly that they feel helpless in dealing with the problems of life. About 10 percent were at the opposite extreme, expressing helplessness. Women age 65 to 74 years were more likely to disagree strongly with feeling helpless in dealing with life than women age 85 years or older, one-third of whom agreed somewhat or strongly. Women with ADL difficulty who received help were more likely to express helplessness than others. Twenty percent agreed strongly that they often feel helpless in dealing with the problems of life, compared with 9 percent of moderately disabled women. Similarly, 16 and 6 percent, respectively, disagreed strongly with the statement that they could do anything they set their minds to.
Overall, the prevalence of mental health problems as indicated by depressive symptomatology was low. Quality of life indicators across physical, social, and cognitive domains also suggest high levels of satisfaction. The most severely disabled women exhibit the poorest mental health and lowest levels of satisfaction, particularly in areas related to physical capacity. On the whole, however, this population of community-resident disabled women exhibits relatively good mental health and expresses a high degree of general well-being.
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