Risk Factors Associated With Depression Biology Essay

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The worlds elderly population has been growing. The global population aged 65 and over was estimated from 9.5 million to 420 million people from 1999s to 2000s.The United Nations predicts by the year 2050 one out of every five persons will be aged over 60 years. Also elderly population is rising in Malaysia. The proportion of Malaysian elderly population has grown from 6.3% to 7.4% from 2000 to 2010. It is expected that the proportion of elder population will increase to 12% by 2030 (Rabieyah Mat & Hajar Md. Taha, 2003).Rapid growth in elderly population will be associated with the rise in risk of illness and disability with advancing age such as late life depression and other mental healths ( Heikkinen, Kauppinen 2004, Administration on Aging , 2004). The World Health Organization has predicted that by 2030, more people will be affected by depression than any other health problem (weil, 2009).

Depression is a most common and serious disorder among the older adult population (Alexopoulos, 2005; Cole, 2003). World Health Organization defined depression as a "common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration". Depression is a key threat not only to mental health and well-being in the elderly but also is projected to be the second leading cause of disability world wide in 2020(Schoevers, Geerlings, Deeg, Holwerda, Jonker and Beekman, 2009). A prevalence of depression has reported 0.4-35% in the community-dwelling elderly (Beekman et al, 1999).

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The World Health Organisation, in the year 2007, has reported a high rate of depression with a lifetime risk of 7-12 % for men and 20-25 % for females in the South East Asian Region (Khan T M, Sulaiman Syed A S, Hassali M A, 2009). There are such studies on prevalence of elderly depression conducted in Malaysia, those studies showed different rate of depression among elderly Malaysian. A survey in an urban community in Malaysia has provided evidence that about 6.3% of Malaysian elderly have depression (Sherina M, Sidik Rampal L, Aini M, M Norhidayati H, 2005.). Also Prevalence of depression among elderly with chronic illness in a rural community in Malaysia was 9 %(Sherina Mohd Sidik , Nor Afiah Mohd Zulkefli and A. Mustaqim,2003 ).In other study, prevalence of depression among patients attending a primary health care clinic in Malaysia was 18% (Sherina Mohd Sidik, Nor Afiah Mohd Zulkefli and Shamsul Azhar Shah,2003 ). WHO (2005)accented that depression, as the fourth most common illness, could lead to physical, emotional, social and economic problem. Depression has many consequences such as increasing the morbidity and mortality (Schoevers, et al 2009), more dependency, both lower ADL, life satisfaction and quality of life (Wada, Ishine, Sakagami, Okumiya, Fuisawa, Murakami,Otsuka, Yano, kita, Matsubayashi; 2004). Also elderly depression are more self-neglect, (Abrams et al., 2002) substance abuse (Devanand, 2002). As well as Lack of social support will increase the risk of loneliness and leads development of depression in old age (Freyne, et al 2005). Studies showed that different factors could cause depression among elderly population such as functional disability (Braam, Prince, Beekma, Delespaul, et al, 2005), inactivity (Castro, Giani, Ferreira, Bastos, Cruz, Boechat, Dantas, 2009), sex, marital status, education status, income and place of residence (Sherina Mohd Sidik, Nor Afiah Mohd Zulkefli and Shamsul Azhar Shah, 2003). It is that Depression is the fourth most disabling disease in Malaysia; ranking third for women and 10th for men (Malaysian Psychiatric Association, 2008) also has extensive consequences on elderly health. Additionally Identifying depression among community-living elders has been problematic. Because of depression is misdiagnosis and under treated in the elderly. The elderly may incorrectly attribute depressive symptoms to the aging process (NIH, 1991,Mandos, 1996).

Unfortunately there are few studies about this subject in Malaysia. These studies identify depression among specific population (such as elderly with chronic diseases, visual impairment and attending in primary health care clinic) and the small sample size (Sherina Mohd Sidik , Nor Afiah Mohd Zulkefli and Shamsul Azhar Shah 2003 ; Naqiah Hairi Noran, Muldha Ghazali Izzuna, Awang Mahmud Bulgiba, Zahari Mimiwati and Said Mas Ayu, 2008 ; Sherina Mohd Sidik, Nor Afiah Mohd Zulkefli and A. Mustaqim,2003). Therefore a little is known about depression and the related factors in general population.

Problem statement

The factors associated with depression in late life are multiple and vary between individuals and population. Research on depression in late life has identified that depression in late life associated with biological, psychological and social factors(George,1994; Kurlowicz 1993) and also few studies contributed theses three aspects in their empirical investigation on elderly depression (Masuchi and Kishi, 2001, Ahn 2006 ). Additionally it still is less understood depression in late life and many of affecting factors reminded inconsistent(Gao, Jin, Unverzagt, Liang, Hall, Ma, Murrell, Cheng, Matesan, Li, Bian and Hendrie,2009, Kaneko, Motohashi, Sasaki, Yamaji,.2007, Cole and Dendukuri, 2003; Vink et al., 2008 ). The results of previous studies regard to many risk factors including older age, female gender, low education, cognitive impairment(Cole and Dendukuri, 2003; Vink et al., 2008) , living alone (Chiung Ho,2003) area of residence(Murata, Kondo, Hirai, Ichida, Ojima 2008) and race/ ethnicity( Bracken & Reintjes ,2010) have been remained unclear. Whereas depression is associated with various specific chronic illnesses and functional status but it still is ambiguous that which a particular disease causes or contribute to depression(Matthew Niti, Tze-Pin Ng,Ee Heok Kua, ,Roger Chun Man Ho And Chay Hoon Tan,2007). Based on the finding of the studies and the importance of depression and related factors there is a need to conduct a study to fulfil the gaps.

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According to Facing rapid population aging, functional limitation and serious concerns about Increasing care giving burden Also the relationship between social support and depression in the elderly remains controversial (Keum Y. Pang,1998 , Kai-Kuen Leung, Ching-Yu Chen, Bee-Horng Lue, Shih-Tien Hsu ,2006, Muramatsu , Yin , Hedeker ,2010).

Most studies have examined the associations among the social environment, life challenge, and health outcomes have been based on Western populations (Beckett, Goldman, Weinstein, Lin, and Chuang2002). Also the much of this evidence about the relationships between marital status, health and gender with depression is based on Western populations. According to different response patterns to depression scale by culture, fewer studies have been conducted in Asian cultures (Soong-NangJang, Ichiro Kawachi ,JiyeunChang ,KachungBoo ,Hyun-GuShin, HyejungLee,Sung-ilCho,2009). There is need to more research into depression in Asia (Murata, Kondo, Hirai, Ichida, Ojima 2008).

The other subject for design the present study is the importance of the relationship between external factors such as life style and socio-environmental in the aging society. Because the elderly are especially affected by external factors when compared with younger age groups (Masuchi and Kishi, 2001). Although the elders' self-esteem is hurt by their reduced roles and senses of isolation (Kim& Park, 2000; Kim, N.J., 2000; Moon&Nam, 2001) also it is that low self-esteem developing a poor or negative self-image (Orth, Robins, & Meier, 2009). But there are few studies about the influence of personality characterises on depression late life (Steunenberg , Beekman ,,Deeg Kerkhof,2010). There are few studies on healthy, community dwelling elderly and most of studies conducted on elderly with disability (Demura, Sato, 2003, Murata, Kondo, Hirai, Ichida, Ojima 2008).

In Malaysia compare to other countries there is little information on the epidemiology of depression in Malaysian population (Mihajlo T Glamcevski G.Dip.Psy, G.Dip.Appl.,Lynne C. Mcarthur, Heng Thay Chong Mrcp, Chong Tin Tan Frcp,2002). Also previous studies identify depression among specific population (such as elderly with chronic diseases, visual impairment and attending in primary health care clinic) and the small sample size (Sherina Mohd Sidik , Nor Afiah Mohd Zulkefli and Shamsul Azhar Shah 2003 ; Naqiah Hairi Noran, Muldha Ghazali Izzuna, Awang Mahmud Bulgiba, Zahari Mimiwati and Said Mas Ayu, 2008 ; Sherina Mohd Sidik, Nor Afiah Mohd Zulkefli and A. Mustaqim,2003).

Although preceding study in Malaysia reported that ethnicity is one risk factor on depression in the elderly Malaysian but relationship between ethnicity and depression require to more research (Sherina M, Sidik Rampal L, Aini M, M Norhidayati H, 2005) Also Sherina Mohd Sidik and et al (2003) mentions that depression is an important problem in primary care practice, therefore primary care doctors should be aware of this problem for early detection and effective management. According to the increase in the number of people with depression in Malaysia (KHAN T M 2009) there is much needed in order to create a national picture of depression and associated risk factors among community living elderly Malaysians that could inform planning decision on the optimum provision of care. Therefore this study conducts to investigate depression and associated risk factors in the community-living elderly Malaysian.

Significance of study

The recognition of depression may be more difficult in late life, as both clinicians and the elderly may incorrectly attribute depressive symptoms to the aging process (NIH, 1991). Due to the low Functional expectations for the elderly, they may not Filly appreciate the degree of impairment caused by depression, and they may consider it as a natural aging process. Furthermore, the result of this study could provide essential information about depression in elderly Malaysian in both rural and urban area. This information will be provide empirical evidence to make decision and motivated the health care professional and social worker to pay more attention to the mental health of Malaysian elderly.

Also important information is needed to investigate the exposure and sensitivity to some major risk factors associated with depression among these elderly groups. These factors then can be incorporated into developing and implementing mental health services such as counseling and community educational programs for Malaysian elderly in both rural and urban area. In the other hand, social work practice implications will be discussed in terms of developing effective plans of culturally sensitive services and intervention strategies to reduce risk and enhance protective factors for depression among Malaysian elderly in rural and urban area.

Specific research questions

Main research objective:

To examine risk factors associated with depression among community living elderly Malaysian.

Specific Objectives:

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1- To determine relationship between Socio-demographic factors (gender, age, , religion, ethnicity, marital status, education, income) and depression among community living elderly Malaysian in urban and rural residence.

2- To determine relationship between living arrangement, social support and depression among community living elderly Malaysian in urban and rural residence.

3- To determine relationship between health problems, functional limitation, ADL/IADL and depression among community living elderly Malaysian in urban and rural residence.

4. To identify the relationship between self-rated health , behaviors / life style (smoking, alcohol intake and physical activity) , self-esteem and depression among community living elderly Malaysian urban versus rural residence.

General objective:

Is there relationship between Socio-demographic factors (gender, age, religion, ethnicity, marital status, education, income) and depression among community living elderly Malaysian in urban and rural residence?

What is the relationship between living arrangement, social support, social network and depression among community living elderly Malaysian in urban and rural residence?

Is there relationship between health problems, functional limitation, ADL/IADL and depression among community living elderly Malaysian in urban and rural residence?

Is there relationship between self-rated health, behaviors / life style (smoking, alcohol intake and physical activity), self-esteem and depression among community living elderly Malaysian urban versus rural residence?

Hypothesis

H1-there is a statistic significant relationship between psychological factors (self-esteem, self-rated health, behavior/ life style) and depression among community-living elderly Malaysian.

H2-there is a statistical significant difference between biological factors (health problems, functional limitation, ADL/IADL) and depression among community-living elderly Malaysian.

H3- there is a statistical significant difference between sociological factors (living arrangement, social support, and social network) and depression among community-living elderly Malaysian.

H4- there is a statistical significant difference between Socio-demographic factors (gender, age, ethnicity, religion, marital status, education, income) and depression among community-living elderly Malaysian.

Definition of variables

Theoretical definition of depression:

World health organization defined depression as a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration.

Operational definition of depression:

In this study depression will be measure by GMS questionnaire a semi- structured psychiatric interview for use with the elderly (Copeland, Dewey, 1999).

Operational definition of risk factors of depression:

In this study risk factors are including physiological, psychological, socio-demographics.

Socio-demographic characteristics factors (gender, age, ethnicity, marital status, education, income, and urban versus rural residence).

Social support will be measure by open-ended questionnaire.

Social network will be measure by open-ended questionnaire.

Living arrangement will be measure by open-ended questionnaire.

Behaviors / life style (smoking, alcohol intake and physical activity).

Self-rated health that will be assessed by global self-rating of health.

Self-reported medical condition or disease will be measure base on 24 medical conditions or diseases.

Functional limitation will be measure by WHODAS questionnaire.

ADL/IADL disability will be measure by Barthel index.

Self-esteem will be measure by Rosenberg questionnaire.

Conceptual Model of the Study

Chapter 2

Literature review

This chapter is divided into two sections including: pervious relevant studies and theoretical framework. Depression in community living elders has been linked to a huge negative consequences, such as self-neglect, (Abrams et al., 2002) substance abuse (Devanand, 2002), functional disability, low satisfaction and quality of life (Lyness, 2004; Yaffe et al., 2003; Montano, 1999; Ong, 2003; Bosworth, Park, McQuoid, Nays & Steffens, 2003, Wada, Ishine, Sakagami, Okumiya, Fuisawa, Murakami,Otsuka, Yano, kita, Matsubayashi; 2004), increased morbidity , increased mortality and suicide (Bosworth et al., 2003; Lyness, 2004; Montano, 1999; Ong, 2003; Yaffe et al, 2003,Conwell, 1994; Takeshita et al., 2002; Yaffe et al., 2003, Schoevers, et al 2009).

Camara et al(2008) conducted prevalence of depression in the elderly Spanish community- dwelling in the 2008. This study mentions that prevalence of depression could be different by different diagnostic criteria and different country. The samples was 1080 elder's aged 60 years and above and depression was measured by the Geriatric Mental State (GMS) Cases of depression were diagnosed with three different sets of diagnostic criteria: AGECAT syndrome, AGECAT diagnosis and DSM - IV criteria. The findings pointed out the prevalence of depression tended to be lower when stringent diagnostic criteria were used. It was 7.0 % with AGECAT syndrome, 5.7% with AGECAT diagnosis among the cases, 4.8% with DSM - IV criteria (Concepción de la Cámara, 2008) . Other study by Wada and et al (2004) conducted on prevalence of depression in four rural Japanese towns community-dwelling in the 2004. In this cross-sectional study the numbers of samples were 5363 elders aged 65+ Depressive symptoms were measured using a 15-item Geriatric Depression Scale. Prevalence of depression was similar (32.3-34.6%) in the four different rural Japanese towns (Sherina M, 2005; Taizo Wada & Shogo Murakamie, 2004). In one cross-sectional study by Sherina Mohd sadik et al (2005) determined the prevalence of elderly depression in an urban area of Selangor Malaysia in the 2005. The numbers of study were 300 elders aged 60. A 30-item Geriatric Depression Scale was used for depression measuring. The result showed that the prevalence of depression was 6.3 % (Sherina M, 2005). In the 2009 Kim and et al conducted a study on depression, and health status in Korean and Japanese institutionalized elderly. Also this study determined predictors of depression in each group. In this cross-sectional study subjects were aged 65-98 (n = 184), from private nursing homes in Korea and Japan. Depression measured by GDS. The results showed that prevalence depression among elderly Korean and elderly Japanese was respectively 8.07% and 5.21 %. Korean elderly had less physical function, and perceived their general health to be poor. Perception of general health was significant predictors of depression in Korean and Japanese subjects. ( Kim, Byeon, Hee kim, Endo, Akahoshi, Ogasawara,2009).

Studies showed that numerous risk factors affect on depression among elderly. Those risk factors are categorized into three groups, including socio-demographics characteristics, physiological health and psychological factors.

Studies showed that decreasing physical health could lead depression among elderly (Koh, Ceca, Koh, Liu, 1986, Blazer, Huges, & George, 1987; Taylor, McQuoid, & Krishnan, 2004). Several chronic illnesses could effect on depression such as arthritis, stroke, cancer, diabetes, high blood pressure, obesity, heart disease,hypothyroidism , Parkinson's disease; chronic lung disease , cardiovascular disease (Creed & Ash, 1992, Finch, Ramsay, &Katona, 1992, Blazer,2003, Cummings,1992, Bosworth et al., 2003; Dunlop, Song, Lyons, Manheim, & Rowland, 2003; Lyness, 2004; Montano, 1999; Ong, 2003; Yaffe et al., 2003,Chan, Chiu, Chien, Thompson, Lam,2006 ). Although Braam et al (2005) investigated a bout depression in later of life in Fourteen community-based studies in nine European countries on a total study sample of 22 570 respondents aged 65 years and older. Measures were harmonised for depressive symptoms (EURO-D scale), functional limitations and chronic physical conditions .the findings showed that the effect of physical disability on depression in elderly is stronger than chronic illness such as Cardiovascular, diabetes, stroke (A.W. BRAAM, S.W. GEERLINGS, & I. MELLER, 2005). Heikkinen and Kauppinen in 2004 in a longitudinal study among75-year-old resident's community living showed that Loneliness, a large number of chronic diseases, poor self-rated health predicted depressive symptomatology. Other cross-sectional study was examined risk factors of depression on 5016 of patients aged 60 years and above attending in a primary health care clinic. Geriatric Depression Scale questionnaire was used as a screening instrument. The associated factors were gender, martial status, low total family income, ethnicity and urban residence (Sherina MOHD SIDIK, 2003). In one cross-sectional study conducted the effects of activities of daily living (ADL) and perceived social support on the level of depression among 102 adults older than the age of 60 years. In this study perceived social support measured by Multidimensional Scale of Perceived Social Support (MSPSS), ADL measured by a 17-item, 5-point Likert-type questionnaire and Symptoms of depression measured by BDI questionnaire. The researchers pointed out those lower levels of ADL and perceived social support lead a higher level of depression (Bozo, Toksabay, Kurum, 2009). Other study confirms the previous findings. This study investigated the relationship between social supports and depression among the Black elderly. The samples were 33 elders over the age of 55 years and attended in a senior center/multipurpose center. A self-administered questionnaire was used that included a social network scale, a depression scale, and a demographic section. This study showed that depression and social support had significantly negative relationship. For depression, respondents who reported a lower monthly income had a significantly higher level of depression than respondents who reported a higher monthly income. For social support, respondents who were married had a significantly higher level of social support than respondents who were not married. As the number of people living in the household increased, level of social support increased. As age increased, level of social support decreased (Dixon, 2009).

Physical illness could lead psychological distress in the form of depressive and anxious symptoms in elderly people. This study examined physical illness both objectively and subjectively and depressive symptoms among 208 older adults. Health problems assessed by Short-Form Health Survey, Depression assessed by Depression, Scales, severity of depressive symptoms assessed by Beck Depression Inventory. Also Multidimensional Scale of Perceived Social Support measured social support. The findings showed that Subjective physical health was positively associated with depressive symptoms for one measure of depression, but was unrelated to depressive symptoms on another measure. High social support and friendship support in particular, physical health had its strongest negative association with depressive symptoms. (Paukert , 2007).

Other study showed active elderly have lower than depressed to inactive elderly. In this study, impact of depression investigate in two groups inactive (control group) and active (practicing weight-lifting, dance or meditation) elderly women. The samples were 20 women aged 60 and above in each group to assessed depression, the Beck Depression Inventory (BDI) was used. The findings showed that active group elderly women had lower than level of depression comparing of non active (Juracy C Castro & Estélio HM Dantas, 2009) .

Other study investigated relationships between depression, lifestyle in community dwelling elderly.1302 elders (657 males and 645females) were used for sample. The geriatric depression scale (GDS) was used to assess depression symptoms in the elderly. In addition, 16 items selected from the four factors of economic situation, physical health, social activity, and personal status were used to assess lifestyle. According to findings depression characteristics of the elderly differ between gender and age groups. Depression increases in the old-old elderly rather than in the young-old elderly and is highest in old-old females. Depression in the old-old elderly was more significantly related to many lifestyle items compared with the young-old elderly, and especially in the old-old elderly, the extent of social activities related to a decrease in depression (Sato, 2003).

Theoretical framework

Theoretical framework for this study is based on George's Social Antecedent Model of Depression(George ,1994)and stress , coping model (Lazarus & Folkman, 1984a, 1984b)and social integration theory(Durkheim,1892) .

George's Social Antecedent Model of Depression

Based on this model risk factors of depression in late life are related to biological, psychological, and social factors (George, 1994; Kurlowic, 1993). George's Social Antecedent Model of Depression divide the risk factors for depression into six stages , demographic factors, early and later events and achievements, social integration and support, vulnerability factors, provoking agents, and coping strategies(George L, 1994). George mentions that the Social Antecedent model of depression is a stage model, in which each higher stage increasingly effect on the precursors of depression"(George, 1994, p.132). This model is consisted of six stages, stage one included demographic variables (age and gender). Stage two consists of early experiences throughout the life course such as childhood deprivations that affect one's vulnerability to depression. Stage three indicates an individual's current statuses including familial relationships and socioeconomic achievements, in which is more recent timing. Stage four consisted of social integration variables, which refer to an individual's belonging to formal aspects of social structure (by religious affiliation and attendance in voluntary organizations) and levels of stability of the wider environments within which individuals function. Stage five is vulnerability and protective factors refer to personal resources and liabilities that influence depression such as chronic stressors and social support. Stage six, provoking agents and coping efforts are more particular and approximate than vulnerability and protective factors, and includes of recent life events and specific coping strategies to confront recent stressors. Also George stated that interactions among risk factors in the model "the effects of one risk factors are contingent on the presence of another risk factors"(George, 1994, p. 134); she also emphasized that direct and interactive effects are not mutually exclusive. For example social factors such as life events increase the risk of depression while social support declines the risk of depression. Interaction life events and social support are directly affected on depression independently. In fact this interaction has been hypothesized in studies on social support as "stress- buffering" which maintains social support is against depression in the existing of life events.

Table 1 shows stage model of the bio-psycho-social Antecedence of depression

Stage name

Indicators

Stage 1: Demographic variables

Age , gender, ethnicity , urban/ rural residence, religion

Stage2:Early/ later event &achievements

education , job

Stage 3: An individual's current statuses

marital status, ,income

Stage 4: Social integration variables

Living arrangement, social network

Stage 5: vulnerability and protective factors

Functional limitation , Disability, Health problem, life style (smoking, alcohol intake, exercise),social support

Stage 6: provoking agents coping strategy

Perceived of life satisfaction of social support, Self-rated health, Self-esteem,

Stress and coping model

According to Lazarus & Folkman(1984a, 1984b) stress is defined a relationship (`transaction') between individuals and their environment (Lazarus 1991). In fact "Psychological stress refers to a relationship with the environment that the person appraises as significant for his or her well being and in which the demands tax or exceed available coping resources" (Lazarus and Folkman 1986, p. 63). In this study, this model supports some variables such as self-esteem, social network, social support, living-arrangement, health problem and disability, behaviour/ lifestyle and self-related health. Based on this model, when elder are facing environmental stressors, elder evaluates the potential of risk (primary appraisal) according to Perception of self. In later stage (second appraisal) elders assess their ability and coping recourses in control of stressors (Cohen, 1984). Series factors of environmental such as age, gender, income, level of education, marital status, religion , ethnicity , job , urban versus rural residence ,health status and behaviour/ lifestyle could cause depression in person. Therefore existing some mediators could decrease depression in person and buffer the effects of these factors such as self-esteem, social support, social network, living arrangement, self-rated health and . One of factors which could be as a primary appraisal is personality characteristics such as self esteem. Self-esteem as a personal coping resource was pointed out that decrease psychological stress and reduces the outcomes of stressful events life (Katz, Rodin, & Devins, 1995; Thoits, 1995). In fact self-esteem as a personal coping resource could influence depression through one's attitudes to thoughts and beliefs about a stressful situation. Studies showed elders with low self-esteem had high depression anxiety, somatization , poorer self-reported health, more pain, and higher disability (Hunter, Kathleen I.; Linn, Margaret W.; Harris, Rachel,1981-1982). Also secondary appraisal depend on some factors such as social support, social network, living arrangement, self-rated health these effect on elderly coping with stress. According to this model there are two types of coping strategies such as problem solving focused and emotional focus. For example social support, social network, living arrangement. Thus we could enhance the effects of these factors for decreasing stress but some health problems are not changeable such as disability, therefore the person should try to cope with these problems. Studies showed positive effects of social network and perceived of social support on chronic diseases and depression(Rongjun Sun,2004). The perceived of social support from family and friends causes that one feel belonging and affiliation , at the result one's psychological well-being increase and loneliness decreases . Social support resources could reduces the outcomes of chronic illnesses by increasing recovery, by arising adherence to treatment recommendations and by promoting psychological adjustment. People with chronic illnesses who perceive less social support, these illustrate higher depression than from these who perceive more social support (Bisschopa, Kriegsmana, Beekmana, Deeg, 2004). Also studies showed that elders who live alone are more vulnerable by stressful events and more depressed(Dean , Kolody, Wood & Matt ,1992; Kwang Soo You, Hae-Ok Lee, Joyce J. Fitzpatrick, Susie Kim, Eiji Marui, Jung Su Lee, Paul Cook, 2009;Bennett,2009) . On the other hand elder with unhealthy lifestyle have more problem in overcoming depression symptoms (Nemade, Reiss, and Dombeck, 2007). It is understood that there are relationship between depression, perceived self-related health and lifestyle. Studies showed that depression is related with smoking behaviors, higher alcohol consumption, less exercise and poor self-related health (J. Woo, S.C. Ho, A.L.M. Yu, 2002;Gool, Kempen, Penninx, Deeg, Beekman& Vaneijk, 2003).

Social integration theory

Durkheim mentions that social structure and psychological well-being have the strongest relationship (Ramos, 2001). George (1997) is defined Durkheim social integration as "the degree to which individuals have formal attachments to social structure. Also operational definition of social integration is usually a number of social roles or types of structural attachments". In fact social integration refers formal ties and social structure. Also others researchers are defined Durkheim's social integration as the frequency and intensity contacts (Su&Ferraro, 1997; House, Landis&Umberson, 1988). It was founded that how social integration and affiliation influence physical and mental health (George, 1997; F.Berkman, Glass, Brissette,E.Seeman, 2000). Studies showed that high level of social integration reduces mortality, chronic diseases such as stroke, coronary heart disease, hypertension, psychological distress, isolation, depression, suicide, and functional limitation (Seeman, 1996; George, 1997). Also social integration through social network provides kind of social support such as instrumental support, appraisal support and emotional support (Weiss, 1974) also provides coping resources and increasing coping with distress and diseases (George,1997). The emotional support causes sense of self-worth and belonging in the person and increasing self-esteem (Thoits, 1995; Pillemer and Glagow, 2000). At the result emotional support increases person's self-esteem and when person encounter stressful situations could make better adaptation with the situation (George, 1997; F.Berkman et al, 20000). Also protective influence of social relationship causes person's health behaviors such as smoking, alcohol consumption and physical inactivity change, when norms share between social network members (Marsden&Friedkin, 1994). Studies showed increasing social disconnection causes raising unhealthy behavior / lifestyle (F.Berkman et al, 2000).

Chapter 3

Methodology

This chapter will describe the data source, the sample size the independent / dependent variables and describe the statistical analysis.

In this study researcher will use a secondary analysis of data from national the mental health and quality of life of older Malaysian survey (MHQoLOM) that employed a cross-sectional research design.

Data source

The data for this study come from the mental health and quality of life of older Malaysian survey (MHQoLOM) that was conducted from 2003 through 2005. The population in the study consist of older Malaysians aged 60 years and over that reside non-institutionalized throughout the thirteen states.

The sampling frame was drawn from the year 2000 census data and the year 2003. A multistage proportional stratified sampling procedure was taking into account (1) the absolute number of older persons in an Enumeration Block by state ;(2) ranking of the Enumeration Blocks with the highest number of 60 years and over population by stratum (rural or urban); and (3) selection of Enumeration Blocks by stratum that meets the needed sample size by state. As the total number of respondents was set at 3000, the size required for urban Enumeration Blocks is made in proportion to the state's distribution. The data collection is base on interview in the Respondent's home. The instruments used in the MHQoLOM were the General Questionnaire and Geriatric Mental State AGECAT Package. The general questionnaire consist of twelve sections, namely socio- demographic , living arrangement, work status, income, social support, ADL/IADL, quality of life, disability, health problem, self-rated health ,behavioral/ life style, Rosenberg self-esteem.

Independent variables

Socio-demographic characteristics is including gender, age, religion, ethnicity, marital status, education, income and urban versus rural residence.

Social factors are including living arrangement, social network and social support.

- Physiological factors are including functional limitation, disability and health problem.

- Psychological Factors is including self-esteem, self-rated health and behavior & life style.

Dependent variable

Depression

Instruments

In this study the researcher used of twelve instruments to measure variables that includes:

Socio-demographic characteristics questionnaire include gender, age, ethnicity, marital status, education, income and urban and rural residence.

living arrangement examine by two questions(1) living with others or (2) living alone

Social support examine by open-ended questionnaire. This questionnaire includes 5 questions as (1) support receives (2) support gives (3) satisfaction with support (4) types of support.

Functional limitation measures by WHODS scale. The scale is 8 items with items answered on: no, little difficulty, difficult, very difficult, cannot at all.

(ADL/ IADL) disability measures by Barthel Index (1965) and Lawton scale (Lawton & Brody, 1969). The 5 of 10 item of Barthel Index covers ADL and IADL examine by six out the nine item of Lawton scale.

health problem will measure by self-reported medical condition or disease based on 24 medical condition as arthritis, asthma, tuberculosis, heart trouble, diabetes, stomach, kidney disease, glaucoma, gout, cataract, liver disease, fracture, cancer, memory problem, stroke, head injury, breathing difficulties , anemia, hypertension, bedsore, fall, faecal incontinence ,prostate problem, numbness at extremities and others.

Self-esteem will measure by Rosenberg self-esteem (1965). The scale is a ten-item LikertHYPERLINK "http://en.wikipedia.org/wiki/Likert_scale" scale with items answered on a four-point scale, from strongly agree to strongly disagree.

Self-rated health included a single item, as follows: "In general, would you say your health is excellent, good, poor or very poor" (Idler et al 2000).

Behavior / life style questionnaire is including 3 sections as smoking, alcohol intake habit and frequency physical activity (very active, moderately active or not active / sedentary).

8- Depression will measure by Geriatric Mental State AGECAT Package. It is designed to be given with the various versions of the Geriatric Mental State in order to clarify diagnosis into the sub-categories of AGECAT. The GMS is a standardized, semi-structured interview for examining and recording the mental state in elderly subjects. It allows the classification of patients by symptom profile and can demonstrate changes in profile over time (Copeland, Dewey, 1999).

Statistical Analysis

Data were analyzed using SPSS version 13 for windows. Descriptive statistics were used to describe the socio-demographic characteristics, living arrangement, social support , behavior / life style , self-rated health , health problem , functional limitation, disability ,prevalence of depression for men and women and rural and urban separately in this study. The predicting factor of depression will determine by mean of univariate analysis and multivariate logistic regression.