Abstract

INTRODUCTION

Elderly people often suffer from depression and it is highlighted as one of the most common and significant psychiatric problems. ²2 . Almeida OP, Almeida SA. Confiabilidade da versão brasileira da Escala de Depressão em Geriatria (GDS) versão reduzida. Arq Neuro-Psiquiatr. 1999;57(2B):421-6. DOI:10.1590/S0004-282X1999000300013
https://doi.org/10.1590/S0004-282X199900... ^{, 8}8 . Djernes JK. Prevalence and predictors of depression in populations of elderly: a review. Acta Psychiatr Scand . 2006;113(5):372-87. DOI:10.1111/j.1600-0447.2006.00770.x
https://doi.org/10.1111/j.1600-0447.2006... According to a systematic review, prevalence worldwide varies between 0.9% and 9.4% in those living in the community and 14% to 42% in those living in a care home. ⁸8 . Djernes JK. Prevalence and predictors of depression in populations of elderly: a review. Acta Psychiatr Scand . 2006;113(5):372-87. DOI:10.1111/j.1600-0447.2006.00770.x
https://doi.org/10.1111/j.1600-0447.2006... Brazilian epidemiological studies carried out with the elderly show that the prevalence of depressive symptoms varies between 195 and 34% in the different regions of the country. ⁴4 . Batistoni SST, Neri AL, Cupertino APFB. Medidas prospectivas de sintomas depressivos entre idosos residentes na comunidade. Rev Saude Publica . 2010;44(6):1137-43. DOI:10.1590/S0034-89102010000600020
https://doi.org/10.1590/S0034-8910201000... ^{, 5}5 . Benedetti TRB, Borges LJ, Petroski EL, Gonçalves LHT. Atividade física e estado de saúde mental de idosos. Rev Saude Publica . 2008;42(2):302-7. DOI:10.1590/S0034-89102008005000007
https://doi.org/10.1590/S0034-8910200800... ^{, 10}10 . Hoffmann EJ, Ribeiro F, Farnese JM, Lima EWB. Sintomas depressivos e fatores associados entre idosos residentes em uma comunidade no norte de Minas Gerais, Brasil. J Bras Psiquiatr . 2010;59(3):190-7. DOI:10.1590/S0047-20852010000300004
https://doi.org/10.1590/S0047-2085201000... ^{, 15}15 . Lima MTR, Silva RS, Ramos LR. Fatores associados à sintomatologia depressiva numa coorte urbana de idosos. J Bras Psiquiatr . 2009;58(1):1-7. DOI:10.1590/S0047-20852009000100001
https://doi.org/10.1590/S0047-2085200900...

The high prevalence of depression requires the attention of health care professionals and managers, as this disease increases the likelihood of functional incapacity in the elderly ¹⁶16 . Motl RW, Konopack JF, McAuley E, Elavsky S, Jerome GJ, Márquez DX. Depressive symptoms among older adults: long-term reduction after physical activity intervention. J Behav Med . 2005;28(4):385-94. DOI:10.1007/s10865-005-9005-5
https://doi.org/10.1007/s10865-005-9005-... and constitutes a significant public health problem.

Among the factors linked to depression, the following stand out: being female, ⁴4 . Batistoni SST, Neri AL, Cupertino APFB. Medidas prospectivas de sintomas depressivos entre idosos residentes na comunidade. Rev Saude Publica . 2010;44(6):1137-43. DOI:10.1590/S0034-89102010000600020
https://doi.org/10.1590/S0034-8910201000... ^{, 6}6 . Castro-Costa E, Lima-Costa MF, Carvalhais S, Firmo JOA, Uchoa E. Factors associated with depressive symptoms measured by the 12-item General Health Questionnaire in Community-Dwelling Older Adults (The Bambuí Health Aging Study). Rev Bras Psiquiatr . 2008;30(2):104-9. DOI:10.1590/S1516-44462008005000007
https://doi.org/10.1590/S1516-4446200800... advanced age, ⁶6 . Castro-Costa E, Lima-Costa MF, Carvalhais S, Firmo JOA, Uchoa E. Factors associated with depressive symptoms measured by the 12-item General Health Questionnaire in Community-Dwelling Older Adults (The Bambuí Health Aging Study). Rev Bras Psiquiatr . 2008;30(2):104-9. DOI:10.1590/S1516-44462008005000007
https://doi.org/10.1590/S1516-4446200800... ^{, 9}9 . Gazalle FK, Lima MS, Tavares BF, Hallal PC. Sintomas depressivos e fatores associados em população idosa no Sul do Brasil. Rev Saude Publica . 2004;38(3):365-71. DOI:10.1590/S0034-89102004000300005
https://doi.org/10.1590/S0034-8910200400... ^{, 12}12 . Kaneko Y, Motohashi Y, Sasaki H, Yamaji M. Prevalence of depressive symptoms and related risk factors for depressive symptoms among elderly persons living in a rural Japanese community: a cross-sectional study. Community Ment Health J. 2007;43(6):583-90. DOI:10.1007/s10597-007-9096-5
https://doi.org/10.1007/s10597-007-9096-... low levels of education ⁴4 . Batistoni SST, Neri AL, Cupertino APFB. Medidas prospectivas de sintomas depressivos entre idosos residentes na comunidade. Rev Saude Publica . 2010;44(6):1137-43. DOI:10.1590/S0034-89102010000600020
https://doi.org/10.1590/S0034-8910201000... ^{, 9}9 . Gazalle FK, Lima MS, Tavares BF, Hallal PC. Sintomas depressivos e fatores associados em população idosa no Sul do Brasil. Rev Saude Publica . 2004;38(3):365-71. DOI:10.1590/S0034-89102004000300005
https://doi.org/10.1590/S0034-8910200400... and living alone. ¹²12 . Kaneko Y, Motohashi Y, Sasaki H, Yamaji M. Prevalence of depressive symptoms and related risk factors for depressive symptoms among elderly persons living in a rural Japanese community: a cross-sectional study. Community Ment Health J. 2007;43(6):583-90. DOI:10.1007/s10597-007-9096-5
https://doi.org/10.1007/s10597-007-9096-... In addition to the socio-demographic characteristics, which are well established in the literature, other factors are associated with depression, such as: smoking, ⁹9 . Gazalle FK, Lima MS, Tavares BF, Hallal PC. Sintomas depressivos e fatores associados em população idosa no Sul do Brasil. Rev Saude Publica . 2004;38(3):365-71. DOI:10.1590/S0034-89102004000300005
https://doi.org/10.1590/S0034-8910200400... comorbidities (cardiovascular, endocrine, neurological, oncological diseases), ²⁴24 . Teng CT, Humes EC, Demetrio FN. Depressão e comorbidades clínicas. Rev Psiquiatr Clin . 2005;32(3):149-59. DOI:10.1590/S0101-60832005000300007
https://doi.org/10.1590/S0101-6083200500... high levels of medicine use, ¹⁵15 . Lima MTR, Silva RS, Ramos LR. Fatores associados à sintomatologia depressiva numa coorte urbana de idosos. J Bras Psiquiatr . 2009;58(1):1-7. DOI:10.1590/S0047-20852009000100001
https://doi.org/10.1590/S0047-2085200900... functional incapacity, ⁶6 . Castro-Costa E, Lima-Costa MF, Carvalhais S, Firmo JOA, Uchoa E. Factors associated with depressive symptoms measured by the 12-item General Health Questionnaire in Community-Dwelling Older Adults (The Bambuí Health Aging Study). Rev Bras Psiquiatr . 2008;30(2):104-9. DOI:10.1590/S1516-44462008005000007
https://doi.org/10.1590/S1516-4446200800... ^{, 10}10 . Hoffmann EJ, Ribeiro F, Farnese JM, Lima EWB. Sintomas depressivos e fatores associados entre idosos residentes em uma comunidade no norte de Minas Gerais, Brasil. J Bras Psiquiatr . 2010;59(3):190-7. DOI:10.1590/S0047-20852010000300004
https://doi.org/10.1590/S0047-2085201000... negative perception of own health, ⁶6 . Castro-Costa E, Lima-Costa MF, Carvalhais S, Firmo JOA, Uchoa E. Factors associated with depressive symptoms measured by the 12-item General Health Questionnaire in Community-Dwelling Older Adults (The Bambuí Health Aging Study). Rev Bras Psiquiatr . 2008;30(2):104-9. DOI:10.1590/S1516-44462008005000007
https://doi.org/10.1590/S1516-4446200800... ^{, 12}12 . Kaneko Y, Motohashi Y, Sasaki H, Yamaji M. Prevalence of depressive symptoms and related risk factors for depressive symptoms among elderly persons living in a rural Japanese community: a cross-sectional study. Community Ment Health J. 2007;43(6):583-90. DOI:10.1007/s10597-007-9096-5
https://doi.org/10.1007/s10597-007-9096-... low levels of physical activity, ⁵5 . Benedetti TRB, Borges LJ, Petroski EL, Gonçalves LHT. Atividade física e estado de saúde mental de idosos. Rev Saude Publica . 2008;42(2):302-7. DOI:10.1590/S0034-89102008005000007
https://doi.org/10.1590/S0034-8910200800... ^{, 18}18 . Reichert CL, Diogo CL, Vieira JL, Dalacorte RR. Physical activity and depressive symptoms in community-dwelling elders from southern Brazil. Rev Bras Psiquiatr. 2011;33(2):165-70. DOI:10.1590/S1516-44462011005000006
https://doi.org/10.1590/S1516-4446201100... ^{, 22}22 . Smith TL, Masaki KH, Fong K, Abbott RD, Ross GW, Petrovitch H, et al. Effect of walking distance on 8-year incident depressive symptoms in elderly men with and without chronic disease: the Honolulu-Asia Aging Study. J Am Geriatr Soc . 2010;58(8):1447-52.DOI:10.1111/j.1532-5415.2010.02981.x
https://doi.org/10.1111/j.1532-5415.2010... suicidal thoughts, ¹²12 . Kaneko Y, Motohashi Y, Sasaki H, Yamaji M. Prevalence of depressive symptoms and related risk factors for depressive symptoms among elderly persons living in a rural Japanese community: a cross-sectional study. Community Ment Health J. 2007;43(6):583-90. DOI:10.1007/s10597-007-9096-5
https://doi.org/10.1007/s10597-007-9096-... insomia, ⁶6 . Castro-Costa E, Lima-Costa MF, Carvalhais S, Firmo JOA, Uchoa E. Factors associated with depressive symptoms measured by the 12-item General Health Questionnaire in Community-Dwelling Older Adults (The Bambuí Health Aging Study). Rev Bras Psiquiatr . 2008;30(2):104-9. DOI:10.1590/S1516-44462008005000007
https://doi.org/10.1590/S1516-4446200800... ^{, 10}10 . Hoffmann EJ, Ribeiro F, Farnese JM, Lima EWB. Sintomas depressivos e fatores associados entre idosos residentes em uma comunidade no norte de Minas Gerais, Brasil. J Bras Psiquiatr . 2010;59(3):190-7. DOI:10.1590/S0047-20852010000300004
https://doi.org/10.1590/S0047-2085201000... and a predominance of negative exchanges in relationships with family and friends. ²³23 . Stafford M, McMunn A, Zaninotto P, Nazroo J. Positive and negative exchanges in social relationships as predictors of depression: evidence from the English Longitudinal Study of Aging. J Aging Health . 2011;23(4):607-28. DOI:10.1177/0898264310392992
https://doi.org/10.1177/0898264310392992... These factors, especially those that can be modified, need to be further explored, taking into account cultural differences between countries and regional differences within those countries, as in Brazil.

Identifying the factors linked to the presence of depressive symptoms may help prevent depression among the elderly ³3 . Araujo AB, Durante R, Feldman HA, Goldstein I, McKinlay JB. The relationship between depressive symptoms and male erectile dysfunction: cross-sectional results from the Massachusetts Male Aging Study. Psychosom Med. 1998;60(4):458-65. and give an opportunity to non-pharmacological treatment strategies.

The aim of this study was to analyze the prevalence of factors associated with depressive symptoms in the elderly.

METHODS

A cross-sectional population and household based study, part of the EpiFloripa Elderly Survey, which took place between September 2009 and June 2010 in Florianópolis, SC, Southern Brazil. ^aaUniversidade Federal de Santa Catarina. EpiFloripa: condições de saúde de adultos e idosos de Florianópolis. Florianópolis; 2009 [cited 2013 Ago 30]. Available from: http://www.epifloripa.ufsc.br/ The estimated population of this municipality in 2009 was 408,163, with 10.8% aged 60 and over. ^bbInstituto Brasileiro de Geografia e Estatística. Estimativas populacionais para o TCU. Estimativas da população para 1º de julho de 2009, segundo os municípios . Brasília; 2009 [cited 2010 Ago 8]. Available from: http://www.ibge.gov.br/home/estatistica/populacao/estimativa2009/POP2009_DOU.pdf Florianópolis has the highest municipal human development index in Brazil (HDI-M 0.86) ^ccPrograma das Nações Unidas para o Desenvolvimento. Atlas de desenvolvimento humano no Brasil (PNUD). Brasília (DF): 2003 [cited 2010 Ago 8]. Available from: http://www.pnud.org.br/IDH/Atlas2003.aspx?indiceAccordion=1&li=li_Atlas2003 and life expectancy at birth in 2009 was 75.8 years. ^ddInstituto Brasileiro de Geografia e Estatística. Síntese dos indicadores sociais: uma análise das condições de vida da população brasileira - 2010 . Rio de Janeiro; 2010 [cited 2010 Ago 8]. Available from: http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/indicadoresminimos/sinteseindicsociais2010/SIS_2010.pdf

The following were assumed in calculating the general sample for the EpiFloripa Elderly Survey: a population of 44,460, ^bcPrograma das Nações Unidas para o Desenvolvimento. Atlas de desenvolvimento humano no Brasil (PNUD). Brasília (DF): 2003 [cited 2010 Ago 8]. Available from: http://www.pnud.org.br/IDH/Atlas2003.aspx?indiceAccordion=1&li=li_Atlas2003 unknown outcome prevalence (50%), sample error equal to four percentage points, 95% confidence level and design effect equal to two. An additional 20% was added to cover the predicted losses, and another 15% in order to control confounding factors, giving a minimum sample size of 1,599 individuals.

The selection process for the sample was in two stages of clusters. In the first stage, 80 of the 420 census tracts were systematically selected according to average monthly income of the head of the household (eight tracts in each income decile). In the second stage the units were the households, tracts with fewer than 150 residences were grouped together, and those with more than 500 residences (respecting the correspondent income decile) were divided, resulting in 83 census tracts.

Trained interviewers collected the data using a standardized, pre-tested questionnaire in face to face interviews, using Personal Digital Assistants (PDAs). The consistence of the data was checked every week and quality control, via the telephone, used a reduced version of the questionnaire with a randomly selected 10% of the interviews.

The outcome was depressive symptoms, obtained using the Geriatric Depression Scale (GDS), which contains 15 questions. The cutoff point used was five/six (not case/case). ²2 . Almeida OP, Almeida SA. Confiabilidade da versão brasileira da Escala de Depressão em Geriatria (GDS) versão reduzida. Arq Neuro-Psiquiatr. 1999;57(2B):421-6. DOI:10.1590/S0004-282X1999000300013
https://doi.org/10.1590/S0004-282X199900...

The independent variables were: age group (60 to 69; 70 to 79; and 80 and over); sex; marital status (married/living with partner; single; divorced/separated; widowed); self-reported skin color (white; dark skinned; black; yellow; indigenous); schooling (illiterate; one to four years of schooling; five to eight years; nine to 11 years; 12 or more years of schooling); actual economic situation compared to that at age 50 (same; worse); per capita household income (1 ^st quartile ≤ R$ 327.50; 2 ^nd quartile: > R$ 327.50 and ≤ R$ 700.00; 3 ^nd quartile: > R$ 700.00 and ≤ R$ 1,500.00; 4 ^th quartile: > R$ 1,500.00); cognitive state, evaluated using the Mental State Mini-test, considering level of schooling (no cognitive deficiency, probable cognitive deficiency); alcohol consumption according to the Alcohol Use Disorders Identification Test (Audit) (none, moderate, excessive consumption); smoking (never smoked, used to smoke; smoker); level of physical activity, assessed using the International Physical Activity Questionnaire (IPAQ) (physically active: who does 150 minutes or more physical activity per week; insufficiently active: who does less than 150 minutes per week); ¹⁷17 . Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation . 2007;116(9):1094-105. DOI:10.1161/CIRCULATIONAHA.107.185650
https://doi.org/10.1161/CIRCULATIONAHA.1... nutritional status, evaluated using Body Mass Index (underweight; normal weight; overweight), ^eeMinistério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Protocolos do Sistema de Vigilância Alimentar e Nutricional – SISVAN na assistência à saúde. Brasília (DF); 2008. (Série B. Textos Básicos de Saúde). height was measured using a portable stadiometer and weight using a digital scale accurate to 100 g; participation in a social or religious group in the last year (yes; no); frequency of monthly socializing with friends and relatives (yes [more than once a month]; no [once a month or less often]); ability to communicate using the internet defined as self- reported ability to use a computer to send and receive messages (yes; no); functional dependency, assessed using the scale of basic and instrumental activities in daily living (incapability/difficulty carrying out up to three activities; incapability/difficulty carrying out 4-15 activities); ²⁰20 . Rosa TEC, Benício MHDA, Latorre MRDO, Ramos LR. Fatores determinantes da capacidade funcional entre idosos. Rev Saude Publica . 2003;37(1):40-8. DOI:10.1590/S0034-89102003000100008
https://doi.org/10.1590/S0034-8910200300... perception of own health (very good/good; regular; bad/very bad); self-reported chronic pain on most days (yes; no).

The following non-communicable chronic diseases reported by the elderly were tested: back or spinal pain, cancer, fibromyalgia, bronchitis or asthma, arthritis/rheumatism, diabetes, hypertension, other cardiovascular diseases, stroke or cerebral ischemia.

Poisson regression was used to assess the association between depressive symptoms and the independent variables. The criteria for insertion in the multivariate model was p < 0.20 and the criteria for the variable to be mantained in the model was p ≤ 0.05 in the Wald test. The first variables to be tested in the adjusted analysis were sociodemographic variables, followed by health, behavioral and social variables. The multivariate analyses took into consideration sample design effect, incorporating weighting through the “syv” command in the Stata program, designed to analyze data from complex samples. The Stata statistical package, version 11.0 (Stata Corp. College Station, EUA), was used for the statistical analyses.

This research met all ethical requirements and was approved by the Ethics Committee for Human Research of the Universidade Federal de Santa Catarina (Process No. 352/2008). Participants in the study signed a consent form.

RESULTS

The interviewers identified 1,911 eligible residences and interviewed 1,705 elderly individuals, with a response rate of 89.2%. Forty-nine interviews in which responses were given by carers were excluded, leaving 1,656. The majority of variables tested scored good or excellent in the quality control (kappa values varying between 0.6 and 0.9).

The sample was composed mainly of women (63.9%); 51.1% were aged between 60 and 69; 58.8% were married; 34.5% had up to four years of schooling and the mean per capita income was R$ 1,347.97.

In the univariate analysis, women, those aged 80 and over and those who were illiterate or had a low level of schooling showed more depressive symptoms. Apart from skin color, the other sociodemographic variables proved to be associated with depressive symptoms in the raw analysis ( Table 1 ).

The presence of depressive symptoms was higher among individuals with cognitive deficit, those with higher functional dependency, those who had suffered a fall within the last year, those who experienced pain most days and those who perceived their own health to be very bad. Variables related to health, except for fibromyalgia and cancer, were linked with depressive symptoms in the raw analysis ( Table 2 ).

Fewer depressive symptoms were observed in elderly individuals who reported having sexual relations, those who used the internet, those who reported high or moderate alcohol consumption, those who participated in social or religious groups, those who did leisure activities and those who had monthly contact with friends or relatives. Only smoking and body mass index were not linked to depressive symptoms in the raw analysis ( Table 3 ).

In the final multivariate model, a higher prevalence of depressive symptoms was linked to low levels of schooling, to being worse off than at age 50, the presence of cognitive deficiency, negative perception of one’s own health, greater functional dependency and experiencing pain most days. Doing leisure activities, participating in social or religious groups and having sexual relations were linked to a lower prevalence of depressive symptoms. Age was inversely associated with depressive symptoms ( Table 4 ).

DISCUSSION

There was a high prevalence of depressive symptoms (23.9%; 95%CI 21.84;26.01), similar to values obtained in other studies ¹⁰10 . Hoffmann EJ, Ribeiro F, Farnese JM, Lima EWB. Sintomas depressivos e fatores associados entre idosos residentes em uma comunidade no norte de Minas Gerais, Brasil. J Bras Psiquiatr . 2010;59(3):190-7. DOI:10.1590/S0047-20852010000300004
https://doi.org/10.1590/S0047-2085201000... ^{, 15}15 . Lima MTR, Silva RS, Ramos LR. Fatores associados à sintomatologia depressiva numa coorte urbana de idosos. J Bras Psiquiatr . 2009;58(1):1-7. DOI:10.1590/S0047-20852009000100001
https://doi.org/10.1590/S0047-2085200900... and higher than that in an epidemiological investigation carried out in Florianópolis in 2002, which detected a 19.7% level of depression among the elderly in the city. ⁵5 . Benedetti TRB, Borges LJ, Petroski EL, Gonçalves LHT. Atividade física e estado de saúde mental de idosos. Rev Saude Publica . 2008;42(2):302-7. DOI:10.1590/S0034-89102008005000007
https://doi.org/10.1590/S0034-8910200800...

Important links were observed between symptoms of depression and socio-demographic, health, behavior and social variables. The literature highlights the association between depressive symptoms and socio-demographic variables, ⁴4 . Batistoni SST, Neri AL, Cupertino APFB. Medidas prospectivas de sintomas depressivos entre idosos residentes na comunidade. Rev Saude Publica . 2010;44(6):1137-43. DOI:10.1590/S0034-89102010000600020
https://doi.org/10.1590/S0034-8910201000... indicating that social inequalities influence living and health conditions and may contribute to the onset of these symptoms. Low levels of schooling, age and economic decline were the socio-demographic variables associated with depressive symptoms.

Individuals with low levels of schooling are at higher risk of having depressive symptoms, ⁴4 . Batistoni SST, Neri AL, Cupertino APFB. Medidas prospectivas de sintomas depressivos entre idosos residentes na comunidade. Rev Saude Publica . 2010;44(6):1137-43. DOI:10.1590/S0034-89102010000600020
https://doi.org/10.1590/S0034-8910201000... indicating that education is a protective factor against the onset of these symptoms. ⁹9 . Gazalle FK, Lima MS, Tavares BF, Hallal PC. Sintomas depressivos e fatores associados em população idosa no Sul do Brasil. Rev Saude Publica . 2004;38(3):365-71. DOI:10.1590/S0034-89102004000300005
https://doi.org/10.1590/S0034-8910200400... A higher level of education enables the individual to increase their resources for dealing with stressful situations. ⁴4 . Batistoni SST, Neri AL, Cupertino APFB. Medidas prospectivas de sintomas depressivos entre idosos residentes na comunidade. Rev Saude Publica . 2010;44(6):1137-43. DOI:10.1590/S0034-89102010000600020
https://doi.org/10.1590/S0034-8910201000...

Age as a protective factor in the final model may be explained by the inclusion of the variable of functional dependency, suggesting that the effect of age on depression can be modified. Increased age is considered to be linked with experiencing different psychosocial episodes (deaths of relatives and friends, break up of conjugal relationships), as well as higher exposure to chronic illness. ¹⁹19 . Rombaldi AJ, Silva MC, Gazalle FK, Azevedo MR, Hallal PC. Prevalência e fatores associados a sintomas depressivos em adultos do sul do Brasil: estudo transversal de base populacional. Rev Bras Epidemiol. 2010;13(4):620-9. DOI:10.1590/S1415-790X2010000400007
https://doi.org/10.1590/S1415-790X201000... Another explanation is that susceptibility to depression and anxiety may decrease with age. Added to this is reduced emotional response and greater resilience when faced with stressful experiences. ¹¹11 . Jorm AF. Does old age reduce the risk of anxiety and depression? A review of epidemiological studies across the adult life span. Psychol Med . 2000;30(1):11-22.

Being socio-economically disadvantaged increases the risk of depression, as highlighted in the literature. ¹1 . Almeida OP, Pirkis J, Kerse N, Sim M, Flicker L, Snowdon J, et al. Socioeconomic disadvantage increases risk of prevalent and persistent depression in later life. J Affect Disord . 2012;138(3):322-31. DOI:10.1016/j.jad.2012.01.021
https://doi.org/10.1016/j.jad.2012.01.02... Becoming worse off is associated with depressive symptoms. It is not possible to say whether an individual becomes depressed due to worsening economic circumstances (financial stability) or whether depression throughout their life leads to this loss, as they become incapable of dealing with financial and work situations. Social position may be inversely related with some depressive symptoms such as sadness, dwelling on the past and preferring to stay at home, indicating that socio-economic condition may contribute to the onset of these symtoms. ¹⁹19 . Rombaldi AJ, Silva MC, Gazalle FK, Azevedo MR, Hallal PC. Prevalência e fatores associados a sintomas depressivos em adultos do sul do Brasil: estudo transversal de base populacional. Rev Bras Epidemiol. 2010;13(4):620-9. DOI:10.1590/S1415-790X2010000400007
https://doi.org/10.1590/S1415-790X201000... On the other hand, a worsening economic situation may be triggered by depression, as it is related to cognition and to carrying out daily activities. Perfoming these activities may be compromised as depression increases the probability of functional incapacity among the elderly and may lead to dependence, ¹⁶16 . Motl RW, Konopack JF, McAuley E, Elavsky S, Jerome GJ, Márquez DX. Depressive symptoms among older adults: long-term reduction after physical activity intervention. J Behav Med . 2005;28(4):385-94. DOI:10.1007/s10865-005-9005-5
https://doi.org/10.1007/s10865-005-9005-... creating a vicious circle.

Cognitive deficiency and depressive symptoms are linked and are interrelated factors. Depression may lead to clinical dementia or dementia may evolve with the depressive symptoms. ¹⁵15 . Lima MTR, Silva RS, Ramos LR. Fatores associados à sintomatologia depressiva numa coorte urbana de idosos. J Bras Psiquiatr . 2009;58(1):1-7. DOI:10.1590/S0047-20852009000100001
https://doi.org/10.1590/S0047-2085200900... Cognitive deficiencies may improve when the patient is treated for depression.

The association between the outcome and chronic pain can be understood by the existence of a model of depression in the elderly that is mainly related to this type of pain. This indicates that the individual was not depressed before and begins experiencing depressive symptoms due to the chronic pain. In the case of osteoarthritis, the leading cause of pain in the elderly, depression can be expected in conjunction with pain and physical incapacity. ¹⁴14 . Leite AA, Costa AJG, Lima BAM, Padilha AVL, Albuquerque EC, Marques CDL. Comorbidades em pacientes com osteoartrite: frequência e impacto na dor e na função física. Rev Bras Reumatol . 2011;51(2):118-23. DOI:10.1590/S0482-50042011000200002
https://doi.org/10.1590/S0482-5004201100...

Depressive symptoms are linked to self-perception of health, as has been seen in other investigations. ⁶6 . Castro-Costa E, Lima-Costa MF, Carvalhais S, Firmo JOA, Uchoa E. Factors associated with depressive symptoms measured by the 12-item General Health Questionnaire in Community-Dwelling Older Adults (The Bambuí Health Aging Study). Rev Bras Psiquiatr . 2008;30(2):104-9. DOI:10.1590/S1516-44462008005000007
https://doi.org/10.1590/S1516-4446200800... ^{, 12}12 . Kaneko Y, Motohashi Y, Sasaki H, Yamaji M. Prevalence of depressive symptoms and related risk factors for depressive symptoms among elderly persons living in a rural Japanese community: a cross-sectional study. Community Ment Health J. 2007;43(6):583-90. DOI:10.1007/s10597-007-9096-5
https://doi.org/10.1007/s10597-007-9096-... Reporting one’s own health as being bad/very bad can be a depressive symptom, in some cases. Depression is a significant marker of incapacity in the elderly, as it affects overall health and, consequently, functional capacity. ⁶6 . Castro-Costa E, Lima-Costa MF, Carvalhais S, Firmo JOA, Uchoa E. Factors associated with depressive symptoms measured by the 12-item General Health Questionnaire in Community-Dwelling Older Adults (The Bambuí Health Aging Study). Rev Bras Psiquiatr . 2008;30(2):104-9. DOI:10.1590/S1516-44462008005000007
https://doi.org/10.1590/S1516-4446200800... ^{, 10}10 . Hoffmann EJ, Ribeiro F, Farnese JM, Lima EWB. Sintomas depressivos e fatores associados entre idosos residentes em uma comunidade no norte de Minas Gerais, Brasil. J Bras Psiquiatr . 2010;59(3):190-7. DOI:10.1590/S0047-20852010000300004
https://doi.org/10.1590/S0047-2085201000... ^{, 15}15 . Lima MTR, Silva RS, Ramos LR. Fatores associados à sintomatologia depressiva numa coorte urbana de idosos. J Bras Psiquiatr . 2009;58(1):1-7. DOI:10.1590/S0047-20852009000100001
https://doi.org/10.1590/S0047-2085200900...

Sexual function can be identified as a health marker, observed in elderly individuals who have begun a process of functional decline, since maintaining an active sex life involves physical, mental and emotional and affective health, internal and external factors. Erectile dysfunction caused by peripheral vascular diseases, prostate surgery or diabetes may affect sexuality or the sex act itself. ²¹21 . Silva RMO. A sexualidade no envelhecer: um estudo com idosos em reabilitação. Acta Fisiatrica . 2003;10(3):107-12. Erectile dysfunction is strongly linked to depressive symptoms ³3 . Araujo AB, Durante R, Feldman HA, Goldstein I, McKinlay JB. The relationship between depressive symptoms and male erectile dysfunction: cross-sectional results from the Massachusetts Male Aging Study. Psychosom Med. 1998;60(4):458-65. and affects quality of life in the elderly. Improving these problems may produce feelings of happiness, resulting in higher self-esteem, better social interaction, feelings of confidence and competence. ²¹21 . Silva RMO. A sexualidade no envelhecer: um estudo com idosos em reabilitação. Acta Fisiatrica . 2003;10(3):107-12. Improvements in these aspects through sexual activity and the perception of sexual virility may contribute to reducing depressive feelings among men. Feelings of love, affection and companionship are the main, inherent aspects of sexual activity in women in old age, ²¹21 . Silva RMO. A sexualidade no envelhecer: um estudo com idosos em reabilitação. Acta Fisiatrica . 2003;10(3):107-12. and perceiving these feelings may contribute to depressive symptoms either not manifesting or decreasing.

Depression can be explained chemically as a decrease in the number of neurotransmitters released, which are responsible for producing hormones such as serotonin and endorphins. Sexual activity and physical activity ⁷7 . Cunha GS, Ribeiro JL, Oliveira AR. Níveis de beta-endorfina em resposta ao exercício e no sobretreinamento. Arq Bras Endocrinol Metab . 2008;52(4):589-98. DOI:10.1590/S0004-27302008000400004
https://doi.org/10.1590/S0004-2730200800... have beneficial effects for the health due to the release of these hormones and provide feelings of well-being and pleasure; thus, it is a protective factor against developing depressive symptoms in both sexes. The other psycho-social benefits of doing physical activity, through social interaction, also stand out. ¹⁸18 . Reichert CL, Diogo CL, Vieira JL, Dalacorte RR. Physical activity and depressive symptoms in community-dwelling elders from southern Brazil. Rev Bras Psiquiatr. 2011;33(2):165-70. DOI:10.1590/S1516-44462011005000006
https://doi.org/10.1590/S1516-4446201100...

There was a lower prevalence of depressive symptoms in the elderly who did leisure activities, corroborating other research. ¹³13 . Ku PW, Fox KR, Chen LJ. Physical activity and depressive symptoms in Taiwanese older adults: a seven-year follow-up study. Prev Med. 2009;48(3):250-5. DOI:10.1016/j.ypmed.2009.01.006
https://doi.org/10.1016/j.ypmed.2009.01.... ^{, 18}18 . Reichert CL, Diogo CL, Vieira JL, Dalacorte RR. Physical activity and depressive symptoms in community-dwelling elders from southern Brazil. Rev Bras Psiquiatr. 2011;33(2):165-70. DOI:10.1590/S1516-44462011005000006
https://doi.org/10.1590/S1516-4446201100... ^{, 22}22 . Smith TL, Masaki KH, Fong K, Abbott RD, Ross GW, Petrovitch H, et al. Effect of walking distance on 8-year incident depressive symptoms in elderly men with and without chronic disease: the Honolulu-Asia Aging Study. J Am Geriatr Soc . 2010;58(8):1447-52.DOI:10.1111/j.1532-5415.2010.02981.x
https://doi.org/10.1111/j.1532-5415.2010... In a study in the South of Brazil, physically active elderly had a 68% lower probability of having depressive symptoms compared with those who were not sufficiently active. ¹⁸18 . Reichert CL, Diogo CL, Vieira JL, Dalacorte RR. Physical activity and depressive symptoms in community-dwelling elders from southern Brazil. Rev Bras Psiquiatr. 2011;33(2):165-70. DOI:10.1590/S1516-44462011005000006
https://doi.org/10.1590/S1516-4446201100... Research from the Honolulu-Asia Aging Study (HAAS), which followed the subjects for eight years, found that those elderly individuals who walked more than 0.25 miles per day (approximately 402 meters) were at lower risk of depressive symptoms. ²²22 . Smith TL, Masaki KH, Fong K, Abbott RD, Ross GW, Petrovitch H, et al. Effect of walking distance on 8-year incident depressive symptoms in elderly men with and without chronic disease: the Honolulu-Asia Aging Study. J Am Geriatr Soc . 2010;58(8):1447-52.DOI:10.1111/j.1532-5415.2010.02981.x
https://doi.org/10.1111/j.1532-5415.2010... Taking into account only leisure time physical activities, elderly individuals in Taiwan had a reduced risk of depressive symptoms after seven years of monitoring. ¹³13 . Ku PW, Fox KR, Chen LJ. Physical activity and depressive symptoms in Taiwanese older adults: a seven-year follow-up study. Prev Med. 2009;48(3):250-5. DOI:10.1016/j.ypmed.2009.01.006
https://doi.org/10.1016/j.ypmed.2009.01....

Taking part in social groups proved to have a protective effect, signaling the importance of a social network in staying healthy and in preventing and/or treating depression in the elderly. However, it cannot be inferred that participating in social groups contributes to no depressive symptoms appearing, it may be that the fact of not having these symptoms contributes to participation in these groups. In that case, participating in groups would be a marker of an individual without depression, i.e., elderly individuals who did not participate in groups may be at higher risk of developing depressive symptoms, which prevents them from participating. It would be important to incentive those who do not attend this type of group to do so and assess the reasons for why this is not occurring.

A limitation of this study was its cross-sectional design, which meant that cause and effect relationships could not be defined. On the other hand, the high response rate contributed to its internal validity, decreasing the chance of systematic errors, and reproducibility was satisfactory. Using a large sample which is representative of the municipality means the results can be extrapolated to the whole population.

Identifying the factors linked to depressive symptoms proved to be significant, as this knowledge can support health care policies for the elderly in Florianópolis (prevention and treatment of depression, especially non-pharmacological strategies, such as programs promoting physical education) as well as contributing to the discussion and understanding of depression in the elderly in Brazil and other countries. It is recommended that longitudinal studies be carried out, aiming to better understand the associated factors, in addition to conducting experimental research analyzing the behavior of modifiable factors and their relationship to depressive symptoms in the elderly.

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