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The EURODEP consortium consists of a number of
independent community based studies of depression
among older people, conducted in centres in Europe
which have been brought together to form a Concerted
Action Programme under the European Community BIO-
MED I initiative. In the first studies, EURODEP is trying
to answer the questions: how much depression exists
among older people in Europe? Does its level vary from
place to place? Does the clinical picture differ between
populations? Is the level of depression consistent with
suicide levels? Is it treated and what are its risk factors?
The increasing proportions of older people in the pop-
ulations of Europe lent urgency to the need to know their
levels of mental illness, of which one of the most prevalent
is depression. First, a systematic review of the world liter-
ature on community-based studies of the prevalence of
depression in later life (aged 55+) was undertaken (1).
Thirty-four studies were eligible for inclusion, with a range
of prevalence rates for depression of 0.4-35%. They
revealed a weighted average for major depression of 1.8%
and for minor depression of 9.8%, while all depressive
syndromes considered clinically relevant reached 13.5%.
A higher rate of prevalence of depression was a consistent
finding for women and among older people in poor socio-
economic circumstances. Because of the diversity of meas-
ures used, it was not possible in such a survey to make
comparisons between individual studies in order to iden-
tify areas of high and low depression prevalence. The need
for a uniform standardised method was clear.
The aims of the first studies were: a) to study the varia-
tion in the prevalence of diagnosable depression among
people aged 65 and over living in the community in dif-
ferent centres in Europe using a standardised method; b)
to examine core symptoms and clinical profiles across
centres: how do they differ? c) to interpret them in rela-
tion to existing socio-economic and risk factor variables;
and d) the harmonisation of scales of depression to allow
other centres to join the consortium for comparing levels
of depressed mood by scale score.
METHOD
Formation of the consortium
The original members of the consortium (Study 1) had
used the Geriatric Mental State (GMS) AGECAT as the
principal case finding and diagnostic instrument for their
studies: Amsterdam (2); Berlin (3); Dublin (4); Iceland
(5); Liverpool (6); London (7); Munich (8); Verona, Italy
Depression among older people in Europe:
the EURODEP studies
RESEARCH REPORT
The data from nine centres in Europe which had used the Geriatric Mental Scale (GMS) AGECAT were analysed to compare prevalence
of diagnoses in subjects aged 65 years and over living in the community. Levels of depressive illness were: Iceland 8.8%, Liverpool 10.0%;
Zaragoza 10.7%; Dublin 11.9%; Amsterdam 12.0%; Berlin 16.5%; London 17.3%; Verona 18.3% and Munich 23.6%. Taking all levels
of depression, five high (Amsterdam, Berlin, Munich, London and Verona) and four low (Dublin, Iceland, Liverpool, Zaragoza) scor-
ing centres were identified. Meta-analysis of all 13,808 subjects yielded a mean level of depression of 12.3% (95% CI 11.8-12.9), 14.1%
for women (95% CI 13.5-14.8) and 8.6% for men (95% CI 7.9-9.3). Symptom levels varied between centres: 40% of the total study pop-
ulation in Amsterdam reported depressive mood against only 26% in Zaragoza. To incorporate studies from other centres using other
methods for depression identification, the EURO-D scale was developed from 12 items of the GMS and validated against other scales
and expert diagnosis. A two factor solution emerged, an ‘affective suffering factor’ and a ‘motivation factor’. The EURO-D scale was
applied to 14 population based surveys. Depression score tended to increase with age unlike levels of prevalence of depression. Large
between centre differences were evident in levels of depression unexplained by age, gender or marital status. These data show that depres-
sive illness defined as suitable for intervention is common among older people in Europe. Opportunities for effective treatment are
almost certainly being lost. Levels of depressive symptoms vary significantly between high and low scoring centres, prompting the next
phase of this study, an examination of risk factors in Europe.
Key words: EURODEP, depression, old age, GMS-AGECAT, EURO-D
JOHN R.M. COPELAND
1
, AARTJAN T.F. BEEKMAN
2
, ARJAN W. BRAAM
2
, MICHAEL E. DEWEY
1
, PHILIPPE DELESPAUL
3
,
R
EBECCA FUHRER
4
, CHRISTOPHER HOOIJER
5
, BRIAN A. LAWLOR
6
, SIRKKA-LIISA KIVELA
7
, ANTHONY LOBO
8
, HALGRIMUR
MAGNUSSON
9
, ANTHONY H. MANN
10
, INGEBORG MELLER
11
, MARTIN J. PRINCE
12
, FRIEDEL REISCHIES
13
, MARC ROE-
LANDS
14
, INGMAR SKOOG
15
, CESARE TURRINA
16
, MARTEN W. DEVRIES
3
, KENNETH C.M. WILSON
1
1
Department of Psychiatry, University of Liverpool, UK;
2
Department of Psychiatry, Vrije Universiteit, Amsterdam, The Netherlands;
3
Department of Psychiatry,
University of Maastricht, The Netherlands;
4
INSERM U360, Hôpital de la Salpêtriere, Paris, France;
5
DOC-Team Oude Hoeverweg 10, 1816 BT Alkmaar, The
Netherlands;
6
Department of Psychiatry of the Elderly, St. James’s Hospital, Dublin, Ireland;
7
Department of General Practice, University of Turku and Satakunta
Central Hospital, Turku and Pori, Finland;
8
Department of Psychiatry, University Hospital, Zaragoza, Spain;
9
Heilsugaeslustod Grundarfjardar, Iceland;
10
Sections of
Epidemiology and General Practice and Old Age Psychiatry, Institute of Psychiatry, London, UK;
11
Department of Psychiatry, University of Munich, Germany;
12
Section
of Epidemiology, Institute of Psychiatry, London, UK;
13
Department of Psychiatry, Freie Universität, Berlin, Germany;
14
Department of Behaviour Therapy and
Counselling, University of Gent, Belgium;
15
Psykiatriska Kliniken, Sahlgrenska Sjukhuset, Goteborg, Sweden;
16
Clinica Psichiatrica, Ospedale Civile, Brescia, Italy
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46
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February 2004
(9); Zaragoza, Spain (10). The centres decided to come
together and form a Concerted Action, pool their data and
thus give added strength to their analyses of risk factors
and generate new hypotheses for further studies.
To the original nine GMS AGECAT centres, another
centre was added with expertise in the technique of ‘Expe-
rience Sampling’ (Maastricht). Five further centres (Study
2) applied to join - Gothenburg, Sweden (11); Antwerp,
Belgium (12); Bordeaux, France (13); Oulu, Finland (14);
and Amsterdam (15) - which had used other measures. It
was decided to try to harmonise their measures of depres-
sion with those of the other centres. Under the European
Community PECO initiative, an East European centre was
added: Tirana, Albania (not reported here).
Characteristics of the centres
Details on the individual centres for Study 1 are report-
ed elsewhere (16). All the centres took random communi-
ty samples collected between 1990 and 1996, except for
Iceland which had a total population birth cohort born
1895-1897 and interviewed in 1983, and Dublin which
used a general practitioner complete register. The age
range was from 65 upwards for most samples, except Ams-
terdam (65-84), Berlin (70+), Munich (85+) and Iceland
(88-89). Only one centre excluded nursing homes entirely
(Verona). Most samples were urban, except Iceland which
was mixed rural/urban. Their size varied between 202 in
Verona and 5222 in Liverpool. The two samples in Italy
and Spain were predominantly catholic. The samples in
the UK (London and Liverpool), in Germany (Berlin and
Munich), in the Netherlands and in Iceland were predom-
inantly protestant, while the sample in Dublin was
catholic.
Measures
The studies were undertaken using the GMS (17,18)
community version in approved translation. AGECAT
(19,20) is a computerised diagnostic algorithm which uses
scores on GMS items in stage one for each subject to pro-
duce a level of confidence of diagnosis on a scale of 0-4 or
0-5 for each of eight diagnostic syndrome clusters: organ-
ic brain syndrome, schizophrenia, mania, depression (psy-
chotic and neurotic), and obsessional, hypochondriacal,
phobic and anxiety neuroses. Stage 2 reaches a final dif-
ferential diagnosis by comparing level for level, recorded
as either a diagnostic subcase (confidence levels 1 and 2)
or a diagnostic case (confidence levels 3,4 and 5). Thus it
allows the identification of comorbid states. Level 3 and
above on any diagnostic cluster accords with what psychi-
atrists would usually recognise as a case for treatment or
intervention, if available. Good agreement has been
shown between AGECAT cases of depression and DSM-
III major depressive episode and dysthymia taken togeth-
er (21,22). In addition to the GMS, most centres collected
risk factor information and seven undertook follow-up of
their samples.
Data analysis for the pooled data took place in Liver-
pool. The Liverpool and Berlin samples were gender and
age stratified. The overall prevalence figures for these cen-
tres are therefore adjusted using the appropriate weights
to take this into account.
STUDY 1A: PREVALENCE OF DEPRESSION
IN EUROPEAN CENTRES
Results
Substantial differences in the prevalence of depression
were found, with Iceland having the lowest level at 8.8%,
followed by Liverpool 10.0%; Zaragoza 10.7%; Dublin
11.9%; Amsterdam 12.0%; Berlin 16.5%; London 17.3%;
Verona 18.3% and Munich 23.6%. When all five AGE-
CAT depression levels, including both subcases of depres-
sion and cases, were added together, five high scoring cen-
tres emerged (Amsterdam, Berlin, Munich, London and
Verona) with a prevalence of all levels of depression of
30.4 to 37.9%, and four low scoring centres (Dublin, Ice-
land, Liverpool, Zaragoza) with prevalence levels between
17.7 to 21.4%. Women almost invariably dominated over
men. The examination of the proportions of subcases to
cases, and psychotic to neurotic depression, although
revealing some striking differences between centres, pro-
vided no obvious explanation for the difference in preva-
lence (see also 16).
Although age-specific prevalence rates varied between
centres, there was no constant association between preva-
lence and age.
The meta-analysis of the pooled data on the nine Euro-
pean centres yielded 13,808 subjects, with an overall
prevalence of depression of 12.3% (95% CI 11.8-12.9);
14.1% for women (95% CI 13.5-14.8) and 8.6% for men
(95% CI 7.9-9.3).
Discussion
It was concluded that considerable variation existed in
the levels of depression across Europe, although the
cause was not immediately obvious. Cases and subcases
taken together showed even greater variability, particular-
ly for women, suggesting that it was not simply a matter
of variation in case/subcase criteria, which were in any
event standardised by computer. It is possible that risk
factors for well/subcase and subcase/case transitions in
both directions vary, although this was not true for Liver-
pool (23), where subcases shared similar risk factors to
cases. Although there were substantial levels of depres-
sion in all centres, it can also be said that between 62 and
82 percent of older persons had no depressive level on
the AGECAT system. It was finally concluded that sub-
stantial opportunities for treatment existed. Not all stud-
ies assessed treatment. Those that did, e.g. Liverpool,
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47
found around 10 % of case level depression received anti-
depressant medication.
STUDY 1B: PRESENTATION OF DEPRESSION
AND DEPRESSIVE SYMPTOMS IN EUROPE
Results
The proportions of depressive symptoms were found to
vary between centres. In Amsterdam, for example, 40% of the
general population of older people reported depressive mood
compared to 26% in Zaragoza. Symptoms such as ‘future
bleak’, ‘hopelessness’, ‘wish to be dead’ were generally rare,
but the last reached higher levels in Berlin, Munich and
Verona. Sleep disturbance was admitted by only 15% of the
population in Dublin, but 54% and 60% in Munich and
Berlin. Large differences for some symptoms were found with-
in the very old populations in Iceland, Berlin and Munich: in
men aged 85 and over, the prevalence of ‘depressed mood’,
‘crying’, ‘cannot cry’, ‘life not worth living’ and ‘wish to be
dead’ was 9%, 3%, 4%, 2% and 3%, respectively, in Iceland,
whereas it was 50%, 33%, 26%, 30% and 29% in Munich,
and 41%, 21%, 15%, 16% and 25% in Berlin, whereas there
was no difference for ‘guilt’ and ‘energy loss’. These differ-
ences were also evident for women (see also 24).
As expected from the prevalence levels of depression,
many symptoms were more common among women. Cen-
tres where the prevalence of depression was low tended to
have fewer symptoms among the well (i.e., those with no
depressive level), but there were inconsistencies, so that a
low level of symptoms in the ‘well’ did not necessarily pre-
dict a lower level in the depressed.
Discussion
We conclude that surprising variations in prevalence of
depressive symptoms occurred between centres, and were
not always consistent with levels of depressive illness. The
high level of serious symptoms of depression in populations
aged 85 and over in the German centres compared to others,
and particularly to Iceland, may have been due to the linger-
ing aftermath of the Second World War in this generation.
Less variation with age occurred than expected and was
inconsistent between centres. There was no consistent
relationship between proportions of symptoms in well
persons and cases for all centres. In all, it can be said that
the levels of depressive symptoms among over 60% of the
older general population of Europe were low, so that pejo-
rative stereotypes of old age in Europe as naturally
depressed were not upheld.
STUDY 2A: HARMONISATION OF MEASURES
OF DEPRESSION IN OLDER PEOPLE
Method
Because new centres had entered the consortium,
which had not used the GMS AGECAT, attempts were
made to harmonise the depression measures which they
had used with the GMS items, so that a common scale
could be derived (the EURO-D, 25). Most of the non-
GMS AGECAT centres had used the Short Care, the
Center for Epidemiological Studies - Depressive Scale
(CES-D), the Comprehensive Psychopathological Rating
Scale (CPRS) and the Zung Self Rating Depression Scale
(ZSDS). Common items were identified by scrutiny of
these instruments, and algorithms for fitting items from
other instruments to the GMS were derived. This was
undertaken by direct observation of item correspon-
dence or by expert opinion. The resulting twelve item
scale was checked in each centre for internal consisten-
cy, criterion validity and uniformity of factor and analyt-
ic profiles.
Results
It was concluded that the EURO-D Scale, from whichev-
er scale it had been derived, was entirely consistent and
seemed to capture the essence of its parent instrument. It
was also judged to have a comparable factor structure what-
ever its origin, but a two factor solution was optimal.
‘Depression’, ‘tearfulness’, and ‘wishing to die’ loaded on
the first factor, which we called ‘affective suffering’, while
‘loss of interest’, ‘poor concentration’ and ‘lack of enjoy-
ment’ loaded on the second, called the ‘motivation factor’.
It was concluded that the diverse depression measures cov-
ered common conceptual domains, and often had similarly
worded items. Even differences in modes of administration
(for example, self report versus semi-structured clinical
interview) did not seem to prevent the extraction of broad-
ly comparable data with common scaling properties.
STUDY 2B: APPLICATION OF THE EURO-D SCALE
Method
Subjects from the 14 population based surveys were
used to test the EURO-D with respect to the main inter-
active effects of centre, age, gender and marital status (see
also 26). Between centre variance was partitioned accord-
ing to centre sub-characteristics, geographical region,
prominent religion and survey instrument used.
Results
It was noted that EURO-D scores tended to increase
with increasing age, unlike the levels of prevalence of
depression. Women had generally higher scores than men,
and widowed and separated subjects higher scores than
those who were currently or never married.
Discussion
The EURO-D Scale, it appeared, could be reduced to
two well characterised factors, ‘motivation’ and ‘affective
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48
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suffering’. The motivation factor seemed to account for
the positive association with age, while the affective suf-
fering factor was responsible for the gender difference.
The gender difference was modified by marital status,
being negligible among those who had never married,
and equally evident among the currently married, the
widowed and the separated. There was no evidence for a
continuation of the gender difference with increasing
age. The effects of age, gender and marital status
accounted for less than 1% of the variance in the EURO-
D Scale.
It was concluded that there were large between centre
differences, which could be explained neither by the age,
gender or marital status characteristics of the population,
nor by the instruments used to survey them.
Reasonably consistent, but small effects of age, gender
and marital status on depression symptoms have been
observed across the 14 European centres. It is concluded
that while symptoms of depression increase with age,
depression may be over-diagnosed in older persons
because of an increase in complaints of lack of interest
and motivation which may be affectively neutral and pos-
sibly related to cognitive decline.
STUDY 3: RELIGIOUS BEHAVIOUR AND DEPRESSIVE
SYMPTOMS IN EUROPE
Method
We examined the influence of religion on the level of
both depressive symptoms and illness across the Euro-
pean centres. The EURO-D Scale was used in this analy-
sis to allow all the centres, original and additional, to
participate. The influence of religion is of interest to the
collaboration because of the split between North and
South Europe and between protestant and roman
catholic groups, with some catholic centres (Ireland, Bel-
gium, and in part Liverpool) being in the more northerly
parts of the continent, and Spain, Italy and France in the
more southerly. The addition of Albania had the advan-
tage of introducing a largely Muslim religious group (see
also 27).
The protective effects of being a religious person were
examined using data from 13 community based studies in
11 centres.
Results
Fewer depressive symptoms were found in those
catholic countries with high rates of regular church
attendance, while in protestant countries high levels of
depressive symptoms were associated with lower levels
of attendance. It was concluded that religious practice,
especially when it is embedded within a traditional
value-orientation, may facilitate coping with adversity in
later life.
Interactive effects showed the results to be more pro-
nounced among older women. It was concluded that older
Europeans appear to benefit from religious practice.
CONCLUSIONS
However interpreted, these results make it plain that
depression as an illness is common among older people in
Europe. Although it was not possible to assess the size of
the population receiving treatment, it is known that in the
London and Liverpool centres it falls often well below
15% of depressed persons judged as likely to benefit.
There is no reason to suppose these figures are better in
other European countries. Opportunities for effective
treatment are almost certainly being lost.
THE FUTURE
The consortium is now addressing the risk factors for
depression in this age group, and prognosis. We shall
also be examining comorbidity with organic states, espe-
cially dementia. Issues such as daily life, handicap and
depression, the validity of social measures of depression
and the concept of handicap and the daily life of older
people in Europe are being explored by the use of the
Experience Sampling Method developed at the Maas-
tricht Centre.
The consortium looks to extend its work into ran-
domised controlled treatment trials of depression between
centres and to study better methods for service delivery.
The EURODEP consortium gave rise to the ASIADEP
consortium, consisting of nine similar centres distributed
in Asian countries (Japan, China, South Korea, Taiwan,
Singapore, Malaysia and India) which will shortly be
reporting their results.
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