SULAIMAN A. AL-SHAMMARI 1 * AND ABDULLAH AL-SUBAIE 2 1 Professor and Chairman, College of Medicine, King Saud University, Riyadh, Saudi Arabia 2 Associate Professor, College of Medicine, King Saud University, Riyadh, Saudi Arabia SUMMARY Objectives. To assess the prevalence of depression and associated factors in elderly people in Saudi Arabia. Method. A cross-sectional national survey of the elderly population of Saudi Arabia was conducted between January 1994 and December 1995. A stratied two-stage sampling technique was used to select the study subjects. In the rst stage, a random sample of primary health care centres (PHCs) was selected in each of the ve administrative regions of the country. The family health records (FHR) of each selected PHC were reviewed and a list of the elderly (60 years and over) was compiled. In the second stage, a sample of the subjects was selected from the FHR and contacted for a personal interview. The subjects' physical, social and environmental health status were assessed by an interview during which a structured questionnaire was completed. The Geriatric Depression Scale (GDS) was used to screen for depression. Other items of information in the questionnaire included subjects' sociodemographic characteristics, activities of daily living (ADL), laboratory and radiological investigations. Results. The total number of elderly subjects included in this study was 7970. Their mean age+standard deviations was 68.8+7.7 (male 69.1+.7.7; and female 67.7+7.5) years. Depressive symptoms were reported in 3110 (39%) of the subjects, and 8.4% were in the severe depressive symptoms score group. Personal characteristics that correlated strongly with depression were poor education ( p 0.001), unemployment ( p 0.001), divorced or widowed status ( p 0.001), old age and being a female ( p 0.001). Living in a remote rural area with poor housing arrangements and limited accessibility within the house and poor interior conditions were also signicantly associated with high depressive symptoms ( p 0.001). Limited privacy, such as having a particular room specied for the elderly, was associated with more depressive symptoms than sharing a room with another person ( p 0.001). Lower incomes inadequate for personal needs as well as depending on charity or other relatives were associated with more cases of depression ( p 0.001). The proportion of cases of depression correlated positively with the number of medical diagnoses and medications received ( p 0.001). Signicant depression was associated with loss of a close relative, living alone and limited participation in recreational activities. Perception of poor health and dependence on others for daily activities were associated with more depressive symptoms ( p 0.001). Also health problems, especially faecal or urinary incontinence, were associated with more depressive symptoms ( p 0.001). Conclusion. Depressive symptoms are common among Saudi elderly. Detection and management rates were low. Primary care teams could help these patients if properly trained. A simple instrument such as the Geriatric Depression Scale is useful and easily administered. Copyright # 1999 John Wiley & Sons, Ltd. KEY WORDSdepression; Saudi; elderly; geriatric depression scale The Kingdom of Saudi Arabia has a population of 16.9 million (12.7 million Saudi) and occupies an area of over 2 250 000 km 2 , giving a population density of 6.6 per km 2 (Al-Maalomat, 1994). Saudi Arabia houses the two Muslim holy mosques, namely Mecca and Madina. The Saudi population is homogeneous, with about 50% younger than 16 years of age. The Saudi elderly constitute about 600 000 (5%) of the total population (Nutfaji, 1981). This percentage is expected to further increase due to improvement in socio- economic standards and health care. Studies on utilization of psychiatric services showed an under- representation of the elderly population (Al-Subaie et al., 1996; El-Esra and Amin, 1988; El-Rufaie, CCC 08856230/99/09073909$17.50 Received 3 April 1998 Copyright # 1999 John Wiley & Sons, Ltd. Accepted 4 February 1999 INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY Int. J. Geriat. Psychiatry 14, 739747 (1999) *Correspondence to: Professor S. Al-Shammari, Dept. of Family & Community Medicine, College of Medicine, King Saud University, PO Box 2925, Riyadh 11461, Saudi Arabia. Tel: 4670836. Fax: 966-1-4671967. Contract/grant sponsor: King Abdulaziz City for Science and Technology. 1988; Al-Subaie, 1989). This, however, may reect help-seeking patterns, the small proportion of this age group in the Saudi society, or may be a true nding, indicating low prevalence of psychiatric disorders in the Saudi elderly. Western community- based studies show the prevalence of severe depression which warrants treatment in elderly people to be about 15%; these rates are nearly twice as great among primary care attenders (Tylee and Katona, 1996; Macdonald, 1986). UK studies show that the cost of depression in old age (in terms of excess health and social service utilization) is likely to be very high, even after allowing for the eects of associated social isolation and physical disability (Tylee and Katona, 1996). Other primary care studies show that only a minority of the depressed elderly are identied or treated (Macdo- nald, 1986). Elderly patients may not recognize their symptoms as constituting an emotional rather than a physical illness or believe that little can be done to help. Diagnostic diculties often arise from the absence of overtly low mood in older depressed patients, whose presenting symptoms are more likely to be altered sleep and appetite, agitation and multiple somatic complaints (Kivela and Pahkala, 1988). Depression is also likely to be missed in the presence of physical illness (Tylee et al., 1993) and psychological symptoms are much less likely to result in a correct diagnosis of depression if detected late in the consultation (Tylee et al., 1995). Depression in old age carries a worse prognosis than earlier in life in terms of persistence and recurrence, increased mortality ( particularly in men, Murphy et al., 1988) and higher risk of suicide (Lindesay, 1991; Cattell and Jolley, 1995). As many patients with depression respond favourably to treatment, there are potential benets inherent in the early detection and treatment of depressive disorders. The Geriatric Depression Scale (GDS) (Williams and Wallace, 1993; Sheikh and Yesavage, 1986) is a simple instrument that can help in detection of depression among the elderly, for whom it was specically developed. In Saudi Arabia there is scarcity of data on various aspects of health of the elderly and available studies are hospital-based, describing to a limited extent the health situation of the elderly (Al-Shammari et al., 1995; Alballa et al., 1993; Al-Shammari, 1994). The objectives of this household study are to determine the prevalence of depression in Saudi elderly and to identify the associated social and health factors. METHOD The design was a cross-sectional national survey conducted between January 1994 and December 1995. A two-stage stratied sampling technique was used in the selection of the elderly subjects, who were all Saudi nationals. There are about 600 000 people over the age of 60 in Saudi Arabia. The study sample was estimated to be 7600 elderly using the formula N P(1-P)/e 2 , where N sample size, P prevalence of disorder taken at 15%, standard error 0.25%. The rst-stage sampling units were the list of primary health centres (PHC) in each of the ve administrative regions of the Kingdom (ie North, West, East, South and Central). A random sample of PHCs was selected from both urban and rural areas of each region. In the rural and nomadic areas, the number of health centres selected was proportional to the size of the village or collection of Bedouins. The family health records (FHR) in a (PHC) catchment area population served as the second-stage sampling frame. It is compulsory for the primary health care centres to locate and update catchment area population households for the purpose of opening a family health record. A systematic random sample of the elderly was selected from the FHRs. Each selected elderly person was contacted by telephone or other avail- able means to arrange for a personal visit to his/her house. The information collected during the visit included: (1) sociodemographic data, which included personal information, socioeconomic aspects of life and housing conditions; (2) physical health information; (3) level of activityfor this purpose we used the Activity of Daily Living Scale (ADL) (Katz et al., 1970); (4) the Geriatric Depression Scale (GDS), a 30-item instrument that requires responses of yes or no to the presence or absence of depressive symptoms in the elderly population (Fillenbaum, 1984; Yesavage et al., 1983). Those elderly subjects who scored 1020 on the Geriatric Depression Scale (Yesavage et al., 1983) were considered to suer from mild depression; a score of 2130 suggests severe depression. Subjects who were unable to read were helped by the GP, who was trained in the ADL, GDS and diagnosis of depression. Each statement was read to subjects in a standard fashion. The ADL and GDS scales were translated into Arabic by one of the authors and then independently back-translated into English until the two versions became almost identical. The translated questions were found to have the same Copyright # 1999 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 14, 739747 (1999) 740 S. A. AL-SHAMMARI AND A. AL-SUBAIE meaning in Saudi culture. They were tested against a clinical interview by a psychiatrist in a pilot sample and validity was satisfactory. For the purpose of the study the GDS was used as screening instrument and patients with depressive symptoms were referred to their own area psychiatrists, with no further follow-up from the researchers. Data collected in each region were entered in the mainframe computer at the College of Medicine in Riyadh. Health morbidity was measured by responses to interview on questionnaires. Inter- national classication of diseases ICD-9 was used to classify the clinical diagnoses made through history, physical examination and appropriate laboratory tests. These included blood analysis for count, haemoglobin, ESR, urea, creatinine and sugar. The subject's urine was tested microscopi- cally and bacteriologically. Chi-square test was calculated between depression score as polytomous dependent variable and other variables to test for association. RESULTS The total number of elderly subjects included in this study was 7970. The response rate was 98.8% in males and 79.8% in females. The research team visited the subjects about four times on average to encourage them to complete the study. The male dropouts were replaced rather more easily, which led to over-representation of male over female subjects. Their mean age and standard deviations were 68.8+7.7 with no gender dierence (male 69.1+7.7 and female 67.7+7.7 years). Thirty-nine per cent of the elderly scored above 10 on the GDS. Mild depressive symptoms (1020 score) were present in 30.6%, with more severe depressive symptoms (a score of more than 20) shown by 8.4%. As shown in Table 1, signicant depressive symptoms were more common in the poorly educated, unemployed, divorced or widowed, very old and the female sex as well as in those living in rural and remote areas. Also, depressive symptoms were more common among those who had poor housing arrangements such as limited space and accessibility within the house and poor interior upkeep of the house (Table 2). Interestingly, limited privacy, such as having a particular room specied for the elderly, was associated with more depressive symptoms than sharing a room with another person. Table 3 shows the depression scores relating to nancial status. Lower incomes that do not full personal needs as well as depending on charity or other relatives were associated with more cases of depression. The proportion of cases of depression correlated positively with the number of medical diagnoses and medication received, as shown in Table 4. Also, as shown in Table 5, signicant depression was associated with loss of a close relative, living alone and limited participation in recreational activities. Perception of poor health and dependence on others for daily activities were associated with more depressive symptoms. Also health problems, especi- ally faecal or urinary incontinence, were associated with more depressive symptoms (Table 6). DISCUSSION The nding of more depression in the divorced and widowed is in keeping with numerous other studies (Pfeitter and Murrell, 1986; Murphy, 1982; Linn et al., 1980). Likewise, poor education and unemployment are expected to be associated with depressive ndings. The rapid industrialization and modernization probably contribute to the dissatis- faction with housing standards in the elderly. Like unemployment, lower incomes, social isolation and being dependent on others for fullment of personal needs were associated in this study with depressive feelings and disorders, as suggested by other researchers, who also found that loneliness and loss events were important contributing factors to the development of depression (Linn et al., 1980; Katona, 1994). As reported by previous studies, poor physical health and limited activities of daily living were associated with more depression and depressive symptoms (Murphy, 1982; Katona, 1994). The Saudi culture and traditional social values dictate high respect for and care of the elderly by members of the extended family (El-Eslam, 1983; El-Sendiony, 1981) and this may explain the small number of the Saudi elderly in this study who were living alone compared to the elderly in other communities (Vida, 1994; Coolen, 1993). The association between more privacy and depression can be explained by the tendency of the elderly in the extended family system of Saudi Arabia to associate more privacy with alienation and neglect by other family members. Copyright # 1999 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 14, 739747 (1999) DEPRESSION AMONG SAUDI ELDERLY 741 The prevalence of depressive symptoms in our study was about 39%, which is somewhat higher than gures reported by previous workers (Blazer, 1982; Marwijk et al., 1994). Also, the proportion of signicant depression (a score of more than 20) was 8.4%, which is higher than the 1.7% of Weisman (Weisman et al., 1985) and the 3.7% of Blazer and Williams (Blazer and Williams, 1980) but lower than the 15% of Macdonald (1986). The lack of epidemiological studies on the prevalence of depression in other age groups in Saudi Arabia makes it dicult for us to examine the eect of age in our study, although it seems that the proportion of depressed subjects increases with age. This is supported by similar western studies (Fiprichs et al., 1981) but contrasts with some other western studies reporting no eect of age on depressive symptomatology (Eaton and Kessler, 1981). Major depression (in contrast to symptoms) was reported to be less prevalent among the elderly in the USA than in other stages of the life cycle (Weisman et al., 1985). It is, nevertheless, expected that the ageing process brings with it more physical ailments, losses and dependence that are known to be associated with depression. Deliberate self- harm and suicide are uncommon in Saudi Arabia (Al-Subaie, 1989) but further investigation is needed to assess and compare our elderly with others (Lindesay, 1991; Pierce, 1987). The male to female ratio in our study was 1: 1.7 for severe depression and 1: 1.4 for depressive symptoms, which is in keeping with worldwide gures of more prevalence of depression and depressive symptoms Table 1. Depression by sociodemographic characteristics of elderly (N 7970) Characteristics N 7970 (100) Depression score p-value 010 4860 (61.0) 1120 2440 (30.6) 2130 670 (8.4) Residence Urban 5249 (65.9) 3338 (63.6) 1512 (28.8) 399 (7.6) w 2 25.2224 Rural 2525 (31.7) 1415 (56.0) 862 (34.1) 248 (9.8) df 4 Remote 196 (2.5) 107 (54.6) 66 (33.7) 23 (11.7) p 0.001 Sex Male 4938 (62.0) 3304 (66.9) 1305 (26.4) 329 (6.7) w 2 196.1691 Female 3032 (38.0) 1556 (51.3) 1135 (37.4) 341 (11.3) df 2 p 0.0001 Age 6064 2805 (35.2) 1909 (68.1) 737 (26.3) 159 (5.7) 6569 2060 (25.9) 1248 (60.6) 657 (31.9) 155 (7.5) w 2 161.0870 7079 2261 (28.4) 1301 (57.5) 721 (31.9) 239 (10.6) df 8 8089 692 (8.7) 338 (48.8) 258 (37.3) 96 (13.9) p 0.0001 90 152 (1.9) 64 (42.1) 67 (44.1) 21 (13.8) Marital status Single 748 (9.4) 502 (67.1) 186 (24.9) 60 (8.0) w 2 128.1276 Married 5585 (70.1) 3548 (63.5) 1631 (29.2) 406 (7.3) df 4 Divorced/widowed 1637 (20.5) 810 (49.5) 623 (38.1) 204 (12.5) p 0.001 Educational level Illiterate 6320 (79.3) 3608 (57.1) 2119 (33.5) 593 (9.4) w 2 147.4074 Read and write 1337 (16.8) 1002 (74.9) 269 (20.1) 66 (4.9) df 2 More than read and write 313 (3.9) 250 (79.9) 52 (16.6) 11 (3.50) p 0.001 Occupation Not working 4390 (55.1) 2433 (55.4) 1500 (34.2) 457 (10.4) w 2 155.8625 Unskilled work 2675 (33.6) 1767 (66.1) 747 (27.9) 161 (6.0) df 8 Semi-skilled work 696 (8.7) 513 (72.7) 145 (20.8) 38 (5.5) p 0.001 Skilled work 61 (0.8) 46 (75.5) 11 (18.0) 10 (6.8) Intermediate work 148 (1.9) 101 (68.2) 37 (25.0) 10 (6.8) Copyright # 1999 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 14, 739747 (1999) 742 S. A. AL-SHAMMARI AND A. AL-SUBAIE Table 2. Depression by housing Characteristics N 7970 (100) Depression score p-value 010 4860 (61.0) 1120 2440 (30.6) 2130 670 (8.4) Housing Villa/palace 2432 (30.5) 1653 (68.0) 608 (25.0) 171 (7.0) w 2 94.1042 Small house 3092 (38.8) 1746 (56.5) 1056 (34.2) 290 (9.4) df 6 Flat 1778 (22.3) 1102 (62.0) 541 (30.4) 135 (7.6) p 0.001 Other 668 (8.4) 359 (53.7) 235 (35.2) 74 (11.1) Private room No specic 1342 (16.8) 774 (57.7) 430 (32.0) 138 (10.3) w 2 872.0132 Specied shared 3884 (48.7) 2498 (64.3) 1116 (28.7) 270 (7.0) df 4 Specied for me 2744 (34.4) 1588 (57.9) 894 (32.6) 262 (9.6) p 0.001 Accessibility within house Good 3072 (38.5) 1995 (64.9) 818 (26.6) 259 (8.4) w 2 143.6002 Acceptable 4052 (50.8) 2498 (61.7) 1259 (31.1) 295 (7.3) df 2 Poor 846 (10.6) 367 (43.4) 363 (42.9) 116 (13.7) p 0.001 Interior condition of house (interviewer) Optimum 1963 (24.6) 1376 (70.1) 482 (24.6) 105 (5.4) w 2 358.5225 Acceptable 4824 (60.5) 3038 (63.0) 1406 (29.2) 380 (7.9) df 4 Poor 1183 (14.8) 446 (37.7) 552 (46.7) 185 (15.6) p 0.001 Satisfaction (interviewee) Optimum 1885 (23.7) 1336 (70.9) 453 (24.0) 96 (5.1) w 2 371.6411 Adequate 4912 (61.6) 3087 (62.9) 1430 (29.1) 395 (8.0) df 4 Poor 1173 (14.7) 437 (37.3) 557 (47.5) 179 (15.3) p 0.001 Table 3. Depression by nancial status N 7970 Depression score p-value 010 4860 (61.0) 1120 2440 (30.6) 2130 670 (8.4) Monthly income 52500 4048 (50.8) 2198 (54.3) 1475 (36.4) 375 (9.3) w 2 91.1703 25004999 2351 (29.5) 1563 (66.5) 625 (26.6) 163 (6.9) df 2 500014 999 1225 (15.4) 828 (67.6) 282 (23.0) 115 (9.4) p 0.001 15 000 346 (4.3) 271 (78.3) 58 (16.8) 17 (4.9) Source of nance Self 2589 (32.5) 1798 (69.5) 632 (24.4) 159 (6.1) w 2 243.9108 Children 2393 (30.0) 1304 (54.5) 839 (35.1) 250 (10.5) df 10 Other relation 178 (2.2) 82 (46.1) 80 (44.9) 16 (9.0) p 0.0001 Charity 292 (3.7) 122 (41.8) 134 (45.9) 36 (12.3) Government 2004 (25.1) 1303 (65.0) 531 (26.5) 170 (8.5) Others 514 (6.5) 251 (48.8) 224 (43.6) 39 (7.6) Fullment of needs Very good 1193 (15.0) 850 (71.3) 281 (23.6) 62 (5.2) w 2 177.7653 Fair 4324 (54.3) 2764 (63.9) 1213 (28.1) 347 (8.0) df 4 Poor 2453 (30.8) 1246 (50.8) 946 (38.6) 261 (10.6) p 0.001 Copyright # 1999 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 14, 739747 (1999) DEPRESSION AMONG SAUDI ELDERLY 743 in females (Weisman et al., 1985; Livingston and Hinchlie, 1993). It seems that many cases of depression do not seek treatment in our study. Similarly low detection and treatment rates were reported by western studies (Mullan et al., 1994; Copeland et al., 1992). The gap between recognition and intervention is striking and explanations might be related to the erroneous and ageist beliefs held by doctors that depression is inevitable and `normal' in the face of multiple losses, deteriorating health and impending death and that older people are too frail to tolerate physical treatment or too inexible to benet from psychotherapy. In addition, some PHC doctors may feel helpless to induce improvement in their patients' social circumstances. Others may feel lacking in expertise in initiating treatment of depression in older patients (Freer, 1987). The primary care physician is uniquely placed to initiate and monitor care (Murry, 1989; Russell and Hime, 1988). The other PHC team members, such as nurses, occupational therapists and health visitors, as well as volunteers, may be eectively recruited in such programmes (Murry, 1989; Table 4. Depression by number of diagnoses and medication N 7970 Depression score p-value 010 4860 (61.0) 1120 2440 (30.6) 2130 670 (8.4) No. of diagnoses Nil 2903 (36.4) 1828 (63.0) 883 (30.4) 192 (6.6) w 2 104.8495 One 2805 (35.2) 1783 (63.6) 832 (29.7) 190 (6.8) df 8 Two 1555 (19.5) 880 (56.6) 497 (32.0) 178 (11.5) p 0.0001 Three 512 (6.4) 275 (53.7) 163 (31.8) 74 (14.5) Four 195 (2.5) 94 (48.2) 65 (33.7) 36 (18.5) No. of medications Nil 2245 (28.2) 1615 (71.9) 492 (21.9) 138 (6.2) w 2 283.810 One 1529 (19.2) 1014 (66.3) 403 (26.4) 112 (7.3) df 12 Two 1558 (19.6) 912 (58.5) 524 (33.6) 122 (7.8) p 0.0001 Three 1236 (15.5) 628 (50.8) 487 (39.4) 121 (9.8) Four 614 (7.7) 304 (49.5) 232 (37.8) 78 (12.7) Five 340 (4.3) 154 (45.3) 140 (41.2) 46 (13.5) Six 448 (5.6) 233 (52.0) 162 (36.2) 53 (11.8) Table 5. Depression by living arrangements, loss of close relative and recreational activities N 7970 Depression score w 2 1 df 1 p-value 010 4860 (61.0) 1120 2440 (30.6) 2130 670 (8.4) Living arrangements Alone 430 (5.4) 229 (53.3) 134 (31.2) 67 (15.6) w 2 32.3 df 3 With family 7540 (94.6) 4631 (58.1) 2306 (28.9) 603 (7.6) p-value 50.0001 Loss of close relative No 7299 (91.6) 4466 (61.2) 2242 (30.7) 591 (8.1) w 2 10.8 df 3 Yes 671 (8.4) 394 (58.7) 198 (29.5) 79 (11.8) p-value 0.01 Participation in recreational activities No 6436 (80.8) 3818 (59.3) 2030 (31.5) 588 (9.1) w 2 45.6 df 3 Yes 1534 (19.3) 1042 (67.9) 410 (26.7) 82 (5.4) p-value 50.001 Copyright # 1999 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 14, 739747 (1999) 744 S. A. AL-SHAMMARI AND A. AL-SUBAIE Greengross, 1987; Collins et al., 1995). They need proper training and back-up support from mental health professionals to perform this task well. As reported by Al-Faris et al., training of PHC doctors in Saudi Arabia to recognize mental illness resulted in a better identication of cases and less use of laboratory investigation and prescription (Al-Faris et al., 1997). The `at risk' registers Table 6. Depression by health perception, activities of daily living and other health problems N 7970 Depression score p-value 010 4860 (61.0) 1120 2440 (30.6) 2130 670 (8.4) Health perception Good 5730 (71.9) 4012 (70.0) 1438 (25.1) 280 (4.9) w 2 779.5457 Poor 1876 (23.5) 707 (37.7) 834 (44.5) 335 (17.9) df 4 Cannot say 364 (4.7) 141 (38.7) 168 (46.2) 55 (15.1) p 0.001 Activities of daily living Independent 6518 (81.8) 4390 (67.4) 1767 (27.1) 361 (5.5) w 2 731.9718 Dependent 1452 (18.2) 470 (32.4) 673 (46.4) 309 (21.3) df 2 p 0.0001 Health problems Joint pain No 4069 (66.3) 2885 (70.9) 998 (24.5) 186 (4.6) w 2 269.1024 Yes 1759 (28.7) 704 (40.0) 800 (45.5) 255 (14.5) df 2 Cannot say 311 (5.0) 164 (52.7) 107 (34.4) 40 (12.9) p 0.001 Eyes Normal 4277 (53.7) 2858 (66.8) 1150 (26.9) 269 (6.3) w 2 142.7816 Abnormal 3693 (46.3) 2002 (54.2) 1290 (34.9) 401 (10.9) df 2 p 0.0001 Hearing diculty No 6493 (81.5) 4186 (64.5) 1851 (28.5) 456 (7.0) w 2 200.6130 Yes 1477 (18.5) 674 (45.6) 589 (39.9) 214 (14.5) df 2 p 0.0001 Cardiorespiratory problem No 4904 (79.9) 3159 (64.4) 1428 (29.1) 317 (6.5) w 2 130.1822 Yes 1235 (20.1) 594 (43.1) 477 (38.6) 164 (13.3) df 2 p 0.0001 Headache No 3637 (45.6) 2668 (73.4) 768 (21.1) 201 (5.5) w 2 431.2540 Yes 4333 (54.4) 2192 (50.6) 1672 (38.6) 469 (10.8) df 2 p 0.0001 GIT diculty No 3041 (49.5) 2050 (67.4) 791 (26.0) 200 (6.6) w 2 103.8178 Yes 2858 (46.6) 1581 (55.3) 1025 (35.9) 252 (8.8) df 4 Cannot say 240 (3.9) 122 (50.8) 89 (37.1) 29 (12.1) p 0.0001 Faecal incontinence No 7874 (98.8) 4827 (61.3) 2403 (30.5) 644 (8.2) w 2 53.5929 Yes 96 (1.2) 33 (34.4) 37 (38.5) 26 (27.1) df 2 p 0.0001 Urinary incontinence No 7425 (93.2) 4662 (62.8) 2187 (29.5) 576 (7.8) w 2 160.4266 Yes 545 (6.8) 198 (36.3) 253 (46.4) 94 (17.3) df 2 p 0.001 Copyright # 1999 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 14, 739747 (1999) DEPRESSION AMONG SAUDI ELDERLY 745 currently maintained in the primary health centres could be extended to include a special note of older people with specic diculties or vulnerability. ACKNOWLEDGEMENTS This study was supported by the King Abdulaziz City Institute for Science and Technology. The authors are grateful to all doctors, nurses, social workers and other medical and non-medical personnel, without whose support and under- standing the study could not have been performed. REFERENCES Alballa, S. R., Bamgboye, E. A. and Al-Sekait, M. et al. (1993) Causes of morbidity among a sample of elderly hospital patients in Riyadh, Saudi Arabia. J. Trop. Med. Hygiene 96, 157162. Al-Faris, E., Al-Subaie, A. and Khoja, T. et al. (1997) Training primary health care physicians in Saudi Arabia to recognise psychiatric illness. Acta Psychiatr. Scand. 96, 439444. Al-Maalomat (1994) An Arabic Encyclopedia. United Horizons, Riyadh. Al-Shammari, S. A. (1994) Causes of ill-health among elderly patients seen at a primary care clinic at King Khalid University Hospital, Saudi Arabia: An oppor- tunity for prevention. Saudi Med. J. 15, 358363. Al-Shammari, S. A., Jarallah, J. S. and Felimban, F. M. et al. (1995) Clinical and epidemiological pattern of long stay inpatients: An opportunity for the provision of out-reach community services in Saudi Arabia. J. Pub. Health Med. 17, 179186. Al-Subaie, A. (1989) Psychiatry in Saudi Arabia: Cultural perspective. Trans. Cult. Psychiat. Res. Rev. 26, 245262. Al-Subaie, A., Marwah, M. K., Hawari, R. A. and Rahim, F. E. (1996) Psychiatric emergencies in a university hospital in Riyadh, Saudi Arabia. Int. J. Ment. Health 25, 5968. Blazer, D. (1982) The epidemiology of late-life depres- sion. Am. Geriatr. Soc. 30, 589592. Blazer, D. and Williams, C. D. (1980) Epidemiology of dysphoria and depression in an elderly population. Am. J. Psychiat. 137, 439444. Cattell, H. and Jolley, D. J. (1995) One hundred cases of suicide in elderly people. Brit. J. Psychiat. 166, 451457. Collins, E., Katona, C. and Orrell, M. W. (1995) The management of depression in the elderly by general practitioners, 2. Attitudes to ageing and factors aecting practice. Fam. Pract. 12, 1217. Coolen, J. A. I. (1993) Changing Care for the Elderly in the Netherlands: Experiences and Research Findings from Policy Experiments in the Netherlands. Van Gorcum, Maastricht. Copeland, J. R., Davison, I. A., Dewey, M. E. et al. (1992) Alzheimer's disease, other dementias, depres- sion and pseudodementia: Prevalence, incidence and three-year outcome in Liverpool. Brit. J. Psychiat. 161, 230239. Eaton, W. W. and Kessler, J. G. (1981) Rates of symptoms of depression in a national sample. Am. J. Epidemiol 114, 528538. El-Eslam, M. F. (1983) Cultural changes and inter- generational relationships in Arabian families. Fam. Psychiat. 4, 321329. El-Esra, A. and Amin, A. (1988) Hospital admission in a psychiatric division in Saudi Arabia. Saudi Med. J. 9, 2530. El-Rufaie, O. (1988) A psychiatric clinic in a primary care setting: Evaluation of the experience. Saudi Med. J. 9, 2024. El-Sendiony, M. (1981) The Eect of Islamic Sharia on Behavioural Disturbance in the Kingdom of Saudi Arabia. Makka Printing and Publishing, Makkah, Saudi Arabia. Fillenbaum, G. G. (1984) The Wellbeing of the Elderly: Approaches to Multidimensional Assessment. Oset publication No. 84. World Health Organization, Geneva, pp. 8687. Fiprichs, R. R., Aneshensel, C. S. and Clarck, V. A. (1981) Prevalence of depression in Los Angeles Country. Am. J. Epidemiol. 113, 691699. Freer, C. B. (1987) Consultation-based screening of the elderly in general practice: A pilot study. J. Roy. Coll. Gen. Pract. 37, 455456. Greengross, S. (1987) The role of the general practitioner in the care of the elderly. In The Medical Annual (D. J. P. Gray, Ed.). Johnson Wright, Bristol. Katona, C. L. E. (1994) Depression in Old Age. Wiley, Chichester. Katz, S. et al. (1970) Progress in development of the index of ADLS. Gerontologist 10, 2030. Kivela, S. L. and Pahkala, K. (1988) Symptoms of depression in old people in Finland. Z. Gerontol. 21, 257263. Lindesay, J. (1991) Suicide in the elderly. Int. J. Geriatr. Psychiat. 6, 355361. Linn, M. W., Hunter, K. and Harris, R. (1980) Symptoms of depression in recent life event in the community of the elderly. J. Clin. Psychol. 36, 675682. Livingston, G. and Hinchlie, A. C. (1993) The epi- demiology of psychiatric disorders in the elderly. Int. Rev. Psychiat. 5, 317326. Macdonald, A. J. P. (1986) Do general practitioners `miss' depression in elderly patients? Brit. Med. J. 292, 365367. Copyright # 1999 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 14, 739747 (1999) 746 S. A. AL-SHAMMARI AND A. AL-SUBAIE Marwijk, H. V., Hoeksema, H. L., Hermans, J., Kaptein, A. A. and Mulder, A. J. (1994) Prevalence of depressive symptoms and depressive disorder in primary care patients over 65 years of age, Fam. Pract. 11, 8084. Mullan, M., D'Ath, P., Katona, P. and Katona, C. (1994) Screening, detection and management of depression in elderly primary care attenders, 2. Detection and tness for treatment: A case record study. Fam. Pract. 11, 267270. Murphy, E. (1982) Social origins of depression in old age. Brit. J. Psychiat. 141, 135142. Murphy, E., Smith, R., Lindesay, J. and Slattery, J. (1988) Increased mortality rates in late-life depression. Brit. J. Psychiat. 152, 347353. Murry, J. L. (1989) Health maintenance. Primary Care (Care of the Aging Patient) 16, 289303. Nutfaji, M. A. (1981) Projection of Saudi population by sex and age 19752000 AD. King Saud University, College of Administrative Science, Riyadh. Pfeitter, J. F. and Murrell, S. A. (1986) Etiologic factors in the onset of depressive symptoms in older adults. J. Abnorm. Psychol. 95, 282291. Pierce, D. (1987) Deliberate self-harm in the elderly. Int. J. Geriatr. Psychiat. 2, 105110. Russell, F. and Hime, M. (1988) Functional screening of elderly people living at home. Practitioner 232, 889892. Sheikh, J. A. and Yesavage, J. A. (1986) Geriatric Depression Scale (GDS): Recent ndings and develop- ment of a shorter version. Clinical Gerontology: A Guide to Assessment and Intervention (T. L. Brink, Ed.). Howarth Press, New York. Tylee, A., Freeling, P. and Kerry, S. (1993) Why do general practitioners recognize major depression in one woman patient but miss it in another? Brit. J. Gen. Pract. 43, 327330. Tylee, A., Freeling, P., Kerry, S. and Burns, T. (1995) How does the content of consultations aect the recognition by general practitioners of major depres- sion in women? Brit. J. Gen. Pract. 45, 575581. Tylee, A. and Katona, C. L. E. (1996) Detecting and managing depression in older people. Brit. J. Gen. Pract. 46, 207208. Vida, S. (1994) An update on elder abuse and neglect. Can. J. Psychiat. 39, 534540. Weisman, N. M., Hyers, J. K., Tischler, G. E. et al. (1985) Psychiatric disorders (DSM3) and cognitive impairment among the elderly in a USA urban community. Acta Psychiatr. Scand. 71, 366379. Williams, E. I. and Wallace, P. (1993) Health checks for people aged 75 and over. British Journal of General Practice. Occasional Paper No. 59. Yesavage, J. A. et al. (1983) Development and validation of a geriatric depression screening scale: A preliminary report. J. Psychiatr. Res. 17(1), 3749. Copyright # 1999 John Wiley & Sons, Ltd. Int. J. Geriat. Psychiatry 14, 739747 (1999) DEPRESSION AMONG SAUDI ELDERLY 747 Copyright of International Journal of Geriatric Psychiatry is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.