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Depression in the Iranian Elderly: A Systematic Review and Meta-Analysis

Depression in the Iranian Elderly: A Systematic Review and Meta-Analysis Hindawi Journal of Aging Research Volume 2021, Article ID 9305624, 9 pages https://doi.org/10.1155/2021/9305624 Review Article Depression in the Iranian Elderly: A Systematic Review and Meta-Analysis 1 2,3,4 5 Hedayat Jafari, Dariush Ghasemi-Semeskandeh, Amir Hossein Goudarzian, 5 5 Tahereh Heidari, and Azar Jafari-Koulaee Nursing Department of Medical Surgical Nursing, Traditional and Complementary Medicine Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran Institute for Biomedicine, Eurac Research Institute, Bolzano, Italy Department of Genetics, Leiden University Medical Center, Leiden, Netherlands Research Committee, Faculty of Health, Mazandaran University of Medical Sciences, Sari, Iran Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran Correspondence should be addressed to Azar Jafari-Koulaee; jafaria241@gmail.com Received 16 April 2021; Accepted 4 August 2021; Published 16 August 2021 Academic Editor: Carmela R. Balistreri Copyright © 2021 Hedayat Jafari et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Depression can lead to increased medical costs, impaired individual and social functioning, nonadherence to therapeutic proceeding, and even suicide and ultimately affect quality of life. It is important to know the extent of its prevalence for successful planning in this regard. *is study was conducted to determine the prevalence of depression in the Iranian elderly. *is systematic review and meta- analysis study was done through Medline via PubMed, SCOPUS, Web of Science, ProQuest, SID, Embase, and Magiran with determined keywords. Screening was done on the basis of relevance to the purpose of the study, titles, abstracts, full text, and inclusion and exclusion criteria. *e quality of the articles was assessed using the Newcastle-Ottawa standard scale. After primary and secondary screening, 30 articles were finally included in the study. According to the 30 articles reviewed, the prevalence of depression in the Iranian elderly was 52 percent based on the random-effects model (CI 95%: 46–58). According to the results of the present study, depression in the Iranian elderly was moderate to high. *erefore, more exact assessment in terms of depression screening in elderly people seems necessary. Coherent and systematic programs, including psychosocial empowerment counselling for the elderly and workshops for their families, are also needed. Researchers can also use the results of this study for future research. loneliness and isolation [8], anxiety, and depression [9]. 1. Introduction Mental health disorders have also been reported as the *e phenomenon of aging as one of the most sensitive most common disorders in the elderly, with depression periods of human life is one of the most important being the most prevalent [10, 11]. It was reported that economic, social, and health challenges in the world that is approximately 5 million older adults worldwide experi- expanding with the growing trend [1, 2]. Statistics show ence late-onset depression [12]. According to the World that the world population over 60 will double between Health Organization, depression is characterized by 2000 and 2050, reaching from 11 to 22 percent [3, 4]. *e persistent sadness and lack of interest or enjoyment age pyramid of the Iranian population is also moving from previously or in pleasurable activities [13]. Unfortunately, youth to old age, so that the number of elderly people in depression is less common in the elderly. Aging depres- 1414 reached more than 10 million and the percentage of sion is a condition that does not occur naturally due to aging reached more than 11% [5]. *e aging process and aging, and the general symptoms that are a prominent its associated changes may make the elderly more vul- symptom of depression may not be seen. Most of the nerable to potential threats such as chronic illnesses [6, 7], depressed elderly have fewer complaints of feelings of 2 Journal of Aging Research sadness and grief caused by a depressed mood. Mental nationality residing in Iran. Exclusion criteria included the preoccupation with health status and extreme and ob- following: (1) low-quality studies based on scale; (2) no relation with the subject and inadequate data such as failure sessive attention to physical symptoms are other char- acteristics of depression in the elderly. Another common to report the percentage of depression. Also, books and symptom of depression in the elderly is a complaint of studies without full text and studies in format of abstracts of cognitive symptoms such as forgetfulness and distraction, conference papers were excluded. so that the term false dementia is used to describe this clinical picture [14–16]. Factors such as loneliness, de- 2.3. Quality Assessment of Studies. *e quality of the selected creased ability to work, impaired social support, having articles was assessed based on the Newcastle-Ottawa scale. one or more physical ailments, and multiple therapeutic *is scale measures the research design, response rate, interventions can be risk factors for depression in the sample representation, objectivity/reliability of the result, elderly [17]. Depression in the elderly can lead to in- computation power provided, and appropriate statistical creased medical costs, impaired individual, occupational analysis. Finally, articles with a score of at least 7 were in- and social functioning, nonadherence to therapeutic cluded in the study. *e quality of studies was evaluated proceeding, and even suicide and ultimately affect one’s independently by two researchers, and the third researcher quality of life [18, 19]. Depression is also one of the most was used in case of disagreement. important predictors of treatment outcome and survival in these patients [20]. *erefore, it is important to pay attention to the challenges and psychological needs of the 2.4. Data Extraction. Data were extracted using a checklist elderly as well as identify and evaluate the prevalence of consisting of first author’s name, year of publication, type of depression in order to prevent depression and its un- study, place of study, sample size, mean age of participants, pleasant side effects and to achieve successful aging and and percentage of depression. *e necessary information optimal quality of life. A review of the literature revealed was extracted from related articles by two independent that there have been several descriptive studies on the researchers. prevalence of depression in the Iranian elderly [21, 22], and so far, only one review study has been conducted in 2.5. Statistical Analysis. *e studies reporting the prevalence Iran that has reviewed articles on depression in the Ira- of depression in the Iranian elderly samples were synthesized nian elderly by 2015 [23]. Given the time elapsed from this using both fixed-effects and random-effects models. *e study, it is necessary to conduct more comprehensive method to be used for pooling of studies was inverse var- study with more accurate and generalizable methods for iance. Statistical heterogeneity among reviewed studies was continuous evaluation. *erefore, the present study was also assessed with I2 statistic. Potential publication bias was conducted to determine depression in the Iranian elderly visually evaluated with a funnel plot and statistically tested in a systematic review and meta-analysis. by Egger’s test statistic which is based on a weighted linear regression of the treatment effect on its standard error [24]. 2. Materials and Methods Statistical analyses were implemented on R version 4.1.0 [25] via metafor package [26]. *is systematic review and meta-analysis was performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) with the aim of determining 3. Results depression in the Iranian elderly in 2020. After primary and secondary screening, 30 studies were finally included in the systematic review and meta-analysis. 2.1. Search Strategy. We searched Medline via PubMed, Details of screening steps are presented in Figure 1. SCOPUS, Web of Science, ProQuest, SID, EMBASE, and Magiran, from the earliest date possible until the end of 2019. 3.1. Description of Studies. *irty articles included in this Databases were searched by using keywords including “Depression” OR “Depressive Disorders,” “Iran,” “Preva- study were all observational studies and had a good locative distribution throughout Iran. GDS, BDI, Beck, DASS-21, lence,” and “Elderly OR Aged OR Older adult.” Boolean operators (AND and OR) were used. After searching the Kessler, HADS, and Elderly Health Master Plan tools were used to assess depression in the elderly. *e age range of the database, a list of articles was prepared by two researchers participants ranged from 64.22 to 76.97. Other details are independently and the duplicate articles were removed. *e studies were screened based on the titles, abstracts, and full presented in Table 1. text of the articles. Finally, eligible articles were included in the study process based on inclusion and exclusion criteria. 3.2. Meta-Analysis Results. *e range of sample size from the included articles varied from 52 to 9965, with a mean and 2.2. Inclusion and Exclusion Criteria. *e inclusion criteria median of 863 and 315, respectively. Based on the 30 were the following: (1) observational studies with keywords identified articles, the reported prevalence of depression listed in the title or abstract of the articles; (2) published in ranged from 9 to 100 percent, with the average of 52.15 Persian or English; (3) studies with samples of Iranian percent. Journal of Aging Research 3 Records identified through database Additional records identified through searching other sources (n = 799) (n = 2) Duplicates (n = 45) Total records (n = 801) Records excluded based Records screened (n = 756) on title, abstract, inclusion and exclusion criteria (n = 701) Full-text articles assessed for eligibility (n = 55) Records excluded, with reasons (n = 25) (1) Lack of proper reporting of results = 14 (2) Studies in Iranian elderly that do not Studies included in resident in Iran = 1 qualitative synthesis (3) Low quality of (n = 30) studies = 10 Studies included in quantitative synthesis (meta-analysis) (n = 30) Figure 1: Process of study selection (PRISMA). Table 1: Characteristics of the included studies (N � 30). Average of Author (year) Prevalence of Quality of Study type Place of study Instrument Sample, n (%) age, mean (reference) depression, n (%) study (SD) Normal: 201 (67) Male: 155 Mild: 60 (20) Gharangic Bandar (51.7) Moderate: 30 (10) Cross-sectional GDS-15 68 (6.7) 7 (2010) [27] torkaman Female: 145 Severe: 9 (3) (48.3) Total depressed: 33% Normal: 90 (36.3) Male: 125 Moderate: 101 Manzoori (2007) (50.4) (40.7) Cross-sectional Isfahan GDS-15 Not reported 7 [28] Female: 123 Severe: 57 (23) (49.6) Total depressed: 63.7% Included Eligibility Screening Identification 4 Journal of Aging Research Table 1: Continued. Average of Author (year) Prevalence of Quality of Study type Place of study Instrument Sample, n (%) age, mean (reference) depression, n (%) study (SD) Normal: 9 (15.8) Mild: 36 (64.9) Mobasheri Descriptive- Moderate: 9 (15.8) Shahrekord BDI-21 57 68.7 (16.1) 7 (2008) [29] analytical Severe: 2 (3.5) Total depressed: 84.2% Normal: 166 (55.3) Mild: 84 (28) Male: 137 (45) Moderate: 31 Ashrafi (2017) Cross-sectional Salmas GDS-15 Female: 163 68.74 (6.32) (10.33) 7 [30] (55) Severe: 19 (6.3) Total depressed: 44.7% Normal: 106 (57.6) Male: 97 (52.7) Moderate: 52 (28.3) Payahoo (2012) Descriptive- Tabriz GDS Female: 87 69.4 (7.9) Severe: 26 (14.1) 7 [31] analytical (47.3) Total depressed: 42.4% Alahyari (2014) Descriptive- Total depressed: Tehran Beck 100 Not reported 7 [32] analytical 12% Normal: 45 (43.2) Mild: 16 (15.4) Moderate: 30 (28.9) Ghafari (2009) Descriptive- Male: 25 (24) Tehran DASS-21 64.22 (4.57) Severe: 8 (7.7) 7 [22] analytical Female: 79 (76) Very severe: 5 (4.8) Total depressed: 56.8% Nejati (2006) Cross-sectional, Total depressed: Tehran GDS 120 Not reported 7 [33] comparative 79.8% Alipour et al. Comparative- Male: 70 (70) Total depressed: Tehran HADS 76.97 7 (2009) [12] analytical Female: 30 (30) 40% Normal: 259 (21.4) Borderline: 225 Rajabizadeh (18.6) Cross-sectional Kerman Beck 1212 Not reported 7 (2002) [34] Depressed: 728 (60) Total depressed: 60% Mild: 78 (65) Male: 20 (16.7) Moderate: 31 (25.8) Kashfi (2011) Cross sectional Shiraz Beck Female: 100 70 Severe: 11 (9.2) 7 [35] (83.3) Total depressed: 100% Ghaderi (2010) Descriptive, Total depressed: Bookan GDS 302 70.69 7 [36] cross-sectional 23.3% Male: 66 (33) Saeedi (2009) Cross-sectional Ahvaz GDS Female: 134 71 (8) Total depressed: 9% 8 [37] (67) Normal: 189 (47.1) Alizadeh (2012) Descriptive- Tehran Kessler 402 Not reported Moderate: 187 7 [21] analytical (46.5) Normal: 71 (28.4) Mild: 171 (68.4) Sharifzadeh Descriptive- Elderly health Birjand 250 71 (7.8) Severe: 8 (3.2) 7 (2007) [38] analytical master plan Total depressed: 71.6% Journal of Aging Research 5 Table 1: Continued. Average of Author (year) Prevalence of Quality of Study type Place of study Instrument Sample, n (%) age, mean (reference) depression, n (%) study (SD) Normal: 895 (57.4) Mild: 420 (26.9) Male: 861 (55) Moderate: 169 Bakhtiari (2018) Cross-sectional Amirkola GDS Female: 699 69.3 (7.4) (10.8) 7 [18] (45) Severe: 76 (4.9) Total depressed: 42.6% Normal: 473 (47.9) Mild: 420 (26.9) Moderate: 169 Mirzaei (2015) Prospective Yazd DASS 9965 Not reported (10.8) 7 [15] Severe: 76 (4.9) Total depressed: 52.1% Male: 642 Taheri tanjanai (47.5) Total depressed: Cross-sectional Tehran GDS-15 69 (7) 8 (2016) [39] Female: 708 36.7% (52.5) Male: 125 Keshavarzi (27.9) Total depressed: Cross-sectional Shiraz GDS 65.99 (7.89) 7 (2015) [11] Female: 322 38.1% (72.1) Male: 763 Ahangar (2017) (54.9) Total depressed: Cross-sectional Amirkola GDS-15 68.87 (7.23) 7 [40] Female: 627 43.5% (45.1) Mild: 167 (43.6) Male: 178 Moderate: 71 (18.5) Babazadeh (45.4) Severe: 134 (35.0) Cross-sectional Khoy DASS-21 68.22 7 (2016) [41] Female: 209 Very severe: 6 (1.6) (54.6) Total depressed: 98.7% Mild: 96 (30.4) Male: 146 (46) Sadeghi (2017) Cross-sectional Severe: 45 (14.3) Shahrood GDS-15 Female: 169 Not reported 7 [42] analytical Total depressed: (54) 44.7% Normal: 112 (22.4) Mild: 239 (47.8) Male: 290 (58) Khalili (2016) Descriptive, Moderate: 120 (24) Kashan GDS-15 Female: 210 72.07 (9.03) 7 [43] cross-sectional Severe: 29 (5.8) (42) Total depressed: 77.6% Normal: 271 (48.13) Mild: 98 (17.41) Male: 227 Moderate: 144 Emami (2017) (32.48) Cross-sectional Tehran BDI-13 69.66 (7.91) (25.58) 8 [44] Female: 348 Severe: 50 (8.88) (60.52) Total depressed: 51.87% Normal: 24 (9.8) Male: 130 Mild: (50) Nazemi (2013) Descriptive- (53.3) Moderate: (29.5) Tehran GDS-15 75.8 (8.7) 8 [45] analytical Female: 114 Severe: (10.7) (46.7) Total depressed: 90.2% Male: 720 (46) Nondepressed: 1165 Mokhber (2011) Razavi Analytical GDS Female: 845 70.14 (7.57) (78) 7 [46] khorasan (54) Depressed: 330 (22) 6 Journal of Aging Research Table 1: Continued. Average of Author (year) Prevalence of Quality of Study type Place of study Instrument Sample, n (%) age, mean (reference) depression, n (%) study (SD) Normal: 895 (56) Male: 864 Mild: 436 (27) Hosseini (2018) (54.4) Moderate: 176 (11) Cross-sectional Babol GDS-15 69.38 (7.44) 7 [47] Female: 725 Severe: 82 (5) (45.6) Total depressed: 43.67% Male: 917 Nondepressed: 1435 Majdi (2011) A population- Razavi (46.4) (72.2) GDS 71.14 (7.78) 7 [48] based study khorasan Female: 1045 Depressed: 440 (52.9) (22.3) Normal: 14 (34.2) Mild: 16 (39.1) Dehkordi (2014) Descriptive- Moderate: 7 (17) Shahrekord GDS-15 52 72.9 (6.5) 7 [49] analytical Severe: 4 (9.7) Total depressed: 65.8% Normal: (32.4) Mild: (18.5) Male: 223 Moderate: (40.2) Karami (2014) Descriptive- (58.2) Kermanshah Beck 70.11 (5.7) Severe: (5.7) 7 [50] analytical Female: 160 Very severe: (3.1) (41.8) Total depressed: 67.6% Weight Weight Study Events Total Proportion 95%-CI (fixed) (random) Gharangic 99 300 0.33 [0.28; 0.39] 1.1% 3.5% Manzoori 158 248 0.64 [0.57; 0.70] 1.0% 3.5% Mobasheri 48 57 0.84 [0.72; 0.93] 0.1% 2.8% Ashrafi 134 300 0.45 [0.39; 0.50] 1.3% 3.6% Payahoo 78 184 0.42 [0.35; 0.50] 0.8% 3.5% Alahyari 12 100 [0.06; 0.20] 0.2% 0.12 3.0% Ghafari 59 104 [0.47; 0.66] 0.57 0.4% 3.3% Nejati 96 120 [0.72; 0.87] 0.80 0.3% 3.2% Alipour 40 [0.30; 0.50] 100 0.40 0.4% 3.3% Rajabizadeh [0.57; 0.63] 727 1212 0.60 4.9% 3.6% Kashfi [0.97; 1.00] 120 120 1.00 0.0% 0.6% Ghaderi 70 302 0.23 [0.19; 0.28] 0.9% 3.5% Saeedimehr 18 200 0.09 [0.05; 0.14] 0.3% 3.2% Alizadeh 187 402 0.47 [0.42; 0.52] 1.7% 3.6% Sharifzadeh 179 250 0.72 [0.66; 0.77] 0.9% 3.5% Bakhtiari 665 1560 0.43 [0.40; 0.45] 6.5% 3.7% Mirzaei 5192 9965 0.52 [0.51; 0.53] 42.1% 3.7% Taheri Tanjanai 495 1350 0.37 [0.34; 0.39] 5.3% 3.6% Keshavarzi 170 447 0.38 [0.34; 0.43] 1.8% 3.6% Ahangar 605 1390 0.44 [0.41; 0.46] 5.8% 3.6% Babazadeh 382 387 0.99 [0.97; 1.00] 0.1% 2.4% Sadeghi 141 315 0.45 [0.39; 0.50] 1.3% 3.6% Khalili 388 500 0.78 [0.74; 0.81] 1.5% 3.6% Emami 298 575 0.52 [0.48; 0.56] 2.4% 3.6% Nazemi 220 244 0.90 [0.86; 0.94] 0.4% 3.3% Mokhber 344 1565 0.22 [0.20; 0.24] 4.5% 3.6% Hosseini 694 1589 [0.41; 0.46] 6.6% 0.44 3.7% Majdi 438 1962 [0.20; 0.24] 5.8% 0.22 3.6% Dehkordi 34 52 [0.51; 0.78] 0.65 0.2% 3.0% Karami 259 [0.63; 0.72] 383 0.68 1.4% 3.6% [0.46; 0.47] Fixed effect model 26283 0.47 100.0% -- Random effects model 0.52 [0.46; 0.58] -- 100.0% 2 2 = 98%, τ = 0.3957, p = 0 Heterogeneity: I 0.2 0.4 0.6 0.8 1 Figure 2: Forest plot of the selected studies. Journal of Aging Research 7 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 –2 024 Logit Transformed Proportion Figure 3: Funnel plot of the selected studies. It can be found in Figure 2 that the synthesized prev- another study was conducted in Shiraz. In the study of alence of depression among the elderly people in Iran for the Saeedi et al. [37], the Geriatric Depression Scale (GDS) was random-effects model was 52% (95% CI: 46–58). *e Q-test used and, in the latter, the Beck Depression Inventory was for pooled estimates was statistically significant at the level of used. Also, in the study by Saeedi et al., the elderly surveyed 0.001 (Q � 1890.68, df � 29, p< 0.001, I2 � 98%) representing were retirees of the Ahwaz oil industry, while in the other noticeable between-study heterogeneity. study, not all of the subjects were retired from a particular *e publication bias was also evaluated by visualizing the organization. Not all individuals in Kashafi et al.’s study [35] funnel plot for analysis. *e funnel plot (Figure 3) depicts (unlike Saeedi et al.’s study) did not use retirement benefits how heterogeneous the effect sizes of the elected studies are. and thus may experience more economic and social prob- *e p value associated with Egger’s test is 0.748, indicating lems and have less access to health care and support. *is may be the cause of the difference in the prevalence of symmetry of the funnel plot. depression in the two mentioned studies. 4. Discussion 4.1. Limitations. Despite the strengths of the study, re- According to the results of this study, the prevalence of strictions such as not searching studies in languages other depression in the Iranian elderly was 52%. In a similar study, than Persian and English prevented access to all studies in the prevalence of depression in the Iranian elderly was 43 this field. percent, according to a review of studies conducted between 2001 and 2015 [23]. Comparison of the results of the present study and the mentioned study [23] indicates that the 5. Conclusion prevalence of depression in the Iranian elderly has increased over time. Also, another study with a review of 83 studies in According to the results of this study, depression in the this field reported that 27 percent of the elderly suffer from Iranian elderly was moderate to high. *erefore, more exact depression [51], with the prevalence of depression in this assessment in terms of depression screening in elderly study being less than the prevalence of depression in the people seems necessary. According to the World Health Organization’s motto of prevention prior to treatment, Iranian elderly. Possible reasons for the difference in the prevalence of depression in these studies may be the health managers can use the results of this study and em- phasize to screen for depression in nursing homes as well as structures intended by governments and the culture of societies in relation to elderly people and their needs. In in rural health homes. Coherent and systematic programs, including psychosocial empowerment counselling for the some countries, especially developed countries, there is a more favourable formalized mental healthcare system for the elderly and workshops for their families, are also needed. Researchers can also use the results of this study for future elderly, which can affect the prevention and promotion of their mental health, especially depression screening. Also, research. increasing rates of disease and medicine consumption in developing countries such as Iran may increase the expe- Data Availability rience of depression in the elderly. In the present study, the lowest prevalence of depression *e data used in the study are available from the corre- was in the study by Saeedi et al. [37] and the highest was in sponding author upon request via e-mail. the study by Kashafi et al. [35]. Possible reasons for the differences in results may be the differences in the place of Conflicts of Interest study and the different cultural contexts and tools used. Saeedi et al.’s study [37] was conducted in Ahvaz, and *e authors declare no conflicts of interest. Standard Error 8 Journal of Aging Research [15] M. Mirzaei, R. Sahaf, S. Mirzaei, E. Sepahvand, A. Pakdel, and Acknowledgments H. Shemshadi, “Depression and its associated factors in el- *is study was approved by the Student Research Com- derly nursing home residents: a screening study in khorra- mittee of the Mazandaran University of Medical Sciences mabad,” Iranian Journal of Ageing, vol. 10, no. 1, pp. 54–61, with the ethical code of IR.MAZUMS.REC.1398.5930 (Grant [16] E. 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Depression in the Iranian Elderly: A Systematic Review and Meta-Analysis

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Hindawi Journal of Aging Research Volume 2021, Article ID 9305624, 9 pages https://doi.org/10.1155/2021/9305624 Review Article Depression in the Iranian Elderly: A Systematic Review and Meta-Analysis 1 2,3,4 5 Hedayat Jafari, Dariush Ghasemi-Semeskandeh, Amir Hossein Goudarzian, 5 5 Tahereh Heidari, and Azar Jafari-Koulaee Nursing Department of Medical Surgical Nursing, Traditional and Complementary Medicine Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran Institute for Biomedicine, Eurac Research Institute, Bolzano, Italy Department of Genetics, Leiden University Medical Center, Leiden, Netherlands Research Committee, Faculty of Health, Mazandaran University of Medical Sciences, Sari, Iran Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran Correspondence should be addressed to Azar Jafari-Koulaee; jafaria241@gmail.com Received 16 April 2021; Accepted 4 August 2021; Published 16 August 2021 Academic Editor: Carmela R. Balistreri Copyright © 2021 Hedayat Jafari et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Depression can lead to increased medical costs, impaired individual and social functioning, nonadherence to therapeutic proceeding, and even suicide and ultimately affect quality of life. It is important to know the extent of its prevalence for successful planning in this regard. *is study was conducted to determine the prevalence of depression in the Iranian elderly. *is systematic review and meta- analysis study was done through Medline via PubMed, SCOPUS, Web of Science, ProQuest, SID, Embase, and Magiran with determined keywords. Screening was done on the basis of relevance to the purpose of the study, titles, abstracts, full text, and inclusion and exclusion criteria. *e quality of the articles was assessed using the Newcastle-Ottawa standard scale. After primary and secondary screening, 30 articles were finally included in the study. According to the 30 articles reviewed, the prevalence of depression in the Iranian elderly was 52 percent based on the random-effects model (CI 95%: 46–58). According to the results of the present study, depression in the Iranian elderly was moderate to high. *erefore, more exact assessment in terms of depression screening in elderly people seems necessary. Coherent and systematic programs, including psychosocial empowerment counselling for the elderly and workshops for their families, are also needed. Researchers can also use the results of this study for future research. loneliness and isolation [8], anxiety, and depression [9]. 1. Introduction Mental health disorders have also been reported as the *e phenomenon of aging as one of the most sensitive most common disorders in the elderly, with depression periods of human life is one of the most important being the most prevalent [10, 11]. It was reported that economic, social, and health challenges in the world that is approximately 5 million older adults worldwide experi- expanding with the growing trend [1, 2]. Statistics show ence late-onset depression [12]. According to the World that the world population over 60 will double between Health Organization, depression is characterized by 2000 and 2050, reaching from 11 to 22 percent [3, 4]. *e persistent sadness and lack of interest or enjoyment age pyramid of the Iranian population is also moving from previously or in pleasurable activities [13]. Unfortunately, youth to old age, so that the number of elderly people in depression is less common in the elderly. Aging depres- 1414 reached more than 10 million and the percentage of sion is a condition that does not occur naturally due to aging reached more than 11% [5]. *e aging process and aging, and the general symptoms that are a prominent its associated changes may make the elderly more vul- symptom of depression may not be seen. Most of the nerable to potential threats such as chronic illnesses [6, 7], depressed elderly have fewer complaints of feelings of 2 Journal of Aging Research sadness and grief caused by a depressed mood. Mental nationality residing in Iran. Exclusion criteria included the preoccupation with health status and extreme and ob- following: (1) low-quality studies based on scale; (2) no relation with the subject and inadequate data such as failure sessive attention to physical symptoms are other char- acteristics of depression in the elderly. Another common to report the percentage of depression. Also, books and symptom of depression in the elderly is a complaint of studies without full text and studies in format of abstracts of cognitive symptoms such as forgetfulness and distraction, conference papers were excluded. so that the term false dementia is used to describe this clinical picture [14–16]. Factors such as loneliness, de- 2.3. Quality Assessment of Studies. *e quality of the selected creased ability to work, impaired social support, having articles was assessed based on the Newcastle-Ottawa scale. one or more physical ailments, and multiple therapeutic *is scale measures the research design, response rate, interventions can be risk factors for depression in the sample representation, objectivity/reliability of the result, elderly [17]. Depression in the elderly can lead to in- computation power provided, and appropriate statistical creased medical costs, impaired individual, occupational analysis. Finally, articles with a score of at least 7 were in- and social functioning, nonadherence to therapeutic cluded in the study. *e quality of studies was evaluated proceeding, and even suicide and ultimately affect one’s independently by two researchers, and the third researcher quality of life [18, 19]. Depression is also one of the most was used in case of disagreement. important predictors of treatment outcome and survival in these patients [20]. *erefore, it is important to pay attention to the challenges and psychological needs of the 2.4. Data Extraction. Data were extracted using a checklist elderly as well as identify and evaluate the prevalence of consisting of first author’s name, year of publication, type of depression in order to prevent depression and its un- study, place of study, sample size, mean age of participants, pleasant side effects and to achieve successful aging and and percentage of depression. *e necessary information optimal quality of life. A review of the literature revealed was extracted from related articles by two independent that there have been several descriptive studies on the researchers. prevalence of depression in the Iranian elderly [21, 22], and so far, only one review study has been conducted in 2.5. Statistical Analysis. *e studies reporting the prevalence Iran that has reviewed articles on depression in the Ira- of depression in the Iranian elderly samples were synthesized nian elderly by 2015 [23]. Given the time elapsed from this using both fixed-effects and random-effects models. *e study, it is necessary to conduct more comprehensive method to be used for pooling of studies was inverse var- study with more accurate and generalizable methods for iance. Statistical heterogeneity among reviewed studies was continuous evaluation. *erefore, the present study was also assessed with I2 statistic. Potential publication bias was conducted to determine depression in the Iranian elderly visually evaluated with a funnel plot and statistically tested in a systematic review and meta-analysis. by Egger’s test statistic which is based on a weighted linear regression of the treatment effect on its standard error [24]. 2. Materials and Methods Statistical analyses were implemented on R version 4.1.0 [25] via metafor package [26]. *is systematic review and meta-analysis was performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) with the aim of determining 3. Results depression in the Iranian elderly in 2020. After primary and secondary screening, 30 studies were finally included in the systematic review and meta-analysis. 2.1. Search Strategy. We searched Medline via PubMed, Details of screening steps are presented in Figure 1. SCOPUS, Web of Science, ProQuest, SID, EMBASE, and Magiran, from the earliest date possible until the end of 2019. 3.1. Description of Studies. *irty articles included in this Databases were searched by using keywords including “Depression” OR “Depressive Disorders,” “Iran,” “Preva- study were all observational studies and had a good locative distribution throughout Iran. GDS, BDI, Beck, DASS-21, lence,” and “Elderly OR Aged OR Older adult.” Boolean operators (AND and OR) were used. After searching the Kessler, HADS, and Elderly Health Master Plan tools were used to assess depression in the elderly. *e age range of the database, a list of articles was prepared by two researchers participants ranged from 64.22 to 76.97. Other details are independently and the duplicate articles were removed. *e studies were screened based on the titles, abstracts, and full presented in Table 1. text of the articles. Finally, eligible articles were included in the study process based on inclusion and exclusion criteria. 3.2. Meta-Analysis Results. *e range of sample size from the included articles varied from 52 to 9965, with a mean and 2.2. Inclusion and Exclusion Criteria. *e inclusion criteria median of 863 and 315, respectively. Based on the 30 were the following: (1) observational studies with keywords identified articles, the reported prevalence of depression listed in the title or abstract of the articles; (2) published in ranged from 9 to 100 percent, with the average of 52.15 Persian or English; (3) studies with samples of Iranian percent. Journal of Aging Research 3 Records identified through database Additional records identified through searching other sources (n = 799) (n = 2) Duplicates (n = 45) Total records (n = 801) Records excluded based Records screened (n = 756) on title, abstract, inclusion and exclusion criteria (n = 701) Full-text articles assessed for eligibility (n = 55) Records excluded, with reasons (n = 25) (1) Lack of proper reporting of results = 14 (2) Studies in Iranian elderly that do not Studies included in resident in Iran = 1 qualitative synthesis (3) Low quality of (n = 30) studies = 10 Studies included in quantitative synthesis (meta-analysis) (n = 30) Figure 1: Process of study selection (PRISMA). Table 1: Characteristics of the included studies (N � 30). Average of Author (year) Prevalence of Quality of Study type Place of study Instrument Sample, n (%) age, mean (reference) depression, n (%) study (SD) Normal: 201 (67) Male: 155 Mild: 60 (20) Gharangic Bandar (51.7) Moderate: 30 (10) Cross-sectional GDS-15 68 (6.7) 7 (2010) [27] torkaman Female: 145 Severe: 9 (3) (48.3) Total depressed: 33% Normal: 90 (36.3) Male: 125 Moderate: 101 Manzoori (2007) (50.4) (40.7) Cross-sectional Isfahan GDS-15 Not reported 7 [28] Female: 123 Severe: 57 (23) (49.6) Total depressed: 63.7% Included Eligibility Screening Identification 4 Journal of Aging Research Table 1: Continued. Average of Author (year) Prevalence of Quality of Study type Place of study Instrument Sample, n (%) age, mean (reference) depression, n (%) study (SD) Normal: 9 (15.8) Mild: 36 (64.9) Mobasheri Descriptive- Moderate: 9 (15.8) Shahrekord BDI-21 57 68.7 (16.1) 7 (2008) [29] analytical Severe: 2 (3.5) Total depressed: 84.2% Normal: 166 (55.3) Mild: 84 (28) Male: 137 (45) Moderate: 31 Ashrafi (2017) Cross-sectional Salmas GDS-15 Female: 163 68.74 (6.32) (10.33) 7 [30] (55) Severe: 19 (6.3) Total depressed: 44.7% Normal: 106 (57.6) Male: 97 (52.7) Moderate: 52 (28.3) Payahoo (2012) Descriptive- Tabriz GDS Female: 87 69.4 (7.9) Severe: 26 (14.1) 7 [31] analytical (47.3) Total depressed: 42.4% Alahyari (2014) Descriptive- Total depressed: Tehran Beck 100 Not reported 7 [32] analytical 12% Normal: 45 (43.2) Mild: 16 (15.4) Moderate: 30 (28.9) Ghafari (2009) Descriptive- Male: 25 (24) Tehran DASS-21 64.22 (4.57) Severe: 8 (7.7) 7 [22] analytical Female: 79 (76) Very severe: 5 (4.8) Total depressed: 56.8% Nejati (2006) Cross-sectional, Total depressed: Tehran GDS 120 Not reported 7 [33] comparative 79.8% Alipour et al. Comparative- Male: 70 (70) Total depressed: Tehran HADS 76.97 7 (2009) [12] analytical Female: 30 (30) 40% Normal: 259 (21.4) Borderline: 225 Rajabizadeh (18.6) Cross-sectional Kerman Beck 1212 Not reported 7 (2002) [34] Depressed: 728 (60) Total depressed: 60% Mild: 78 (65) Male: 20 (16.7) Moderate: 31 (25.8) Kashfi (2011) Cross sectional Shiraz Beck Female: 100 70 Severe: 11 (9.2) 7 [35] (83.3) Total depressed: 100% Ghaderi (2010) Descriptive, Total depressed: Bookan GDS 302 70.69 7 [36] cross-sectional 23.3% Male: 66 (33) Saeedi (2009) Cross-sectional Ahvaz GDS Female: 134 71 (8) Total depressed: 9% 8 [37] (67) Normal: 189 (47.1) Alizadeh (2012) Descriptive- Tehran Kessler 402 Not reported Moderate: 187 7 [21] analytical (46.5) Normal: 71 (28.4) Mild: 171 (68.4) Sharifzadeh Descriptive- Elderly health Birjand 250 71 (7.8) Severe: 8 (3.2) 7 (2007) [38] analytical master plan Total depressed: 71.6% Journal of Aging Research 5 Table 1: Continued. Average of Author (year) Prevalence of Quality of Study type Place of study Instrument Sample, n (%) age, mean (reference) depression, n (%) study (SD) Normal: 895 (57.4) Mild: 420 (26.9) Male: 861 (55) Moderate: 169 Bakhtiari (2018) Cross-sectional Amirkola GDS Female: 699 69.3 (7.4) (10.8) 7 [18] (45) Severe: 76 (4.9) Total depressed: 42.6% Normal: 473 (47.9) Mild: 420 (26.9) Moderate: 169 Mirzaei (2015) Prospective Yazd DASS 9965 Not reported (10.8) 7 [15] Severe: 76 (4.9) Total depressed: 52.1% Male: 642 Taheri tanjanai (47.5) Total depressed: Cross-sectional Tehran GDS-15 69 (7) 8 (2016) [39] Female: 708 36.7% (52.5) Male: 125 Keshavarzi (27.9) Total depressed: Cross-sectional Shiraz GDS 65.99 (7.89) 7 (2015) [11] Female: 322 38.1% (72.1) Male: 763 Ahangar (2017) (54.9) Total depressed: Cross-sectional Amirkola GDS-15 68.87 (7.23) 7 [40] Female: 627 43.5% (45.1) Mild: 167 (43.6) Male: 178 Moderate: 71 (18.5) Babazadeh (45.4) Severe: 134 (35.0) Cross-sectional Khoy DASS-21 68.22 7 (2016) [41] Female: 209 Very severe: 6 (1.6) (54.6) Total depressed: 98.7% Mild: 96 (30.4) Male: 146 (46) Sadeghi (2017) Cross-sectional Severe: 45 (14.3) Shahrood GDS-15 Female: 169 Not reported 7 [42] analytical Total depressed: (54) 44.7% Normal: 112 (22.4) Mild: 239 (47.8) Male: 290 (58) Khalili (2016) Descriptive, Moderate: 120 (24) Kashan GDS-15 Female: 210 72.07 (9.03) 7 [43] cross-sectional Severe: 29 (5.8) (42) Total depressed: 77.6% Normal: 271 (48.13) Mild: 98 (17.41) Male: 227 Moderate: 144 Emami (2017) (32.48) Cross-sectional Tehran BDI-13 69.66 (7.91) (25.58) 8 [44] Female: 348 Severe: 50 (8.88) (60.52) Total depressed: 51.87% Normal: 24 (9.8) Male: 130 Mild: (50) Nazemi (2013) Descriptive- (53.3) Moderate: (29.5) Tehran GDS-15 75.8 (8.7) 8 [45] analytical Female: 114 Severe: (10.7) (46.7) Total depressed: 90.2% Male: 720 (46) Nondepressed: 1165 Mokhber (2011) Razavi Analytical GDS Female: 845 70.14 (7.57) (78) 7 [46] khorasan (54) Depressed: 330 (22) 6 Journal of Aging Research Table 1: Continued. Average of Author (year) Prevalence of Quality of Study type Place of study Instrument Sample, n (%) age, mean (reference) depression, n (%) study (SD) Normal: 895 (56) Male: 864 Mild: 436 (27) Hosseini (2018) (54.4) Moderate: 176 (11) Cross-sectional Babol GDS-15 69.38 (7.44) 7 [47] Female: 725 Severe: 82 (5) (45.6) Total depressed: 43.67% Male: 917 Nondepressed: 1435 Majdi (2011) A population- Razavi (46.4) (72.2) GDS 71.14 (7.78) 7 [48] based study khorasan Female: 1045 Depressed: 440 (52.9) (22.3) Normal: 14 (34.2) Mild: 16 (39.1) Dehkordi (2014) Descriptive- Moderate: 7 (17) Shahrekord GDS-15 52 72.9 (6.5) 7 [49] analytical Severe: 4 (9.7) Total depressed: 65.8% Normal: (32.4) Mild: (18.5) Male: 223 Moderate: (40.2) Karami (2014) Descriptive- (58.2) Kermanshah Beck 70.11 (5.7) Severe: (5.7) 7 [50] analytical Female: 160 Very severe: (3.1) (41.8) Total depressed: 67.6% Weight Weight Study Events Total Proportion 95%-CI (fixed) (random) Gharangic 99 300 0.33 [0.28; 0.39] 1.1% 3.5% Manzoori 158 248 0.64 [0.57; 0.70] 1.0% 3.5% Mobasheri 48 57 0.84 [0.72; 0.93] 0.1% 2.8% Ashrafi 134 300 0.45 [0.39; 0.50] 1.3% 3.6% Payahoo 78 184 0.42 [0.35; 0.50] 0.8% 3.5% Alahyari 12 100 [0.06; 0.20] 0.2% 0.12 3.0% Ghafari 59 104 [0.47; 0.66] 0.57 0.4% 3.3% Nejati 96 120 [0.72; 0.87] 0.80 0.3% 3.2% Alipour 40 [0.30; 0.50] 100 0.40 0.4% 3.3% Rajabizadeh [0.57; 0.63] 727 1212 0.60 4.9% 3.6% Kashfi [0.97; 1.00] 120 120 1.00 0.0% 0.6% Ghaderi 70 302 0.23 [0.19; 0.28] 0.9% 3.5% Saeedimehr 18 200 0.09 [0.05; 0.14] 0.3% 3.2% Alizadeh 187 402 0.47 [0.42; 0.52] 1.7% 3.6% Sharifzadeh 179 250 0.72 [0.66; 0.77] 0.9% 3.5% Bakhtiari 665 1560 0.43 [0.40; 0.45] 6.5% 3.7% Mirzaei 5192 9965 0.52 [0.51; 0.53] 42.1% 3.7% Taheri Tanjanai 495 1350 0.37 [0.34; 0.39] 5.3% 3.6% Keshavarzi 170 447 0.38 [0.34; 0.43] 1.8% 3.6% Ahangar 605 1390 0.44 [0.41; 0.46] 5.8% 3.6% Babazadeh 382 387 0.99 [0.97; 1.00] 0.1% 2.4% Sadeghi 141 315 0.45 [0.39; 0.50] 1.3% 3.6% Khalili 388 500 0.78 [0.74; 0.81] 1.5% 3.6% Emami 298 575 0.52 [0.48; 0.56] 2.4% 3.6% Nazemi 220 244 0.90 [0.86; 0.94] 0.4% 3.3% Mokhber 344 1565 0.22 [0.20; 0.24] 4.5% 3.6% Hosseini 694 1589 [0.41; 0.46] 6.6% 0.44 3.7% Majdi 438 1962 [0.20; 0.24] 5.8% 0.22 3.6% Dehkordi 34 52 [0.51; 0.78] 0.65 0.2% 3.0% Karami 259 [0.63; 0.72] 383 0.68 1.4% 3.6% [0.46; 0.47] Fixed effect model 26283 0.47 100.0% -- Random effects model 0.52 [0.46; 0.58] -- 100.0% 2 2 = 98%, τ = 0.3957, p = 0 Heterogeneity: I 0.2 0.4 0.6 0.8 1 Figure 2: Forest plot of the selected studies. Journal of Aging Research 7 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 –2 024 Logit Transformed Proportion Figure 3: Funnel plot of the selected studies. It can be found in Figure 2 that the synthesized prev- another study was conducted in Shiraz. In the study of alence of depression among the elderly people in Iran for the Saeedi et al. [37], the Geriatric Depression Scale (GDS) was random-effects model was 52% (95% CI: 46–58). *e Q-test used and, in the latter, the Beck Depression Inventory was for pooled estimates was statistically significant at the level of used. Also, in the study by Saeedi et al., the elderly surveyed 0.001 (Q � 1890.68, df � 29, p< 0.001, I2 � 98%) representing were retirees of the Ahwaz oil industry, while in the other noticeable between-study heterogeneity. study, not all of the subjects were retired from a particular *e publication bias was also evaluated by visualizing the organization. Not all individuals in Kashafi et al.’s study [35] funnel plot for analysis. *e funnel plot (Figure 3) depicts (unlike Saeedi et al.’s study) did not use retirement benefits how heterogeneous the effect sizes of the elected studies are. and thus may experience more economic and social prob- *e p value associated with Egger’s test is 0.748, indicating lems and have less access to health care and support. *is may be the cause of the difference in the prevalence of symmetry of the funnel plot. depression in the two mentioned studies. 4. Discussion 4.1. Limitations. Despite the strengths of the study, re- According to the results of this study, the prevalence of strictions such as not searching studies in languages other depression in the Iranian elderly was 52%. In a similar study, than Persian and English prevented access to all studies in the prevalence of depression in the Iranian elderly was 43 this field. percent, according to a review of studies conducted between 2001 and 2015 [23]. Comparison of the results of the present study and the mentioned study [23] indicates that the 5. Conclusion prevalence of depression in the Iranian elderly has increased over time. Also, another study with a review of 83 studies in According to the results of this study, depression in the this field reported that 27 percent of the elderly suffer from Iranian elderly was moderate to high. *erefore, more exact depression [51], with the prevalence of depression in this assessment in terms of depression screening in elderly study being less than the prevalence of depression in the people seems necessary. According to the World Health Organization’s motto of prevention prior to treatment, Iranian elderly. Possible reasons for the difference in the prevalence of depression in these studies may be the health managers can use the results of this study and em- phasize to screen for depression in nursing homes as well as structures intended by governments and the culture of societies in relation to elderly people and their needs. In in rural health homes. Coherent and systematic programs, including psychosocial empowerment counselling for the some countries, especially developed countries, there is a more favourable formalized mental healthcare system for the elderly and workshops for their families, are also needed. Researchers can also use the results of this study for future elderly, which can affect the prevention and promotion of their mental health, especially depression screening. Also, research. increasing rates of disease and medicine consumption in developing countries such as Iran may increase the expe- Data Availability rience of depression in the elderly. In the present study, the lowest prevalence of depression *e data used in the study are available from the corre- was in the study by Saeedi et al. [37] and the highest was in sponding author upon request via e-mail. the study by Kashafi et al. [35]. Possible reasons for the differences in results may be the differences in the place of Conflicts of Interest study and the different cultural contexts and tools used. Saeedi et al.’s study [37] was conducted in Ahvaz, and *e authors declare no conflicts of interest. Standard Error 8 Journal of Aging Research [15] M. Mirzaei, R. Sahaf, S. Mirzaei, E. Sepahvand, A. Pakdel, and Acknowledgments H. Shemshadi, “Depression and its associated factors in el- *is study was approved by the Student Research Com- derly nursing home residents: a screening study in khorra- mittee of the Mazandaran University of Medical Sciences mabad,” Iranian Journal of Ageing, vol. 10, no. 1, pp. 54–61, with the ethical code of IR.MAZUMS.REC.1398.5930 (Grant [16] E. R. Vieira and E. Brown, R. Patrick and P. Raue, “Depression no. 5930, dated 2019), and the authors acknowledge its fi- in older adults,” Journal of Geriatric Physical :erapy, vol. 37, nancial support. no. 1, pp. 24–30, 2014. [17] N. Khodadady, F. Sheikholeslami, S. Rezamasuoleh, and References M. Yazdani, “Rate of depression in late-life in superannuated government employed center of Guilan University of medical [1] T. L. M. Amaral, C. D. A. Amaral, N. S. D. Lima, sciences,” Journal of Holistic Nursing and Midwifery, vol. 17, P. V. Herculano, P. R. d. Prado, and G. T. R. Monteiro, no. 1, pp. 16–22, 2007. “Multimorbidade, depressão e qualidade de vida em idosos [18] M. Bakhtiyari, M. Emaminaeini, H. Hatami, S. Khodakarim, atendidos pela Estrategia ´ de Saude ´ da Fam´ılia em Senador and R. 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Journal of Aging ResearchHindawi Publishing Corporation

Published: Aug 16, 2021

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