CLINICAL ISSUES

Exploring risk factors for depression among older men residing in Macau
Moon Fai Chan and Wen Zeng

Aim. To determine the prevalence of depression level of older men in Macau and identify factors that predict depression. Background. Studies have revealed the contribution of psychosocial factors such as stress, dissatisfaction at work and stressful life events to older men and the mental health burdens pose a grave threat to their quality of life. Design. A descriptive survey. Method. The study was conducted from JulyAugust 2004 in six parishes in Macau; 839 older men aged 60+ completed a structured questionnaire. Outcome measures. Predisposing characteristics, social and daily activities, health history and need/behaviours and depression level were collected. Multiple logistic regression models were used to identify factors to predict older men who will have depression. Results. The prevalence rate of depression of older men was 86%. It showed that a history of stroke (p = 0039), insomnia (p < 0001), palpitations (p = 0014), poor social network (p = 0005) and self-perceived health status (p = 0001) and perceived low ability to meet living costs (p < 0001) were signicant risk factors for depression. Conclusion. We should focus on older men by reducing their burden to meet living costs, improving their sleep quality and helping them to expand their social network. These should help in both prevention and recognition of the onset of depression. Those with the low social network scores could be targeted for more intensive support from the beginning. Relevance to clinical practice. It is important to screen regularly for depression status among older men in the community. Attention to poor perceived health and not enough on the ability to meet living costs were needed and important to follow up. Key words: depression, older men, Macau, mens health, nurses, nursing
Accepted for publication: 3 December 2010

Introduction
In the Chinese community, the failure to report a depressed mood to ones physician as a symptom is relatively common (Woo et al. 1994, Tsai et al. 2005, Harris et al. 2006). The illness beliefs of depressed Chinese patients reect a focus on their physical symptoms and seldom highlight their depression as their main concern (Chou & Chi 2005). Concomitantly, another belief of Chinese patients is that
Authors: Moon Fai Chan, PhD, CStat, Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Wen Zeng, RN, MNS, PhD, Associate Professor, Kiang Wu Nursing College of Macau, Macau SAR, China

health professionals are more interested in their physical rather than their psychological symptoms (Lai 2000). Chinese depressed older people suffer from emotional as well as somatic disturbances, but are more likely to focus on their physical problems and believe that their emotional problems result from their physical disturbances (Chou & Chi 2005, Chen et al. 2009). In fact, men did not present symptoms of depression, because these symptoms are not the culturally approved idioms for men (Dean & Ensel
Correspondence: Moon Fai Chan, Assistant Professor, Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore 117574, Singapore. Telephone: +65 65168684. E-mail: nurcmf@nus.edu.sg

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 26452654 doi: 10.1111/j.1365-2702.2010.03689.x

2645

MF Chan and W Zeng

1983, Roose & Glassman 2001). Hence, these depressed men may allow their depressive symptoms to go untreated (Harris et al. 2006). Older men nd it difcult to express themselves verbally, and expressing depression was a sign of personal weakness and they believed that they should be able to overpower depression (Heifner 1990). Previous studies have revealed the contribution of psychosocial factors such as stressful life events, like caring for sick relatives or facing their death, to old-aged men (Heifner 1990). The rate of socio-psychological stress elevated, perhaps because men in late-life need to deal with or aggravated by such changes. The socially sanctioned way for men to carry on with such changes despite intolerable strains at home or at work may result in the manifestation of psychosomatic symptoms while it will reect in depressed. Therefore, understanding how stressed they are is important in enabling health professionals to provide suitable advice for them during this transition period. Previous studies indicated that older men are at risk for inferior treatment response and poor antidepressant tolerability (Heifner 1990, Lebowitz et al. 1997, Wilhelm et al. 2002). Other studies revealed that many older people were more physically unhealthy and had their activities limited by depression (Wilhelm et al. 2002, Chou & Chi 2005, Harris et al. 2006). Anthropologists have also documented the effects of increasing poverty on social and personal identity as communities and households transform to face the pressures of modernity. Social exclusion has a price; yet efforts to analyse the emotional burden of these struggles remain rare. Stressful life circumstances have well-documented effects on psychosocial health and mental health burden. For example, the more the number of chronic illnesses, the more the chance to be depressed (Zeng 2002, Chou & Chi 2005). Research on psychosocial stress is fundamentally about the costs of living in a society. Kleinman and Cohen (2001) suggested that common mental health disorders, particularly depression, reveal how an individual responds to society and vice versa. Examining psychosocial stress allows for the assessment of individuals relationships with their social network without solely focusing on those who have progressed to diagnosable mental health disorders.

Design
From JulyAugust 2004, a survey was conducted in Macau to identify risk factors for depressed older men in the community.

Sampling
One thousand and two hundred samples were selected at random from this population. The target samples were drawn from the Census Department of Macau based on the 2003 census database (Statistics and Census Service 2010). The sample was selected using the proportionate, stratied sampling method by Parish. The inclusion criteria were being male, able to communicate/read in Cantonese or Chinese and aged 60 or above. The power analysis of the study is based on our primary interest, odd ratios (OR) of factors related to depression. A logistic regression model was used and 45 covariates were expected in the model (Zeng 2002, Li et al. 2003) with an expected OR of 28 and squared multiple correlation of 034, a sample size of around 1200 was required and this setting can achieve 80% power at 5% signicance level (nQuery Advisor 2001). Based on the population ratio, the research team calculated the required samples for each parish. At the end of the study, 866 samples (N. Sr. de Fa tima: n = 267, St. Anto nio: n = 271, S. La o: n = 106, Se zaro: n = 88, S. Lourenc : n = 93 and Taipa: n = 41) replied giving a response rate of 722%. However, not all of them completed the section on depression questions, so only 839 samples were used in this report.

Survey instruments
First, an intensive review of the existing literature describing health and three existing measuring tools were used to form the instrument. The instrument consisted of three parts. Part one was comprised of demographic data (i.e. age, body weight, height, living status, income per month, perceived satisfaction on cost of living). Part two consisted of basic health needs/behaviour information [i.e., type of chronic illness, type of symptoms in the past three months and perceived health status assessed by one item, which was a ve-point scale from (1) very poor to (5) very good]. Part three was the physical and daily activities information, comprised of three tools: (1) The Chinese version Modied Barthel Index (MBI): ten items to measure physical activity level (Hobart et al. 1999, Leung et al. 2007), which is one of the most commonly used measures of an individuals selfcare performance. The Chinese MBI consists of 10 items: personal hygiene, bathing, feeding, toileting, stair climbing,

Aims and methods

Aims
Our aim is to explore the prevalence of depression level of a group of older men in Macau and to identify factors associated with depression.
2646

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 26452654

Clinical issues

Depression of older men in Macau

dressing, bowel and bladder control, ambulation of wheelchair and chairbed transfer. An individuals performance is rated depending on the amount of physical assistance required and the social signicance of the tasks. The total score ranges from 0, which indicates an inability to perform, to a maximum of 100, indicating complete independence in self-care performance; (2) The Geriatric Depression Scale Short Form (GDS-15): 15 closed-ended questions to assess depression level, and it is one of the most popular tools used in clinical settings, is available in many languages, including Chinese (Lee 1992), and is intended to assess depression in older people, and its focus is on asking how the older subjects felt during the previous week. One point is assigned to each question and a summary of all questions yields a total score from 015. Scores below 8 are considered normal and those of 8 or above are indicative of a moderate to severe level of depression (Lee 1992); and (3) The Lubben Social Network Scale (SNS): ten items to explore social relationship (Lubben & Gironda 2000), which is a measure of ve aspects of social networks: family network, networks of friends, helping others, condence in relationships and living arrangements and the Chinese version was used for this study (The Lubben Social Network Scale 2009). The items are scored on a six-point scale ranging from 05 and the sum of these 10 items is the score of this scale, with higher scores showing higher levels of social support; and 11 task-orientated questions were set to examine the elders ability (i.e. able to shop alone? able to prepare light foods?): these tasks were used to determine the ability of an individuals daily activities. For part three, ve experts established content validity and the content validity index was 098. Cronbachs alpha was used to examine the internal consistency in each measurement tool (Polit et al. 2001) and the alpha value for the MBI, C-GDS-15 and SNS was 081, 079 and 088, respectively.

An information sheet, which included the nature and purpose of the study, was attached to the questionnaire. Each participant gave his written consent before completing the questionnaire. The participants were told that they had the right to withdraw from the study at any time and for any reason and that the data would be kept in strictest condence.

Statistical analysis
Descriptive statistical analysis of the quantitative data was conducted using SPSS 16 (SPSS Inc., Chicago, IL, USA). Several statistical techniques were employed for the analysis of data. Descriptive statistics were used to analyse background variables. In addition, means and standard deviations (SD) for each of the variables were calculated. To examine which factors predict depression, bivariate analyses including chi-square test and Fishers exact test were used to examine the association between each factor and depressed status. Factors that show signicance in the bivariate analysis were included in the logistic regression (backward, Ward) analysis to determine which factors predict depression, and all p values <005 were taken as statistically signicant. We calculated population-attributable risk percentage (PAR%) by using adjusted OR from the nal multiple logistic regression model for each risk factor that was signicantly associated with an increased risk for depression, apart from host factors (Jekel et al. 2001). The PAR% was calculated according to the following formula: PAR% = {[Pe(OR 1)]/[1 + Pe(OR 1)]} 100% where Pe is the proportion of the population exposed control to the risk factor and OR is the adjusted OR of the risk factor (Rothman & Greenland 1998).

Findings
Predisposing characteristics and depression status
The predisposing characteristics of the subjects are shown in Table 1. Among the subjects, 86% (n = 72) had been identied as depressed. For those who are depressed, 643% (n = 45) and 569% (n = 41) had less than MOP$2000 (US$1 = MOP$79) per month income and perceived a very low/low ability to meet living costs, respectively, but only 427% (p = 0018) and 251% (p < 0001) of the men reported no depression. However, no statistically signicant associations were found on age (p = 0435), education (p = 0708), ethics group (p = 0422), marital status (p = 0617), living status (p = 0054) and required spectacles (p = 0573) and hearing aid (p = 0617).
2647

Data collection and ethical issues

The researchers were all nursing students on a full-time nursing degree course; they made the phone calls to invite potential subjects to join the study. If the subject agreed, a face-to-face interview was arranged and took place at her living place. Training was provided to all nursing student researchers by the research team members and their intraclass correlation was 082. It took approximately 3045 minutes to complete the collection of all data for each subject. Human subject approval was granted by the Research Ethics Committee of the College. A detailed explanation of the objectives, procedures and possible outcomes of the study was given to the participants in their homes by the researchers.

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 26452654

MF Chan and W Zeng Table 1 Comparison of demographic factor of the older men by depression status Depression status Total (n = 839) n (%) Yes (n = 72) n (%) No (n = 767) n (%) v2 test v2 p-value

Demographic Age group (years) 6069 7079 80 or above Mean SD Median (Range) Education Illiterate Primary Secondary College or above Ethics group Chinese Portuguese-Chinese Asian/European/American Marital status Single Married Divorce/others Live alone Alone With spouse With relatives Ability to meet living costs Very low/low Average/high/very high Monthly income (in MOP$) 1000 or below 10012000 20013000 30014000 40015000 5001+ Need spectacles No Yes Need a hearing aid No Yes

385 322 132 714 700 82 418 262 77

(459) (384) (157) 77 (6098) (98) (498) (312) (92)

35 23 14 721 710 9 38 19 6

(486) (319) (194) 89 (6096) (125) (528) (264) (83)

350 299 118 714 700 73 380 243 71

(456) (390) (154) 75 (6098) (95) (495) (317) (93)

167

0435

057

0569

139

0708

821 (979) 7 (08) 11 (13) 22 (26) 680 (810) 137 (163) 97 (116) 272 (324) 470 (560) 233 (278) 604 (722) 103 264 116 88 73 180 (125) (320) (141) (107) (89) (218)

72 (1000) 0 (00) 0 (00) 3 (42) 56 (778) 13 (181) 14 (194) 25 (347) 33 (458) 41 (569) 31 (431) 15 30 6 6 5 8 (214) (429) (86) (86) (71) (114)

749 (977) 7 (09) 11 (15) 19 (25) 624 (814) 124 (162) 83 (108) 247 (322) 437 (570) 192 (251) 573 (749) 88 234 110 82 68 172 (117) (310) (146) (109) (90) (228)

173

0422

096

0617

582

0054

3322

<0001**

1369

0018*

626 (750) 209 (250) 822 (984) 13 (16)

52 (722) 20 (278) 72 (1000) 0 (00)

574 (752) 189 (248) 750 (983) 13 (17)

032

0573

125

0617

*p < 005; **p < 001. Depressed status is based on the GDS-15, not depressed (7 or below), depressed (8 or above). t-test. 2 missing data. 15 missing data. 4 missing data. Fishers exact test.

Physical and psychosocial factors and depression status

For MBI, men scoring 100 were classied as the totally dependency group; otherwise, they were mild to totally
2648

independency. For SNS, scoring 20 or above were classied as the enough to good group on social networking; otherwise, they were not enough. In Table 2, among men

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 26452654

Clinical issues Table 2 Comparison of social and daily activity factors of older men by depression status

Depression of older men in Macau

Depression status Total (n = 839) n (%) Yes (n = 72) n (%) No (n = 767) n (%) v2 test v2 p-value

Social and dialy activity factors Modied Barthel Index 099 (mild independency to totally independency) 100 (totally dependency) Social Network Scale 19 or below (not enough) 20+ (enough/good) Ability to do the following tasks 1. Able to shop alone (no) 2. Able to make exchange when shopping (no) 3. Able to do heavy housework (like scrub oors) (no) 4. Able to switch on/off the TV (no) 5. Able to open and read magazine or newspaper (no) 6. Able to look up numbers, dial, receive and make calls (no) 7. Able to prepare light foods (no) 8. Able to plan and cook full meals (no) 9. Able to travel by taking bus or taxi (no) 10. Able to visit relatives or friends (no) 11. Able to take medications in the right dose at the right time (no)

80 (95) 759 (905) 248 (296) 589 (704) 26 11 48 1 0 6 18 39 39 33 8 (31) (13) (57) (01) (00) (07) (21) (47) (47) (40) (10)

17 (236) 55 (764) 41 (569) 31 (431) 8 4 14 0 0 0 7 10 12 10 1 (111) (56) (194) (00) (00) (00) (97) (139) (167) (143) (14)

63 (82) 704 (918) 207 (271) 558 (729) 18 7 34 1 0 6 11 29 27 23 7 (23) (09) (44) (01) (00) (08) (14) (38) (35) (30) (09)

1809

<0001**

2819

<0001**

1684 1097 2750 009 N/A 057 2154 1504 2562 2149 016

<0001** 0010* <0001** 0998 0987 <0001** <0001** <0001** <0001** 0514

*p < 005; **p < 001. Depressed status is based on the GDS-15, not depressed (7 or below), depressed (8 or above). 2 missing data. Fishers exact test. 1 missing data. 4 missing data.

who were depressed, 236% (n = 17) and 569% (n = 41) scored as mild to totally independency and not enough, but for those who are not depressed, only 82% (p < 0001) and 271% (n = 207) on mild to totally independency and not enough, respectively. For the 11 daily activity tasks, for depressed men, signicant association was found on unable to shop alone (p < 0001), make exchange when shopping (p = 001), do heavy housework (p < 0001), prepare light foods (p < 0001), plan and cook full meals (p < 0001), visit relatives or friends (p < 0001) and take bus or taxi (p < 0001).

Predictors of depressed older men

The multiple logistic regression was used to identify factors to predict older men who will have depression. The results showed that factors, like the ability to meet living cost, social network, stroke problem, insomnia, palpitations and selfperceived health, were signicant risk factors for depression (Table 4). This model had a good t under the Hosmer Lemeshow goodness-of-t test (R2 = 0612, v2 = 991, p = 0078), with 721% sensitivity (predicted depressed), 794% specicity (predicted none depressed) and 782% overpower. Older men with SNS scores 19 or below (not enough) were 22 times more likely to be depressed than men with 20 or above (enough/good) SNS scores (p = 0005). Men who had stroke were 256 times more like to be depressed than no such chronic illness (p = 0.039). In addition, those men who reported had insomnia and palpitations symptoms in the past three months were 500 (p < 0001) and 27 (p = 0014) times more likely to had depressed than those who had no such symptoms. Men who perceived his health status was very poor/poor were 247 times more likely to had depression than those who reported average/good/very good (p = 0001). Those who reported very low/low on perceived

Health needs/behaviour factors and depression status

In Table 3, for the type of chronic illness, more depressed men had heart disease (p = 0023), stroke (p = 0012) and lung disease (p < 0001) than those who are not depressed. In the past three months, more depressed men had reported backache (p < 0001), joint pains (p = 0010), insomnia (p < 0001), palpitations (p < 0001) and short of breath (p < 0001) than those who are not depressed. Moreover, more depressed men (458%) perceived very poor/poor health status than those who were not depressed (120%, p < 0001).

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 26452654

2649

MF Chan and W Zeng Table 3 Comparison of health needs/behaviour factors of older men by depression status Depression status Total (n = 839) n (%) Yes (n = 72) n (%) No (n = 767) n (%) v2 test v2 p-value

Health needs/behaviour

Type of chronic illness Hypertension (yes) 362 (431) Heart disease (yes) 141 (168) Stroke (yes) 49 (58) Fracture after 60 years(yes) 22 (26) Arthritis (yes) 65 (77) Diabetes (yes) 132 (157) Chronic lung disease (yes) 106 (126) Prostate disorders (yes) 66 (79) Eye problems (yes) 227 (271) Cancer (yes) 23 (27) Gouty (yes) 56 (67) Spur (yes) 64 (76) Osteoporosis (yes) 11 (13) Type of symptoms in the previous three months Backache (yes) 142 (169) Joint pains (yes) 170 (203) Insomnia (yes) 124 (148) Palpitations (yes) 53 (63) Short of breath (yes) 54 (64) Perceived health Very poor/poor 125 (149) Average/good/very good 714 (851) Required to pay for the consultation fee No 390 (640) Yes 219 (360)

33 19 9 1 7 16 21 7 25 3 8 3 2 27 23 34 14 12

(458) (264) (125) (14) (97) (222) (292) (97) (347) (42) (111) (42) (28) (375) (319) (472) (194) (167)

329 122 40 21 58 116 85 59 202 20 48 61 9 115 147 90 39 42

(429) (159) (52) (27) (76) (151) (111) (77) (263) (26) (63) (80) (12) (150) (192) (117) (51) (55)

023 517 635 047 043 250 1950 037 235 060 249 134 131 2371 665 6582 2293 1369 5944

0630 0023* 0012* 0995 0512 0114 <0001** 0541 0126 0439 0115 0352 0242 <0.001** 0010* <0001** <0001** <0001** <0001**

33 (458) 39 (542) 38 (623) 23 (377)

92 (120) 675 (880) 352 (642) 196 (358)

009

0765

*p < 005; **p < 001. Depressed status is based on the GDS scores, no depression (7 or below, no), depressed (8 or above, yes). Fishers exact test. 230 missing data.

ability to meet living costs were 330 times more likely than those who reported average/high/very high (p < 0001). Table 4 shows the PAR% for a selection of risk factors. Out of the total risk in this population for depressed men, the highest attributable risk percentage is the ability to meet living cost (366%), the second and third was insomnia (319%) and social network (245%), respectively.

Discussion
In this study, we have found that the prevalence rate of depression of older men in Macau is 86%, that is lower than Taiwan (409%) (Chen et al. 2009) and Holland (295%) (Verhagen et al. 2008). In our ndings, older men who express not enough on nancial strain and report poor perceived health are more likely to be depressed. In Macau, many older men belong to the most impoverished segment of society, and nancial difculty is a major source of chronic
2650

worry. This may be especially true for the older men in Macau because there was a rapid growth on cost of living in the past decade (Yearbook of Statistics 2007). The results of this study conrm other studies that the importance of selfrated health status is a strong predictor of recovery from depression (Chou & Chi 2005, Chen et al. 2009). Moreover, we have found that almost all predisposing factors such as education and marital status are not signicantly related to depression. These ndings are consistent with other studies where marital status (Lapierre 2009) and education (St. John et al. 2009) are not associated with depression. Surprising us is that, in the regression model, the functional disability and the MBI are not signicantly related to depression in our older men. One explanation might be that other healthrelated variables such as perceived health status and having chronic illness such as stroke may overshadow the effect of functional impairment on depression. Another reason might be that our samples are living in the community and relatively

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 26452654

Clinical issues Table 4 Logistic regression model of older men on depression (n = 812) Predictor OR 95% CI p-value

Depression of older men in Macau

Demographic factors Ability to meet living costs Very low/low 330 225484 1 Average/high/very high Social and daily activity factors Social Network Scale 19 or below (not enough) 22 126383 20+ (enough/good) 1 Health needs/behaviour factors Type of chronic illness: stroke No 039 016095 Yes 1 Type of symptoms in the previous three months Insomnia No 020 011036 Yes 1 Palpitations No 037 016081 Yes 1 Perceived health Very poor/poor 247 142430 Average/good/very good 1

<0001**

0005**

0039*

<0001**

0014*

0001**

Hosmer and Lemeshow test, v2 = 991, df = 5, p = 0078; R2 = 0612. OR, odd ratios. *p < 005; **p < 001. Reference point; sensitivity is 721%, specicity is 794% and overall is 788%.

healthy, if they become disabled in daily activities, most of them are immediately admitted into nursing homes because many family members are unable to take care of them at home. Our data suggest that for men who had not enough, social networking is positively associated with depression. In line with Chou and Chi (2005) and Seeman et al. (2002) studies, they suggested that social network is the factor that affects mostly health behaviours and declining health and increasing disability overshadowed social support in explaining depression and found that social isolation measures were equally important. Men may derive less of a health-related benet from their social support networks because they experience more burdens (Litwin 2001, Seeman et al. 2002). Mens longevity, like their social support networks, may be a doubleedged sword if they live longer with more disability. Although men live lesser than women on average, they are also more likely to live with morbidity from chronic diseases, such as hypertension and diabetes (Strawbridge et al. 1992) and under stress (Pearson et al. 1993). Although the prevalence of depression among older men has been documented, less

research has been conducted on their social and health behavioural risks for depression level. There is clear evidence that men worry about their general health and the circumstances of their lives (Benazzi 2002, Chen et al. 2009). Worldwide, men must balance the economic, emotional and health needs of the household with their own emotional and health needs, and psychosocial stress impacts the range of possibilities available to achieve this balance. Research on psychosocial stress is fundamentally about the costs of living in a society. Kleinman and Cohen (2001) suggest that common mental health disorders, particularly depression, reveal how an individual responds to the society and vice versa. Examining psychosocial stress allows for the assessment of individuals relationships with their social network without solely focusing on those who have progressed to diagnosable mental health disorders. The stress response increases if individuals lack outlets for frustration or have no way of predicting the intensity and duration of the stressor, or a sense of control is a crucial predictor of how a individual experiences stress (Benazzi 2002). Most of these criteria are based on Euro-centric models of stress; however, the degree to which the sense of control impacts individuals in Chinese settings remains unexamined. Further studies, especially with longitudinal method, are needed to explore this issue. Another interesting nding of the present study is that insomnia was signicantly related to depression in the older men. Sleep is a vital ingredient in life and is an active and complex rhythmic state that may be affected by the ageing process (Lai & Good 2005). As people age, they tend to have a harder time falling asleep and more trouble staying asleep than when they were younger. Most common sleep-related complaints of older people includes taking longer time to fall asleep, awakening more often, waking too early and needing to nap and being sleepy in the daytime (Joyce et al. 2001, Lai & Good 2005). The consequences of sleep disorders can result in tiredness, fatigue, depression, greater anxiety, irritability, pain sensitivity, muscle tremors, immunosuppression and lack of daytime alertness (Pandi-Perumal et al. 2002). Many older people with sleep problems suffer from a variety of medical and psychosocial disorders, and these are very often associated with disturbance of sleep. These include psychiatric illnesses, particularly depression; Alzheimers disease and other neurodegenerative diseases; cardiovascular disease; upper airway incompetence; pulmonary disease; arthritis; pain syndromes; prostatic disease endocrinopathies; and other illnesses (Bliwise et al. 1992). In fact, hypnotic medications are frequently prescribed by physicians for disturbed sleep and are regularly taken by 1519% older adults (Clapin-French 1986, Morgan et al. 1988, Englert & Linden 1998). However, hypnotic medications should not be the mainstay of
2651

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 26452654

MF Chan and W Zeng

management for most of the causes of disturbed sleep and are overused and have habit-forming potential. It is because it can cause daytime residual effects, decrease tolerability, dependence, altered sleep stages and rebound insomnia (Morin & Kwentus 1988, Gillin & Byerley 1990).

Limitations
In line with most studies, limitations that need to be noted may have affected its results. One potential limitation is that the power of the study based on the existing sample size will reduce from 8069%, which increases the chances of type II errors, which affects the signicance of the results. Nevertheless, the results reported here should encourage other researchers to examine the mixture of factors contributing to health status, cognitive function and mental status among older men in Macau. Second, results showed that insomnia was one of the factors related to depression. However, it is not clear whether insomnia is a specic risk factor leading to depression or the depression is the consequence of this symptom from a psychological point of view. Further studies, especially with qualitative approach, are needed to clarify this issue.

(Lebowitz et al. 1997, Tsai et al. 2004). Providing a suitable living environment can improve sleep quality and may improve depressive symptoms, and maintaining their cognitive function and improving their functional abilities may be crucial for preventing suffering from insomnia which is a kind of depressive symptom. Apart from the ndings, these conclusions resonate with recent Macau guidance on managing depression in older men. These stress the importance of prevention, early detection, stepped care with more intensive treatment for greater severity of illness and a multifaceted approach to management.

Relevance to clinical practice

The factors related to depression among older men not only are biological changes and physical limitations but also lie in their social, family and day-to-day living conditions. We should focus on older men by reducing their burden to meet living costs, improving their sleep quality and helping them to expand their social network. These should help in both the prevention and recognition of onset of depression. Those with the low social network scores could be targeted for more intensive support from the beginning. Furthermore, improving their health conditions and functional abilities may be crucial for preventing suffering from depressive symptoms.

Conclusions
It is important to screen for depressive symptoms regularly among older men in the community. According to the PAR%, we should focus on older men by reducing their burden to meet living costs, improving their sleep quality and helping them to expand their social network. These should help in both prevention and recognition of the onset of depression (Zhu & Leong 2006). Those with the low social network scores could be targeted for more intensive support from the beginning. Attention to poor perceived health and not enough on the ability to meet living costs was needed and important to follow up by social support and health care professional consultations. Light therapy and antidepressants were found to decrease depressive symptoms in older people

Acknowledgement
The authors thank the Instituto de Acc a o Social do Governo da R.A.E.M., China, for their support in the research project.

Contributions
Study design: WZ; data collection and analysis: WZ, MFC and manuscript preparation: MFC, WZ.

Conict of interest
The author(s) declare that they have no conict of interests.

References
Benazzi F (2002) Depressive mixed state frequency: age/gender effects. Psychiatry and Clinical Neurosciences 56, 537 543. Bliwise DL, King AC, Harris RB & Haskell WL (1992) Prevalence of self-reported poor sleep in a healthy population aged 5065. Social Science and Medicine 34, 4955. Chen H-C, Yang CCH, Kuo TBJ, Su T-P & Chou P (2009) Gender differences in the relationship between depression and cardiac autonomic function among community elderly. International Journal of Geriatric Psychiatry, doi: 10.1002/gps.2341. Chou K-L & Chi I (2005) Prevalence and correlates of depression in Chinese oldest-old. Journal of Geriatric Psychiatry 20, 4150. Clapin-French E (1986) Sleep patterns of aged persons in long-term care facilities. Journal of Advanced Nursing 11, 5766. Dean A & Ensel W (1983) Socially structured depression in men and women. Research in Community and Mental Health 3, 113139.

2652

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 26452654

Clinical issues Englert S & Linden M (1998) Differences in self-reported sleep complaints in elderly persons living in the community who do or do not take sleep medication. Journal of Clinical Psychiatry 59, 137144. Gillin JC & Byerley WF (1990) Drug therapy: the diagnosis and management of insomnia. New England Journal of Medicine 322, 239248. Harris T, Cook DG, Victor C, DeWilde S & Beighton C (2006) Onset and persistence of depression in elderly people results from a 2-year community follow-up study. Age and Ageing 35, 2532. Heifner C (1990) The male experience of depression. Perspectives in Psychiatric Care 33, 1018. Hobart JC, Van der Putten JJ, Freeman JA & Thompson AT (1999) Development and testing of a short form Barthel Index. Neurology, Neurosurgery, and Psychiatry 67, 264. Jekel JF, Katz DL & Elmore JG (2001) Epidemiology, Biostatistics and Preventive Medicine. W.B. Saunders Company, Philadelphia. pp. 231245. Joyce MB, Hauks JH & Keene AM (2001) Medical-Surgical Nursing. Clinical Management for Positive Outcome, 6th edn. W.B. Saunders Company, New York. pp. 345351. Kleinman A & Cohen A (2001) A global view of depression from an anthropological perspective. In Depression: Social and Economic Timebomb (Dawson A & Tylee A eds). World Health Organization by BMJ Publishing Group, London, pp. 1116. Lai DWL (2000) Measuring depression in Canadas elderly Chinese population: use of a community screening instrument. Canadian Journal of Psychiatry 45, 279284. Lai HL & Good M (2005) Music improves sleep quality in elderly adults. Journal of Advanced Nursing 49, 234244. Lapierre TA (2009) Marital status and depressive symptoms over time: age and gender variation. Family Relations 58, 404416. Lebowitz BD, Pearson JL & Schneider LS (1997) Diagnosis and treatment of depression in late life: consensus statement update. Journal of American Medical Association 278, 11861190. Lee HB (1992) Chinese translation of Geriatric Depression Scale. Clinical Gerontologist 12, 9091. Leung SOC, Chan CCH & Shah S (2007) Development of a Chinese version of the modified Barthel Index validity and reliability. Clinical Rehabilitation 21, 912922. Li DD, Li XL, Liu W, Qiu SM & Zeng W (2003) The depressive states of the aged population in the elderly centers of Macau. Macau Journal of Nursing 2, 2123. Litwin H (2001) Social network type and morale in old age. The Gerontologist 41, 516524. Lubben JE & Gironda MW (2000) Social support networks. In Comprehensive Geriatric Assessment (Osterweil D, Brummel-Smith K & Beck J eds). McGraw-Hill, New York, pp. 121 137. Morgan K, Dallosso H, Ebrahim S, Arie T & Fentem PH (1988) Prevalence, frequency and duration of hypnotic drug use among the elderly living at home. British Medical Journal (Clinical Research Edition) 296, 601602. Morin CM & Kwentus JA (1988) Behavioral and pharmacological treatments for insomnia. Annals of Behavioral Medicine 10, 91100. Pandi-Perumal SR, Seils LK, Kayumov L, Ralph MR, Loe A, Moller H & Swaab DF (2002) Senescence, sleep and circadian rhythms. Ageing Research Reviews 1, 559604. Pearson JD, James GD & Brown DE (1993) Stress and changing lifestyles in the Pacific: physiological stress responses of Samoans in rural and urban settings. American Journal of Human Biology 5, 4960. Polit DF, Beck CT & Hungler BP (2001) Essentials of Nursing Research: Methods, Appraisal and Utilization, 5th edn. Lippincott, Philadelphia, PA. nQuery Advisor (2001) Statistical Solutions. Belfast, North Durbin. Roose SP & Glassman AH (2001) Relationship between depression and other medical illness. JAMA 286, 16871690. Rothman K & Greenland S (1998) Modern Epidemiology, 2nd edn. Lippincott Williams & Wilkins, Philadelphia, PA. pp. 233245. Seeman TE, Singer B, Ryff C, Dienberg Love G & Levy-Storms L (2002) Social relationships, gender and allostatic load across two age cohorts. Psychosomatic Medicine 64, 395406.

Depression of older men in Macau St. John PD, Montgomery PR & Tyas SL (2009) Alcohol misuse, gender and depressive symptoms in communitydwelling seniors. International Journal of Geriatric Psychiatry 24, 369 375. Statistics and Census Service (2010) Government of Macao Special Administrative Region, Macau. Available at: http://www.dsec.gov.mo/default.aspx. Strawbridge WJ, Kaplan GA, Camacho T & Cohen RD (1992) The dynamics of disability and functional change in an elderly cohort: results from the Alameda County study. Journal of the American Geriatrics 40, 799806. The Lubben Social Network Scale (2009) Available at: http://www2.bc.edu/ ~norstraj/intro.html. Tsai YF, Wong TKS & Juang YY (2004) The effects of light therapy on depressed elders. International Journal of Geriatric Psychiatry 19, 545548. Tsai YF, Chung JWY, Wong TKS & Huang CM (2005) Comparison of the prevalence and risk factors for depressive symptoms among elderly nursing home residents in Taiwan and Hong Kong. International Journal of Geriatric Psychiatry 20, 315321. Verhagen M, van der Meij A, Franke B, Vollebergh W, de Graaf R, Buitelaar J & Janzing JG (2008) Familiarity of major depressive disorder and gender differences in comorbidity. Acta Psychiatrica Scandinavica 118, 130138. Wilhelm K, Roy K, Mitchell P, Brownhill S & Parker G (2002) Gender differences in depression risk and coping factors in a clinical samples. Acta Psychiatrica Scandinavica 106, 4553. Woo J, Ho SC & Lau J (1994) The prevalence of depressive symptoms and predisposing factors in an elderly Chinese population. Acta Psychiatrica Scandinavica 89, 813. Yearbook of Statistics in 2006 (2007) Statistics and Census Service. Government of Macao Special Administrative Region, Macau. Zeng W (2002) Psychologial symptoms of hypertensive patients in Macau. Macau Journal of Nursing 1, 1821. Zhu MX & Leong SM (2006) Relation between cognition function and intelligent recreational activities of the homestaying aged persons in Macao. Macau Journal of Nursing 5, 1719.

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 26452654

2653

MF Chan and W Zeng

The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary.com/journal/jocn

Reasons to submit your paper to JCN:

High-impact forum: one of the worlds most cited nursing journals and with an impact factor of 1228 ranked 23 of 85 within Thomson Reuters Journal Citation Report (Social Science Nursing) in 2009. One of the most read nursing journals in the world: over 1 million articles downloaded online per year and accessible in over 7000 libraries worldwide (including over 4000 in developing countries with free or low cost access). Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Early View: rapid online publication (with doi for referencing) for accepted articles in nal form, and fully citable. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.

2654

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 26452654

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.