Professional Documents
Culture Documents
Aims Conclusions
To explore whether cultural engagement in older adults is Cultural engagement appears to be an independent risk-
associated with a reduced risk of developing depression over the reducing factor for the development of depression in older age.
following decade.
Declaration of interest
Method
None.
Working with data from 2148 adults in the English Longitudinal
Study of Ageing who were free from depression at baseline, we
Keywords
used logistic regression models to explore associations between
frequency of cultural engagement (including going to museums, Depressive disorders; epidemiology; psychosocial interventions.
theatre and cinema) and the risk of developing depression over
the following 10 years using a combined index of the Centre for Copyright and usage
Epidemiological Studies Depression Scale (CES-D) and physician- © The Royal College of Psychiatrists 2018. This is an Open Access
diagnosed depression. article, distributed under the terms of the Creative Commons
Attribution licence (http://creativecommons.org/licenses/by/4.
Results 0/), which permits unrestricted reuse, distribution, and repro-
There was a dose–response relationship between frequency of duction in any medium, provided the original work is properly
cultural engagement and the risk of developing depression cited.
Mental health is an important determinant of successful ageing and on depressive symptomatology in the general population. There
longevity. It is, however, prone to decline with age because of life remains little research into whether cultural engagement can itself
events and circumstances commonly experienced by older adults act as a risk-reducing factor for the development of depression, and
such as bereavement, lone living, impoverished social interactions, therefore play a preventative role. However, cultural engagement
poor health, retirement and worsening economic condition.1 In combines many risk-reducing factors for depression incidence,
England, it has been estimated that approximately one in four which suggest that it could be a protective factor. For example, cul-
people aged 65 or over are depressed, with the prevalence of depres- tural engagement includes social interaction (either through visiting
sive symptoms increasing with age.2 Depression in older age is also with friends or interaction with other attendees or staff), which can
commonly underdiagnosed and undertreated3 and is associated be a source of social support and act as buffer stress, and thereby
with a higher risk of dementia, diabetes, cardiovascular disease, reduce the onset and progression of depressive symptoms.18
stroke and both specific and all-cause mortality.4–8 In light of this, Going to cultural venues is also a way of reducing sedentary behav-
there has been much research undertaken to identify factors that iour, which is associated with depression, partly through increased
can protect against the development of depression, including social inflammatory responses.19 Furthermore, the emotional response to
networks and social support,9 physical activity10 and cognitive cultural activities such as music has been found to involve brain
stimulation.11 However, despite this, there is a recognised lack of regions critical to the processing of positive emotions and
effective multimodal psychosocial interventions for the prevention reward.20 Cultural activities also require cognitive and perceptual
of depression in older adults.12 engagement, which itself is associated with lower levels of depres-
sion.21 Besides, cultural engagement has been found to support
coping behaviours in the face of physical health challenges.22
Cultural engagement and mental health However, despite these promising theoretical justifications for
Over the past decade, there has been growing research demonstrat- the protective role of cultural engagement on depression incidence,
ing the effects of cultural engagement on depression. This has to the authors’ knowledge, there are currently no studies exploring
included studies of active cultural engagement (such as singing, this relationship using validated depression scales. Consequently,
dancing or doing artistic activities)13–15 and receptive cultural we hypothesised that cultural engagement in older adults is asso-
engagement (such as visiting museums and galleries).16,17 ciated with a reduced risk of developing depression over the follow-
However, to date, much of this research has centred on the impact ing decade, and tested this hypothesis using a nationally
of cultural engagement on recovery for people with depression or representative cohort study of older adults in England.
225
Fancourt & Tymoszuk
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Cultural engagement for the prevention of depression in older adults
score); and (b) excluding participants who had a CES-D score of two Table 1 Participant demographics
at baseline indicating possible subclinical symptoms.
Covariates all measured at wave 2 (n = 2148) Values
The third sensitivity analysis explored the possibility of reverse
Gender: women, n (%) 1108 (51.6)
causality (whereby precursors to the development of depressive
Age, years: mean (s.d.) 62.9 (7.5)
symptoms may alter/reduce participation in cultural activities), by Ethnicity, Black and minority ethnic: n (%) 19 (0.9)
conducting a subgroup analysis excluding participants who devel- Relationship status, in relationship: n (%) 1669 (77.7)
oped depressive symptoms in the first wave following baseline. Education, n (%)
The fourth sensitivity analysis tested whether excluding those NVQ1/CSE or no qualification 547 (25.5)
with depression at baseline led to a biased sample, so we re-ran ana- NVQ2/GCE O level 470 (21.9)
NVQ3 A level/higher education 710 (33.1)
lyses including the 335 participants who already had depressive
Degree 421 (19.6)
symptoms or a diagnosis of depression at baseline, which allowed Employment status, n (%)
us to assess whether cultural participation was associated with the Not working/retired 1119 (52.1)
development or continuation of depressive symptoms. Part time 428 (19.9)
The fifth sensitivity analysis tested the assumption of a thresh- Full time ≥35 h/week 601 (28.0)
old of ≥3 on the CES-D scale: as another study has suggested a Health-related issues
threshold of ≥4 for identifying people with elevated depression26 Eyesight problems, n (%) 110 (5.1)
Hearing problems, n (%) 297 (13.8)
we re-ran our analyses using this threshold.
Chronic pain, n (%) 46 (2.1)
Finally, in order to ascertain whether cultural engagement was Chronic illness, n (%) 497 (23.1)
merely a proxy for having a more open personality type, which Alcohol consumption, n (%)
itself might have been protective against developing depression, ≥5 days per week 609 (28.4)
we also controlled for personality using the Midlife Development 1–4 days per week 914 (42.6)
Inventory personality scale.27 Sensitivity analyses are shown in Once or twice a month 257 (12.0)
Every couple of months or less 368 (17.1)
supplementary Tables 1–6 available at https://doi.org/10.1192/bjp.
Social isolation score (0–9), mean (s.d.) 4.8 (1.8)
2018.267. All analyses were carried out using Stata SE Version 14.1. Engaged in civic activities, n (%) 399 (18.6)
Have a hobby, n (%) 1768 (82.3)
Read a daily newspaper, n (%) 1448 (67.4)
Results Frequency of cultural engagement
Never 216 (10.1)
Less than once a year 324 (15.1)
Description of the participants
Once or twice a year 584 (27.2)
Our sample included a total of 2148 participants. The frequency dis- Every few months 635 (29.6)
tribution for the demographic characteristics of the participants is Once a month or more 389 (18.1)
presented in Table 1, along with descriptive data of frequency of cul- Number of participants with depression across 616 (28.7)
the 10 years, n (%)
tural engagement. Participants had a mean age of 62.9 years (range
52–89). In total, 74.8% participants reported going to a gallery or
museum at least once a year.
adjusting just for sociodemographic factors, but results were attenu-
ated when considering other health and social covariates.
Rate of depression by cultural attendance
At baseline, all participants were below the threshold for depression Sensitivity analyses
on CES-D, but over the next 10 years, 616 participants (28.7%)
Our sensitivity analysis found very similar results when weighting to
recorded a CES-D score above the threshold for depression or
account for missing data (using fully adjusted models: for every few
reported having been diagnosed since the last wave on at least one
months, OR = 0.71, 95% CI 0.48–1.05; for once a month or more,
occasion. The overall incidence rate was 3.31 (95% CI 3.06–3.58)
OR = 0.53, 95% CI 0.34–0.83) (supplementary Table 1).
per 100 person-years. There was an above-average incidence rate
When we took into account subclinical symptoms of depression
for those who never engaged with culture or engaged only infre-
at baseline through exclusions of participants feeling depressed over
quently (up to once or twice a year) (Table 2). However, more fre-
the previous week or participants with an indication of subclinical
quent attendance (every few months or more) was associated with a
CES-D symptoms at baseline, results were materially unaffected
below-average incidence rate.
(supplementary Table 2).
To test the reverse causal hypothesis of depressive symptoms
Logistic regression analysis leading to reduced engagement with culture, we re-ran the regression
Engaging with culture every few months or more was associated models excluding the 174 participants who showed above-threshold
with a reduced risk of developing depression across the 10 years, symptoms of depression in the first wave following baseline. This
independent of demographic factors (model 1), additional health- exclusion had little effect on the estimates (using fully adjusted
related factors and behaviours (model 2), and additional social
and civic engagement (model 3). There was evidence of a dose– Table 2 Depression incidence rates per 100 person-years and 95%
response relationship with more frequent attendance associated confidence intervals by frequency of cultural engagement
with a lower risk. For fully adjusted models, this equated to a 32% New cases of depression in Rate per 100
lower risk of developing depression for people who attended every participants over the 10 person-years
few months (OR = 0.68, 95% CI 0.47–0.99, P = 0.046) and a 48% years, n (95% CI)
lower risk for people who attended once a month or more (OR = Never 89 5.17 (4.20–6.37)
0.52, 95% CI 0.34–0.80, P = 0.003) (Table 3). Less than once a year 104 3.80 (3.14–4.61)
Tests for trend were significant (OR = 0.87, 95% CI 0.79–0.95, Once or twice a year 174 3.47 (2.99–4.03)
Every few months 167 2.99 (2.57–3.48)
P = 0.002). Less frequent attendance (just once or twice a year)
Once a month or more 82 2.31 (1.86–2.87)
appeared to be associated with a reduced risk of depression when
227
Fancourt & Tymoszuk
Table 3 Associations between cultural engagement and the risk of developing depression over the following 10 years (n = 2148)a
models: for every few months, OR = 0.67, 95% CI 0.44–1.02; for once to the Patient Health Questionnaire) or prevalence of low mood or
a month or more, OR = 0.58, 95% CI 0.36–0.93; supplementary general life satisfaction (both using a single self-report item).31
Table 3). These studies are also set in the context of others that have found
Including participants who already showed depressive symp- associations between receptive cultural engagement and well-
toms at baseline also did not lead to results being attenuated being and life satisfaction.32 However, our study is the first to
(using fully adjusted models: for every few months, OR = 0.66, focus specifically on the prevention of depression in older age
95% CI 0.47–0.94; for once a month or more, OR = 0.57, 95% CI (rather than the presence of general mental health symptomatology)
0.38–0.84; supplementary Table 4). using a longitudinal sample and a validated depression scale.
Using the alternative cut-off score of ≥4 on CES-D, again results
were materially unaffected, although there was a slight loss of power
Strengths and limitations
because only 419 participants with depression were detected over
the 10 years compared with 616 using the lower threshold (using The strengths of this study are that it used well-validated measures
fully adjusted models: for every few months, OR = 0.67, 95% CI of depression and tested different thresholds, finding consistent
0.44–1.01; for once a month or more, OR = 0.58, 95% CI 0.37– results. It also used data from a large nationally representative
0.94; supplementary Table 5). cohort study with consistent collection of key variables every
Finally, results were maintained even when adjusting for open 2 years and a follow-up of a decade. The rich data-set enabled us to
personality type (cultural engagement once a month or more, include all identified confounding variables in our statistical models.
OR = 0.53, 95% CI 0.34–0.82; supplementary Table 6). The main limitation is that this study is observational rather
than interventional. We have presented longitudinal associations
that attempt to account for issues such as reverse causality and con-
Discussion founding. But causality cannot be assumed and it is possible that
residual variables remain. Consequently, interventional studies are
Main findings recommended as a way of exploring whether cultural engagement
The main finding of this study was a dose–response relationship could be recommended as an activity to promote positive mental
between frequency of cultural engagement and the risk of develop- health in older adults and reduce the incidence rate of depression
ing depression over a 10-year period among adults aged ≥50 who in older adults; especially those identified as being most at risk.
were free from depression at baseline. Notably, this finding was Indeed, there have already been calls for more use to be made of cul-
independent of sociodemographic factors, health and behavioural tural venues such as museums and galleries as sites for health pro-
factors and other forms of social and civic engagement including motion and public health interventions,30 and these results suggest
other hobbies, social interactions, community group and civic there could be benefits for mental health.
engagement. It was also independent of open personality type. A further limitation is that it is possible that subthreshold low
mood or depression may have contributed to reduced cultural
engagement. However, we ran analyses with and without partici-
Comparisons with findings from other studies
pants with depression at baseline, as well as further excluding par-
In relation to prior research, this is the first known longitudinal ticipants who had taken antidepressants or had counselling in the
study to explore cultural engagement in relation to the prevention past 2 years, who had even very minor symptoms of depression at
of depression in older age. One previous cross-sectional study baseline, who reported feeling low over the past week even if they
found associations between receptive cultural engagement and did not score above-threshold at baseline and who went on to
both low anxiety and low depression (using the Hospital Anxiety develop depression within 2 years of baseline. None of these add-
and Depression Scale) as well as good satisfaction with life (using itional analyses affected the significance of our results.
a single self-report item).28 However, as this study was cross- Finally, it is possible that a participant experienced a depressive
sectional, it is unclear whether reverse causality was present. episode in between waves but did not report it to their doctor and
Other cross-sectional studies have, in contrast, found no associ- recovered by the next CES-D assessment. However, this is anticipated
ation between cultural engagement and feelings of anxiety and to be a very low number of participants and given the robustness of
depression (using the EuroQol-5D).29 Two previous longitudinal our findings in response to a range of sensitivity analyses we do not
studies have explored mental health more broadly. A Swedish occu- believe this would have affected the broad findings reported here.
pational cohort found weak associations between receptive cultural
engagement in the workplace and emotional exhaustion (using the
Maslach Burnout Inventory) but not depression symptoms (using Summary
the Hopkins Symptom Checklist).30 And a Swiss household study In conclusion, we found that engagement with cultural activities
found no associations between receptive cultural engagement and (including going to the cinema, museums or galleries or the theatre,
either common somatic symptoms (using a cumulative scale similar concert or opera) appears to be an independent risk-reducing factor
228
Cultural engagement for the prevention of depression in older adults
for the development of depression in older age. Given our analyses 12 Forsman AK, Schierenbeck I, Wahlbeck K. Psychosocial interventions for the
prevention of depression in older adults: systematic review and meta-analysis.
specifically tested the potential contribution of reverse causality
J Aging Health 2011; 23: 387–416.
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13 Fancourt D, Perkins R. Effect of singing interventions on symptoms of postnatal
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Daisy Fancourt, PhD , Wellcome Research Fellow, Department of Behavioural
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Science and Health, University College London, UK; Urszula Tymoszuk, PhD, Research
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London; and Research Department of Epidemiology and Public Health, University College functioning of older adults. Gerontologist 2006; 46: 726–34.
London, UK 16 Solway R, Thompson L, Camic PM, Chatterjee HJ. Museum object handling
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The English Longitudinal Study of Ageing was developed by a team of researchers based at the
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University College London, NatCen Social Research, the Institute for Fiscal Studies and the
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