Coping and Depression in Old Age: A Literature Review

According to a review article by Rosenvinge and Rosenvinge [1], 10–19% of older persons in the general population suffer from symptoms of depression, and 2–4% suffer from a major depressive disorder. Among older people living in an institution, a systematic review reports a median prevalence of major depression of 10%, and of depressive symptoms in 29% of the residents [2,3]. Another study showed that about 50% of elderly people in long-term care suffer from depressive symptoms and 20% from major depression [4]. A further study reported that about 30% of all referrals to the specialist psychiatric health service are older people suffering from depression [5]. Since older persons constitute the fastest growing part of the population and because depression is among the most common psychiatric disorders in this group, the future cost of depression to the patient, the carer and the health services will be significant [6].

In a review on prognostic factors for depression in older persons the following variables were found to lead to a poor prognosis: older age, chronic somatic comorbidity, more functional limitations, a higher baseline depression level and the locus of control (LOC) being more external than internal [7]. In a systematic review comparing the prognosis for depression in different age groups, remission rates of depression show little difference between middle-aged and older persons, but relapse rates appear higher in older persons [8]. Depression in older people is related to increased mortality [9]. This makes it important to further investigate the prognosis for older persons suffering from depression and to include the concept of coping, as this factor is reported to be relevant in the understanding of depression in older persons [10,11].

The concept of coping was first adopted by psychologists in the 1960s and 1970s and was applied to refer to the struggle of overcoming and managing the stresses of living and adapting [12]. Different theoretical perspectives have defined coping as personality traits where the way a person copes is determined by the kind of person they are [13], and as a process where coping is seen as a situation-specific and flexible state [12]. Situational factors may be the changeability or controllability of a situation, and personality factors may include the aspects of self-confidence, self-efficacy [14] and LOC [15], two central concepts of the theories of personality called control orientation that constitutes parts of a person’s total available coping resources [16]. LOC relates to the generalized expectations regarding who or what is responsible for the outcomes. If the person attributes the outcome to luck or powerful others, the belief is labeled external control, and if the relation is attributed to personal effort, the belief is labeled internal control [15,17]. Self-efficacy refers to the perception that one has the abilities to enact these responses [14], and sense of control (SOC) [18] is understood as the perception of control in a certain situation [16].

According to a transactional perspective on coping, the person and the environment are understood to be in an ongoing reciprocal relationship, where the stressors in life are evaluated in an appraisal process according to the perceived personal resources (i.e. control orientation, self-efficacy) and choices available to the coping person to manage the challenges [19]. Coping, as described by Folkman and Lazarus [19], involves different strategies to alter the stressful situation (i.e. problem-focused coping), as well as efforts to regulate the emotional distress associated with the situation (i.e. emotion-focused coping). The strategies chosen depend both upon situational and individual factors: the coping resources. Other theorists have further developed different concepts of coping related to the coping strategies of Folkman and Lazarus [20,21], like coping actions and coping style [22,23].

Also, Pargament [24] shows that the subjective meaning or orientation of values like religiosity is important for decisions and thus serves as part of the system of coping resources that form the basis of the chosen coping strategies, activities and actions. According to Pargament [24], the concept of religiosity can be studied through the entire process of coping in terms of stressors, appraisal, orientation of values, activities and outcome. Conceptually, processes of coping concerning religiosity have become a specific category of coping called ‘religious coping’. Religious coping has been operationalized in different ways, but basically as an instrument to measure either religious beliefs or behavior that serve as coping strategies to help manage emotional distress [25]. Religious coping can be positive, like spiritual support and positive religious reframing, or negative, i.e. seeing the illness as God‘s punishment [26]. Antonovsky [27], on the other hand, emphasizes that coping is a resource and is, therefore, seen as a personal capacity that can be used in stressful situations to maintain positive health and achieve well-being. To achieve this positive outcome of coping a certain way of viewing the world is required, a perceived SOC, described as ‘... a dispositional orientation toward stressors, characterized and operationalized by a view of life as being comprehensible, manageable and meaningful’ [28]. A high SOC is found to be associated with good mental health [29]. Hence, the concept of coping reflects different parts and perspectives of the coping process. A critical event or stressor may be experienced as a minor or major life event depending on the available internal and external resources, and has to be understood in terms of the subjective meaning and orientation of values. Resources of coping determine outcome, after being mediated by different coping strategies and activities [24].

The growing interest in coping among older persons has stimulated research in the field, but the body of research on coping in relation to depression in old age is scarce. A systematic review would contribute to a better understanding of the field today and may contribute to meeting a growing interest from personnel in both the specialist and primary health care service who serve depressed older persons. On this basis we conducted a systematic computer-based literature review, including studies where the participants had a mean age of 60 years or more, and where different concepts of coping were studied in relation to depression.

Two researchers (S.E.K./G.H.B.) and a librarian (L.M.W.) conducted systematic, computer-aided searches in MEDLINE, PsycINFO, Embase and CINAHL (last search 11.07.2012). The terms used for searching the databases were ‘aged’, ‘aged, 80 and over’, ‘gerontology, aged (attitudes toward)’, ‘aging’, ‘geriatric psychiatry’, ‘geriatric psychotherapy’, ‘geriatric patient’, ‘elderly’, ‘elder care’, ‘depression’, ‘depressive disorder’, ‘depressive disorder, major’, ‘depression reactive’, ‘affective disorder’, ‘psychotic, endogenous depression’, ‘long-term depression’, ‘organic depression’, ‘reactive depression’, ‘coping’, ‘ways of coping questionnaire’, ‘locus of control’, ‘coping behavior’, ‘internal external LOC’, ‘exp. coping behavior’, ‘sense of coherence’ and ‘SOC’. The MeSH terms and CINAHL headings were limited to major concepts (focused), except the CINAHL heading ‘internal external LOC’, which became an ‘exploded’ search. The keywords, CINAHL headings and MeSH terms were combined in different ways to yield maximum results. This paper reviews published research studies on coping in relation to depression in older persons, focusing on:

(i) Identifying which categories of coping have been studied

(ii) The study design

(iii) The characteristics of the sample

(iv) The aim of each study

(v) Identifying which generic measures of coping have been used

(vi) The primary findings of the studies regarding the relationship between coping and depression in older persons

Papers were included in the review if the following criteria were met:

– Mean age ≥60 years

– A quantitative design

– Instrument used to assess depression was exclusive to this purpose

– At least one generic measure of coping was used

– An assessment of the relationship between coping and depression was performed

– The study was published in a journal and appeared in the English language

Papers were excluded from the review if:

– They were theoretical, qualitative or review articles or comments on studies

– They were disseminations

In total 1,727 hits were screened for potentially relevant papers among titles and abstracts; 164 articles were then retrieved for full-text evaluation of the inclusion criteria by two of the authors (A.-S.H./G.H.B.). Reference lists were checked to retrieve relevant publications which had not been identified by the computer-aided search. Potentially relevant articles retrieved from disseminations were included. Finally, 66 articles were evaluated by two researchers (A.-S.H./G.H.B.) as fulfilling the inclusion criteria and were further analyzed and their relevant data extracted in the form of tables. In addition, a search of the database www.salutogenesis.fi was conducted (G.H.B.; 30.06.2012) and 41 potentially relevant articles were retrieved. Of these, 9 articles met the inclusion criteria. Thus, 75 articles from five databases were evaluated as meeting the criteria for inclusion in this review.

The methodological quality of each of the studies was assessed by two of the authors (G.H.B./A.-S.H.), based on theoretical considerations and methodological aspects and according to a checklist of predefined criteria as described by Licht-Strunk et al. [7] and Oxman [30]. The list contains 7 quality criteria. A study receives 1 point for each of the following criteria: (i) being a longitudinal study, (ii) containing information about the setting, (iii) including more than 100 participants and (iv) applying a definition of coping with reference to the literature; 2 points are given for each of the following criteria: (v) information about the diagnosis of depression according to criteria in the Diagnostic and Statistical Manual of Mental disorders (DSM) or the International Classification of Diseases (ICD), (vi) use of well-established measures of depression and (vii) use of well-established measures of coping (table 1). We chose to give these 3 latter criteria 2 points because valid and reliable information about the assessment of coping and depression in the studies was regarded to be of outmost importance to the evaluation of a relation between coping and depression, which is the main focus of this review. A total score was calculated by summing the number of positively scored criteria (range 0–10). We chose to consider a study as ‘high quality’ when it scored more than 5 points (≥60% of the maximum attainable score of 10) and ‘low quality’ when it scored 5 points or less [7].

Of the 75 studies in total, 38 were clinically based and 37 were community based. Of the clinically based studies, 26 were conducted in hospitals or in GP practices, 6 in psychogeriatric clinics, 4 in nursing homes and 2 studies were from memory clinics. The clinical studies included patients with a variety of disorders such as depression in 12 studies, somatic disorders in general (not specified) in 11, different cardiac disorders in 8, cognitive impairment in 2, Parkinson’s disease in 2, cancer in 2 and pain disorders in 1 study (tables 2, 3).

In total, 24 studies had a longitudinal and 51 had a cross-sectional design (tables 2, 3). Two studies met all 7 quality criteria and received 10 points, 3 studies got 9 points, 6 studies got 8 points, 16 studies received 7 points and 17 studies got 6 points. Thus, 44 of the 75 studies received 6 points or more and were evaluated to be of relatively high quality (18 longitudinal and 26 cross-sectional studies). The studies which received less than 6 points were mainly characterized by the following: not having a longitudinal design, the number of participants was below 100, a diagnostic evaluation of depressive disorders was not applied, the use of well-established instruments to assess coping was not included and, lastly, a definition of the concepts of coping was not described with a reference to the literature (table 1).

Information about depressive symptoms was obtained from self-report instruments, observation inventories, structural interviews, or from diagnostic evaluations applying the DSM-III/-R/IV criteria (table 4). A total of 21 different instruments were used in the studies to assess the symptoms of depression. The Center for Epidemiological Studies – Depression scale (CES-D) [31] was most often applied (24 studies). Four studies used a scale constructed for the specific study (table 4).

In all, 55 different measures of coping were applied in the 75 studies, and the instruments were found to be related theoretically with the following four clusters: (i) sense of coherence, (ii) various instruments of control orientation, (iii) coping strategies, style or actions (referred to as coping strategies hereafter), and (iv) religious coping. These clusters are again found to represent two different, but related parts of the coping process, resources and strategies of coping. The coping concepts, sense of coherence and control orientation, are both theoretically referred to as resources of coping [16,32]. Religious coping may be understood both as a strategy of coping representing religious activities [24] and as resources of coping, when religiosity can serve as a system of values that may guide the individual’s choices of coping strategies in times of stress [33,34]. The concept of religious coping is based on the theories of Folkman and Lazarus [19], and is thus related as strategies of coping [33].

In total, 9 studies included more than one of the four clusters of coping, and these were a combination of an instrument of control orientation and coping strategies in 7 studies and between control orientation and religious coping in 2 studies [35,36] (tables 2, 3). The Sense of Coherence scale [37] was the most frequently used instrument and was applied in 9 studies (table 5). Among the total of 18 different instruments assessing control orientation, 3 instruments (the Internal/External Control of Reinforcement scale [15], the Multi-Health Locus of Control scale [38] and the Internal Locus of Control (mastery) [39]) were applied in 6 studies each (table 5). Five studies used instruments to assess control orientation specifically made for those studies. Regarding the 30 different instruments of coping strategies, the COPE inventory was applied most often, in 4 studies. Three studies used instruments of coping strategies specifically made for those studies. Among the 7 different instruments of religious coping, the Religious Coping index was most often applied, in 5 studies (table 5).

No studies reported information about difficulties with administration of the coping instruments in older participants. However, 11 studies excluded participants with cognitive impairment, a diagnosis of dementia or major depression [40,41,42,43,44,45,46,47,48,49,50]. Three studies (1 from a nursing home, 1 community-based study and 1 study from a memory clinic) excluded items regarded as irrelevant to the situation of the participant [51,52,53]. Of the studies of older persons suffering from depression, cognitive impairment, or from nursing homes, 10 studies screened their participants for cognitive impairment, and 9 applied the Mini-Mental Status Examination (MMSE) [26,35,51,54,55,56,57,58,59,60,61]. The criteria of exclusion varied from MMSE ≤6 to 25 points, but most often a cutoff at 24 and 25 points was used.

In the 44 studies with a quality score of 6 or more points, the main finding was of a strong association between resources and strategies of coping and depression, and this association appeared to be stable over time.

All 9 studies using SOC were of higher quality (2 longitudinal and 7 cross-sectional studies; table 1). Of these 9 studies, 4 recruited participants from community settings and 5 recruited older persons from clinical settings of whom 3 studies were from somatic hospitals, including participants after suicide attempts (2 studies) and older persons with somatic disorders (1 study). Further, 1 study included depressed older persons from psychogeriatric clinics and 1 study included participants from nursing homes with different somatic disorders. These studies reported a negative relationship between SOC and depressive symptoms (tables 2, 3). In the longitudinal studies, a higher total score on the SOC at baseline was related to fewer depressive symptoms at follow-up among participants, and was associated with a lower score on a depression scale in a nonremission group of depressed suicide attempters. The cross-sectional studies reported that higher total SOC scores were associated with lower scores on the depression scales. One study reported a negative association between SOC and depressive symptoms in depressed persons but not in the control group [59], and another study found SOC to mediate the association between depressive symptoms and attachment [62] (tables 2, 3).

Among the total of 36 studies related to the concept of control orientation, 22 were of higher quality (10 longitudinal and 12 cross-sectional; table 1). In studies of higher quality, the samples were recruited from the community in 13 studies. Of the 9 studies from the clinical settings, 3 included participants with different cardiac disorders, 2 included participants suffering from depression, 2 had participants from nursing homes, 1 study had participants with cognitive decline and 1 study included participants with somatic disorders in general (GP; tables 2, 3). Among the 10 longitudinal studies of higher quality, a high ‘internally oriented recovery LOC’ or ‘desired LOC’ (perceived control in a situation), self-efficacy, optimism, mastery and a low externally oriented LOC at baseline were all associated with fewer depressive symptoms and/or less persistent depression at follow-up (table 2). Of the 12 cross-sectional studies of higher quality, a high internal LOC, self-efficacy and low externally oriented control was found to be associated with less depressive symptoms (table 3). Two longitudinal studies report some results of no association, i.e. 1 study including LOC and self-efficacy [63] and another including optimism [64] at baseline did not find these concepts of control orientation associated with reduced depressive symptoms after treatment (table 2). Furthermore, 2 cross-sectional studies focusing on ‘belief of chance’ as control orientation did not find associations with degree of depressive score (table 3).

Of the total of 37 studies concerning coping strategies in relation to depression, 14 were of higher quality (7 longitudinal and 7 cross-sectional; table 1). Nine studies had recruited older persons from clinical settings and 5 of the studies were community based. From clinical settings, 4 studies included participants with different cardiac disorders, 3 included depressed participants, 1 included participants suffering from pain, and 1 study included cognitively impaired older persons (tables 2, 3). Of the 7 longitudinal studies of higher quality, an increased use of adaptive- and approach-oriented coping strategies (as opposed to avoidance), acceptance, finding meaning, appraisal, positive reappraisal, and low avoidance coping at baseline were associated with less depression at follow-up. Both the longitudinal and cross-sectional studies reported low levels of avoidance coping associated with lower levels of depressive symptoms. In addition, the 7 cross-sectional studies of higher quality reported low levels of passive coping and emotion-oriented coping (avoidance), denial, self-blame, complaint behavior, catastrophizing, and mystery beliefs to be associated with lower levels of depressive symptoms. Also, findings of high levels of problem- and task-oriented, active, cognitive and behavioral coping, ignoring pain, and coping self-statements were all associated with lower levels and absence of depressive symptoms. Three cross-sectional and 5 longitudinal studies reported of some additional aspects of strategies (i.e. avoidance, blaming, refocusing, praying, help seeking, appraisal and thought suppression) not being associated with symptoms of depression, or of symptoms of depression at follow-up (tables 2, 3).

From the total of 12 studies applying an instrument of religious coping, 6 were of higher quality (2 longitudinal and 4 cross-sectional; table 1) and all were recruiting older persons from clinical settings with participants suffering from depression (2 studies), somatic disorders, not specified (3 studies), and cancer (1 study; tables 2, 3). Among the longitudinal studies, high levels of positive religious coping and low levels of negative religious coping at baseline were related to lower levels of depressive symptoms at follow-up. Corresponding to the longitudinal studies, the cross-sectional studies found increased use of positive religious coping associated with lower levels of depressive symptoms. High levels of intrinsic religiosity were found to be important for a low depression score only in the cross-sectional studies. In 2 studies of higher quality (1 longitudinal and 1 cross-sectional), some additional aspects of religious coping (public and private religious practice, negative religious coping and religious coping index) were studied and shown not to be associated with depressive symptoms (tables 2, 3).

The discussion of the relation between coping and depression in older persons is based on the findings reported in the studies of higher quality. Although coping was defined in many ways throughout the studies, they formed four clusters of concepts, i.e. sense of coherence, control orientation, coping strategies, and religious coping. All high-quality studies reported findings of a relationship in which more adaptive coping (higher SOC, internal control orientation, active strategies, and use of more religious or positive coping) were associated with less depressive symptoms (tables 2, 3).

SOC may be viewed as a personal coping resource [32]. We found a positive relation between higher SOC and a lower degree of depressive symptoms in samples of older persons, which is in line with the findings from a systematic review on mixed age groups [29]. The finding that a stronger SOC is associated with fewer symptoms of depression indicates that the SOC may be a health-promoting factor, as proposed in the theory of salutogenesis, and that SOC as a coping resource contributes to the management of stress and promotes effective coping in older people [27].

Control orientation may be seen as another personal coping resource [32]. In this review of cross-sectional and longitudinal studies of higher quality, a strong and consistent relationship between higher internal control orientation and reduced levels of depressive symptoms were found in community-based populations among older persons with somatic disorders, and in older persons suffering from major depression or being dependent on care. This relation suggests that a high internal personal control orientation acts to prevent feelings of helplessness and depression, and may protect against these perceptions in times of stress and hardiness, as opposed to older persons having a low internal control orientation. This finding is in accordance with other research among mixed age groups [10,29] and older people [7,65]. Conclusively, the ability of an older person to retain good coping resources in terms of a strong SOC and high internal control seems important for mental health and in the understanding of depression in late life.

Regarding the association between coping strategies and depression, the majority of the high-quality studies, both cross-sectional and longitudinal, reported that emotion-oriented (avoidance) coping was positively related to more depressive symptoms and that more frequent use of problem-oriented (active strategies) coping was related to less depressive symptoms. The studies regarding coping strategies are community based or have recruited samples from clinical settings, and the results considering these samples indicate that active and problem-focused strategies may act as adaptive coping strategies in times of stress and protect against symptoms of depression. Studies including older persons suffering from major depression, cognitive decline, or dependence on care are scarce, but the results are in line with those from the community-based and clinical settings, including older persons suffering from somatic disorders. However, we found a great variability in the use of different instruments of coping strategies in all the samples. Many of these instruments were not well established or validated in this age group and it is difficult to compare the results with other studies (table 5).

Considering the associations between religious coping and depression, the main finding is of a significant relationship. Higher use of religious coping, in terms of more religious activities and religiosity as available coping resources, is associated with lower levels of depressive symptoms in the majority of the studies of high quality among both the cross-sectional and longitudinal studies. The studies examining religious coping and depression were mainly recruiting their samples from clinical settings. Religious practice is defined as the nature and time spent on religious activities, and could be understood in terms of coping strategies [26], while religious coping is a more broadly defined concept ‘designed to assist people in the search for a variety of significant ends in stressful times: a sense of meaning and purpose, emotional comfort, personal control, intimacy with others, physical health, or spirituality’ [33], with the latter definition expressing concepts more in line with resources of coping. Older persons suffering from somatic disorders and major depression may find meaning, emotional comfort and control in religious beliefs and activities, and religious coping could be a protective factor against depression in late life. The studies reviewed support this notion. Stronger and more personal religious beliefs were associated with lower depressive symptoms both at baseline and after a period of time. However, the number of studies is small and, further, the different concepts of religious coping might capture different phenomena (coping resources and coping strategies, respectively).

It is a strength that we conducted a broad and thorough literature search, and that two researchers independently evaluated all the papers. We included all the coping perspectives used to study the relationship between coping and depression in this age group, in addition to evaluating all the papers according to quality criteria. The multitude of different concepts of coping, definitions and measures reported in the studies is an obvious limitation and may cause validity and reliability problems (table 5). We agree with other researchers who state that the variety of instruments for measuring coping and definitions of the concepts of coping make it difficult to compare the results of the studies and to draw firm conclusions, and we support the need for a further systematization of the theory and methodology of the coping field [63]. Few studies of older persons suffering from major depression and cognitive decline were found, and this also makes it difficult to conclude regarding coping and depression in these categories of elderly persons. Most of the studies including older persons suffering from major depression and cognitive decline have further excluded participants with more than a mild cognitive decline, so the included participants are not representative of the entire groups. This review is also limited because a meta-analytic approach in evaluating the studies statistically had to be omitted due to the variability in measures and designs. Also, because of the exclusion of articles written in languages other than English, the pool of research on this topic may have been limited. Consequently, the findings of this review must be interpreted cautiously.

The findings of this review imply that the instruments for measuring coping strategies and resources among older persons should be further theoretically and methodologically developed to reduce validity and reliability challenges. Despite the multitude of instruments of coping and the different settings where the studies took place, the results are quite unambiguous and show a significant relation between strategies and resources of coping and depressive symptoms in older persons, and the results are stable over time. There is also a need for validation and research on the instruments used for assessing strategies and resources of coping in samples of older persons with cognitive decline, including those who suffer from disorders like dementia and major depression. Instruments to assess resources and strategies of coping can be used to identify those at risk of developing a late-onset depressive disorder, a chronic course of recurrent depression, or worsening of depressive symptoms.

Our review of longitudinal and cross-sectional studies suggests a strong relationship between resources and strategies of coping and depressive symptoms in older persons from clinical and community settings. Higher SOC and internal control orientation and more use of active coping strategies and positive religious coping were related to lower levels of depressive symptoms. This finding supports the results from other reviews reporting a significant relation between concepts of coping and depressive symptoms. However, the huge variety of instruments measuring coping supports the need for a further systematization of the theory and the instruments of coping. In addition, further development of the instruments and research on coping in both populations of older persons suffering from major depression and cognitive decline is required.