Second, the data from Nakamura and colleagues are
in contrast to those of previous studies
being married and socially active are associated with bet-
ter quality of life and lower risk of institutionalization and
mortality. This population-based study was not designed
to investigate whether living with others (marriage) miti-
gated the risk of being admitted to institutionalized care
for older individuals with comorbid depressive symptoms.
The authors acknowledged the limitations of the study:
the sampling strategies and the unbalanced sample size
(the majority of older individuals with depressive symp-
toms were living with a family member). The observatio-
nal nature of the study design and the lack of documented
treatment history for depressive symptoms during follow-
up make it difficult to determine the relationship between
marital status and admission to long-term care. Thus, fur-
ther study is needed.
Third, the perceived quantity (too much) of social
support received may not necessarily reduce the impact of
depressive symptoms in older people. Potentially, this may
negate the opportunities to independently engage in activ-
ities that may boost of feelings of achievement of self-
esteem. But more importantly to consider the satisfaction
and the quality of functional support that older individuals
need (e.g. whom they can trust and reliable person) may
increase their level of confidence to engage in daily activ-
ities or social interaction to decrease the effect of depres-
sive symptoms. A population-based study of older adults
living in Switzerland (N 5 12,286)
investigated the mag-
nitude and independence of the association between the
four social relationship domains and major depressive dis-
order and depressive symptoms and found that perceived
quality and frequency of social relationships (except mari-
tal status) were associated with clinical depression and
depressive symptoms. This underscores the need for well-
controlled trials to compare the effectiveness of psychoso-
cial interventions to treat depressive symptoms, quantita-
tively or qualitatively, in individuals living with a spouse
or others and those living alone.
Fourth, many factors contribute to institutionalization
in older people (e.g., dementia, being widowed, depres-
sion, hearing impairment, vision impairment, dependence
in basic activities of daily living, severe mobility impair-
ment, severity of cognitive impairment, urge incontinence,
living alone, social isolation, behavioral symptoms, living
with others (spouse), chronic diseases (e.g., Parkinson’s
disease, stroke, neurological problems), caregivers with
emotional stress, history of falls and fall risk).
These features highlight the challenges of managing older
people with comorbid disease with depressive symptoms.
Only with a concerted effort from practitioners and policy
makers aware of these challenges can collaborative strat-
egies that address physical, psychological, attitudes of
health behavior and religiosity,
and social problems be
developed. Such strategies will reduce admission to long-
term care and the emotional stress of caregivers.
The present study provides some important insights
into the role of marriage and caregivers in those older
individuals living with depressive symptoms. In particular,
those with high depressive symptoms should be targeted
for intervention to reduce the risk of major depression,
admission to long-term care, and functional decline.
Research should also focus on how to reduce caregiving
stress using valid outcome measures; the potential benefits
of respite care and outdoor activities (e.g., group walking
exercise) are worthy of consideration. Such targeted inter-
ventions may include interdisciplinary teams and active
involvement of older adults with depressive symptoms to
prevent the slippery slope of greater disability and depend-
ence on caregivers.
Abebaw Mengistu Yohannes, PhD, MSc
Department of Physical Therapy, School of Behavioral
and Applied Sciences, Azusa Pacific University, Azusa, CA
Conflict of Interest: None.
Author Contributions: AMY is sole author.
Sponsor’s Role: None.
1. Nakamura T, Michikawa T, Imamura H et al. Relationship between
depressive symptoms and activity of daily living dependence in older Japa-
nese: The Kurabuchi study. J Am Geriatr Soc 2017; https://doi.org/10.
2. Lenze EJ, Schulz R, Matire LM et al. The course of functional decline in
older people with persistently elevated depressive symptoms: Longitudinal
findings from the Cardiovascular Health Study. J Am Geriatr Soc 2005;53:
3. Murphy RA, Hagaman AK, Reinders I et al. Depressive trajectories and
risk of disability and mortality in older adults: Longitudinal findings from
the health, aging and body composition study. J Geriontol A Biol Sci Med
4. Cuijpers P, Smit F. Subthreshold depression as a risk indicator for major
depressive disorder: A systematic review of prospective studies. Acta Psy-
chiatr Scand 2004;109:325–331.
5. Onder G, Liperoti R, Soldato M et al. Depression and risk of nursing home
admission among older adults in home care in Europe: Results from the
Aged in Home Care (AdHOC) Study. J Clin Psychiatry 2007;68:1392–1398.
6. Miller LM, Dieckmann NF, Mattek NC et al. Social activity decreases risk
of placement in a long-term care facility for a prospective sample of
community-dwelling older adults. Res Gerontol Nurs 2014;7:106–112.
7. Manzoli L, Villary P, Pirone G et al. Martial status and mortality in the
elderly: A systematic review and meta-analysis. Soc Sci Med 2007;64:77–94.
8. Barger SD, Messerli-Burgy N, Barth J. Social relationship correlates of
major depressive disorder and depressive symptoms in Switzerland: Nation-
ally representative cross sectional study. Public Health 2014;14:273.
9. Yohannes AM. Is it quality or quantity of social support needed for
patients with chronic medical illness? J Psychosom Res 2013;74:87–88.
10. Yohannes AM, Koenig HG, Baldwin RC et al. Health behavior and religi-
osity in older patients admitted to intermediate care. Int J Geriatr Psychia-
11. Gaugler JE, Yu F, Kirchbaum K et al. Predictors of nursing home admis-
sion for persons with dementia. Med Care 2009;47:191–198.
EFFECT OF CHIKUNGUNYA VIRUS INFECTION ON
INDIVIDUALS AND THE HEALTHCARE SYSTEM
To the Editor: Chikungunya virus infection (CHIKV) is a
major public health problem throughout the world, with
See the Reply by Lang et al.
JAGS MARCH 2018–VOL. 66, NO. 3 LETTERS TO THE EDITOR 633