Archives of Gerontology and Geriatrics 55 (2012) 574579

Family functioning and social support for older patients with depression in anurban area of Shanghai, China

Jikun Wang *, Xudong Zhao

Department of Psychiatry, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200092, China

A R T I C L E I N F O

Article history:

Received 8 February 2012

Received in revised form 31 May 2012

Accepted 18 June 2012

Available online 6 July 2012

Keywords:

Chinese

Geriatric depression

Family functioning

Family Assessment Device

Social support

A B S T R A C T

Purpose: Geriatric depression is now very common and leads to significant economic costs and family

burden in China. Families with a depressed patient often report problematic family functioning in

Western samples, and lack of social support is strongly associated with geriatric depression. However, the

relationship between geriatric depression, family functioning and social support in mainland China has

not been well studied.

Materials and methods: This study compared family functioning and social support in a Chinese sample of

elderly patients with major depression and non-depressed elderly people, and evaluated the impact of

family functioning, social support and socio-demographic factors on depression. A questionnaire was

administered to 102 elderly patients with major depression and 107 non-depressed elderly people.

Results: The elderly patients with major depression had worse family functioning and lower social

support than elderly individuals without depression. Multivariate linear regression analysis showed

associations between depressive symptoms and unhealthy family functioning, lower social support and

single marital status.

Conclusions: The findings suggest that family interventions and improvement of social support are

important in reducing depression among elderly patients. In addition, strategies to alleviate geriatric

depression should be considered by the whole society, the community, family members and the

depressed elderly patients themselves.

2012 Elsevier Ireland Ltd. All rights reserved.

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Archives of Gerontology and Geriatrics

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1. Introduction

With the rapidly aging population in China, increasing attention isbeing paid to the mental and physical health of older people.Depression is very common and represents a major mental disorderin those who are older (Back & Lee, 2011), adversely affecting dailyfunctioning and quality of life worldwide (Wada et al., 2005).Geriatric depression puts an immense burden on patients, theirfamilies and society as a whole (Chen et al., 2005). In addition,depression is a very costly disorder in China (Hu, He, Zhang, & Chen,2007). Providing effective treatment could result in a significantreductioninthetotalburdenassociated withdepression.Therefore, itis imperative to explore factors influencing the prognosis of geriatricdepression in China and improve treatment strategies. Family factorsand social support are two important aspects associated with healthin aging people (Leung, Chen, Lue, & Hsu, 2007).

Family impairment refers to a familys inability to accomplishtasks that are important for their well being (Miller, Ryan, Keitner,

* Corresponding author at: P.O. Box 244, Tongji University, Siping Road 1239,

Shanghai 200092, China. Tel.: +86 21 65988874; fax: +86 21 65988874.

E-mail address: liwangjk@gmail.com (J. Wang).

0167-4943/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.http://dx.doi.org/10.1016/j.archger.2012.06.011

Bishop, & Epstein, 2000). Accumulating evidence has found thatimpaired family functioning is strongly associated with the courseof depression in older people. For example, some research hasdemonstrated that depression damages the mental and physicalheath of the elderly, and contributes to risk of suicide (Kaneko,Motohashi, Sasaki, & Yamaji, 2007). In addition, the caregivers ofolder people with depression report a significant burden (Xie,Zhang, Peng, & Jiao, 2010) and are likely to have depressivesymptoms, which can result in the impairment of familyfunctioning. One study found that family involvement had aneasing effect on psychological symptoms for people with medicaldiseases, and elderly people with mental problems benefited fromfamily interventions (Leung et al., 2007). Depressed men andwomen in a community have poorer family functioning than non-depressed individuals, and depression has a strong relationshipwith poorer marital functioning, suggesting that targeting onlydepressive symptoms in treatment may not be enough to resolvemarital difficulties that persist even when depressive symptomsremit (Herr, Hammen, & Brennan, 2007). Moreover, familyfunctioning and depression may interact with each other, whichmeans depression could affect family functioning, and familyfunctioning could affect the prognosis of depression (Restifo &Bogels, 2009).

http://dx.doi.org/10.1016/j.archger.2012.06.011mailto:liwangjk@gmail.comhttp://www.sciencedirect.com/science/journal/01674943http://dx.doi.org/10.1016/j.archger.2012.06.011

J. Wang, X. Zhao / Archives of Gerontology and Geriatrics 55 (2012) 574579 575

The relationship between geriatric depression and social supporthas also received attention. For example, social support was found tohave a significant impact on mental health among elderly people inChinese rural districts (Xie et al., 2010). The buffering effects of socialsupport are considered to be dependent on the type of stress andsupport (Bisschop, Kriegsman, Beekman, & Deeg, 2004; Bisschop,Kriegsman, Deeg, Beekman, & van Tilburg, 2004). Another studyindicated that less emotional support is associated with moredepressive and anxiety symptoms in older people (Leung et al.,2007). Particularly, low social support can be dangerous for elderlyindividuals (Mazzella et al., 2010). A poor social network can lead tovulnerability and even death in this population (Clausen, Wilson,Molebatsi, & Holmboe-Ottesen, 2007).

In summary, considerable research has shown that depressionhas a strong relationship with impaired family functioning andlack of social support. However, most research on the associationbetween geriatric depression and family functioning has beenconducted with Western samples. Few studies have exploredfamily functioning among Chinese older patients with depression.Culture is related to experiences and coping styles associated withdepression (Kleinman, 2004; Ryder et al., 2008). Furthermore,healthy and unhealthy family functioning may vary in differentcultures (Keitner et al., 1991). Previous research on the relationshipbetween social support and geriatric depression has mainlyemphasized instrumental and emotional social support (Leunget al., 2007) as well as subjective and objective social support andsupport utilization (Xie et al., 2010). However, studies have notexamined which aspects of social support come from individualssuch as family, friends and significant others.

Thus, it is important to explore the characteristics of familyfunctioning and specific sources of social support for depressedelderly patients compared to non-depressed elderly people inChina. In addition, the association between depression and familyimpairment and social support in Chinese elderly patients withmajor depression should be examined. For the purpose ofimproving the prognosis and quality of life of those with geriatricdepression, we designed a cross-sectional questionnaire surveyaimed at (a) exploring the characteristics of perceived familyfunctioning and social support in elderly patients with majordepression and non-depressed elderly people in mainland China,(b) evaluating the association between depression and familyfunctioning, social support and socio-demographic factors amongelderly patients with major depression, and (c) exploring factorspredicting depression among elderly depressed patients.

2. Materials and methods

2.1. Sample

The sample comprised 102 older Chinese patients who metDSM-IV-TR criteria (American Psychiatric Association, 2000) formajor depressive disorder and 107 non-depressed elderly peoplein the community. The patients came from the PsychiatryDepartment of Shanghai East Hospital affiliated with TongjiUniversity in Shanghai, China. Depressive symptoms wereassessed using the Geriatric Depression Scale (GDS) (Yesavageet al., 1983), with a score above 10 indicating depressedindividuals. The non-depressed elderly people were recruited inthe community through a neighborhood committee. Exclusioncriteria for all subjects included neurological disorders, severephysical problems and substance abuse or dependence within the3 months prior to the study. Control subjects did not have a currentpsychiatric disorder. This study was approved by the localInstitutional Review Board of Tongji University. Written informedconsent was obtained from all volunteer subjects after anexplanation of the study was provided.

2.2. Instruments

The GDS, Family Assessment Device (FAD) (Epstein, Baldwin, &Bishop, 1983; Miller, Epstein, Bishop, & Keitner, 1985), Multidimen-sional Scale of Perceived Social Support (MSPSS) (Zimet, Powell,Farley, Werkman, & Berkoff, 1990) and a self-designed questionnairefor collecting demographic data were used in the study.

2.2.1. The GDS

Depression in the older patients was assessed by the GDS, aninstrument used to assess depression in the elderly. It consists of30 items. Subjects are asked to respond based on their feelings inthe previous one week. Each item includes two answer choices:Yes or No, with each answer indicating depression assignedone point. Scores range from 0 to 30, with higher scores indicatinghigher levels of depression. The GDS has an internal consistency ofa = 0.85. Scores from 0 to 10 are considered in the normal range.Scores from 11 to 20 are considered to represent minimal to milddepression, and moderate to severe depression is indicated byscores of 2130.

2.2.2. The FAD

Family functioning was assessed using the Chinese version ofthe Family Assessment Device (FAD-CV). The FAD is a 60-item selfreport inventory that measures family members perceptions ofvarious aspects of family functioning according to the McMasterModel of Family Functioning (MMFF) (Miller et al., 2000). TheMMFF assesses six dimensions of family functioning: ProblemSolving (the ability of the family to resolve problems thatmaintains effective family functioning); communication (howfamily members exchange information with each other); roles(how the family assigns responsibilities in the family to ensurefulfillment of family functions); Affective Responsiveness (wheth-er the family members respond with a full spectrum of feelingsexperienced by human beings); Affective Involvement (thefamilys ability to be interested in each other); behavior control(rules that the family adopts to handle dangerous situations, tomeet psychobiological needs and interpersonal socializing behav-ior within and outside the family); and overall General Function-ing. Health pathology cutoff scores have been established for theFAD for each dimension of family functioning (Miller et al., 1994).Higher scores indicate worse family functioning. The validity andreliability of the Chinese FAD has been demonstrated (Shek, 2001,2002). The testretest reliability is 0.530.81, and coefficientalphas range from 0.53 to 0.94.

2.2.3. The MSPSS

The MSPSS is a 12-item self-report instrument with a seven-point scale (from 1 = strongly disagree to 7 = strongly agree) thatmeasures perceptions of social support from friends, family andsignificant others. Higher scores indicate lowerer perceivedsupport. The psychometric properties of the MSPSS werepreviously investigated in a Chinese sample in Hong Kong (Chou,2000). The MSPSS was used to assess social support in this studybecause of several advantages offered by it. First, it focuses on thesubjective feeling of social support that plays a significant role indepression. In addition, it evaluates three sources of social supportincluding family, friends and significant others. Finally, a 12-itemscale is easy to use (Chou, 2000).

2.3. Data analysis

Descriptive statistics were carried out for socio-demographicdata. Independent t-tests and x2 tests were used to analyzesociodemographic characteristics of the subjects between groups.Independent t-tests were used to compare the FAD scores and

Table 1Sociodemographic data of the depressed and non-depressed elderly groups,

mean SD or n (%).

Variables Depressed

elderly

Not-depressed

elderly

p=

Number 102 107

Age (years) 64.5 2.86 63.8 2.84 0.061Gender 0.356

Male 46 (45.1) 52 (48.6)

Female 56 (54.9) 55 (51.4)

Education (years) 10.2 2.51 10.7 2.18 0.136Educational level

Primary school 12 (11.8) 7 (6.5)

Secondary school 45 (44.1) 40 (37.4)

High school 38 (37.3) 55 (51.4)

University 6 (5.9) 5 (4.7)

Marital status

Married (remarried) 88 (86.3) 102 (95.3)

Single (never married,

divorce or widowed)

12 (13.7) 5 (4.7)

GDS

Mild 30 (29.4)

Moderate/severe 72 (70.6)

J. Wang, X. Zhao / Archives of Gerontology and Geriatrics 55 (2012) 574579576

MSPSS scores between depressed elderly patients and non-depressed elderly people. Pearsons correlation was used to assessthe association between depression scores, FAD scores and socialsupport scores among depressed elderly patients. We usedmultiple linear regression with stepwise analysis to study thesignificant factors predictive of depression. All data wereperformed using the SPSS 13.0 statistical software package.

3. Results

3.1. General data

The distribution of socio-demographic characteristics of the209 subjects is shown in Table 1. The resulting data represented102 depressed and 107 non-depressed elderly people. Subjectsranged in age from 60 to 80 years. The depressed elderly patientshad the following characteristics: 46 (45.1%) were male and 56(54.9%) were female; their mean age was 64.5 years (SD = 2.86);they had a mean of 10.2 years of schooling (SD = 2.51), and mostpatients (81.4%) had an educational level of secondary or highschool. The non-depressed elderly people had the followingcharacteristics: 52 (48.6%) were male and 55 (51.4%) were female;their mean age was 63.8 years (SD = 2.84); they had a mean of 10.7years of schooling (SD = 2.18), and most patients (88.8%) had aneducational level of secondary or high school. The t-test and x2 testshowed that there were no significant differences between

Table 2Statistical comparison of parameters in the depressed group by independent t-tests, m

Mild depression (n = 30)

Family functioning

PS 2.42 0.26 CM 2.39 0.34 RL 2.32 0.58 AR 2.39 0.36 AI 2.10 0.30 BC 2.60 0.20 GF 2.26 0.29

Social support

Total support 46.68 12.20 Family 13.22 5.22 Friends 21.69 4.59 Significant others 11.76 5.06

Notes: PS, Problem Solving; CM, Communication; RL, Roles; AR, Affective Responsiven

Unhealthy scores of FAD are underlined. High scores of FAD indicate worse family fun* p < 0.05.** p < 0.01.

depressed elderly patients and non-depressed elderly people ingender, age or educational level (p > 0.05) (Table 1). Depressionscores for depressed elderly patients ranged from 30 (29.4%),indicating a mild level of depression, to 72 (70.6%), indicatingmoderate or severe depression.

3.2. FAD and MSPSS scores in the depressed patients

Table 2 lists the FAD and MSPSS scores for the depressed elderlypatients with mild or severe depression. Results of independent t-tests showed significant differences in FAD scores for ProblemSolving and Affective Involvement dimensions as well as MSPSSscores between the two groups. The elderly patients with severedepression had worse family functioning and lower social supportfrom family, friends and significant others (p < 0.01) than thosewith mild depression (Table 2). All scores for FAD dimensions werein the unhealthy range for depressed elderly patients with mild orsevere depression.

3.3. FAD and MSPSS scores in the study groups

Table 3 lists the FAD and MSPSS scores for the depressed elderlypatients and non-depressed elderly people. Results of independentt-tests showed significant differences in scores on the FAD andMSPSS between the two groups, except for the Roles dimension onthe FAD. The depressed elderly patients had worse familyfunctioning (p < 0.01) and lower social support from family,friends and significant others (p < 0.01) (Table 3). All dimensionsof the FAD (represented by subscale scores) for depressed elderlypatients were in the unhealthy range. For non-depressed elderlypeople, only the Behavioral Control score on the FAD was in theunhealthy range.

3.4. Relationship between depression, family functioning and

social support

In our study, depression measured by the GDS was significantlypositively correlated with negative family functioning, whichinfluenced the depression scores directly, and was positivelyrelated to lower social support from family, friends and significantothers (p < 0.05) (Table 4).

3.5. Socio-demographic factors, family functioning and social support

predicting the level of depression among elderly depressed patients

Table 5 shows the results of multivariate linear regression ofdepression with socio-demographic variables, family functioning

ean SD.

Severe depression (n = 72) t p

2.63 0.57 2.596 0.011*2.48 0.29 0.883 0.3792.34 0.28 0.256 0.7992.47 0.59 0.786 0.4342.27 0.57 2.107 0.038*2.72 0.57 1.551 0.1242.30 0.54 0.417 0.677

55.90 13.79 3.345 0.001**16.53 5.61 2.854 0.005**24.17 2.59 2.766 0.007**15.20 6.33 2.896 0.005**

ess; AI, Affective Involvement; BC, Behavioral Control; GF, General Functioning.

ctioning and high scores of MSPSS indicate lower social support.

Table 4Correlation between depression, family functioning and social support.

Parameters 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

1. Depression

2. PS 0.334**

3. CM 0.189 0.737**

4. RL 0.112 0.752** 0.792**

5. AR 0.209* 0.783** 0.804** 0.819**

6. AI 0.404** 0.696** 0.587** 0.636** 0.555**

7. BC 0.253* 0.848** 0.729** 0.745** 0.734** 0.709**

8. GF 0.174 0.809** 0.822** 0.907** 0.889** 0.644** 0.801**

9. Family support 0.396** 0.302** 0.368** 0.459** 0.519** 0.302** 0.273** 0.515**

10. Friends support 0.347** 0.214* 0.259** 0.286** 0.336** 0.082 0.252** 0.256** 0.380**

11. Significant others support 0.391** 0.322** 0.358** 0.481** 0.501** 0.303** 0.270** 0.509** 0.961** 0.389**

Notes: PS, Problem Solving; CM, Communication; RL, Roles; AR, Affective Responsiveness; AI, Affective Involvement; BC, Behavioral Control; GF, General Functioning.* p < 0.05.** p < 0.01.

Table 3Statistical comparison of parameters in the two groups by independent t-tests, mean SD.

Depressed elderly Normal elderly t p

Family functioning

PS 2.46 0.46 2.04 0.35 7.328 0.0001**CM 2.39 0.51 2.10 0.29 5.055 0.0001**RL 2.30 0.45 2.22 0.20 1.774 0.077AR 2.38 0.50 2.12 0.36 4.435 0.0001**AI 2.20 0.30 2.08 0.54 1.980 0.049*BC 2.61 0.44 2.22 0.27 7.881 0.0001**GF 2.25 0.44 1.96 0.26 5.669 0.0001**

Social support

Total support 49.08 13.29 25.59 9.18 14.927 0.0001**Family 14.08 5.53 7.50 3.06 10.638 0.0001**Friends 22.34 4.25 9.79 3.32 23.712 0.0001**Significant others 12.66 5.63 8.21 3.38 6.914 0.0001**

Notes: PS, Problem Solving; CM, Communication; RL, Roles; AR, Affective Responsiveness; AI, Affective Involvement; BC, Behavioral Control; GF, General Functioning.

Unhealthy scores of FAD are underlined. High scores of FAD indicate worse family functioning and high scores of MSPSS indicate lower social support.* p < 0.05.** p < 0.01.

Table 5Multivariate linear regression with the GDS as the dependent variable among the depressed elderly patients.

B p< 95% CI Adjusted R2 R2

Constant 31.725

PS 4.374 0.004** 1.629 to 7.492

CM 0.682 0.533 1.484 to 2.849

RL 3.519 0.049* 0.346 to 7.255

AR 1.160 0.422 1.698 to 4.018AI 2.784 0.001** 1.278 to 4.497

BC 0.216 0.895 3.035 to 3.467GF 2.976 0.202 1.623 to 7.574Family support 0.243 0.180 0.599 to 0.114Friend support 0.229 0.002** 0.091 to 0.369

Other support 0.049 0.778 0.391 to 0.294Marital status 1.914 0.036* 0.181 to 3.069 0.455 0.514

Notes: PS, Problem Solving; CM, Communication; RL, Roles; AR, Affective Responsiveness; AI, Affective Involvement; BC, Behavioral Control; GF, General Functioning. Total

n = 102.* p < 0.05.** p < 0.01.

J. Wang, X. Zhao / Archives of Gerontology and Geriatrics 55 (2012) 574579 577

and social support. Five variables entered into the regressionmodel. Problem Solving, Roles and Affective Involvement dimen-sions of family functioning as well as social support from friendswere positively related to level of depression, and marital status(including never married, divorced or widowed) was negativelyassociated with level of depression (Table 5).

4. Discussion

The health of older people in developed countries is considereda significant issue, and considerable research has focused on

psychological and physical health among the aging population(Chalise, Saito, Takahashi, & Kai, 2007). Old age is related tophysical as well as psychological health issues, including lonelinessand depression (Carruth & Logan, 2002). Depression has beenshown to be strongly associated with family dysfunction inWestern countries. China has experienced rapid economicdevelopment, and the population has been aging rapidly overrecent years (Dong, Beck, & Simon, 2010). Depression is one of themost common psychiatric disorders in elderly people in Chineserural districts (Xie et al., 2010). Less social support, worse familyfunctioning and a higher level of depression may be related to

J. Wang, X. Zhao / Archives of Gerontology and Geriatrics 55 (2012) 574579578

quality of life among older people. Therefore, focusing on therelationship between family functioning and social support amongolder patients with depression is helpful in formulating effectiveinterventions to improve the prognosis of geriatric depression inChina.

Some research has found that the severity of depression isrelated to impairment of family functioning. The current studyshowed that the older patients with severe depression perceivedmore severe family impairment and lower social support fromfamily, friends and other significant people in their lives. Thisfinding suggests that clinicians should pay more attention tofamily interventions for older patients with more severe depres-sion.

Family functioning is strongly associated with depression, withan interaction between the two. For example, less psychologicaldistress has been reported by elderly people perceiving morefamily involvement (Leung et al., 2007). Therefore, there is a greatneed for research on the role of family functioning in the course ofgeriatric depression. In our study, scores on most dimensions offamily functioning for elderly depressed patients were higher thanthose for the non-depressed elderly people, except for Roles. Inaddition, all scores on dimensions of the FAD for depressed elderlypatients were in the unhealthy range. All findings indicatedunhealthy family functioning among depressed elderly patients,suggesting that the treatment of geriatric depression shouldinclude family interventions. Family is considered a significantsource of support for elderly people in China because the cultureemphasizes the whole family system including nuclear andextended family, as well as collectivism (Leung et al., 2007). Inaddition, FAD scores for Behavioral Control among non-depressedelderly people were also in the unhealthy range. TraditionalChinese values emphasize that the rules of the family shouldconform to hierarchical rules such as submissiveness of wife tohusband and son to father. However, industrialization andurbanization have led to social changes that have significantlyinfluenced the traditional values of Chinese families (Tam &Neysmith, 2006). Thus, the unhealthy scores for Behavioral Controlmay indicate the impact of social adjustment and adaptation onthe rules of the family.

The results of the current study also indicated that socialsupport from family, friends and significant others of elderlydepressed patients was significantly lower than that for non-depressed elderly people. Social support can modulate theinfluence of stressful events on mental health. For example, bettersocial support can reduce the effect of stressful events onpsychological health and decrease the incidence of depression(Mohr & Genain, 2004). In addition, social support is positivelyrelated to psychological and physical health (Huo & Zhang, 2007).Some research has indicated that the empty nest elderly in Chineserural districts experience a lack of social support (Xie et al., 2010).With the development of the Chinese economy, there is limitedsocial support for elderly people because their children may departto study or work earlier than before (Wang & Zhao, 2012). Thus,elderly people with depression may experience a lack of emotionalsupport from their children. This finding suggests that it isimportant for older depressed patients to receive more socialsupport from the community, friends and other family members.

In this study, depression was significantly correlated withfamily functioning and social support. Depression, as measured bythe GDS, was positively associated with social support scores andFAD scores. Research studies have repeatedly found that familyfunctioning is strongly correlated with the development andprognosis of depression. Improving family functioning couldimprove the prognosis of geriatric depression. Social supportplays a significant role in the incidence of depression (Peirce, Frone,Russell, Cooper, & Mudar, 2000). Therefore, improved family

functioning and increased social support could minimize theoccurrence of depression.

To develop effective measures to reduce depression levelsamong elderly people, factors predicting the level of depressionshould be identified. Some research has found that female gender,single status, functional impairment, physical disease, lack ofsocial support, lack of religious beliefs and low economic status arerisk factors for geriatric depression (Avila-Funes, Garant, & Aquilar-Navarro, 2006; Beekman et al., 2001; Bruce & Hoff, 1994; Prince,Harwood, Thomas, & Mann, 1998; Xie et al., 2010). In our study,multivariate linear regression analysis indicated that ProblemSolving, Roles and Affective Involvement dimensions of familyfunctioning as well as social support from friends were positivelyassociated with depression. The elderly depressed patients hadworse family functioning and lower social support. Unhealthyfamily functioning may increase the level of depression in theelderly because mental and physical disorders make socialactivities difficult (Xie et al., 2010), and elderly patients arereluctant to keep contact with friends, neighbors and other familymembers. Furthermore, the spouses of depressed elderly patientsmay have a considerable burden due to taking care of theirdepressed family member. In families with a depressed elderlypatient, it can be very difficult to solve many family problems andmarital conflicts, and family members may find it difficult to copewith the household responsibilities. Additionally, the mostimportant source of social support from family for elderly patientsis often the spouse. However, because of the long-term burden onthem, the spouses of elderly patients may not continue toemphasize the Affective Involvement and interests of their spouse.Thus, poor family functioning in regard to Problem Solving, Rolesand Affective Involvement can be predictive factors for geriatricdepression. Moreover, social support from other sources includingfriends, social resources and other relatives could be important inimproving the prognosis of geriatric depression. Thus, socialsupport from friends could be considered another predictive factorfor depression among elderly patients.

Consistent with a previous study (Xie et al., 2010), the results ofthe current study revealed that single marital status (nevermarried, divorced or widowed) was related to a higher level ofdepression among elderly patients. Being married or cohabitingcan contribute significantly to being socially connected, and socialsupport from family, friends, neighbors, the community and othersocial groups are significant influencing factors on life satisfactionin elderly people (Enkvist, Ekstrom, & Elmstahl, 2012). Thus, forsingle elderly patients with depression, more attention should bepaid to social support from family members and the community.

5. Study limitations

Some limitations of the present study must be acknowledged.First, it is a cross-sectional design. Longer term follow-up studiesare needed to explore the specific impact of family functioning andsocial support on geriatric depression. Second, because theresearch is based on Chinese elderly patients with depression inShanghai, there is a need to replicate and assess the findings indifferent Chinese districts. Third, the study sample included onlyoutpatients. Future studies should use larger samples and includeinpatients. Last, only one family member completed the FAD in thisstudy. The results reflect an individual not a family perspective onfamily functioning, and future studies might include othermethods (e.g., objective assessment of family functioning) as well.

6. Conclusions

The results of the current study indicate that elderly patientswith major depression had worse family functioning and lower

J. Wang, X. Zhao / Archives of Gerontology and Geriatrics 55 (2012) 574579 579

social support than non-depressed elderly people, and there werecorrelations between depression and family functioning as well associal support. Problem Solving, Roles and Affective Involvementdimensions of family functioning, social support from friends andmarital status were significant predictors of depression in elderlypatients. To reduce depression in this population, more familyinterventions should be undertaken. Multidimensional societalstrategies to reduce the depression of elderly patients should beconsidered involving social support from friends, other familymembers and social groups (Xie et al., 2010).

Conflict of interest statement

None.

Acknowledgements

This study was supported by a grant from the Ministry ofScience and Technology (2009BAI77B05). The authors wish tothank all of the people who assisted them in the study.

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Family functioning and social support for older patients with depression in an urban area of Shanghai, ChinaIntroductionMaterials and methodsSampleInstrumentsThe GDSThe FADThe MSPSSData analysisResultsGeneral dataFAD and MSPSS scores in the depressed patientsFAD and MSPSS scores in the study groupsRelationship between depression, family functioning and social supportSocio-demographic factors, family functioning and social support predicting the level of depression among elderly depressed patientsDiscussionStudy limitationsConclusionsConflict of interest statementAcknowledgementsReferences