National context of healthcare, economy and religion, and the association between disability and depressive symptoms in older Europeans: results from the EURODEP concerted action.

Associations between disability and depression have been shown to be consistent across cultures among middle-aged adults. In later life the association between disability and depression is much more substantial and may be amenable to influences by health care facilities as well as economic and sociocultural factors. Fourteen community-based studies on depression in later life in 11 western European countries contribute to a total study sample of 22,570 respondents aged 65 years or older. Measures are harmonised for depressive symptoms (EURO-D scale) and disability. Using multilevel modelling to control for the stratified data structure we examined whether the association between disability and depressive symptoms is modified by national health care and mental health care availability, national economic circumstances, demographic characteristics and religious tradition. The association between depressive symptoms and disability is attenuated by health care expenditure and availability of mental health care and also by gross domestic product; it was more pronounced in countries with high levels of orthodox religious beliefs. Higher levels of depressive symptoms are found in countries with a larger gross domestic product (per capita) and higher health care expenses but are interpreted with care because of measurement differences between the centres. The findings from this contextual perspective indicate that general and mental health care should be geared to one another wherever possible.