it is estimated that by 2020 , depression will be the second leading cause of morbidity after ischemic heart disease .
lifetime prevalence of depression estimates varied widely , 8.6% in europe , 16.9% in the us , and 3% in japan .
furthermore , about 14% of the global burden of disease has been attributed to neuropsychiatric disorders .
the prevalence of major depression is approximately 2 times higher in women than in men .
furthermore , the increased rates of depressive symptoms are observed in women after the birth of a child ( postpartum depression ) , in the unemployed , in older people and after cardiovascular and neurological disturbances . at the ages over 65-year - old , depression is the most common mental health problem and probably the most frequent cause of emotional suffering in late life .
the aging of the world population results in the increasing prevalence of depression in the elderly and is estimated to affect one in seven people . moreover ,
the prevalence of major depression in higher age groups is estimated to be 14% in the community and of subsyndromal depression ( includes depressive syndromes such as dysthymia , bereavement , adjustment disorder with depressed mood , and minor depression ) 1530% . however , depression is not a natural part of aging and with appropriate treatment it is often reversible .
untreated , depression poses a critical impact on well - being and the quality of life of the elderly leading to serious functional impairment , reduced quality of life , high rates of suicide attempts , increased health care utilization and health expenditures .
despite the fact that persons with depression often seek help in primary care , they are not recognized as having depressive symptoms by the general practitioner .
consequently , depression is under - detected and under - treated in primary health care .
it has been noticed that only 11% ( in china ) to 61% ( in belgium ) of patients with severe mood disorders received any care in the year before . among the elderly ,
the major risk factors for depression are the female gender , co - morbidity where the prevalence of depression range from 10% to 43% , social network losses , low social support , cognitive deficits , and negative life events . in greece , the prevalence of depression in people over 60-year - old shows high variability , ranging from 6% to 70% depending on study design and studied population groups .
the aim of the present study was to estimate a possible under - detection of depression in members of the daycare centers for older people ( kapi ) in the municipality of patras and tripolis in greece .
further objectives were to estimate the prevalence of depressive symptoms in older people , to investigate the possible risk factors and to compare with other findings for greece .
a cross - sectional study was conducted among the registered and active members of the four kapi in the municipality of patras and tripolis , west - greece , and peloponnese , respectively , in the time period from march 2011 to october 2012 .
the choice of age ( 60 years and over ) was made according to the age limit of registration for the kapi .
an anonymous questionnaire was developed to collect basic demographic , medical , and socioeconomic data including three questions from the 
european health interview survey ( ehis )  regarding self - reported and/or by a physician - diagnosed depression , in the last 12 months or during the lifetime course ( hs.4 , hs.5 , hs.6 ) .
none of the participants suffer from cognitive deficits according to their medical records and prescribed medications .
all of the participants who state suffering from depression in the last 12 months or during a lifetime period were confirmed according to their medical history data and their prescribed medications for depression . moreover , to all participants the greek validated version of the geriatric depression scale-15 ( gds-15 ) was applied , to screen for depressive symptoms .
the scores of the gds-15 were compared to the corresponding answers of the ehis questions .
associations between the gds-15 score and various recorded basic parameters were made . during the study period ,
the same researcher visited either in the morning or in the afternoon , one of the four centers , and distributed the questionnaires to the members . in the most cases , a face to face interview
about 400 persons ( active members ) visit daily one of the kapi , of whom 378 agreed to participate in the study .
the majority of the nonactive members do not visit the centers for several reasons such as serious health problems or moving to another area .
the gds-15 was first developed by yesavage et al . , ( 1982 ) has been tested and used extensively in many countries to assess depressive symptoms in elderly , in community , in acute , and in long - term care settings .
it is a brief questionnaire , in which participants are asked to response to the 15 closed questions by answering yes or no , in reference to how they felt on the day of administration .
the gds-15 has been standardized and adapted in a greek elderly population and was found to have a 92% sensitivity and a 95% specificity .
scores 05 are considered normal , 610 indicate moderate depression , and 1115 indicate severe depression .
the study was approved by the plenary meeting of the medical school of patras and the ethics committee of the university of patras , greece .
participants were informed about the aims and procedures of the study and provided written informed consent for participation .
moreover , the board of both kapi at the municipality of patras and tripolis approved the research protocol and the conduction of the study .
statistical analysis was performed with statistical analysis was performed using spss for windows ( version 17.0 , spss , chicago , il , usa ) .
the chi - square test was used to test the difference between categorical variables . a p < 0.05 was considered as statistically significant .
a total of 378 individuals ( 239 from three kapi in patras and 139 from kapi in tripolis ) took part in the study ( response rate 94.5% ) , 55% males , and mean age 74 years .
demographic and socioeconomic characteristics of the study population according to the results of the gds-15 , 48.1% ( 45% in patras , 53.3% in tripolis ) of the studied population revealed to have depressive symptoms , 38.6% of moderate and 9.5% of severe form [ figure 1 ] . having ever been affected with chronic depression reported 19.0% , of them 12.7% being diagnosed by a medical doctor , and 11.9% having received medication . nearly , 10% reported having experienced depressive symptoms during the last 12 months .
distribution of the severity of depressive symptoms based on the scores of the geriatric depression scale-15 ( n = 378 , in % ) . about 05 no depression , 610 moderate depression , and 1115 severe depression of the 162 subjects who reported never been affected by a depression in patras and of 106 in tripolis , 27.7% and 44.7% screened positive for moderate and severe depressive symptoms , respectively . in 28 ( 11.7% )
individuals who reported not to know if they have / had depression in patras and 10 ( 7.2% ) in tripolis , depressive symptoms were observed in 60.7% and 90% , respectively , applying the gds-15 [ table 2 ] .
depressive symptoms were more frequent in women members of the three kapi of patras than in men , ( 54.6% vs. 37.4% , p = 0.027 ) , not married , including divorced and widowed , than married ( 55.6% vs. 38.9% , p = 0.038 ) , and the participants living alone at home ( 62% vs. 38.1% , p = 0.003 ) .
furthermore , depression was more frequent in older adults with chronic diseases compared to elderly without co - morbidity ( 50.8% vs. 27.5% , p = 0.02 ) and the participants with lower educational level ( 52.6% vs. 31.3% , p = 0.007 ) [ table 3 ] .
in addition , the semi - urban area of tripolis depressive symptoms was also more frequent in women ( 62.9% vs. 45.5% , p = 0.012 ) comparison to men , not married , including divorced and widowed , ( 85.6% vs. 38.9% , p < 0.001 ) and in subjects without children ( 91.7% vs. 49.2% , p = 0.001 ) .
depressive symptoms were more common in elderly with chronic diseases compared to elderly without co - morbidity ( 62.4% vs. 4.5% , p < 0.001 ) , in participants with low monthly income ( 63.7% vs. 25.8% , p = 0.001 ) , and in older adults suffering from insomnia ( 88.6% vs. 6.7% , p < 0.001 ) [ table 4 ] .
comparison of results between gds-15 and ehis question hs.4 depression in association to various demographic - socioeconomic characteristics in members of kapi in patras depression in association to various demographic socioeconomic characteristics in members of kapi in tripolis
the present study reveals a high percentage ( 48.1% ) of the members of open daycare centers for older people in urban area of patras and semi - urban area of tripolis , to suffer from both moderate and severe depressive symptoms .
these findings differ from the results of previous studies in greece , where lower rates of depression in similar populations were observed . on the other hand , the study of mamplekou et al .
, conducted in various greek islands and cyprus , revealed rates of 25% and 35% for severe depression ( gds score > 10 ) , while 54% and 70% scored above the depression cut - off of five , respectively .
a recent study in four kapi of municipality in attica indicates an overall prevalence rate of 30.3% , more detailed 22.2% for moderate , and 8.1% for severe depressive symptoms , measured with gds-15 .
, conducted in a health center in northern greece , where the prevalence of mild to moderate depression in women and men was estimated to be 29.9% and 19.6% , respectively , according to geriatric depression screening scale . in the study of papadopoulos et al . ,
which was conducted in a rural area in central greece , the prevalence of depressive symptoms was 39% , 27% of mild ( gds-15 > 6 ) , and 12% of severe type ( gds-15 > 10 ) . a study conducted in uk with the largest community sample of people aged 75 years and higher showed lower rates of moderate and severe depressive symptoms ( gds - score 3 = 34.6% , 6 = 8.0% , 8 = 3.1% ) than the present study .
however , it must be noted that different thresholds were used as compared to our study . except the high prevalence of depressive symptoms
, the present study reveals that a remarkable percentage of the study population is not aware of having depression and was never been diagnosed with this condition .
the low self - reported percentage of diagnosed depression in contrary to the results obtained by the gds-15 screening , suggests a substantial under - detection in the specific population group .
as other studies had shown , depression seems to be the most under - diagnosed disease in primary health care and especially patients in early stages of disease are less likely to be detected .
it is estimated that only 3555% are recognized by primary care physicians , although it is known , that depression is one of the most common disorders in older adults who are seeking help in primary health care .
our findings come to support these high rates of under - diagnosis since one in two of the participants screened with depressive symptoms , is not recognized and does not receive the appropriate medication .
moreover , it has been observed that depressive disorders are not only under - recognized but also under - treated and often not in line with current medical standards .
other studies reveal that only 19% of patients are receiving appropriate anti - depressive treatment , or that 43% of patients who have been diagnosed with depression by their general practitioner were prescribed an antidepressant , 34% are not being treated appropriate and 41% remain without treatment .
several reasons are described in the literature for under - diagnosis and under - treatment of depression in older adults .
the study of bartels pointed out that elderly people with depressive symptoms are less likely to use special mental health care but prefer to access the general health care system .
however , general practitioners are more likely to under - detect depression due to lack of experience , lack of continuous training in mental health , or due to their attitude regarding depression as a  natural  consequence of ageing and as accessory symptom of a physical disease .
last but not least , stigmatization of depressed individuals may lead to low recognition , treatment discontinuation and nonadherence of therapy in older patients .
depression , even the most severe forms , is one of the diseases with high treatment effectiveness if diagnosed at an early stage .
studies have shown , that various interventions , combining enhanced strategies of physicians and patient education , specialist services support , as well as monitoring of medication compliance have a positive effect on recognition , management , and outcome of the disease .
consequently , it is wishful to train primary care physicians , as well as nurses and social workers to raise the awareness of recognizing depression , especially in older adults .
the application of the short and user - friendly gds-15 by general practitioners would increase the ability to detect and treat depression in the elderly population , as shown in this study .
the present study revealed women having higher rates of depression than men , a result , which is in agreement with other studies conducted in greece and other countries .
other aggravating factors for depression in the present study , as well as in several other studies , are the low education level , being not married , including being widowed or divorced and in patients with chronic diseases , which is confirmed by previous studies
. the limitations of the present study derive from the fact that , the prevalence of depression depends on the cut - off scores are used to distinguish between no depression , moderate and severe form of depression , and the validity of this threshold against the clinical diagnosis .
the observed variations in the mentioned studies , may be attributed to different characteristics of the rural , urban , and island populations ; the cut - off score and the tools that have been used to estimate depression or to other parameters that were not measured . even though the prevalence of depression seems to be high in the studied population ,
if the registered members of kapi who do not visit the day care centers due to various reasons would have been included , very possibly the prevalence of depressive symptoms would be higher .
however , the study was conducted in a specific population , that is , the members of daycare centers for older people and thus our findings can not be generalized for the whole older population .
depression in the older population shows a high prevalence is associated with specific demographic and socioeconomic characteristics and appears to be an under - diagnosed disease . to respond to this problem and to focus on prevention and early detection of depression in older adults
, it is necessary to create a strong supportive network and simultaneously to strengthen the already existing programs , institutions and services in the community , and primary health care .
 objective : the objective of this study was to estimate the prevalence and probable under - diagnosis of depressive symptoms in elderly of an urban and semi - urban area in greece.materials and methods : a cross - sectional study was conducted among the members of 4 days care centers for older people ( kapi ) , three in the municipality of patras , west - greece , and in one in tripolis , peloponnese , greece . 
 a total of 378 individuals took part in the study , aged > 60 years . 
 a questionnaire was developed to collect basic demographic data , including three questions from the european health interview survey , regarding self - reported or by a physician - diagnosed depression . 
 moreover , to all participants the greek validated version of the geriatric depression scale-15 ( gds-15 ) was applied , to screen for depressive symptoms.results:according to gds-15 , 48.1% of the studied population screened positive for depressive symptoms ( 38.6% moderate , 9.5% severe ) , whereas having ever been affected with chronic depression reported 19.0% by themselves . in 162 members of kapi of patras and in 106 of tripolis , who never reported 
 have been affected by depression and depressive symptoms were observed in 27.7% and 44.7% , respectively . in 28 individuals from patras , who reported not to know if they have depression and in 10 from tripolis , depressive symptoms 
 were observed in 60.7% and 90% , respectively , applying the gds-15.conclusion:except the high prevalence , the present study reveals a remarkable under - detection of depressive symptoms in older adults . 
 various interventions in primary care are necessary so as to increase detection rates of depression among the elderly . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION