The Prevalence of severe depression in Iranian older adult: A meta-analysis and meta-regression

The Prevalence of severe depression in Iranian older adult: A meta-analysis and meta-regression | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article The Prevalence of severe depression in Iranian older adult: A meta-analysis and meta-regression Nader Salari, Masoud Mohammadi, Aliakbar Vaisi-Raygani, Alireza Abdi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.17178/v4 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Feb, 2020 Read the published version in BMC Geriatrics → Version 4 posted 4 You are reading this latest preprint version Show more versions Abstract Background: Depression is one of the most common psychiatric disorders in the older adult and one of the most common risk factors for suicide in the older adult. Studies show different and inconsistent prevalence rates in Iran. This study aims to determine the prevalence of severe depression in Iranian older adult through a meta-analysis approach. Methods: The present meta-analysis was conducted between January 2000-August 2019. Articles related to the subject matter were obtained by searching Scopus, Sciencedirect, SID, magiran, Barakat Knowledge Network System, Medline (PubMed), and Google Scholar databases. The heterogeneity of the studies was evaluated using I 2 index and the data were analyzed in Comprehensive Meta-Analysis software. Results : In a study of 3948 individuals aged 50-90 years, the overall prevalence of severe depression in Iranian older adult was 8.2% (95% CI: 4.14-6.3%) based on meta-analysis. Also, in order to investigate the effects of potential factors (sample size and year of study) on the heterogeneity of severe depression in Iranian older adult, meta-regression was used. It was reported that the prevalence of severe depression in Iranian older adult decreased with increasing sample size and increasing years of the study, which is significantly different (P<0.05). Conclusion : Considering the high prevalence of severe depression in Iranian older adult, it is necessary for health policy makers to take effective control measures and periodic care for the older adult. Geriatrics & Gerontology Prevalence Severe depression Iranian older adult Meta-analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Older adult is an inevitable biological process that affects all living things and is associated with unpleasant experiences in some cases [1]. The aging process refers to the gradual decline in the function of the body's systems, including cardiovascular, respiratory, genitourinary, endocrine glands, and immune system [2]. Social, economic, and scientific developments in recent years have increased life expectancy and reduced mortality rates, leading to an increase in the world's older adult population [3]. The older adult population is estimated to be doubled during next 40 years in the world [4]. Today, aging has become a major global phenomenon and according to WHO statistics, the number of older adult in Southwest Asian countries, including Iran, will reach 15% of the total population by 2030 [5]. Other reports suggest that the number of people aged ≥ 60 years will increase from 841 million people in 2013 to 1.2 billion people in 2025, with 70% of them living in developing countries and 8 out of every 10 older adult people in the world are expected to live in developing areas by 2050 [6]. Iran, as one of the developing countries, is not excluded from these demographic changes, with the older adult population is projected to grow from 8.2% in 2011 to 10% in 2021 [8]. Despite the growth of the older adult population, the needs and problems of this stratum are more pronounced and need to be taken into consideration [7-9]. Depression is one of the most common psychiatric disorders in the older adult and one of the most common risk factors for suicide in the older adult [10], which accounts for nearly 24% of successful suicides, and older adult suicide victims attempted suicide in their first depression attack. The frequency of the symptoms of major depression has been reported to be 8-15% and approximately 30% among the non-hospitalized and hospitalized older adult, respectively [10-12]. Previous studies in different parts of Iran show different reports of the prevalence of severe depression, including 23% in Isfahan [13], 3.3% in Birjand [14], and 11% prevalence in the study in Gilan [15]; therefore, as can be seen, the reported information provides scattered and inconsistent information and since interventional studies to reduce the prevalence of severe depression in the older adult require accurate and consistent information in order to prevent severe depression problems and complications in this population, the question is, how much is the overall prevalence of severe depression in Iranian older adult? The aim of the present study is to review the overall prevalence of severe depression in Iranian older adult based on a meta-analysis approach. methods This study is a meta-analysis, based on the findings of studies on the prevalence of severe depression among Iranian older adult, including articles published in domestic and foreign journals and searches carried out in the databases of Sciencedirect, Scopus, SID, magiran, Medline (PubMed), Barakat Knowledge Network System, and Google Scholar between January 2000 to August 2019. The search process was carried out using the keywords Older adult, Depression, Mood Disorders, Types of Depression, Severe Depression and their English equivalents and their possible combinations, search engine using both English and Persian words and (AND) and (OR) operators were used in combination to provide more comprehensive access to all articles, therefore, the OR operator was used to check for common names for disorders such as (Older adult OR Aging), (depression OR Depressive Disorder), (mood disorders OR Affective Disorders). The AND operator was also used among the keywords (Older adult AND depression AND severe depression) by matching words in the MeSH browser. Evaluation of articles and quality control All articles were first collected using the selected keywords and a list of abstracts was prepared after the search was completed. After hiding the article specifications, including the name of the magazine and the author, the full text of the articles was made available to the reviewers. Each article was studied independently by two reviewers and if the article was excluded, the reason was mentioned. Articles in Persian and English extracted from cross-sectional studies on the prevalence and of severe depression in Iranian older adult met the inclusion criteria. Other review, case-control, cohort, and intervention studies were excluded from the list of articles. The studies were then reviewed based on four-phase PRISMA (2009. STROBE checklist was used to review studies. This checklist consists of various methodological aspects, including study objectives, determination of appropriate sample size, type of study, sampling method, research population, data collection method, definition of variables and procedure, study data collection tool, study objectives, statistical tests, and findings. Accordingly, a maximum quality evaluation score of 32 was considered and articles with scores below 14 were excluded from the study. Statistical analysis Data were analyzed using Comprehensive Meta-analysis software (Biostat, Englewood, NJ, USA version 3), the heterogeneity of the studies was assessed using the I 2 test and probability of publication bias Funnel chart using Egger test and significance level 0.05 and also to investigate the effects of potential factors on heterogeneity of studies from Meta-regression test. Results Based on investigations on the prevalence of severe depression in Iranian older adult, including articles published in domestic and foreign journals and searches in Magiran, SID, Barakat Knowledge Network System databases, Medline, ScienceDirect, Scopus, and Google scholar, PRISMA 2009 was used to show the reviewing process (Figure 1). A total of 191 articles met the initial inclusion criteria based on initial reviews after deleting 912 duplicate articles. Ultimately 13 articles entered the meta–analysis phase after excluding 172 unrelated articles, 6 articles during secondary review because of lack of access to their abstracts and main articles, and low quality of articles (Table 1). Publication bias The heterogeneity of the studies was evaluated using I 2 test that was equal to 98.7%, indicating high heterogeneity of the included studies, so, random effects model was used to combine the results of the studies. Also, the results of the publication bias were compared using Egger test (Figure 2), which was not statistically significant (P= 0.061). The total number of samples included in the study was 3948 individuals aged 50-90 years. The overall prevalence of severe depression among Iranian older adult was 8.2% (95% CI: 4.6-14.3%) according to the meta-analysis. The highest prevalence of severe depression among Iranian older adult 46.3% was seen among the older adult in Qom (95% CI: 38.6.-54.3%) in 2009 [18], and the lowest prevalence of severe depression 0.3% was also reported in the older adult in Kerman Province (95% CI: 0.1-0.9%) in 2003 [14] (Figure 3). Fig. 3 shows the prevalence of severe depression by a random effects model, in which the black square indicates the prevalence rate and the length of the segment on which, the square is located, represents 95% CI in each study. The diamond sign indicates the prevalence rate at the national level in all studies. Sub-group analysis and Meta-regression Table 2 reports the results of the sub-group analysis according to the Geographical region, year of publication, and sample size (Table 2). In order to investigate the effects of potential contributing factors on the heterogeneity of studies on prevalence of severe depression in Iranian older adult, the meta-regression test was used to study the three factors of sample size, year of study and age of study participants (Figures 4, 5 and 6). With increasing sample size and year of study, the prevalence of severe depression in Iranian older adult decreases, which is statistically significant (Figure 4 and 5) (P<0.05) and With increasing age of study participants, the prevalence of severe depression in Iranian older adult increases, which is statistically significant (Figure 6) (P<0.05). DISCUSSION The results of the present study and investigation of 3948 people aged 50-90 years, the overall prevalence of severe depression in Iranian older adult was reported to be 8.2% based on a meta-analysis. Results of a meta-analysis study showed the overall prevalence of depression in the older adult was 43% in Iran between 2001 and 2015 [26]. A study in Sweden showed the prevalence of depression was 4.2% and the moderate-severe type was 1.6% [27]. A study in China also showed that the overall prevalence of depression in the older adult was 36.9%, and reported that the prevalence of symptoms was higher in women 50.4% as compared to men 33.3%. In general, the prevalence of moderate to severe depression was 3.9% in their study [28]. The prevalence of mild-moderate depression and mild-severe depression was reported to be 27%, and 12% in a study in Greek, respectively [29]. Another study in China reported that 26.5% and 4.4% of older adult people with depression had mild and severe depression, respectively [30]. Depression is often not diagnosed in the older adult and has important impacts on quality of life, clinical outcomes, functional status, medical services, mortality, and disability [31]. Depression in the older adult also leads to increased drug use, increase costs for drugs and over-the-counter drugs, higher risk of alcohol abuse, increased length of stay, and cost of care [32]. Depression occurs in the older adult, similar to younger people due to socio-psychological and biological factors [33]. Depression is a relapsing persistent disease, and risk factors for depression in older adult people include social isolation, marital status, divorce or separation, low socioeconomic status, debilitating comorbidities, insomnia, and functional and cognitive disorders [34]. Based on the results of various studies it was reported that depression in older adult had a significant relationship with married statues, satisfaction with place of living, use of medicine, living with spouse and children, emotional support of family, members, emotional support of friends, emotional support of others, satisfaction with relations and satisfaction with overall support [15, 19 and 23]. These studies also reported that Prevalence of mental disorders among older age, female, low education, marital status, activity, and income, unemployed and disabled older adult was significantly [19, 20, and 25] Increased rates of depression in the older adult, especially the severe type reported in this study, are often neglected, making it difficult to diagnose and treat the disease in a timely manner. This is an unfortunate reality because depression is a disorder for which effective treatments are available today. The results of interventional studies Legrand et al [36] and Koshyar et al [37] were indicated in the reducing depression: regular physical activity and appropriate diet were Reduced the level of depression, These studies reported that both outdoors and indoors 15-min self-paced walks and Participating in enjoyable and pleasant exercises were associated with significant and positive affective, There is scientific agreement that exercise temporarily makes people feel more positively activated so that more frequent exercise may lead to a greater cumulative effect on positive affect and perhaps more opportunities to reduce negative thoughts and ruminative processes [36, 37]. It is also worth noting that the reduced mental ability and the feeling of sadness is not part of the normal aging process and this mood state should be considered important [34, 35]; therefore, considering the foregoing, screening and secondary prevention measures by nurses and healthcare providers are of great importance. Moreover, increasing families' awareness of depression in the older adult will also pave the way for early diagnosis and more appropriate treatment. Limitations The most important limitations of the current study include the lack of access to full text and the poor quality of some of the studies studied. CONCLUSIONS Considering the high prevalence of severe depression in the Iranian older adult, it is necessary for health policy makers to take effective control measures including periodic care for the older adult. Abbreviations WHO: World Health Organization SID: Scientific Information Database STROBE: Strengthening the Reporting of Observational Studies in Epidemiology for cross- sectional Study PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Declarations Acknowledgements The authors thank the faculty members of the Faculty of Nursing and Midwifery, Kermanshah University of Medical Sciences. Funding Not declared. Availability of data and materials Datasets are available through the corresponding author upon reasonable request. Authors’contributions AVR and RJ and NS contributed to the design, MM and AA and BKH statistical analysis, participated in most of the study steps. SHSH and AD prepared the manuscript. RJ and MM and NS assisted in designing the study, and helped in the, interpretation of the study. All authors have read and approved the content of the manuscript Ethics approval and consent to participate Not declared. Consent for publication Not applicable. 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Tables Due to technical limitations the tables are available as a download in the Supplemental Files Supplementary Files Tab1.docx Tab2.docx PRISMA2009checklist.docx Cite Share Download PDF Status: Published Journal Publication published 03 Feb, 2020 Read the published version in BMC Geriatrics → Version 4 posted Editorial decision: Accept 26 Jan, 2020 Editor assigned by journal 27 Dec, 2019 Submission checks completed at journal 26 Dec, 2019 Editor invited by journal 26 Dec, 2019 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7812","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":280303,"identity":"72e7b239-c0c6-4b27-844b-f118ffa1a5b8","order_by":1,"name":"Nader Salari","email":"","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nader","middleName":"","lastName":"Salari","suffix":""},{"id":280304,"identity":"27d5edc9-d1c1-4430-b46d-3c358593c113","order_by":2,"name":"Masoud Mohammadi","email":"","orcid":"","institution":"Kermanshah University of Medical 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12:05:49","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28564,"visible":true,"origin":"","legend":"Funnel plot of results on the prevalence of severe depression among Iranian elderly","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/379edb3f-588d-4c1a-aaee-f26c3832389e/v4/2.jpg"},{"id":328061,"identity":"31724753-b79f-4ae1-b68c-a61e46fc18ed","added_by":"auto","created_at":"2020-01-06 12:05:50","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":81919,"visible":true,"origin":"","legend":"Prevalence of severe depression in Iranian elderly based on a random effects model","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/379edb3f-588d-4c1a-aaee-f26c3832389e/v4/3.jpg"},{"id":328062,"identity":"ab9c79c5-7501-449a-bcf2-6b0b6be98199","added_by":"auto","created_at":"2020-01-06 12:05:50","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":33737,"visible":true,"origin":"","legend":"A meta-regression chart of the prevalence of severe depression in Iranian elderly by sample size","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/379edb3f-588d-4c1a-aaee-f26c3832389e/v4/4.jpg"},{"id":328063,"identity":"4e7a8081-bf68-45eb-9504-baf03feaaa30","added_by":"auto","created_at":"2020-01-06 12:05:50","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":34763,"visible":true,"origin":"","legend":"A meta-regression chart of the prevalence of severe depression in Iranian elderly by year of study","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/379edb3f-588d-4c1a-aaee-f26c3832389e/v4/5.jpg"},{"id":328064,"identity":"d2c25468-14b6-4785-b4b6-688eed318f49","added_by":"auto","created_at":"2020-01-06 12:05:50","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":25838,"visible":true,"origin":"","legend":"A meta-regression chart of the prevalence of severe depression in Iranian older adult by age of study participants","description":"","filename":"Fig6.jpg","url":"https://assets-eu.researchsquare.com/files/379edb3f-588d-4c1a-aaee-f26c3832389e/v4/Fig 6.jpg"},{"id":13484115,"identity":"09b73185-e30b-4e99-85f6-14681dc609cc","added_by":"auto","created_at":"2021-09-16 21:56:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":459643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7812/v4/45d3903a-4c73-4280-92cf-9db9fa858214.pdf"},{"id":328060,"identity":"08947f84-15e5-4caf-8f10-bbd19f16f325","added_by":"auto","created_at":"2020-01-06 12:05:49","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14225,"visible":true,"origin":"","legend":"","description":"","filename":"Tab1.docx","url":"https://assets-eu.researchsquare.com/files/379edb3f-588d-4c1a-aaee-f26c3832389e/v4/Tab 1.docx"},{"id":328058,"identity":"e687726b-31a4-409b-b7c5-b03b5bc9c8d9","added_by":"auto","created_at":"2020-01-06 12:05:49","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14097,"visible":true,"origin":"","legend":"","description":"","filename":"Tab2.docx","url":"https://assets-eu.researchsquare.com/files/379edb3f-588d-4c1a-aaee-f26c3832389e/v4/Tab 2.docx"},{"id":328056,"identity":"0f352b8c-31a9-4bc4-b2ce-6867bb3e35bc","added_by":"auto","created_at":"2020-01-06 12:05:49","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26997,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMA2009checklist.docx","url":"https://assets-eu.researchsquare.com/files/379edb3f-588d-4c1a-aaee-f26c3832389e/v4/PRISMA 2009 checklist.docx"}],"financialInterests":"","formattedTitle":"The Prevalence of severe depression in Iranian older adult: A meta-analysis and meta-regression","fulltext":[{"header":"Background","content":"\u003cp\u003eOlder adult is an inevitable biological process that affects all living things and is associated with unpleasant experiences in some cases [1]. The aging process refers to the gradual decline in the function of the body's systems, including cardiovascular, respiratory, genitourinary, endocrine glands, and immune system [2].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Social, economic, and scientific developments in recent years have increased life expectancy and reduced mortality rates, leading to an increase in the world's older adult population [3]. The older adult population is estimated to be doubled during next 40 years in the world [4].\u003c/p\u003e\n\u003cp\u003eToday, aging has become a major global phenomenon and according to WHO statistics, the number of older adult in Southwest Asian countries, including Iran, will reach 15% of the total population by 2030 [5]. Other reports suggest that the number of people aged \u0026ge; 60 years will increase from 841 million people in 2013 to 1.2 billion people in 2025, with 70% of them living in developing countries and 8 out of every 10 older adult people in the world are expected to live in developing areas by 2050 [6].\u003c/p\u003e\n\u003cp\u003eIran, as one of the developing countries, is not excluded from these demographic changes, with the older adult population is projected to grow from 8.2% in 2011 to 10% in 2021 [8]. Despite the growth of the older adult population, the needs and problems of this stratum are more pronounced and need to be taken into consideration [7-9].\u003c/p\u003e\n\u003cp\u003eDepression is one of the most common psychiatric disorders in the older adult and one of the most common risk factors for suicide in the older adult [10], which accounts for nearly 24% of successful suicides, and older adult suicide victims attempted suicide in their first depression attack. The frequency of the symptoms of major depression has been reported to be 8-15% and approximately 30% among the non-hospitalized and hospitalized older adult, respectively [10-12].\u003c/p\u003e\n\u003cp\u003ePrevious studies in different parts of Iran show different reports of the prevalence of severe depression, including 23% in Isfahan [13], 3.3% in Birjand [14], and 11% prevalence in the study in Gilan [15]; therefore, as can be seen, the reported information provides scattered and inconsistent information and since interventional studies to reduce the prevalence of severe depression in the older adult require accurate and consistent information in order to prevent severe depression problems and complications in this population, the question is, how much is the overall prevalence of severe depression in Iranian older adult?\u003c/p\u003e\n\u003cp\u003eThe aim of the present study is to review the overall prevalence of severe depression in Iranian older adult based on a meta-analysis approach.\u003c/p\u003e"},{"header":"methods","content":"\u003cp\u003eThis study is a meta-analysis, based on the findings of studies on the prevalence of severe depression among Iranian older adult, including articles published in domestic and foreign journals and searches carried out in the databases of Sciencedirect, Scopus, SID, magiran, Medline (PubMed), Barakat Knowledge Network System, and Google Scholar between January 2000 to August 2019. The search process was carried out using the keywords Older adult, Depression, Mood Disorders, Types of Depression, Severe Depression and their English equivalents and their possible combinations, search engine using both English and Persian words and (AND) and (OR) operators were used in combination to provide more comprehensive access to all articles, therefore, the OR operator was used to check for common names for disorders such as (Older adult OR Aging), (depression OR Depressive Disorder), (mood disorders OR Affective Disorders). The AND operator was also used among the keywords (Older adult AND depression AND severe depression) by matching words in the MeSH browser.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluation of articles and quality control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll articles were first collected using the selected keywords and a list of abstracts was prepared after the search was completed. After hiding the article specifications, including the name of the magazine and the author, the full text of the articles was made available to the reviewers. Each article was studied independently by two reviewers and if the article was excluded, the reason was mentioned. Articles in Persian and English extracted from cross-sectional studies on the prevalence and of severe depression in Iranian older adult met the inclusion criteria. Other review, case-control, cohort, and intervention studies were excluded from the list of articles. The studies were then reviewed based on four-phase PRISMA (2009.\u003c/p\u003e\n\u003cp\u003eSTROBE checklist was used to review studies. This checklist consists of\u0026nbsp; various methodological aspects, including study objectives, determination of appropriate sample size, type of study, sampling method, research population, data collection method, definition of variables and procedure, study data collection tool, study objectives, statistical tests, and findings. Accordingly, a maximum quality evaluation score of 32 was considered and articles with scores below 14 were excluded from the study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using Comprehensive Meta-analysis software (Biostat, Englewood, NJ, USA version 3), the heterogeneity of the studies was assessed using the I\u003csup\u003e2\u003c/sup\u003e test and probability of publication bias Funnel chart using Egger test and significance level 0.05 and also to investigate the effects of potential factors on heterogeneity of studies from Meta-regression test.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBased on investigations on the prevalence of severe depression in Iranian older adult, including articles published in domestic and foreign journals and searches in Magiran, SID, Barakat Knowledge Network System databases, Medline, ScienceDirect, Scopus, and Google scholar, PRISMA 2009 was used to show the reviewing process (Figure 1). A total of 191 articles met the initial inclusion criteria based on initial reviews after deleting 912 duplicate articles. Ultimately 13 articles entered the meta\u0026ndash;analysis phase after excluding 172 unrelated articles, 6 articles during secondary review because of lack of access to their abstracts and main articles, and low quality of articles (Table 1).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublication bias\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe heterogeneity of the studies was evaluated using I\u003csup\u003e2\u003c/sup\u003e test that was equal to 98.7%, indicating high heterogeneity of the included studies, so, random effects model was used to combine the results of the studies. Also, the results of the publication bias were compared using Egger test (Figure 2), which was not statistically significant (P= 0.061).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe total number of samples included in the study was 3948 individuals aged 50-90 years. The overall prevalence of severe depression among Iranian older adult was 8.2% (95% CI: 4.6-14.3%) according to the meta-analysis. The highest prevalence of severe depression among Iranian older adult 46.3% was seen among the older adult in Qom (95% CI: 38.6.-54.3%) in 2009 [18], and the lowest prevalence of severe depression 0.3% was also reported in the older adult in Kerman Province (95% CI: 0.1-0.9%) in 2003 [14] (Figure 3). Fig. 3 shows the prevalence of severe depression by a random effects model, in which the black square indicates the prevalence rate and the length of the segment on which, the square is located, represents 95% CI in each study. The diamond sign indicates the prevalence rate at the national level in all studies.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSub-group analysis and Meta-regression \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 reports the results of the sub-group analysis according to the Geographical region, year of publication, and sample size (Table 2).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn order to investigate the effects of potential contributing factors on the heterogeneity of studies on prevalence of severe depression in Iranian older adult, the meta-regression test was used to study the three factors of sample size, year of study and age of study participants (Figures 4, 5 and 6). With increasing sample size and year of study, the prevalence of severe depression in Iranian older adult decreases, which is statistically significant (Figure 4 and 5) (P\u0026lt;0.05) and With increasing age of study participants, the prevalence of severe depression in Iranian older adult increases, which is statistically significant (Figure 6) (P\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe results of the present study and investigation of 3948 people aged 50-90 years, the overall prevalence of severe depression in Iranian older adult was reported to be 8.2% based on a meta-analysis. Results of a meta-analysis study showed the overall prevalence of depression in the older adult was 43% in Iran between 2001 and 2015 [26]. A study in Sweden showed the prevalence of depression was 4.2% and the moderate-severe type was 1.6% [27]. A study in China also showed that the overall prevalence of depression in the older adult was 36.9%, and reported that the prevalence of symptoms was higher in women 50.4% as compared to men 33.3%. In general, the prevalence of moderate to severe depression was 3.9% in their study [28]. The prevalence of mild-moderate depression and mild-severe depression was reported to be 27%, and 12% in a study in Greek, respectively [29]. Another study in China reported that 26.5% and 4.4% of older adult people with depression had mild and severe depression, respectively [30].\u003c/p\u003e\n\u003cp\u003eDepression is often not diagnosed in the older adult and has important impacts on quality of life, clinical outcomes, functional status, medical services, mortality, and disability [31]. Depression in the older adult also leads to increased drug use, increase costs for drugs and over-the-counter drugs, higher risk of alcohol abuse, increased length of stay, and cost of care [32]. Depression occurs in the older adult, similar to younger people due to socio-psychological and biological factors [33]. Depression is a relapsing persistent disease, and risk factors for depression in older adult people include social isolation, marital status, divorce or separation, low socioeconomic status, debilitating comorbidities, insomnia, and functional and cognitive disorders [34].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on the results of various studies it was reported that depression\u0026nbsp; in\u0026nbsp; older adult\u0026nbsp; had\u0026nbsp; a\u0026nbsp; significant\u0026nbsp; relationship\u0026nbsp; with\u0026nbsp; married\u0026nbsp; statues, satisfaction\u0026nbsp; with\u0026nbsp; place\u0026nbsp; of\u0026nbsp; living,\u0026nbsp; use\u0026nbsp; of\u0026nbsp; medicine,\u0026nbsp; living\u0026nbsp; with spouse\u0026nbsp; and\u0026nbsp; children,\u0026nbsp; emotional \u0026nbsp;support\u0026nbsp; of\u0026nbsp; family,\u0026nbsp; members, emotional\u0026nbsp; support\u0026nbsp; of\u0026nbsp; friends,\u0026nbsp; emotional\u0026nbsp; support\u0026nbsp; of\u0026nbsp; others, satisfaction with relations and satisfaction with overall support [15, 19 and 23].\u003c/p\u003e\n\u003cp\u003eThese studies also reported that Prevalence of mental disorders among older age, female, low education, marital status, activity, and income, unemployed and disabled older adult was significantly [19, 20, and 25]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIncreased rates of depression in the older adult, especially the severe type reported in this study, are often neglected, making it difficult to diagnose and treat the disease in a timely manner. This is an unfortunate reality because depression is a disorder for which effective treatments are available today. The results of interventional studies Legrand et al [36] and Koshyar et al [37] were indicated in the reducing depression: regular physical activity and appropriate diet were Reduced the level of depression, These studies reported that both outdoors and indoors 15-min self-paced walks and Participating in enjoyable and pleasant exercises were associated with significant and positive affective, There is scientific agreement that exercise temporarily makes people feel more positively activated so that more frequent exercise may lead to a greater cumulative effect on positive affect and perhaps more opportunities to reduce negative thoughts and ruminative processes [36, 37].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;It is also worth noting that the reduced mental ability and the feeling of sadness is not part of the normal aging process and this mood state should be considered important [34, 35]; therefore, considering the foregoing, screening and secondary prevention measures by nurses and healthcare providers are of great importance. Moreover, increasing families' awareness of depression in the older adult will also pave the way for early diagnosis and more appropriate treatment.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most important limitations of the current study include the lack of access to full text and the poor quality of some of the studies studied.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eConsidering the high prevalence of severe depression in the Iranian older adult, it is necessary for health policy makers to take effective control measures including periodic care for the older adult.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eWHO: World Health Organization\u003c/p\u003e\n\u003cp\u003eSID: Scientific Information Database\u003c/p\u003e\n\u003cp\u003eSTROBE: Strengthening the Reporting of Observational Studies in Epidemiology for cross- sectional Study\u003c/p\u003e\n\u003cp\u003ePRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors thank the faculty members of the Faculty of Nursing and Midwifery, Kermanshah University of Medical Sciences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDatasets are available through the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo;contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAVR and RJ and NS contributed to the design, MM and AA and BKH statistical analysis, participated in most of the study steps. SHSH and AD prepared the manuscript. RJ and MM and NS assisted in designing the study, and helped in the, interpretation of the study. All authors have read and approved the content of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFakari FR, Hashemi MA, Fakari FR. A Qualitative Research: Postmenopausal Women s Experiences of Abuse. Procedia\u0026ndash;Social and Behavioral Sciences. 2013; 82:57\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eDelvarian M, Hashemi M. 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Medical\u0026nbsp; Journal\u0026nbsp; of\u0026nbsp; Hormozgan University. 2011; 14: 319-325.\u003c/li\u003e\n\u003cli\u003eGharanjik A, Mohammadi Shahbolaghi F, Ansari G, Najafi\u0026nbsp; F,\u0026nbsp; Ghaderi\u0026nbsp; S,\u0026nbsp; Ashrafi\u0026nbsp; K,\u0026nbsp; et\u0026nbsp; \u0026nbsp; The Prevalence\u0026nbsp; of\u0026nbsp; Depression\u0026nbsp; in\u0026nbsp; Older\u0026nbsp; Turkmen Adults in 2010. Sija. 2011; 6: 34-39.\u003c/li\u003e\n\u003cli\u003eGhaderi S,\u0026nbsp; Sahaf\u0026nbsp; R,\u0026nbsp; Mohammadi\u0026nbsp; Shahbalaghi F,\u0026nbsp; Ansari\u0026nbsp; G,\u0026nbsp; Gharanjic\u0026nbsp; A,\u0026nbsp; Ashrafi\u0026nbsp; K,\u0026nbsp; et\u0026nbsp; Prevalence\u0026nbsp; of\u0026nbsp; Depression\u0026nbsp; in\u0026nbsp; Older adult\u0026nbsp; Kurdish Community Residing in Boukan, Iran\u0026nbsp; (Persian). Sija 2012; 7: 57-66.\u003c/li\u003e\n\u003cli\u003eMiri MR, Salehiniya H, Tiyuri A, Bahlgerdi M, Taghizadeh AA. Prevalence of mental disorders and its related factors among older adult of Birjand, 2014. Journal of Nursing. 2015; 2(2): 94-103\u003c/li\u003e\n\u003cli\u003eKhalili Z, Taghadosi M, Heravi-Karimooi M, Sadrollahi A, Gilasi H. Assessment of the Associations of Depression With Elder Abuse Among the Older adult in Kashan City, Iran. Salmand: Iranian Journal of Ageing. 2016; 10 (4) :8-17\u003c/li\u003e\n\u003cli\u003eAshrafi K, Sahaf R, Mohammadi Shahbalaghi F, Farhadi A, Ansari Gh, Najafi F, et al. Prevalence of Depression inTurk Azeri Older Adults of Iran. Journal of Sabzevar University of Medical Sciences. 2017; 23(6): 856-865.\u003c/li\u003e\n\u003cli\u003eSarokhani D, Parvareh M, Hasanpour Dehkordi A, Sayehmiri K, Moghimbeigi A. Prevalence of Depression among Iranian Older adult: Systematic Review and Meta-Analysis. Iran J Psychiatry. 2018; 13(1):55-64.\u003c/li\u003e\n\u003cli\u003eSj\u0026ouml;berg L, Karlsson B, Atti AR, Skoog I, Fratiglioni L, Wang HX. Prevalence of depression: Comparisons of different depression definitions in population-based samples of older adults. J Affect Disord. 2017; 221:123-131.\u003c/li\u003e\n\u003cli\u003eHe G, Xie JF, Zhou JD, Zhong ZQ, Qin CX, Ding SQ. Depression in left-behind older adult in rural China: Prevalence and associated factors. Geriatr Gerontol Int. 2016; 16(5):638-43.\u003c/li\u003e\n\u003cli\u003ePapadopoulos F,\u0026nbsp; Petridou\u0026nbsp; E,\u0026nbsp; Argyropoulou\u0026nbsp; S, Kontaxakis V, Dessypris N, Anastasiou A, et al. Prevalence and correlates of depression in late life: a population based study from a rural Greek town.\u0026nbsp; Int\u0026nbsp; J\u0026nbsp; Geriatr\u0026nbsp; \u0026nbsp; 2005;\u0026nbsp; 20:\u0026nbsp; 350-357.\u003c/li\u003e\n\u003cli\u003eGao S, Jin Y, Unverzagt F, Liang C, Hall K, Ma F, et\u0026nbsp; \u0026nbsp; Correlates\u0026nbsp; of\u0026nbsp; depressive\u0026nbsp; symptoms\u0026nbsp; in rural\u0026nbsp; older adult\u0026nbsp; Chinese.\u0026nbsp; Int\u0026nbsp; J\u0026nbsp; Geriatr\u0026nbsp; Psychiatry. 2009; 24: 1358-1366.\u003c/li\u003e\n\u003cli\u003eP\u0026eacute;rez\u0026ndash;Rojo G, Izal M, Montorio I, Penhale B. Risk factors of elder abuse in a community dwelling Spanish sample. Archives of Gerontology and Geriatrics. 2009; 49(1):17\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eBeach SR, Schulz R, Castle NG, Rosen J. Financial exploitation and psychological mistreatment among older adults: Differences between African Americans and Non\u0026ndash;African Americans in a population\u0026ndash;based survey. Gerontologist. 2010; 50(6):744\u0026ndash;57.\u003c/li\u003e\n\u003cli\u003eDong X, Simon MA, Evans DA. Prevalence of Self\u0026ndash;Neglect across Gender, Race, and Socioeconomic Status: Findings from the Chicago Health and Aging Project. Gerontology. 2011; 58(3):258\u0026ndash;68.\u003c/li\u003e\n\u003cli\u003eHeravi\u0026ndash;Karimooi M, Anoosheh M, Froughan M, Sheikhi MT, Hajizadeh E. Elder abuse by family members: An exploration in the lived experiences of older people. Iranian Journal of Nursing Research. 2010; 5(18):6\u0026ndash;17.\u003c/li\u003e\n\u003cli\u003eLachs MS, Pillemer K. Elder abuse. Lancet. 2004; 364(9441):1263\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eLegrand FD, Mille CR. The effects of 60 minutes of supervised weekly walking (in a single vs. 3\u0026ndash;5 session format) on depressive symptoms among older women: Findings from a pilot randomized trial. Mental Health and Physical Activity. 2009; 2(2):71-5.\u003c/li\u003e\n\u003cli\u003eKoshyar H, Najafi Z, Azhari A, Mazlom SR. Comparison the effect of regular physical activity and fun on the Changes in rates of depression and cognitive disorders in Older adult women Residents of nursing homes in Mashhad. IJOGI. 2015;17(32):1-9.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eDue to technical limitations the tables are available as a download in the Supplemental Files\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Prevalence, Severe depression, Iranian older adult, Meta-analysis","lastPublishedDoi":"10.21203/rs.2.17178/v4","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.17178/v4","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Background: Depression is one of the most common psychiatric disorders in the older adult and one of the most common risk factors for suicide in the older adult. Studies show different and inconsistent prevalence rates in Iran. This study aims to determine the prevalence of severe depression in Iranian older adult through a meta-analysis approach.\n \nMethods: The present meta-analysis was conducted between January 2000-August 2019. Articles related to the subject matter were obtained by searching Scopus, Sciencedirect, SID, magiran, Barakat Knowledge Network System, Medline (PubMed), and Google Scholar databases. The heterogeneity of the studies was evaluated using I 2 index and the data were analyzed in Comprehensive Meta-Analysis software.\n \nResults : In a study of 3948 individuals aged 50-90 years, the overall prevalence of severe depression in Iranian older adult was 8.2% (95% CI: 4.14-6.3%) based on meta-analysis. Also, in order to investigate the effects of potential factors (sample size and year of study) on the heterogeneity of severe depression in Iranian older adult, meta-regression was used. It was reported that the prevalence of severe depression in Iranian older adult decreased with increasing sample size and increasing years of the study, which is significantly different (P\u003c0.05).\n \nConclusion : Considering the high prevalence of severe depression in Iranian older adult, it is necessary for health policy makers to take effective control measures and periodic care for the older adult.","manuscriptTitle":"The Prevalence of severe depression in Iranian older adult: A meta-analysis and meta-regression","msid":"","msnumber":"","nonDraftVersions":[{"code":4,"date":"2020-01-06 12:05:48","doi":"10.21203/rs.2.17178/v4","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-01-26T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-12-27T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-12-26T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-12-26T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":3,"date":"2020-01-03 20:59:44","doi":"10.21203/rs.2.17178/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2019-12-24T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-12-19T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-12-18T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-12-18T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2019-12-12 19:25:44","doi":"10.21203/rs.2.17178/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2019-12-17T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2019-12-10T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorAssigned","content":"","date":"2019-12-09T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-12-09T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2019-12-09T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2019-12-09T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"checksComplete","content":"","date":"2019-12-08T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-12-08T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2019-11-13 20:42:02","doi":"10.21203/rs.2.17178/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2019-12-04T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **By using the meta-analysis on the published paper between January 2000-August 2019, this manuscript is somehow of great interesting that determining the prevalence of severe depression in Iranian elderly through a meta-analysis approach.\nComments are detailed below.\n1.In results part, the lowest prevalence of severe depression 0.03% was also reported in the elderly in Kerman Province (95% CI: 0.1-0.9%) in 2003 .However in the Fig3 the severe depression rate is 0.03% for Kerman province. Please explain the difference here.\n2.why not organize the table 1 part according to the published time ?\n3.Please included the articles is published in English or Persian in Table1.\n4. Any possible explain why there was big difference of depression prevalence rate among those provinces in Table 1?\n5.Figure legend part, Figure 2. should be Figure 2: .**\n\nComments to Author:\n---\n"},{"type":"decision","content":"Major revision","date":"2019-12-04T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2019-11-18T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n\nComments to Author:\n---\nThe authors conducted a meta-analysis to determine the prevalence of severe depression in Iranian elderly. The manuscript is well written and the analyses the authors did are straightforward. However, in my opinion, the paper has some shortcoming regarding the data analysis. Reader would like to know what caused the depression, which factors are associated with severe depression, and how we can prevent and improve the depression in elderly. But the authors only showed the prevalence of depression, this is not enough. For example, why \"The highest prevalence of severe depression among Iranian elderly46.3% was seen among the elderly in Qom (95% CI: 38.6.-54.3%) in 2009, and the lowest prevalence of severe depression 0.03% was also reported in the elderly in Kerman Province (95% CI: 0.1-0.9%) in 2003\", which factors affect the prevalence rate of depression in Qom and Kerman, and what lead to the difference of depression prevalence between these two provinces? The authors should do more in-depth analysis of the data, provide more information in discussion.\nGiven these shortcomings the manuscript requires major revisions.\n"},{"type":"reviewerAgreed","content":"","date":"2019-11-15T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-11-12T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2019-11-12T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2019-11-07T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-11-06T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-11-06T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ee610e69-9486-42a8-a102-e8531c8f227f","owner":[],"postedDate":"January 6th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":46910,"name":"Geriatrics \u0026 Gerontology"}],"tags":[],"updatedAt":"","versionOfRecord":{"articleIdentity":"rs-7812","link":"https://doi.org/10.1186/s12877-020-1444-0","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2020-02-03 12:00:00","publishedOnDateReadable":"February 3rd, 2020"},"versionCreatedAt":"2020-01-06 12:05:48","video":"","vorDoi":"10.1186/s12877-020-1444-0","vorDoiUrl":"https://doi.org/10.1186/s12877-020-1444-0","workflowStages":[]},"version":"v4","identity":"rs-7812","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-7812","version":["v4"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}