versão impressa ISSN 0080-6234
Rev. esc. enferm. USP v.42 n.3 São Paulo set. 2008
Living with depression: women's life histories*
Viviendo con la depresión: historias de vida de mujeres
Cintia Adriana Vieira GonçalesI; Ana Lúcia MachadoII
in Psychiatric Nursing. Doctoral Student in Nursing at School of Nursing, University
of São Paulo (EEUSP). Professor at the University of Vale do Paraíba.
São José dos Campos, SP, Brazil. firstname.lastname@example.org
IIAssociate Professor at the Department of Psychiatric and Maternal-Child Nursing from School of Nursing, University of São Paulo (EEUSP). São Paulo, SP, Brazil. email@example.com
This work aimed at understanding and describing the life stories of women suffering from depression. A qualitative approach was used in the research and data collection was carried out at Centro de Atenção Psicossocial (CAPS - Psychosocial Attention Center) in Sao Paulo city by means of interviews using Oral Narratives as the methodological framework. Six collaborators participated in the study. It is observed that depression is a historically experienced disease. The past is reported as something distressful, painful and heavy. In the present, depression takes over and encompasses life, in a way that life itself becomes a mere background. The possibility of a possible future is foreseen by some collaborators. Thus, this study allowed for understanding that people's life stories, projects and needs are different, and the therapeutic project and the care provided by the nurse should meet those particular requirements.
Keywords: Women; Depression; Life change events; Mental health.
En este estudio se tuvo como objetivo comprender y describir historias de vida de mujeres con depresión. La investigación tuvo un abordaje cualitativo y la recolección de datos se realizó en un Centro de Atención Psicosocial (CAPS) de la ciudad de Sao Paulo, a través de entrevistas utilizándose como referencial metodológico la Historia Oral de Vida. Participaron del estudio seis colaboradoras. La depresión es una dolencia vivenciada históricamente. El pasado es relatado como sufrido, doloroso y pesado. En el presente, la depresión asume todo el espacio y abarca la vida de forma que se vuelve apenas cortina de fondo. La probabilidad de un futuro posible es vislumbrada por algunas de las colaboradoras. Así, este estudio hizo posible comprender que las personas tienen, en sus historias de vida, proyectos y necesidades diferentes y que el plan terapéutico y el cuidado prestado por el enfermero deben ser dirigidos para atender sus singularidades en el mundo.
Descriptores: Mujeres; Depresión; Acontecimientos que cambian la vida; Salud mental.
Depression is a disease that concerns academics from all over the world. Current statistics indicate that over 400 million people suffer from depression. The risk for men to suffer from this disease is 11%, whereas it may reach 18.6% for women. The World Health Organization (WHO) estimates that depression will move from fourth to second position in the ranking of costly and fatal diseases in the next 20 years, superseded only by heart disease(1).
Depression has been registered since long ago, and descriptions of what people call depression nowadays may be found in very old texts(2). Around 400 B.C., Hippocrates used the term melancholia for this mental perturbation. The word melancholia, etymologically, comes from the Greek expression melano chole, meaning black bile. The term depression was first used in English to describe dejection in 1660, and became commonly used about the middle of the 19th century(3).
Depression is, essentially, a recurring episodic disorder, and each episode generally lasts from a few months to years, with an intervening normal period. In about 20% of the cases, however, depression follows a chronic course without remission (continuous), especially, when there is not an available appropriate treatment.
One of the tragic results observed in this disorder is suicide, since about 15% to 20% of people with depression end their life by committing suicide(1).
This disease reaches people from both genders, in all ages, regardless of their socioeconomic status or country(1).
Almost two thirds of the people with depression do not receive any treatment, and 50% of the patients who seek a general practitioner are properly diagnosed. In addition, 50% of those who arrive at the basic healthcare unit with depression symptoms, in average, receive neither the appropriate diagnosis nor the appropriate treatment(4).
The human being is complex and researchers still do not agree on the comprehension of why a person suffers from only one depressive episode, whereas others present several setbacks, taking antidepressants for the rest of their lives, and others even commit suicide.
Therefore, studies like this are necessary, with the purpose of listening to the person who experiences the disease, learning their life experience and the context in which they are inserted.
Illness experience is a term that refers to the means by which the people and social groups respond to a given episode of disease. The illness experience is the relation between the macroscopic universe of the meanings established by the society and people's microscopic universe. The experience itself reveals both social and cognitive, and both personal and collective aspects(5).
The need to be fast enough to see all the patients who wait in the line of the Single Health System (SHS), the use of technology and the immediatism of our times often make professionals forget the singularity of the person who is being seen. Their life history is often present in the anamnesis record, but the healthcare is generally provided in a homogeneous way, as if it were something for present moment. Yet, there are questions about the reason why some people get better whereas others only get worse, and about whether the treatments provided are the same, after all. Are people all the same? Are they different? Or are they similar and different, depending on the observed aspect?
A study with nurses from a basic healthcare unit showed an average theoretical knowledge level regarding depression, but they lack both updated information about the therapeutics and also responsibility, caused by not assuming patients as if they belonged to the basic health unit, which still translates the point of view of a mental hospital and inadequate nursing care to the person with depression(6).
Nowadays, it is observed that it is better to understand the reality faced by the patient instead of trying to measure it, as in a rationalistic parameter(7). This factor shows the importance of respecting the many dimensions and trying to understand them.
Therefore, the authors of the present study search for answers for their questions: what is the life history of people with depression?; what is their past like?; which experiences have they been through?.
In face of these questions, it is possible to understand the importance of this study for obtaining answers, since, by knowing better the person who experiences depression, the healthcare professional can obtain subsidies to make a single therapeutic plan, something that will resonate in the life of these people.
The purpose of the present study was to understand and describe the life histories of women who suffer from depression.
This study features the qualitative methodology, since it is seen as the most appropriate method for understanding the dynamic character of the experiences undergone by these people. It is also believed that it will be able to provide a broader and clearer view of the studied object, considering the proposed purpose for this study.
Thus, the rationalism in its scientific intention is particularly unable to realize and apprehend the dense and symbolic aspects of the experience lived(7).
The Oral Narrative was chosen as the methodological reference, being considered a valuable resource for the development of studies related to groups' and people's social experiences(8).
Narrative is a privileged instrument to interpret the social process of the people involved, as it considers subjective experiences as important data that speak beyond and through themselves(9).
It is a very frequently used method in the nursing and mental healthcare areas, because it can help understand broader sociocultural contexts of the history and the meanings attributed to specific subjects by its members, in their daily life. It is an important apprehension source of the personal history, inserted in the social history(10).
After the interview, the oral report was transcribed, so that it could be provided to the public. In order to do so, the transcription, textualization and transcreation stages were properly observed(8).
Data collection was carried out at a Centro de Atenção Psicossocial (CAPS - Psychosocial Attention Center) located in the northern area of the city of São Paulo
Following the denomination of the methodological reference, interviewees are called contributors, due to the fact that they are active participants in the study developed, not merely informers(8).
In order to meet the purpose of this study, some selection criteria were observed: people with clinical diagnosis of depression who attended CAPS for treatment and who were able to narrate their life history. Six women were then selected, from 21 to 47 years old.
Data collection was carried out through a semi-structured interview, with an open question: Tell me the history of your life up to this moment. At the end of the interviews, the researchers recorded them on a field journal, which has all notes, both from the development of the study and the development of the interviews, as well as notes of the non-verbal communication, which also integrates the speeches(8).
Provided with the consent of the contributors, the interviews were recorded and, afterwards, the stages of transcription, textualization, transcreation and reading were applied to the final text. Thus, the process was interesting because of the facial expressions and gestures demonstrated. Some people were surprised when they read their own histories, and some of them said it was a moment of reflection that helped them understand this stage of their lives.
The present study had its project (CEP No. 4112004) evaluated and approved by the Ethics Committee of University of São Paulo. All of the methodological procedures complied with the standards established by Resolution 196/96, which addresses the Guidelines for Research Involving Human Beings(11). The contributors were guided, regarding the study purpose, and agreed to sign the term of consent.
RESULTS AND DISCUSSION
Alceste is 44 years old, from São Paulo. She is married, mother of five children (two single, two married and one deceased) and has two granddaughters. She lives with her husband and their two single children. She did not finish fundamental school. She weaves crochet, but nowadays she does not work. She is a Catholic.
I do not understand why my son passed away, it is too much pain. I want to go after him, but I don't know where. I want to meet him, but I am divided between him and my youngest son, who still needs me (Alceste).
Alceste was indicated by her psychologist, who coordinates a therapeutic group. The invitation was made in person. She agreed to participate in the research and received the authors well, saying that it is good to talk. During the interview, she was pale, kept her head down, a paused and low tone of voice. She cried a lot when she talked about the son who died seven months ago and showed his photograph, that she always carries in her wallet.
She narrated a much-struggling childhood, in a ranch in the countryside of São Paulo. Her mother was very submissive and her father had some type of mental disorder. He was an alcoholic, he beat her mother a lot, tried suicide several times and was hospitalized in psychiatric hospitals. He committed suicide a month before her son died. Her mother also died 11 years ago.
[...] I lost my mother and I was very sad [...] and after my father committed suicide, the doctor said he had deep depression [...] about one month later my son got pneumonia... and was hospitalized at the ICU (Alceste).
In her narrative, she tells the history of a mother who was always taking care of this son, whose disease was said to have no cure by the doctors since the boy was only five years old. For 21 years she dedicated her life to the care of this son, who died at the age of 26.
I cried... I had that in my mind every year that passed by: my son is not going to survive" (Alceste).
The center of the narrative is the care of this son and the suffering due to losing him. That was her life project the whole time, and after her son's death, there was no meaning to continue her life. She seems to have no purpose in life.
Urânia is 47 years old, from São Paulo. She is married, mother of three children and has one grandson. She lives with her husband and two of her children. The oldest son is married and lives with his wife and their son in a house at the backyard of the same house. She did not finish fundamental school. She is a seamstress but nowadays does not work. She is a Protestant.
Everything changes us, the children getting married, my mother and my father-in-law, who helped me died; my husband drinks too much, the friends disappeared. And everything just piled up (Urânia).
Urânia was indicated by her psychologist, who coordinates one of the therapeutic groups, because she had been recently discharged from the group and was attending individual sessions. The researcher contacted her by telephone. She accepted to participate in the study and the interview was held at CAPS, after a session with this psychologist.
On the day of the interview she was pale, had baggy eyes, her hands were shaking, she kept her head down and her eyes were full of tears, but she did not cry.
She presented a chronologically clear narrative, and she started by telling a problem she had in her childhood, because she did not like being contradicted. Whenever that happened, she would throw herself to the ground, tear her hair, bite herself, tear her clothes and hit her head against the wall. At the age of eight years old, her parents divorced, and she said she suffered a lot. According to her, her father was a womanizer, and violent. He had a gun at home and would always threaten to kill her mother. After the separation, her father went away to live with another woman and had a mistress. He was shot with his own revolver by this woman, when she saw him with his mistress, and had to be hospitalized in the ICU. She mentioned she suffered very much with it, because his mistress did not let her see her father. She got married when she was 20 years old, pregnant, and she said she was regretful only a month after the wedding, but she is still with him because of their children. They have been through difficult moments; he has had extramarital affairs and became an alcoholic.
During the whole narrative, Urânia mentions several times that everything was piling up, that everything causes feelings in her. As if life events were coming from the outside and hitting her. She seems to have let herself drift through life and the questions that remain are: what is her life project? Where does she deposit her singularity and understands alterity?
Atê is 21 years old, from São Paulo. She is single and does not have any children. She lives with her parents and a younger sister. She is a university student, does not work, and she has no religion.
What hurts me is that I was a fool, I aborted, I believed in him. I was a fool to fall for him by giving credit to his words. After the abortion, he left me, I was alone. It is like this, we learn (Atê).
Atê was indicated by the coordinating psychologist of another therapy group. She accepted to participate after the telephone contact,. The interview was made before the group. When she was invited to participate in the study, she showed a lot of interest and receptivity. Her narrative happened clearly. She mentioned she was not feeling very well and was anxious due to her school exams. At times, tears came to her eyes, but she did not cry. At the end of the interview, she hugged the interviewer, and said she was available for other interviews, if that was necessary.
She started the narrative by telling about her childhood, the difficulties with her father, who gave her only one present in her whole life and was always a dictator, trying to keep her at home. By the time she was 14 years old, she started dating an ex-enemy from her childhood and got pregnant. The boy told her to have an abortion, otherwise he would not continue dating her, and she agreed to do it. However, he broke up with her anyway; according to her, at that moment, she started to feel the symptoms of depression.
During the narrative, she mentioned several times that she changes completely. In other words, her lifestyle changes depending on the circumstances and on the boyfriends. Adolescence?
The stress that remained was for having been deceived. She believed in her boyfriend and he did not do what had been agreed, did not stay with her after the abortion. She says she has learned a lot with the situation and seems to be armed to face the world, showing resentment and blaming the other.
What is her life project? How does she situate her singularity in the world? At the time of the interview, she was taking a graduation course and dating a young man, to whom she referred as being her future husband.
Polímnia is 23 years old, from São Paulo. She is single and does not have any children. She lives with her parents and two sisters (she is the middle daughter). She is a university student, does not work, and she is a Kardecist spiritualist.
I have always been very shy, indecisive, dependent on my family. I feel like I have lost a lot for being like this and I feel like I have fallen behind, because my younger sister got into college before I did" (Polímnia).
Polímnia was indicated by the same psychologist that treated Atê, because they attend the same therapeutic group. After the telephone contact, she accepted to participate, and the interview was carried out after the group session. She is from a Japanese-descendent family and she was shy during the interview, keeping her head down, speaking slowly, with her lips and hands shaking. Polímnia had tears in her eyes when she talked about her depressive crises. She said it was difficult to tell her history because it was very long, but it was actually the shortest of the six interviews.
She started the narrative from the moment she came to CAPS. She narrates a life of insecurities, difficulties to have a relationship, doubts, feelings of loss, non-acceptance of herself and attempts to change her lifestyle. She mentioned feeling lost in the world and not fitting in the family structure, which was changing.
She mentioned that she has always been overprotected by her family and that, perhaps, she has placed herself into this family world and found it difficult to leave it. When her sisters started dating, going to university and working, she felt bothered and noticed that something was not right. She is the middle daughter, and she said several times that her sister, who is a year younger than she is, had mocked her and by starting university before her. Maybe that shows there is also a cultural matter of hierarchy.
At the time of the interview, she was taking a graduation course and said she was glad for having made friends in the classroom.
Hera is 43 years old, from Ceará. She is divorced and mother of two children (a sixteen year-old boy and a six year-old girl). She lives with her two children. She is taking fundamental school classes, and she is unemployed. She is a Catholic.
My life has always been this way, grief. I have raised my children alone. I have worked night and day. I have several reasons for depression. Everything is very sad (Hera).
Hera was indicated by the psychologist of the same therapy group that Alceste attends. At a personal contact after a group session, she accepted to participate. On the scheduled day for the interview, she said she was not feeling well and postponed it. The interview was held at CAPS, after a therapeutic group session. She provided a dispersive narrative, poor in details. During the interview, she moved a lot on the chair, moving her arms, gesticulating and taking her hands to her head several times.
Her narrative was marked by sentences like life of suffering, childhood of suffering, my life history was a failure, there comes a time your mind cannot stand it, everything piles up, I have several reasons for depression, everything causes suffering.
She made a lot of interruptions during her a narrative, trying to summarize the events, as if she did not value her feelings.
She said she had had a very sad and poor childhood in Ceará. Her mother was very submissive and her father, an alcoholic who had always hit her mother. She said she would never get married to an alcoholic, however she came to São Paulo with a cousin from Ceará. They started dating, had a child and he became an alcoholic. She got divorced and started a new relationship, had her second child and that boyfriend also became an alcoholic.
At the time of the interview, she was unemployed and she said she had broken up with this last boyfriend, but that he sometimes contacted her. She still presented a lot of depression symptoms. What is her life project? Is it surviving to the difficulties as they appear?
Afrodite is 36 years old, from São Paulo. She is in her second marriage, mother of two children and has a granddaughter. She lives with her husband, two children (a twenty-one year-old girl and a 10 month-old boy) and a granddaughter (ten months old). She did not finish fundamental school, and she does not work.
Everything is so sad, my God! How can a mother live like this, without a son? Having to bury a son (Afrodite).
Afrodite was indicated by the psychiatrist who treated her, and agreed to participate after a telephone contact. She said it is always good to talk about what happened. She scheduled the interview twice and did not show up. She apologized and said that she could not make it because she takes care of her son and a grandson, who are both ten months old. The interview was then scheduled a third time, and this time she could go and answer to the interview at CAPS. The contributor cried a lot during the entire interview, especially when she spoke about her deceased son. She brought several photos of this son and of all the family to show to the interviewer.
First of all, the interview treated the sociodemographic data, and when she looked at the notebook she saw the question about children and started the narrative immediately. The recorder was already turned on, and when she made a little pause, she was asked the guiding question of the research. She continued the report.
With a very sad look, as if she was looking at something far away, she told of the episode of the sudden death of her 14 year-old son, while he played soccer, seven months ago. She cried during the entire the interview. She said that when he died, she was recovering from postpartum depression. The narrative focused on her family life with this son. She spoke about him as being a brilliant child who lived intensely, and about how happy they were. She said the whole family misses him and waits for the day of their death to meet him again.
She narrates a childhood of much suffering, with financial difficulties. Her father was an alcoholic. He would hit her mother, her sisters and herself. She started to work when she was still an adolescent, and when she was 16 years old she got pregnant and married. She got divorced from this man because he also became an alcoholic. She got married for the second time and she says this man loves her very much, but she has not been happy since her eldest son died.
Afrodite said she lives for her youngest son, and that she would not be here if it was not for him, even though her psychiatrist told her she should live for herself. She clearly states that her life purpose is to live for her family and that she tries very hard to continue living without her son.
The presence of the past in the speeches makes each person retrace their steps, which belong only to them. For being a singular individual, the way each person tells the history of their life, the way they order it, the events they highlight and the ones they ignore, the words they choose, are important characteristics that lead to the comprehension of any interview(12).
The authors tried to understand and to describe life histories from the contributors' point of view, as they were narrated, without any judgment, respecting the singularity and the existence of each person, with their specificities, from the assumption that people live their experiences differently, within the complexity of a human being who dwells in this world.
It was observed that the contributors experience depression from a historical perspective. They recalled striking facts that were accumulating and that may have started the disease.
The disease is experienced so intensely that it is the first thing they narrated, when the interview was initiated with the question: Tell me what your life history is, up to this moment. In this context, the authors could visualize a tiny life, reduced by the depression that encompassed them and took those human beings over, for whom happiness does not exist, there is just a great emptiness, suffering, despair, a feeling of loss, the wish to go away and never come back.
Moreover, is there an exit from this dark tunnel? Some contributors already manage to visualize a possible exit, a future, a possibility. The path they are taking now is linked to the path they took in the past, but it is important to recognize that it can always be a moment of changes. Eventually, choices need to be made and by choosing them, unavoidably, something is left behind.
Images developed during their narratives of the disease shaped the individual suffering and pointed to a given resolution(13). By narrating their histories, the contributors walked the path of their lives again, reviewed facts, and gave them meaning.
Studies like this, which aim to understand how people build up meanings, live the experience of getting ill and state the need to be listened by the nurse, help the construction of a therapeutic plan closer to the patient's needs. Health professionals need to know about these needs, what their projects are, so that they can approach their care towards these projects, whenever it is possible.
It was interesting to notice the reactions of these women when reading their own histories. In face of their own life narratives, they could relive facts and analyze their own lives. Some women thanked the authors very much for this opportunity.
Therefore, it is necessary to understand that people do not experience depression in a uniform way. They have different lives, projects and needs, and the care provided to them should be guided to meet their singularity in the world.
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Received: 04/10/2007 *
Extracted from the dissertation "Depressão: experiência de
pessoas que a vivenciam na Pós-modernidade", School of Nursing,
University of São Paulo, 2005
* Extracted from the dissertation "Depressão: experiência de pessoas que a vivenciam na Pós-modernidade", School of Nursing, University of São Paulo, 2005