Prevalence of depression in elderly women attending the University of Third Age

Abstracts

INTRODUÇÃO: Estudos têm sugerido que o envelhecimento tem relação com a depressão. No entanto, os idosos podem apresentar ausência ou mesmo prevalência baixa de sintomatologia depressiva quando participam de atividades grupais de educação permanente. OBJETIVOS: Investigar a intensidade e prevalência de sintomatologia depressiva em idosas participantes da Universidade para a Terceira Idade (UNITI) da Universidade Federal do Rio Grande do Sul. Verificar se o tempo de participação na UNITI ajuda na melhora do humor e as características das participantes antes e após ingressarem na UNITI. MÉTODO: Participaram 103 idosas integrantes da UNITI. Utilizou-se a Escala de Depressão Geriátrica (GDS) e uma ficha de dados sociodemográficos, que investigava o tempo de participação na UNITI e sua relação com sintomas depressivos, o papel da UNITI na melhora do humor e características das participantes antes e depois de entrarem na instituição. A amostra foi de conveniência. RESULTADOS: Observou-se ausência de sintomatologia depressiva na GDS na amostra estudada (média = 2,65; desvio padrão = 2,42). Do total de idosas, 80,6% apresentaram escores normais na GDS, e nenhuma apresentou depressão grave. Observou-se diferença significativa entre depressão e tempo de participação na UNITI igual ou superior a 1 ano (p < 0,05). Verificou-se também que as participantes apresentaram melhoras no humor e nas áreas pessoal, intelectual, afetiva e social. CONCLUSÕES: É possível envelhecer bem, com ausência de sintomatologia depressiva. Este estudo aponta para a existência de uma associação, a ser melhor investigada, entre menor intensidade de sintomatologia depressiva e tempo de participação na UNITI superior a 1 ano. Também sugere que a participação em uma universidade para a terceira idade traz melhoras aos idosos.

Idoso; depressão; universidade para a terceira idade; envelhecimento

ORIGINAL ARTICLE

Prevalence of depression in elderly women attending the University of Third Age^*

Tatiana Quarti Irigaray^I; Rodolfo Herberto Schneider^II

^IPsychologist. Member, Technical Team, University for the Third Age – Universidade Federal do Rio Grande do Sul (UNITI/UFRGS), Porto Alegre, RS, Brazil. MSc. student in Biomedical Gerontology, Instituto de Geriatria e Gerontologia, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil

^IIGeriatrician. Associate professor, Instituto de Geriatria e Gerontologia, PUCRS, Porto Alegre, RS, Brazil

^{Correspondence}

ABSTRACT

BACKGROUND: Studies have suggested that aging is associated with depression. However, elderly can present absence or low prevalence of depressive symptoms when they participate in group activities of permanent education.

OBJECTIVE: To investigate the intensity and prevalence of depressive symptoms in elderly women attending the University of the Third Age (UNITI) at Universidade Federal do Rio Grande do Sul. To verify whether participation time in UNITI improves the mood and characteristics of participants before and after entering UNITI.

METHOD: One hundred and three UNITI students participated in the study. The Geriatric Depression Scale (GDS) and a form of sociodemographic data were used, investigating the participation time in UNITI and its relation with depressive symptoms, the role of UNITI in the improvement in the mood and characteristics of participants before and after entering this institution. A convenience sample was used.

RESULTS: Absence of depressive symptoms were observed in the GDS of the sample under investigation (mean = 2.65; standard deviation = 2.42). Of all elderly women, 80.6% presented normal scores in the GDS and none presented severe depression. There was significant difference between depression and participation time in UNITI ≥ 1 year (p ≤ 0.05). Participants also presented improvement in mood and in personal, intellectual, affective and social areas.

CONCLUSIONS: It is possible to age well without depressive symptoms. This study shows the existence of an association, which needs further investigation, between minor intensity of depressive symptoms and participation time in UNITI > 1 year. It also suggests that attending a university of the third age brings improvements to the elderly people.

Keywords: Elderly, depression, university of the third age, aging.

Introduction

Depression is one of the most common and important psychiatric problems in the elderly.¹ It is characterized by a disorder in the affective or mood area, having great functional impact on any age group. It is a disorder of a multifactorial nature, which comprehends various biological, psychological and social aspects. It is a mood state experienced by a large number of individuals at some moment of their lives, and is often reported as sadness, longing, anxiety, despondency, among others.²

Batistoni³ defines depression as a psychiatric syndrome whose main symptoms are depressed mood and loss of interest or pleasure in almost all activities. In the elderly, it is heterogeneously manifested, both as to its etiology and to aspects related to its presentation and treatment.

According to a study carried out by Beekman et al.,⁴ there is an important association between physical health and depression in old age. Subjective and more general aspects of physical health, such as functional limitations and perceived health, are more strongly associated with depression than other disease categories.

Depression can be responsible for loss of autonomy and worsening of preexisting pathological conditions. It is frequently associated with increased risk of comorbid conditions and mortality, resulting in increased use of health services, negligence in self–care, reduced adherence to therapeutic treatments and higher risk of suicide.⁵ In the elderly, presence of comorbid conditions and use of multiple drugs make diagnosis and treatment of depression more complex.⁶

According to a study performed by Veras,⁷ the prevalence of depression in the elderly in Rio de Janeiro (Brazil) varied dependent on studied group – it was 20.9% in the district with the best socioeconomic level and 36.8% in that presenting the worst socioeconomic level. To Frank & Rodrigues,⁸ depressive disorders among the elderly who live in the community range from 4.8 to 14.6%, and the prevalence in the elderly in hospitals or institutions is higher, reaching 22%. On the other hand, studies assessing clinically relevant symptoms, but that do not meet sufficient criteria of the International Classification of Diseases, volume 10 (ICD–10) or of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DMS–IV), using symptom scales show a prevalence in the community ranging from 6.4 to 59.3%.⁸

Prevalence of major depression ranges from 0.9 to 42% among Caucasian elderly, and clinically relevant depressive symptoms range from 7.2 to 49%. The main factors involved in depressive disorders and symptoms are female gender, somatic diseases, cognitive and functional decline, lack or loss of social contact and history of previous depression. In old age, risk factors are loss or lack of social contacts, history of previous depression, widowhood, stressing life events, institutionalization in residential cares, low income, dissatisfaction with social support, social isolation, anxiety, lack of social activities, low schooling level and use of antidepressants.⁹

Argimon & Stein¹⁰ consider depression a frequent health problem among the elderly, although its identification is often difficult in clinical practice. In a study conducted by the authors, results have led them to the hypothesis that elderly people have a more fragile physical health than other younger people and, as a consequence, have increased risk of presenting depressive symptoms, not resulting from older age, but due to a more precarious health status.

Decline in physical health is often deemed the main related factor for risk of depression,^3,9 since the presence of diseases frequently leads the elderly to situations of disability and higher dependency. However, major depressive disorders are relatively rare in the elderly, whereas depressive symptoms that have no diagnostic criteria defined by the DSM–IV for depression are common.⁴ On the other hand, studies show a remarkable degree of depressive symptom stability in adults aged less than 70 years and an increase in subsequent ages.^11,12 During aging, an increase in somatic symptoms and lack of well–being is especially observed. Nevertheless, the number of comorbid conditions is responsible for a small part of this association, and somatic symptoms should be seen as depression symptoms, and not as expression of precarious physical health.¹²

Poverty, widowhood, institutionalization and loneliness are also identified as risk factors for the development of depressive symptoms. Changes in social roles, such as retirement, often cause reduction in self–esteem, rhythm of activities and interest in daily life. Loss of close people, such as husband/wife, children or friends, is also a triggering factor of depressive symptoms.² Perception of psychological status contributes as an adjuvant factor to trigger depression, since real or imaginary declines in capabilities, such as dementia and memory loss, may cause depressive symptoms.¹³

According to some studies, there is a great variety of diseases that have direct etiologic relationship with depression in old age. The main comorbid conditions are myocardial infarction, stroke and Parkinson's disease.^14,15 In addition, general aspects of physical health, such as level of functional loss and perceived health, are more correlated with depression than specific diagnoses of this disease.^16–18

In old age, negative and stressing life events are more frequent and require from the elderly the need of adaptation, which may contribute to occurrence of depression.¹³ Depression can be avoided, or even minimized, through the support individuals receive from interpersonal relationships.¹⁹ According to Papalia et al.,²⁰ a strong network of friends and relatives can help the elderly avoid or cope with depression.²⁰ Therefore, certain affective contexts can both trigger and protect individuals against occurrence of depressive symptoms. Risk of depression is increased in the absence of affective relationships, friendships and trust bonds with husband, wife, partner or friend.¹⁹ Antonucci et al.,²¹ assessing differences between men and women, associated quality of social relationships, more specifically negative social relationships, with occurrence of depressive symptoms.

Another study found a direct relationship between social activities and lower prevalence of depressive symptoms in the elderly. Hence, increased social participation acts as an important modifier in the elderly's health, playing a major role in maintaining mental health in old age and being an important means of intervention.²² To Murphy,²³ social support plays a protective role in the presence of an unpleasant event, working as a reducer of the impact of stressing events.

This study aimed at investigating the intensity and prevalence of depressive symptoms in elderly women attending the University of the Third Age (UNITI) at Universidade Federal do Rio Grande do Sul (UFRGS). It also verifies whether participation time in UNITI improves the mood and personal characteristics of participants before and after entering UNITI.

UNITI is an extension project that is part of the Department of Social and Institutional Psychology of the Institute of Psychology at UFRGS. Its activities started in the first semester of 1991, and it has been active for 16 years. UNITI groups are created at every 6 months, including an average of 150 people aged 60 years or more, most of them being elderly women.

UNITI dynamics occurs at a large group, gathering all participants at every Monday, from 2.30 p.m. to 5 p.m., and in small groups, called subprojects, which work in other weekdays and in different schedules. Activities take place during the whole academic year, from March to December. In the large group, works aiming at raising awareness about the aging process are developed, and issues of varied interests are discussed by means of lectures, debates, seminars and studies carried out by participants. Subprojects deal with varied themes, according to the interest of participants. In the second semester of 2006, the following subprojects were taking place: handcraft; cinema debate; Spanish culture, studies and debates; body expression; social group; literature; environment; and music. Subprojects are coordinated by UNITI participants, and new groups may be created as new participants join the group and are willing to develop any study or activity. They are self–managed and work under the supervision of a technical team, which has one psychologist and geriatrician, two psychologists, one pedagogue, one computing technician and undergraduate students in psychology.

According to Castro,²⁴ the work carried out at UNITI is based on the principles of permanent education, which can be defined as a participative pedagogical proposal that provides the elderly with experiments related to their time and to the construction of their space. UNITI's main goal is to enhance the potential of human resources represented by the age group of 60 years or more. It applies strategies that allow social changes, granting the elderly the right to participate according to their own resources. Work dynamics is based on the participants' ability and on their specific needs, within a philosophy that privileges self–discovery. The UNITI project provides the elderly a review in the socialization process, allowing and offering learning experiences about the rhythm and sequence of evolutionary changes throughout life.

Method

Sample

The sample was composed of 103 elderly women, of a total of 155 UNITI participants (153 women and two men). The elderly women were aged between 60 and 86 years and had minimum schooling level of 7 years. The sample was selected by convenience. All 153 UNITI participants were invited to participate in the study, but only 109 consented. Six people were excluded from the sample because they were aged less than 60 years. No elderly women were excluded due to symptoms suggesting dementia.

Instruments

Collection of sociodemographic data

Collection of sociodemographic data included the following variables: gender, age, marital status, schooling level, income, housing conditions, retirement year, occupation, year of UNITI admittance, number of children, grandchildren and great grandchildren, chosen physical activity, health perception, use of drugs, voluntary work and use of cigarette and alcoholic beverage (quantity and frequency). The following issues were also evaluated: 1) Year and semester of UNITI admittance; 2) "Does UNITI help improve your mood?" – Answer choices categorized into: "nothing," "very little," "medium," "very much" and "completely;" 3) "List three personal characteristics before joining UNITI and other three that occurred after you joined UNITI."

Geriatric Depression Scale

Geriatric Depression Scale (GDS)²⁵ is a measure used to scan depression in the elderly, and is one of the most used instruments for that purpose. It is comprised of 15 items in its short version and was particularly developed to scan mood disorders in the elderly, with questions that avoid somatic complaints. It has closed questions, presenting "yes" or "no" answers. Several studies have showed that GDS offers valid and reliable measures.^26,27

Data collection procedures

UNITI was initially contacted, and then participants were included in the sample. All the elderly women signed the consent term and were then invited to provide information concerning sociodemographic data and depression symptoms (GDS).²⁵

Sociodemographic data and GDS are both self–administered; however, a research assistant (psychology student) was always available in case of doubts. The instruments were applied in groups of up to 15 participants.

The project was approved by the Research Ethics Committee at Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre (RS), Brazil.

Data analysis procedures

Description of variables was performed using absolute and relative frequencies, as well as mean (M) and standard deviation (SD), and GDS was grouped by tertiles.

To compare values of depression and participation time in UNITI, Student's t test was used.

Associations with p values ≤ 0.05 were considered significant.

SPSS for Windows, version 13.0 was used for data analysis.

Results

Table 1 shows the sociodemographic characteristics of the sample being studied. As can be seen, the sample was comprised of 103 elderly women aged between 60 and 86 years (mean age of 69.2 years; SD = 6.46). The most frequent marital status was being a widow (44.7%); the most prevalent schooling level was tertiary education (40.8%); and predominant income was between six and 10 minimum wages (38.8%). As to housing conditions, living with family was the most prevalent (52.4%); teacher was the most frequent previous occupation (28.1%); and retirement was the prevalent current occupation (73.8%). Predominant health perception was healthy (81.6%); use of medication (89.3%) and current physical activity (74.8%) were also mentioned. Most elderly women (84.4%) has participated in UNITI for more than 1 year.

Table 2 presents depression intensity among the elderly women according to total GDS data (M = 2.65; SD = 2.42) and also according to tertile grouping. The participants responded to a score ranging from zero to 10 in GDS. According to GDS, grouped by tertiles, the first tertile (< 5), which corresponds to the group with normal scores, was the most frequent scoring (80.6%). In the evaluation of the second tertile (5 to 10), which corresponds to the group with presence of mild to moderate depression, frequency of answers was 19.4%. For the third tertile, which corresponds to the group with higher intensity of depressive symptoms and severe depression, there were no cases with enough score to indicate this type of depression.

Correlation between depression (GDS) and participation time in UNITI was also assessed. Using Student's t test, it was possible to verify a significant difference (p = 0.05) for the variables depression (GDS) and participation time in UNITI lower or equal vs. higher than 1 year. According to such comparison, those who had been participants for more than 1 year presented less depressive symptoms (GDS = 2.39) in relation to those who had participated for 1 year or less (GDS = 4.06).

The answers given concerning the importance of UNITI's role in mood improvement are presented in Table 3.

The characteristics of the elderly women before and after joining UNITI are shown in Table 4. The participants stressed personal aspects and experienced feelings.

Discussion

Different studies have suggested that aging has a strong relation with presence of depression. However, our study showed an absence of depressive symptoms in GDS (M = 2.65; SD = 2.42) in the studied sample. This result is corroborated by many other studies.^28–30

An association between lower intensity of depression and participation in a university for the third age was found by Loures & Gomes.²⁸ For the authors, the hypothesis of a direct association between intensity of depression and participation in a course at the University for the Third Age of Universidade Católica de Goiás (UNATI/UCG) was reinforced after verifying reduction in prevalence of depression by the end of the course, since attending the course probably made the students feel less abandoned, less lonely and less despised, as a result of interacting among themselves, with their colleagues and/or teachers.²⁸ Other studies reinforce the hypothesis of improvements in personal, intellectual, affective and social areas with the participation in universities for the third age.^29,30 Cachioni²⁹ reported that student's participation in the University for the Third Age of São Francisco led them to feel more socially valued and more respected. In addition, the participants obtained educational gains, which were reflected in a higher self–assurance and self–efficacy, in terms of cognition and productivity. In a research carried out by Erbolato³⁰ at the University for the Third Age of Pontifícia Universidade Católica de Campinas, the students revealed that attending the program brought them benefits in personal, intellectual and social areas. Positive changes in their conceptions of aging were also reported, as well as concerning health cares, life routine, confrontation of problems, relationship with friends and self–perception. Differently, a study by Leite et al.³¹ found an important percentage of depression (24.02%) in the elderly attending the University for the Third Age of Universidade Federal de Pernambuco, most of them being classified as minor depression. Cases of depression had relevant relationship with the variables concern, headache, little predisposition, irritation, sadness and dissatisfaction.

In our study, a possible explanation for the absence of depressive symptoms could be due to the influence of the work carried out at UNITI, whose main goal is to value the elderly as an active and participative being in society. At UNITI, the group of elderly searches and decides about motivations of their own lives, rethinks and reformulates their own history, releasing and productively using the resources of their personality.³²

The elderly women, before joining UNITI, had no objectives in life, felt lonely, had access to little information and general culture and felt sad. A possible hypothesis to explain the experience of those feelings could be in the characteristics or our sample, since only 31% have a partner, almost half of them live alone, and most of them are retired. According to Papalia et al.,²⁰ women, because they live longer then men, are more likely to be widows, have two times greater chance of living alone than men, increasing this probability with age. Among those aged 85 years or more, almost 60% of women and 30% of men live alone. The fact of living alone does not determine experience of loneliness in old age. Other factors may play a more significant role in vulnerability to loneliness, such as personality, cognitive skills, physical health and a wide social network. Furthermore, retirement is an important marker of aging in these elderly women, which might have caused break of bonds, relational impoverishment and loss of identity.

The feelings generated in the elderly by the aging process are mostly experienced as something new and destabilizing, resulting in anxiety, fear, conflict, insecurity and especially feelings of loneliness. According to Castro,³² loneliness is originated from the conviction that there is no "group" to which one belongs, i.e., there is loss of identity in relation to oneself. Therefore, insertion of the elderly in the UNITI group is given through the feeling of belonging, which would be a form of bonding and reconstruction of their identity as elderly subjects.³²

By attending UNITI, the elderly have the possibility of interacting with other people, creating a new circle of friends. They also acquire new knowledge and are updated, which is reflected in more opportunities to talk and relate with relatives and other people. As a consequence of those and other factors experienced in the group, the elderly have better self–esteem, which is reflected in a higher sense of self–efficacy. Self–esteem basically means liking oneself, i.e., appreciating oneself genuinely and realistically. Self–esteem is directly associated with problem solving (self–efficacy).³³ Self–efficacy is one's own belief in their ability to organize, solve and perform the necessary actions to achieve certain results. It is a crucial mechanism, because it predicts the achievement level that people reach and has a strong impact on thinking, affection, motivation and action.³⁴ Hence, elderly people with good self–esteem feel more able to solve problems, and such self–perception is proportional to their self–esteem.

At universities for the third age, the elderly are usually encouraged to conquer or maintain a lifestyle as healthy as possible within their biopsychosocial reality. In those spaces, maintenance of the maximum functional ability and conquest and preservation of autonomy, good quality of life and independence are encouraged. The elderly have the possibility of acquiring new information, increase their knowledge and especially make new friends, preventing loneliness and depression.

In Brazil, since the 1990's, there has been a multiplication of programs focused on mature adults and elderly people in Brazilian universities. Between 1990 and 1999, such programs grew from six to around 140. These institutions are currently spread all over the country, with around 200 programs in public and private universities.³⁵ According to Debert,³⁶ such programs were created due to the visibility of old age in the 1990's, since concern about aging and improvement in quality of life of the elderly is something recent. Those spaces are involved in fighting prejudices and stereotypes attributed to old age in the Brazilian context, with the aim of demonstrating that it is possible to attribute new contents to old age.³⁶ Within that perspective, over the next years, old age will no longer be a new fact; perhaps the prejudices, stereotypes and discriminations against the elderly will already be extinguished. Therefore, the future of old age and universities for the third age could be influenced by how individuals will be educated in relation to their destiny and role in society.

Another factor that deserves attention for absence of depressive symptoms are the sociodemographic characteristics of our sample, which was mostly composed of elderly women with high schooling level. Such characteristic could explain low total score in GDS. In a study by Trentini et al.,³⁷ schooling level was the variable most consistently associated with intensity of depression. This association would take place inversely: the higher the schooling level, the lower the intensity of psychological symptoms or somatizations. Schooling level would thus play a protective role against depressive symptoms or against their manifestation. Other studies have also demonstrated a relationship between lower schooling level and higher number of depressed elderly people.^31,38

Among the characteristics of our sample, it is worth stressing that it was mostly composed of middle–class women, retired, with high schooling level, and being a teacher was the most prevalent previous occupation. A possible explanation for this finding may be the fact that UNITI is a project that works inside the university. As a consequence, it attracts people with good physical health and high financial and educational levels. Elderly people with lower schooling level may have performed jobs that were more physically exhausting, have had less access to health care and, therefore, may have more difficulties in going to a university and attending a program like UNITI. According to Silva,³⁹ people who, throughout their lives, had access to educational opportunities are better candidates to face education as a means to confront the challenges caused by the aging process. Therefore, education seems to be a strong indicator of successfully dealing with old age (individuals who had educational experiences throughout their lives would have an additional advantage in experiencing old age).

Although the current characteristic of the aging process shows a higher prevalence of elderly women, it is also important to highlight that the UNITI's study was conducted using a relatively restricted sample, formed only by elderly women, which may not reflect the reality of the elderly in general. The fact that our sample was only composed of elderly women is due to the almost inexistent participation of elderly men in programs for the third age. The number of elderly men attending UNITI has never been higher than 5% throughout its 16 years of existence. According to Debert,³⁶ a remarkable characteristic of programs for the third age is the prevalence of women, who represent the majority of the total population. Elderly men are usually part of associations, federations and confederations of retired people or unions of professional classes. According to that author, this fact may be related to the differences between men and women as to representation of old age and to how such individuals perceive the changes occurred in the aging process, i.e., women have more cultural interest and men are more focused on politics. Therefore, the roles played by genders could be directed towards different paths: men are more focused on citizen's rights and redistribution of wealth, and women on wide cultural changes.

In this study, another important association was between participation time at UNITI (more than 1 year) and lower intensity of depressive symptoms. It indicates the existence of such correlation, which deserves a deeper investigation, but studies explaining this association are still incipient.

The data for this survey cannot be generalized to the whole population. They indicate that it is possible to reach old age well and that programs for the third age may help the elderly remake new life plans, cope with loneliness and develop new skills. This study contributes to reinforcing the argument that education throughout an individual's whole life is a powerful predictor of a happy aging process with quality.

Conclusions

Depression is not necessarily a morbid condition part of old age. Low general average in GDS in elderly women suggests absence of depression. Therefore, the present study shows that it is possible to reach old age well, with absence of depressive symptoms. The use of GDS indicated an association between lower intensity of depressive symptoms and participation time at UNITI higher than 1 year. Thus, the longer the participation time, the lower the intensity of depressive symptoms.

Higher schooling level seems to have an influence on prevalence of depression. For that reason, complementary studies focused on the implementation of educational policies directed to the elderly population could improve the efficacy of physical and psychological health of the elderly, secondarily working as protective factors against depression in old age.

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Received September 25, 2006.

Accepted January 30, 2007.

*

This study was performed at Instituto de Geriatria e Gerontologia, PUCRS, Porto Alegre, RS, Brazil.

Publication Dates

• Publication in this collection
  06 Sept 2007
• Date of issue
  Apr 2007

History

• Accepted
  30 Jan 2007
• Received
  25 Sept 2006