Geriatric Nursing 35 (2014) 105e110
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Reducing depression among community-dwelling older adults using life-story review: A pilot study Moon Fai Chan, PhD, CStat a, *, Katherine S.P. Leong, RN, MN a, Boon Ling Heng, RN, MN a, Blessy Koottappal Mathew, RN, MN a, Sher Banu A.L. Khan, PhD b, Sumathi Sagayamary Lourdusamy, RN, MN a, Mina Nagapan, RN, MN a, Sook Fan Woo, RN, MN a, Wai Yan Chee, RN, MN a, Roger C.M. Ho, MBBS(HK), MMed(Psych) c, Beverley Joan Taylor, RN, PhD d a
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore Malay Studies, Faculty of Arts and Social Sciences, National University of Singapore, Singapore Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore d Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Gippsland Campus, Churchill, Victoria, Australia b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 June 2013 Received in revised form 9 October 2013 Accepted 14 October 2013 Available online 15 November 2013
A life-story review can serve as an effective intervention to express one’s inner feelings and provide emotional catharsis. The research aim was to examine the effects of life-story review on depression levels in community-dwelling older adults in Singapore. This pilot experimental pre-post-follow-up study was conducted from July 2012 to February 2013. Twenty-nine older Malays aged 60 and above, with mild to moderate depression, were randomly allocated to the life-story review (intervention) group (n ¼ 15) or the non life-story review (control) group (n ¼ 14). Depressive symptoms were measured by the Geriatric Depression Scale-15 and collected five times over eight weeks. Generalized estimating equations were used to examine the effects of the intervention on the elders’ depression levels, controlled for age, gender, medication use, existence of chronic disease, and diary writing experience. Reductions in depression scores were found in the intervention group from week 1 (Mean SD 5.9 2.3) to week 8 (1.9 1.6) compared with the control group (week 1: 5.0 1.3; week 8: 3.5 1.5). At week 8, the intervention group showed a significantly lower level of depression than the control group (c2 ¼ 14.61, p < 0.001). This study adds to prior research supporting the use of life story review in improving depression levels in cognitively intact community dwelling older adults. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: Depression Older Malays Life-story review Older adults
Introduction The World Health Organization (WHO) reports that depression affects 121 million people worldwide and is predicted to be the second leading cause of disease burden by the year 2020.1 Depression is a major health care issue and if it is untreated or undertreated, it diminishes quality of life, increases mortality, and leads to many complications.2 Depression presents with sadness, loss of interest in life, guilt feelings, poor appetite, disturbed sleep, and low energy and mood levels.3 The risk of depression Conflict of interests: The author(s) declare that they have no conflict of interests. Contributions: Study design: MFC, SBALK; Data collection: KLSP, BLH; Data analysis: MFC, BKM, SFW, WYC; Preparation: MFC, SBALK, KLSP, BLH, MN, BKM, SFW, WYC, SSD/OL, RCMH, & BJT. * Corresponding author. Tel.: þ65 6516 8684. E-mail address: [email protected] (M.F. Chan). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.10.011
increases with age.4 Rothermund & Brandtstadler5 also observed an age-related increase in depressive symptoms in the elderly, in adjusting to typical age related losses, such as physical health decline and other risk factors resulting in ineffective coping abilities. The onset of aging and accumulation of medical illnesses can result in progression of depression with many consequences. A national mental health survey, based on the population in Singapore, found that the likelihood of lifetime depression prevalence in the population is 5.6%.6 Singapore is a multiracial country comprising mainly Chinese, Malay and Indian citizens. Malays comprise 13% of the total population.7 Another population based survey estimated that the prevalence of poor mental health in Malays is higher (12.7%) than the Chinese and Indian ethnic groups.8 There are a variety of treatment options available for reducing depression.9 The National Institute for Health and Care Excellence
106
M.F. Chan et al. / Geriatric Nursing 35 (2014) 105e110
[NICE]10 discourages the use of pharmacological treatments in the early stages of depression, because the risk-benefit ratio is poor. The NICE advocates the use of non-pharmacological treatments for mild to moderate depression.10 Cujpers, Smit, & Van-Straaten11 showed that psychological interventions for older adults with depressive symptoms are useful. A narrative of one’s life-story gives a sense of identity and has a positive effect on psychosocial aspects, especially for older people, because their life events provide many opportunities for reminiscence. Hanninen12 classified narratives into three overlapping modes; told narrative, inner narrative and lived narrative. He describes told narrative encounters as a verbal chain of human events. The inner narrative conceptualizes the organization of the experience, making it the focus of narrative psychology and allowing the individual to make interpretations of his/her life. Gaydos13 highlighted how getting a person to share their own life helps to unveil deep meanings in their life and allows healing to take place, thus giving them hope to move on with life. Wills & Day14 called life-story review a therapeutic measure, because it allows a person to verbalize their life experiences, which would otherwise be stored only as memories. Westerhof, Bohleijer & Webster15 assert that when memories are shared, the re-telling reconstructs self and identity through social discussion. Life-story work records a person’s life in the past and present.14 The narrative sharing of a person’s life-story can also be expressed as a lifestory book or life book.14 A life-story book serves as a therapeutic tool to enhance communication among different groups of people, such as health care professionals, caregivers and family members.16 A meta-analysis of 12 randomized controlled trial studies concluded that psychosocial interventions had a small but statistically significant effect on depressive symptoms for elderly inpatients.17 Multiple studies have shown that using life-story review for older adults resulted in significant improvements in depressive symptoms as compared to the control group,18 and its effect was maintained up to 9 months.18e20 To summarize, substantial evidence supports the efficacy of life review as a treatment for depression for older adults in Western countries. However, few trials have studied the effectiveness of life-story review for older adults in Southeast Asia and in the community setting. This pilot study explored the effects of life-story review on depression levels in community-dwelling older adults in Singapore. The hypothesis was that there would be statistically significantly lower depression levels for older adults in the life-story review (intervention) group than those in the non life-story review (control) group at eight weeks.
were currently using medications, such as sedative-hypnotics, antidepressants, anti-cholinergics, tranquilizers, melatonin, or antihistamines, were excluded, but we included those participants who had common medical ailments, such as coryza and cough. All participants were recruited from the researchers’ social network. This sampling technique was preferred due to the intimate setting of this experiment (participants’ homes), as most were unwilling to allow strangers into their home. With assurance from their friends, subjects were more likely to agree to participate in this study, thus the snowball technique was appropriate.22 Sample size The sample size was based on an expected effect size for depression levels post-intervention. A recent local study conducted by Chan et al23 reported that the overall effect size of post interventions for Chinese elderly by using life-story review for depressive symptoms was 1.478. Assuming a similar effect size for our study, the nQuery software24 showed that at least 11 participants with complete data per group (total ¼ 22) would be needed to detect this effect with 90% power and 5% significance. All potential subjects were recruited from neighborhood settings, where many older adults were known to sit outside the playground in the daytime, close to their living place. The researcher invited them one-by-one to join the study. Eligibility to participate was based on participants reaching a baseline depression score of mild to moderate levels. The researcher was a Registered Nurse, who worked in a geriatric ward for more than 10 years. A total of 58 elderly people were approached and among these 33 were eligible and 29 consented to participate in the study. They were randomly allocated to the intervention (n ¼ 15) and control (n ¼ 14) groups. No subjects dropped out of the study (see Fig. 1). Measurement The study instrument consisted of two parts. Part 1 was used to collect participants’ demographic information including age, gender, religion, marital status, educational level, medical history and experience in writing a diary. Part 2 used GDS-15 to collect participants’ depression levels,25 which has been utilized widely to screen major depressive disorders. The GDS-15 was available in Malay version and the overall sensitivity and specificity of the GDS15 were 0.97 and 0.95, respectively.26 Procedure
Methods Design The pilot study used an experimental pre-post-follow-up design. The study duration was two months, with repeated measurements taken at week 1 (baseline), 2, 3, 4, and 8 weeks for a total of five assessments on the depression levels. Approval was sought and obtained from the Institutional Review Board ethics committee from the University (NUS-IRB: 12-010). Setting and participants All participants were older Malay adults aged 60 and over, living in the community and the study was conducted at participants’ homes from July 2012 to February 2013. The inclusion criteria were that participants were able to communicate in Malay or English; with a mild to moderate depression at baseline, measured by the Geriatric Depression Scale-15 (GDS-15)21; and they had not been previously diagnosed with dementia or Alzheimer’s disease. Participants who
In week 1, participants’ demographic and GDS-15 scores were collected individually by the same researcher. Participants in the intervention group were asked to share their memories of childhood, family and celebrations at the same time. A week later, at the second session, the contents of the first interview were reviewed with the participants. The participants then continued to share memories about their adulthood, relationships/marriage, parenthood, career/life as a housewife, and their culture, after which the GDS-15 score was collected. The third session conducted in week 3 reviewed the contents of the second interview; and the GDS-15 score was collected. Participants then talked about their current life, their philosophy of life and reminisced about their past. The fourth session conducted in week 4 reviewed the contents of the third interview and collected the GDS-15 score. The first four sessions were undertaken at weekly intervals, because this timing was deemed appropriate for the participant to rest and reflect before the next interview.20,23,27 In the fifth session in week 8, the researcher presented the participants with their life-story book and collected the GDS-15 score. For each interview, transcripts were
M.F. Chan et al. / Geriatric Nursing 35 (2014) 105e110
107
Assessed for eligibility* (n=58)
Excluded (n=29) Did not meet inclusion criteria (n=25) Refused to participate (n=4)
Randomization
Allocated to life-story review (n=15) Received intervention (n=15) Did not receive intervention (n=0)
Lost to follow-up (n=0) or/and Discontinued intervention (n=0)
Analysed (n=15) Excluded from analysis (n=0)
Allocation
Follow-Up
Analysis
Allocated to control (n= 14) Received intervention (n=0) Did not receive intervention (n=14)
Lost to follow-up (n=0) or/and Discontinued (n=0)
Analysed (n=14) Excluded from analysis (n=0)
*screening and collection of baseline data
Fig. 1. CONSORT diagram: participant recruitment, intervention, and assessment.
synthesized and compiled by the co-investigators, who ensured the quality of the text. Each participant’s life-story book was finalized by the research team within one month. Participants in the control group met with the researchers weekly, only to collect the GDS-15 scores. Intervention group procedure The task of creating the participants’ life-story reviews through interviews took place in the comfort of the participants’ homes. During the interview, participants’ shared memories were elicited of their childhood, adolescence, and adulthood years up to their current life. The researcher used a set of guiding questions, developed by Chan et al,23 to conduct the interviews, the responses to which were audio-recorded. The interview sessions between the researcher and the subjects included memory recall using memorabilia, such as photos or personal items.14 The process helped in encouraging the participants to share their stories and express their feelings. Each of these interview sessions lasted for approximately 30e45 min. The participants’ life stories described by text, together with various photographs, were compiled in chronological order into four chapters and bound into a life-story book. Control group procedure The participants from the control group also met with the researcher in their homes. The number of visits was the same as the intervention group, that is, once a week in the first month and the final visit was on week 8. However, no life-story sharing interviews were held during the meeting, which was used solely to collect the depression scores. Randomization All eligible participants were assigned a unique case number according to the sequence in which they were recruited, for
example, the first eligible participant was assigned the number one, and the second eligible assigned the number two and so on. A total of 15 numbers without any duplicates were randomly generated, from 1 to 30, by the Research Randomizer software.28 Participants whose assigned numbers matched the numbers generated by the software were allocated into the intervention group, otherwise, they were assigned to the control group. There was no blinding, because the participants and interviewer knew the allocation groups after randomization. Ethical considerations Written consent was obtained from each participant before obtaining their baseline GDS-15 scores. Each participant was assigned a case number to ensure their anonymity and confidentiality. Participation in this study was voluntary and participants were free to withdraw from the study at any point in time, although none chose to do so. This study was conducted in a home environment and if participants required psychological support they would have been referred to a medical psychiatrist. If such a situation arose, all interventions implemented for that participants would have ceased immediately. None of the participants in this study sought psychological support. Statistical methods Descriptive statistics were used to describe the demographic characteristics of all 29 participants. Generalized estimating equations (GEE) were use to examine the effects of the intervention on the elders’ depression levels adjusted by demographic factors. GEEs have become important and robust analysis of longitudinal data, in which subjects are measured at different time points.23,29 SPSS for Windows was used for all data analysis and all significant levels were set at p < 0.05.
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M.F. Chan et al. / Geriatric Nursing 35 (2014) 105e110
Results
Table 2 Comparison of GDS-15 scores by groups again at eight weeks.
Participants’ characteristics
Week
A total of 29 participants took part in the study and completed the eight weeks. There were 15 participants in the intervention group and 14 participants in the control group (Table 1). The majority of the participants were 60e69 years old (n ¼ 16). There were more women (n ¼ 23) than men in the study, and more than seventy percent of the participants’ education level were primary or below (n ¼ 21). While all participants had Muslim religious beliefs, none had shared life-story experiences and or had kept a personal diary previously. For the participants with some form of chronic illness, 51.7% had hypertension, 41.4% suffered from diabetes, 31.0% suffered from cardiovascular diseases, and 10.3% had a respiratory problem. No significant differences were found between groups for all demographic characteristics and health history. Depressive symptoms outcome Mean SD GDS-15 depression scores by group over 8 weeks are shown in Table 2. The average depression score in the intervention group decreased from 5.9 2.3 in week 1 (baseline) to 1.9 1.6 in week 8, while the depression score in the control group decreased slightly from 5.0 1.3 in week 1 to 3.7 1.5 only in week 8 (See Fig. 2). Table 1 Comparison of demographic characteristics between groups. Demographic
Age (years) 60e69 70e79 80þ Gender Male Female Marital status Married Single Divorced Widowed Education level Primary or below Secondary Finance Old age allowance Support by children Savings Others Write dairy habit No Yes Life-story before No Take medication No Yes Chronic diseasea No Yes Hypertension (yes) Diabetes (yes) Cardiovascular (yes) Respiratory (yes) Others (e.g. osteoporosis) (Yes)
Total (n ¼ 29)
Intervention (n ¼ 15)
Control (n ¼ 14)
n
n
n
%
%
%
16 11 2
55.2 37.9 6.9
10 4 1
66.7 26.7 6.7
6 7 1
42.9 50.0 7.4
6 23
20.7 79.3
3 12
20.0 80.0
3 11
21.4 78.6
11 2 5 11
37.9 6.9 17.2 37.9
5 2 2 6
33.3 13.3 13.3 40.0
6 0 3 5
42.9 0.0 21.4 35.7
21 8
72.4 27.6
13 2
86.7 13.3
8 6
57.1 42.9
1 14 2 12
3.4 48.3 6.9 41.4
0 8 1 6
0.0 53.3 6.7 40.0
1 6 1 6
7.1 42.9 7.1 42.9
28 1
96.6 3.4
14 1
93.3 6.7
14 0
100.0 0.0
14
100.0
29
100
15
100
6 23
20.7 79.3
5 10
33.3 66.7
1 13
7.1 92.9
6 23 15 12 9 3 11
24.1 79.3 51.7 41.4 31.0 10.3 37.9
2 13 7 4 4 2 6
14.3 92.9 50.0 28.6 28.6 14.3 42.9
5 10 8 8 5 1 5
33.3 66.7 53.3 53.3 33.3 6.7 33.3
N/A, not available. a Some participants might suffer from more than one chronic disease.
Control (n ¼ 14) Mean SD
Baseline (T1) Week 2 (T2) Week 3 (T3) Week 4 (T4) Week 8 (T5)
5.0 4.0 3.7 2.6 3.5
1.3 1.3 1.8 1.4 1.5
Intervention (n ¼ 15) Mean SD 5.9 3.5 3.0 2.5 1.9
2.3 2.3 2.8 2.2 1.6
GDS-15, Geriatric Depression Scale-15.
In Table 3, the GEE model result showed that the average depression scores differed significantly between groups (Beta ¼ 1.53, p ¼ 0.038) after being controlled for age, gender, medication use, existence of chronic disease, and diary writing experience. The change in depression score was significantly different between groups at week 2 (Beta ¼ 1.97, p ¼ 0.004), week 3 (Beta ¼ 2.09, p ¼ 0.004), week 4 (Beta ¼ 1.41, p ¼ 0.020), and week 8 (Beta ¼ 2.58, p < 0.001). The only confounding variable that had a statistically significant effect was having chronic disease (Beta ¼ 2.62, p ¼ 0.001), indicating that the depression score increased by 2.62 for elderly, who have chronic disease more than who do not have chronic disease.
Discussion The present study found evidence that the process of developing a life-story book through life-story review helped reduce depression scores among older community dwelling Singaporean Malay people over time, thereby supporting our hypothesis. The current finding is consistent with previous studies19,23,30 that showed life review therapy was effective in reducing depressive symptoms, especially at post-treatment. One possible explanation of the reduction in depression levels over time could be contributed to the quality of the human social interaction between the researcher and the participants in the intervention period.13 The companionship with the researchers and the time spent in interacting to develop a life-story book may have had benefits and added meaning to each participant’s life.31 Through narration, people share their stories of the past and present and this experience creates a feeling of selfworth and being recognized. According to Wills & Days,14 a person’s identity is comprised of a sense of self, continuity and coherence. As a life-story book consists of photographs, pictures and a written account of life events, the process serves as a therapeutic communication between the researcher and the participants as more stories are recounted.14,31,32 Also, because the participants were encouraged to choose the photos to be placed in their lifestory book as a memento, this provided them with freedom of
Fig. 2. Comparison of mean Geriatric Depression Scale (GDS-15) scores between groups.
M.F. Chan et al. / Geriatric Nursing 35 (2014) 105e110 Table 3 Generalized estimating equation (GEE) analysis of GDS-15 scores (n ¼ 29). Variable
Estimate
Standard error
c2
p-value
Intercept Age (years) Group (intervention)a Time (Week 2)b Time (Week 3)b Time (Week 4)b Time (Week 8)b Group (Int) time (Week Group (Int) time (Week Group (Int) time (Week Group (Int) time (Week Gender (male)d Write dairy habit (yes)e Chronic disease (yes)e Medication (yes)e
3.69 0.003 1.53 0.43 0.71 1.79 1.29 1.97 2.09 1.41 2.58 0.06 0.45 2.62 1.44
3.37 0.048 0.74 0.46 0.60 0.37 0.37 0.68 0.72 0.61 0.68 0.55 0.73 0.82 0.82
1.20 0.003 4.29 0.87 1.41 23.71 12.06 8.48 8.31 5.45 14.61 0.01 0.38 10.17 3.12
0.273 0.956 0.038 0.351 0.235
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Reducing depression among community-dwelling older adults using life-story review: A pilot study Moon Fai Chan, PhD, CStat a, *, Katherine S.P. Leong, RN, MN a, Boon Ling Heng, RN, MN a, Blessy Koottappal Mathew, RN, MN a, Sher Banu A.L. Khan, PhD b, Sumathi Sagayamary Lourdusamy, RN, MN a, Mina Nagapan, RN, MN a, Sook Fan Woo, RN, MN a, Wai Yan Chee, RN, MN a, Roger C.M. Ho, MBBS(HK), MMed(Psych) c, Beverley Joan Taylor, RN, PhD d a
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore Malay Studies, Faculty of Arts and Social Sciences, National University of Singapore, Singapore Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore d Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Gippsland Campus, Churchill, Victoria, Australia b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 June 2013 Received in revised form 9 October 2013 Accepted 14 October 2013 Available online 15 November 2013
A life-story review can serve as an effective intervention to express one’s inner feelings and provide emotional catharsis. The research aim was to examine the effects of life-story review on depression levels in community-dwelling older adults in Singapore. This pilot experimental pre-post-follow-up study was conducted from July 2012 to February 2013. Twenty-nine older Malays aged 60 and above, with mild to moderate depression, were randomly allocated to the life-story review (intervention) group (n ¼ 15) or the non life-story review (control) group (n ¼ 14). Depressive symptoms were measured by the Geriatric Depression Scale-15 and collected five times over eight weeks. Generalized estimating equations were used to examine the effects of the intervention on the elders’ depression levels, controlled for age, gender, medication use, existence of chronic disease, and diary writing experience. Reductions in depression scores were found in the intervention group from week 1 (Mean SD 5.9 2.3) to week 8 (1.9 1.6) compared with the control group (week 1: 5.0 1.3; week 8: 3.5 1.5). At week 8, the intervention group showed a significantly lower level of depression than the control group (c2 ¼ 14.61, p < 0.001). This study adds to prior research supporting the use of life story review in improving depression levels in cognitively intact community dwelling older adults. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: Depression Older Malays Life-story review Older adults
Introduction The World Health Organization (WHO) reports that depression affects 121 million people worldwide and is predicted to be the second leading cause of disease burden by the year 2020.1 Depression is a major health care issue and if it is untreated or undertreated, it diminishes quality of life, increases mortality, and leads to many complications.2 Depression presents with sadness, loss of interest in life, guilt feelings, poor appetite, disturbed sleep, and low energy and mood levels.3 The risk of depression Conflict of interests: The author(s) declare that they have no conflict of interests. Contributions: Study design: MFC, SBALK; Data collection: KLSP, BLH; Data analysis: MFC, BKM, SFW, WYC; Preparation: MFC, SBALK, KLSP, BLH, MN, BKM, SFW, WYC, SSD/OL, RCMH, & BJT. * Corresponding author. Tel.: þ65 6516 8684. E-mail address: [email protected] (M.F. Chan). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.10.011
increases with age.4 Rothermund & Brandtstadler5 also observed an age-related increase in depressive symptoms in the elderly, in adjusting to typical age related losses, such as physical health decline and other risk factors resulting in ineffective coping abilities. The onset of aging and accumulation of medical illnesses can result in progression of depression with many consequences. A national mental health survey, based on the population in Singapore, found that the likelihood of lifetime depression prevalence in the population is 5.6%.6 Singapore is a multiracial country comprising mainly Chinese, Malay and Indian citizens. Malays comprise 13% of the total population.7 Another population based survey estimated that the prevalence of poor mental health in Malays is higher (12.7%) than the Chinese and Indian ethnic groups.8 There are a variety of treatment options available for reducing depression.9 The National Institute for Health and Care Excellence
106
M.F. Chan et al. / Geriatric Nursing 35 (2014) 105e110
[NICE]10 discourages the use of pharmacological treatments in the early stages of depression, because the risk-benefit ratio is poor. The NICE advocates the use of non-pharmacological treatments for mild to moderate depression.10 Cujpers, Smit, & Van-Straaten11 showed that psychological interventions for older adults with depressive symptoms are useful. A narrative of one’s life-story gives a sense of identity and has a positive effect on psychosocial aspects, especially for older people, because their life events provide many opportunities for reminiscence. Hanninen12 classified narratives into three overlapping modes; told narrative, inner narrative and lived narrative. He describes told narrative encounters as a verbal chain of human events. The inner narrative conceptualizes the organization of the experience, making it the focus of narrative psychology and allowing the individual to make interpretations of his/her life. Gaydos13 highlighted how getting a person to share their own life helps to unveil deep meanings in their life and allows healing to take place, thus giving them hope to move on with life. Wills & Day14 called life-story review a therapeutic measure, because it allows a person to verbalize their life experiences, which would otherwise be stored only as memories. Westerhof, Bohleijer & Webster15 assert that when memories are shared, the re-telling reconstructs self and identity through social discussion. Life-story work records a person’s life in the past and present.14 The narrative sharing of a person’s life-story can also be expressed as a lifestory book or life book.14 A life-story book serves as a therapeutic tool to enhance communication among different groups of people, such as health care professionals, caregivers and family members.16 A meta-analysis of 12 randomized controlled trial studies concluded that psychosocial interventions had a small but statistically significant effect on depressive symptoms for elderly inpatients.17 Multiple studies have shown that using life-story review for older adults resulted in significant improvements in depressive symptoms as compared to the control group,18 and its effect was maintained up to 9 months.18e20 To summarize, substantial evidence supports the efficacy of life review as a treatment for depression for older adults in Western countries. However, few trials have studied the effectiveness of life-story review for older adults in Southeast Asia and in the community setting. This pilot study explored the effects of life-story review on depression levels in community-dwelling older adults in Singapore. The hypothesis was that there would be statistically significantly lower depression levels for older adults in the life-story review (intervention) group than those in the non life-story review (control) group at eight weeks.
were currently using medications, such as sedative-hypnotics, antidepressants, anti-cholinergics, tranquilizers, melatonin, or antihistamines, were excluded, but we included those participants who had common medical ailments, such as coryza and cough. All participants were recruited from the researchers’ social network. This sampling technique was preferred due to the intimate setting of this experiment (participants’ homes), as most were unwilling to allow strangers into their home. With assurance from their friends, subjects were more likely to agree to participate in this study, thus the snowball technique was appropriate.22 Sample size The sample size was based on an expected effect size for depression levels post-intervention. A recent local study conducted by Chan et al23 reported that the overall effect size of post interventions for Chinese elderly by using life-story review for depressive symptoms was 1.478. Assuming a similar effect size for our study, the nQuery software24 showed that at least 11 participants with complete data per group (total ¼ 22) would be needed to detect this effect with 90% power and 5% significance. All potential subjects were recruited from neighborhood settings, where many older adults were known to sit outside the playground in the daytime, close to their living place. The researcher invited them one-by-one to join the study. Eligibility to participate was based on participants reaching a baseline depression score of mild to moderate levels. The researcher was a Registered Nurse, who worked in a geriatric ward for more than 10 years. A total of 58 elderly people were approached and among these 33 were eligible and 29 consented to participate in the study. They were randomly allocated to the intervention (n ¼ 15) and control (n ¼ 14) groups. No subjects dropped out of the study (see Fig. 1). Measurement The study instrument consisted of two parts. Part 1 was used to collect participants’ demographic information including age, gender, religion, marital status, educational level, medical history and experience in writing a diary. Part 2 used GDS-15 to collect participants’ depression levels,25 which has been utilized widely to screen major depressive disorders. The GDS-15 was available in Malay version and the overall sensitivity and specificity of the GDS15 were 0.97 and 0.95, respectively.26 Procedure
Methods Design The pilot study used an experimental pre-post-follow-up design. The study duration was two months, with repeated measurements taken at week 1 (baseline), 2, 3, 4, and 8 weeks for a total of five assessments on the depression levels. Approval was sought and obtained from the Institutional Review Board ethics committee from the University (NUS-IRB: 12-010). Setting and participants All participants were older Malay adults aged 60 and over, living in the community and the study was conducted at participants’ homes from July 2012 to February 2013. The inclusion criteria were that participants were able to communicate in Malay or English; with a mild to moderate depression at baseline, measured by the Geriatric Depression Scale-15 (GDS-15)21; and they had not been previously diagnosed with dementia or Alzheimer’s disease. Participants who
In week 1, participants’ demographic and GDS-15 scores were collected individually by the same researcher. Participants in the intervention group were asked to share their memories of childhood, family and celebrations at the same time. A week later, at the second session, the contents of the first interview were reviewed with the participants. The participants then continued to share memories about their adulthood, relationships/marriage, parenthood, career/life as a housewife, and their culture, after which the GDS-15 score was collected. The third session conducted in week 3 reviewed the contents of the second interview; and the GDS-15 score was collected. Participants then talked about their current life, their philosophy of life and reminisced about their past. The fourth session conducted in week 4 reviewed the contents of the third interview and collected the GDS-15 score. The first four sessions were undertaken at weekly intervals, because this timing was deemed appropriate for the participant to rest and reflect before the next interview.20,23,27 In the fifth session in week 8, the researcher presented the participants with their life-story book and collected the GDS-15 score. For each interview, transcripts were
M.F. Chan et al. / Geriatric Nursing 35 (2014) 105e110
107
Assessed for eligibility* (n=58)
Excluded (n=29) Did not meet inclusion criteria (n=25) Refused to participate (n=4)
Randomization
Allocated to life-story review (n=15) Received intervention (n=15) Did not receive intervention (n=0)
Lost to follow-up (n=0) or/and Discontinued intervention (n=0)
Analysed (n=15) Excluded from analysis (n=0)
Allocation
Follow-Up
Analysis
Allocated to control (n= 14) Received intervention (n=0) Did not receive intervention (n=14)
Lost to follow-up (n=0) or/and Discontinued (n=0)
Analysed (n=14) Excluded from analysis (n=0)
*screening and collection of baseline data
Fig. 1. CONSORT diagram: participant recruitment, intervention, and assessment.
synthesized and compiled by the co-investigators, who ensured the quality of the text. Each participant’s life-story book was finalized by the research team within one month. Participants in the control group met with the researchers weekly, only to collect the GDS-15 scores. Intervention group procedure The task of creating the participants’ life-story reviews through interviews took place in the comfort of the participants’ homes. During the interview, participants’ shared memories were elicited of their childhood, adolescence, and adulthood years up to their current life. The researcher used a set of guiding questions, developed by Chan et al,23 to conduct the interviews, the responses to which were audio-recorded. The interview sessions between the researcher and the subjects included memory recall using memorabilia, such as photos or personal items.14 The process helped in encouraging the participants to share their stories and express their feelings. Each of these interview sessions lasted for approximately 30e45 min. The participants’ life stories described by text, together with various photographs, were compiled in chronological order into four chapters and bound into a life-story book. Control group procedure The participants from the control group also met with the researcher in their homes. The number of visits was the same as the intervention group, that is, once a week in the first month and the final visit was on week 8. However, no life-story sharing interviews were held during the meeting, which was used solely to collect the depression scores. Randomization All eligible participants were assigned a unique case number according to the sequence in which they were recruited, for
example, the first eligible participant was assigned the number one, and the second eligible assigned the number two and so on. A total of 15 numbers without any duplicates were randomly generated, from 1 to 30, by the Research Randomizer software.28 Participants whose assigned numbers matched the numbers generated by the software were allocated into the intervention group, otherwise, they were assigned to the control group. There was no blinding, because the participants and interviewer knew the allocation groups after randomization. Ethical considerations Written consent was obtained from each participant before obtaining their baseline GDS-15 scores. Each participant was assigned a case number to ensure their anonymity and confidentiality. Participation in this study was voluntary and participants were free to withdraw from the study at any point in time, although none chose to do so. This study was conducted in a home environment and if participants required psychological support they would have been referred to a medical psychiatrist. If such a situation arose, all interventions implemented for that participants would have ceased immediately. None of the participants in this study sought psychological support. Statistical methods Descriptive statistics were used to describe the demographic characteristics of all 29 participants. Generalized estimating equations (GEE) were use to examine the effects of the intervention on the elders’ depression levels adjusted by demographic factors. GEEs have become important and robust analysis of longitudinal data, in which subjects are measured at different time points.23,29 SPSS for Windows was used for all data analysis and all significant levels were set at p < 0.05.
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M.F. Chan et al. / Geriatric Nursing 35 (2014) 105e110
Results
Table 2 Comparison of GDS-15 scores by groups again at eight weeks.
Participants’ characteristics
Week
A total of 29 participants took part in the study and completed the eight weeks. There were 15 participants in the intervention group and 14 participants in the control group (Table 1). The majority of the participants were 60e69 years old (n ¼ 16). There were more women (n ¼ 23) than men in the study, and more than seventy percent of the participants’ education level were primary or below (n ¼ 21). While all participants had Muslim religious beliefs, none had shared life-story experiences and or had kept a personal diary previously. For the participants with some form of chronic illness, 51.7% had hypertension, 41.4% suffered from diabetes, 31.0% suffered from cardiovascular diseases, and 10.3% had a respiratory problem. No significant differences were found between groups for all demographic characteristics and health history. Depressive symptoms outcome Mean SD GDS-15 depression scores by group over 8 weeks are shown in Table 2. The average depression score in the intervention group decreased from 5.9 2.3 in week 1 (baseline) to 1.9 1.6 in week 8, while the depression score in the control group decreased slightly from 5.0 1.3 in week 1 to 3.7 1.5 only in week 8 (See Fig. 2). Table 1 Comparison of demographic characteristics between groups. Demographic
Age (years) 60e69 70e79 80þ Gender Male Female Marital status Married Single Divorced Widowed Education level Primary or below Secondary Finance Old age allowance Support by children Savings Others Write dairy habit No Yes Life-story before No Take medication No Yes Chronic diseasea No Yes Hypertension (yes) Diabetes (yes) Cardiovascular (yes) Respiratory (yes) Others (e.g. osteoporosis) (Yes)
Total (n ¼ 29)
Intervention (n ¼ 15)
Control (n ¼ 14)
n
n
n
%
%
%
16 11 2
55.2 37.9 6.9
10 4 1
66.7 26.7 6.7
6 7 1
42.9 50.0 7.4
6 23
20.7 79.3
3 12
20.0 80.0
3 11
21.4 78.6
11 2 5 11
37.9 6.9 17.2 37.9
5 2 2 6
33.3 13.3 13.3 40.0
6 0 3 5
42.9 0.0 21.4 35.7
21 8
72.4 27.6
13 2
86.7 13.3
8 6
57.1 42.9
1 14 2 12
3.4 48.3 6.9 41.4
0 8 1 6
0.0 53.3 6.7 40.0
1 6 1 6
7.1 42.9 7.1 42.9
28 1
96.6 3.4
14 1
93.3 6.7
14 0
100.0 0.0
14
100.0
29
100
15
100
6 23
20.7 79.3
5 10
33.3 66.7
1 13
7.1 92.9
6 23 15 12 9 3 11
24.1 79.3 51.7 41.4 31.0 10.3 37.9
2 13 7 4 4 2 6
14.3 92.9 50.0 28.6 28.6 14.3 42.9
5 10 8 8 5 1 5
33.3 66.7 53.3 53.3 33.3 6.7 33.3
N/A, not available. a Some participants might suffer from more than one chronic disease.
Control (n ¼ 14) Mean SD
Baseline (T1) Week 2 (T2) Week 3 (T3) Week 4 (T4) Week 8 (T5)
5.0 4.0 3.7 2.6 3.5
1.3 1.3 1.8 1.4 1.5
Intervention (n ¼ 15) Mean SD 5.9 3.5 3.0 2.5 1.9
2.3 2.3 2.8 2.2 1.6
GDS-15, Geriatric Depression Scale-15.
In Table 3, the GEE model result showed that the average depression scores differed significantly between groups (Beta ¼ 1.53, p ¼ 0.038) after being controlled for age, gender, medication use, existence of chronic disease, and diary writing experience. The change in depression score was significantly different between groups at week 2 (Beta ¼ 1.97, p ¼ 0.004), week 3 (Beta ¼ 2.09, p ¼ 0.004), week 4 (Beta ¼ 1.41, p ¼ 0.020), and week 8 (Beta ¼ 2.58, p < 0.001). The only confounding variable that had a statistically significant effect was having chronic disease (Beta ¼ 2.62, p ¼ 0.001), indicating that the depression score increased by 2.62 for elderly, who have chronic disease more than who do not have chronic disease.
Discussion The present study found evidence that the process of developing a life-story book through life-story review helped reduce depression scores among older community dwelling Singaporean Malay people over time, thereby supporting our hypothesis. The current finding is consistent with previous studies19,23,30 that showed life review therapy was effective in reducing depressive symptoms, especially at post-treatment. One possible explanation of the reduction in depression levels over time could be contributed to the quality of the human social interaction between the researcher and the participants in the intervention period.13 The companionship with the researchers and the time spent in interacting to develop a life-story book may have had benefits and added meaning to each participant’s life.31 Through narration, people share their stories of the past and present and this experience creates a feeling of selfworth and being recognized. According to Wills & Days,14 a person’s identity is comprised of a sense of self, continuity and coherence. As a life-story book consists of photographs, pictures and a written account of life events, the process serves as a therapeutic communication between the researcher and the participants as more stories are recounted.14,31,32 Also, because the participants were encouraged to choose the photos to be placed in their lifestory book as a memento, this provided them with freedom of
Fig. 2. Comparison of mean Geriatric Depression Scale (GDS-15) scores between groups.
M.F. Chan et al. / Geriatric Nursing 35 (2014) 105e110 Table 3 Generalized estimating equation (GEE) analysis of GDS-15 scores (n ¼ 29). Variable
Estimate
Standard error
c2
p-value
Intercept Age (years) Group (intervention)a Time (Week 2)b Time (Week 3)b Time (Week 4)b Time (Week 8)b Group (Int) time (Week Group (Int) time (Week Group (Int) time (Week Group (Int) time (Week Gender (male)d Write dairy habit (yes)e Chronic disease (yes)e Medication (yes)e
3.69 0.003 1.53 0.43 0.71 1.79 1.29 1.97 2.09 1.41 2.58 0.06 0.45 2.62 1.44
3.37 0.048 0.74 0.46 0.60 0.37 0.37 0.68 0.72 0.61 0.68 0.55 0.73 0.82 0.82
1.20 0.003 4.29 0.87 1.41 23.71 12.06 8.48 8.31 5.45 14.61 0.01 0.38 10.17 3.12
0.273 0.956 0.038 0.351 0.235
