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Elderly persons experience a complex array of physical, psychological, and social changes while they struggle to adjust to the aging process. As part of the psychosocial developmental task of aging, most people deal with existential issues, at some level, in their efforts to achieve integrity or coherence. In his theory of human development, Erik Erickson describes distinct developmental stages across the lifespan from birth to death (1). The eighth stage occurs in late adulthood and focuses on the dynamics between ego integrity and despair. Persons who achieve integrity can reflect on their lives as being meaningful and rich and are not fearful of death. In contrast, persons in despair are more likely to be disappointed with, and have difficulty making sense of, their past. They struggle with many unresolved issues, which contributes to their existential suffering. Coupled with these developmental tasks, up to 30% of the elderly population (that is, persons aged 65 years and over) may also be struggling with significant depressive symptomatology (2). Depression is relatively common among the elderly, though its prevalence varies depending on residential setting and diagnostic approaches. Generally, prevalence rates are lowest in the community, where up to 3% of elderly persons suffer from clinical depression. Despite this apparent low prevalence rate, however, up to 15% of people living in the community may experience subsyndromal symptoms of depression. In contrast, clinical depression among the elderly is more prevalent in institutional settings, such as nursing homes and hospitals, where 10% to 15% suffer from major depression and 20% to 30% have significant depressive symptoms (3). Despite these high prevalence rates, depression remains underdiagnosed and undertreated (4). Further, many patients are inappropriately treated even when depressive diagnoses are made. Many untreated patients with depression are afflicted with feelings of hopelessness, despair, and existential suffering. Aaron Beck was one of the first to systematically study the link between depression and hopelessness (5). Additional research has confirmed the positive links between depression, hopelessness, and suicide (6–9), though these studies did not focus specifically on the elderly. More recently, Chochinov and colleagues (10) further confirmed these findings in their sample of terminally ill cancer patients, wherein the average patient was aged 71 years. The link between depression and hopelessness raises the following question: If hopelessness and despair contribute to depression and suicidal thought, then what is the role of hope in alleviating this distress? Although early research focused on the role of hopelessness, particularly in psychiatric settings, there has been a more recent shift toward understanding the role of positive indicators, such as hope, in chronic and life-threatening conditions (11). Clinically, many patients and health care professionals testify to the therapeutic value of hope in surviving and coping with chronic or life-threatening events. Empirical findings support these clinical observations, suggesting that hope may facilitate the coping process (12,13), promote healing (14–17), and enhance quality of life (18). Studies specifically examining the role of hope in the elderly have included several populations in different residential settings, such as the community (18–20), continuing care facilities (21–23), and senior citizen centres (24). Some studies have focused on the elderly person’s level of hope within specific illness states such as stroke (25), cancer (26), or cognitive impairment (27). These apparent links between existential issues, depression, and hope provided a conceptual framework for this pilot study. Our primary purpose was to explore the links between depression, the existential issue of integrity, and hope among an elderly population receiving psychiatric care. Our secondary objective was to assess the feasibility of discussing these issues within this population. Definition of TermsWe used Antonovsky’s Sense of Coherence scale (SOC) to measure integrity (28). SOC is a way of seeing the world or an orientation to life that facilitates successful coping. The SOC comprises 3 dimensions: Comprehensibility (the cognitive component), Manageability (the instrumental or coping component), and Meaningfulness (the motivational component). Regarding hope, we used Nekolaichuk and colleagues’ “hope model,” which used factor analytic procedures in a sample of 550 people (29). This model suggests that individuals experience hope along 3 interrelated dimensions: Personal Spirit, Risk, and Authentic Caring. Personal Spirit is a dimension revolving around a core theme of meaning. Within this dimension, a person’s level of hope is closely linked to their meaning in life. Risk is a situational dimension characterized by a common theme of uncertainty. Authentic Caring represents a relational dimension, with underlying themes of credibility and caring. Thus, a person’s hope may be associated with finding meaning in life, taking risks despite uncertainty, and experiencing credible and caring relationships. To assess depression, we used the conceptual framework of Brink and colleagues (30), which was developed specifically for the elderly population. This framework does not rely on somatic symptoms such as sleep disturbance, weight loss, or pessimism about the future, as they may be part of the normal aging process or related to some underlying physical illness. MethodsSample Eligible study participants were involved in a geriatric psychiatry inpatient, outpatient, or day hospital program in the Edmonton region; had an underlying psychiatric illness; were aged 60 years or over; were diagnosed as cognitively intact (that is, subjects had a Mini-Mental State Exam [MMSE] score of at least 26 with no diagnosis of dementia); were English-speaking; and were willing to participate in the study. Exclusion criteria included patients with an acute confusional state (that is, delirium), cognitive impairment (that is, an MMSE score of less than 26 or a diagnosis of dementia), or acute psychoses. All patients provided written consent to participate. The Ethics Review Committee at the University of Alberta and at the Regional Mental Health Service approved the study protocol. Data Collection Procedures Measures The GDSSF is derived from the 30-item GDS Long Form (GDSLF), which has high internal consistency and performance that is comparable to the Hamilton Depression Rating Scale (33). Correlations between the GDSSF and the GDSLF range from 0.66 to 0.89 (31,32,34). The GDSSF is currently being used as a clinical screening tool for most patients admitted to the NARG program. We operationally defined integrity, using Antonovsky’s SOC scale (28). We used the short version (that is, the SOC-13) because it is a brief self-rating measure of psychological well-being and health. Participants were asked to respond to 13 questions relating to different aspects of their lives, using a 7-point Likert scale. Possible scores range from 13 to 91, with higher scores indicating a greater SOC. This instrument has been used with several populations, including the elderly (35). The instrument’s psychometric properties are well documented, according to studies conducted in 20 different countries (36). In 16 studies using the SOC-13, Cronbach alphas ranged from 0.74 to 0.91. The SOC-13 has been positively correlated with global orientation, health, well-being, and coping ability. The factor structure for the scale suggests 1 dominant factor. The SOC-13 was included as a measure of psychological well-being in the 1994–1995 Canadian National Population Health Survey (NPHS) (37). A secondary analysis of the NPHS data included the SOC-13 scale as 1 of the 8 measures of Canadians’ mental health (38). The Hope Differential-Short (HDS) (39,40) is a 9-item measure assessing the personal experience of hope. In this study, patients were asked to rate their experience of hope against 9 bipolar adjective pairs, with each pair located along a 7-point continuum. The HDS is derived from a 3-dimensional theoretical framework with the subscales Personal Spirit, Risk, and Authentic Caring (29). From the HDS, 3 scores ranging from 1 to 7 can be calculated, with 1 score for each of the 3 dimensions. Higher scores indicate an enhanced hope experience. The HDS was used successfully in a research study in a palliative care setting where participants’ average age was 65 years (SD 14.4 years) (39,40). Further validation of the HDS is in progress (40). The Hope Numerical Rating Scale (Hope-NRS) comprises a single scale, with scores ranging from 0 ( “no hope”) to 10 ( “a great deal of hope”). For this study, we asked participants to select a number best describing their level of hope. The Hope-NRS has been used in several settings, including the general population (41), palliative care (39,40), and a recent population-based telephone survey that focused on health and hope (unpublished observations). Data Analysis ResultsDemographics Descriptive statistics for the measures of depression, integrity, and hope are shown in Table 1. On average, participants suffered from mild depression, though there was wide variability among responses. Participants displayed a moderate sense of integrity or coherence, though this also differed substantially across the sample. Although there was substantive variation among individual responses, participants, on average, were moderately hopeful and described their experience of hope as moderately enhanced on all 3 dimensions of the HDS.
Comparison of Patients With Depression and Without Depression We compared mean scores on the SOC-13, the HDS, and the Hope-NRS for the group with depression and the group with no depression, using a t test for independent samples (see Table 2). According to this analysis, patients with no depression had an overall greater sense of integrity and hope than did patients with depression.
Correlations Between Depression, Integrity, and Hope DiscussionThese study findings suggest that psychiatric patients who suffer from depression may have a diminished SOC (that is, integrity) and hope, compared with patients who do not suffer from depression. Buchanan’s comparative study of a clinical population of older adults with depression and with no depression supports these findings (44). Her study found that adults with depression had lower levels of meaning in life and hope than did adults with no depression and revealed an inverse association between meaning in life and depression. This is also supported by Moore’s phenomenological study, wherein suicidal elders described their experiences of meaninglessness under the broad theme of alienation (45). The associations between depression, integrity, and hope are further supported by our study findings, which suggest a moderately high inverse link between depression and integrity and between depression and the Risk subscale of the HDS. It appears that, as depressive symptoms increase in severity, patients’ sense of integrity and risk taking may diminish. An explanation for these associations is that patients with depression may be unable to negotiate the developmental tasks of aging, which leads to an ongoing sense of despair and hopelessness. According to this hypothesis, treatment of depression may enhance integrity and the hope experience and enable patients to address these psychosocial tasks. A second explanation is that integrity and hope may serve as resilient or protective factors against meaninglessness, despair, depressive illness, and suicide. Despite the substantive links between depression, integrity, and hope, the specific nature of these relations remains unclear. It is known, however, that hopelessness is closely linked to suicidal ideation (10,46) and is a substantive predictor of suicide (6–8). In addition, the elderly account for up to 25% of all suicides, with depression underlying two-thirds of these cases (47–50). The links between hopelessness, depression, and suicide are important areas for ongoing research. Despite these positive findings, 3 limitations need to be considered when the study results are interpreted. First, the small convenience sample, although seemingly representative of the study population, limits the generalizability of findings. Given the favourable results, a replication study with a larger sample is warranted. Second, we limited the depression assessment to a single measure. For future studies, a stratified sample could be used to classify participants according to depression severity (that is, normal, mild, and moderate-to- severe). Third, we measured all 3 concepts (that is, depression, integrity, and hope), using quantitative self-rating scales. Future studies might include clinical and qualitative assessments of depression, integrity, and hope, coupled with quantitative measures. In summary, it is apparent that depression, integrity, and hope are highly interrelated among the elderly population and may contribute to their mastery of the psychosocial tasks of late life. This study is unique because it concurrently addresses all 3 concepts with a specific focus on the elderly. These favourable findings suggest a compelling need for the intentional assessment of depression, integrity, and hope in clinical practice and further exploration of these concepts in research. AcknowledgementsWe acknowledge the support and assistance of Dr D Danyluk, Dr R Bland, the Division of Geriatric Psychiatry, the NARG program, and Mental Health Services in Edmonton. References1. Erickson EH. Childhood and society. 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Soc Sci Med 1999;48:591–605. 30. Brink TL, Yesavage JA, Lum O, Heersema PH, Adey M, Rose TL. Screening tests for geriatric depression. Clinical Gerontology 1982;1:37–43. 31. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5:65–172. 32. Alden D, Austin C, Sturgeon R. A correlation between the Geriatric Depression Scale long and short forms. J Gerontology 1989;44:124–5. 33. McDowell I, Newell C. Measuring health: a guide to rating scales and questionnaires. 2nd ed. New York (NY): Oxford University Press; 1996. 34. Lesher EL, Berryhill JS. Validation of the Geriatric Depression Scale-Short Form among inpatients. J Clin Psychol 1994;50:256–60. 35. Baro F, Haepers K, Wagenfeld MO, Gallagher TJ. Sense of coherence in caregivers to demented elderly in Belgium. In Steffanis C, Hippius H, editors. Neuropsychiatry in old age: an update. Toronto (ON): Hofrege and Huber; 1996. p 145–56. 36. Antonovsky A. The structure and properties of the sense of coherence scale. Soc Sci Med 1993;36:725–33. 37. Statistics Canada. National population health survey 1994–1995. Ottawa (ON): Statistics Canada; 1995. (Public use data files, Cat nr 82F0001-XDB). 38. Stephens T, Dulberg C, Joubert N. Mental health of the Canadian population: comprehensive analysis. Chronic diseases in Canada 1999;20(3):1–10. 39. Nekolaichuk CL, Bruera E. Assessing the experience of hope in palliative care patients. Psycho-Oncology 1999;8(Suppl 6):15. Abstract number 51. 40. Nekolaichuk CL, Bruera E. A validation study of the abbreviated Hope Differential in a palliative setting. Paper presented at the Canadian Association of Psychosocial Oncology (CAPO) Conference; May, 2001; Winnipeg (MB). 41. Averill JR, Caitlin G, Chon KK. Rules of hope. New York: Springer–Verlag; 1990. 42. Gall MD, Gall JP, Borg WR. Educational research: an introduction. 7th ed. Boston (MA): Allyn and Bacon; 2003. p 176. 43. Cwikel J, Ritchie K. The short GDS: Evaluation in a heterogeneous, multilingual population. Clin Gerontol 1988;8:63–71. 44. Buchanan DM. Meaning-in-life, depression and suicide in older adults: a comparative survey study. Dissertation abstracts international 1994;54:4075. Abstract nr AAT 9400098. 45. Moore SL. A phenomenological study of meaning in life in suicidal older adults. Arch Psychiatr Nurs 1997;11:29–36. 46. Uncapher H, Gallagher-Thompson D, Osgood NJ, Bongar B. Hopelessness and suicidal ideation in older adults. Gerontologist 1998;38:62–70. 47. Blixen CE, McDougall GJ, Suen LJ. Dual diagnosis in elders discharged from a psychiatric hospital. Int J Geriatr Psychiatry 1997:12:307–13. 48. Conwell Y, Brent D. Suicide and aging. Int Psychogeriatr 1995;7:149–64. 49. Moscicki EK. Epidemiology of suicide. Int Psychogeriatr 1995;7:137–48. 50. Schmid AH, Manjee K, Shah T. On the distinction of suicide ideation versus attempt in elderly psychiatric inpatients. Gerontologist 1994;34:332–9. Author(s)Manuscript received and accepted January 2004. Previously presented at the Spirituality and Health Conference; May 2001; Calgary (AB). Previously presented at the International Federation of Psychiatric Epidemiology; May 2002; Edmonton (AB). Previously presented at the Canadian Academy of Geriatric Psychiatry Annual Meeting; November 2002; Banff (AB). 1. Academic Program Director, Division of Geriatric Psychiatry, Northern Alberta Regional Geriatric Program, Glenrose Rehabilitation Hospital; Associate Clinical Professor, University of Alberta, Edmonton, Alberta. 2. Senior Research Associate, Alberta Cancer Board and Adjunct Faculty, St Stephen’s Theological College, Edmonton, Alberta. Address for correspondence: Dr WT Chimich, NARG Program, 10230-111 Avenue, Edmonton, AB T5G 0B7 e-mail: CLN1@ualberta.ca
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