Effect of group reminiscence therapy on depression in older adults attending a day centre in Shiraz, southern Islamic Republic of Iran

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F. Sharif,¹ A.Mansouri,¹ I. Jahanbin ² and N. Zare ³

تأثير المعالجة الجماعية عن طريق الذكريات على الاكتئاب لدى كبار السن الذين يراجعون عيادية نهارية في شيراز، جنوب جمهورية إيران الإسلامية

فرخندة شريف، أمير منصوري، ايران جهان بين، نجف زير

الخلاصـة: هدفت هذه الدراسة إلى تقصِّي فعالية المعالجة الجماعية عن طريق الذكريات على أعراض الاكتئاب لدى المسنين الذين يراجعون عيادة نهارية في شيراز، جمهورية إيران الإسلامية، وشملت الدراسة 49 شخصاً تزيد أعمارهم على 60 عاماً وساهموا في 6 جلسات استذكار كانت تعقد مرتين أسبوعياً ولمدة 3 أسابيع مع استيفاء نسخة بالفارسية من مقياس الاكتئاب لدى المسنين الذي يتألف من 15 بنداً. وقد نقصت الأحراز الوسطية للاكتئاب بقدرٍ يُعْتَدُّ به إحصائياً من 8.18 (بانحراف معياري 1.20) قبل التدخل إلى 6.73 (بانحراف معياري 1.20) وذلك مباشرةً بعد المعالجة، ووصلت إلى 7.55 (بانحراف معياري 1.19) بعد مرور شهر على التدخل. وعندما حلل الباحثون النتائج وفق الخصائص الديموغرافية، وجدوا أن الحالة الزواجية بمفردها ذات اختلاف إحصائي يُعْتَدُّ به في أحراز الاكتئاب بالمقارنة بين ما قبل التدخل وما بعده.

ABSTRACT The aim of this study was to examine the effectiveness of group reminiscence therapy on depression symptoms among elderly people attending a day centre in Shiraz, Islamic Republic of Iran. A sample of 49 people aged 60+ years participated in 6 group reminiscence sessions that were held twice weekly for a 3-week period and completed a Farsi version of the 15-item geriatric depression scale. Mean depression scores decreased significantly from 8.18 (SD 1.20) before the intervention to 6.73 (SD 1.20) immediately after it and 7.55 (SD 1.19) 1 month after the intervention. When analysed by demographic characteristics only marital status showed a statistically significant difference in depression scores comparing before and after the intervention.

Effet de la thérapie par la réminiscence en groupe chez des personnes âgées consultant dans un centre de jour à Shiraz (sud de la République islamique d’Iran)

RÉSUMÉ L’objectif de cette étude était d’évaluer l’efficacité de la thérapie par la réminiscence en groupe chez des personnes âgées consultant dans un centre de jour de Shiraz (République islamique d’Iran). Un échantillon de 49 personnes âgées de 60 ans et plus a pris part à 6 séances de réminiscence en groupe. Ces séances, organisées deux fois par semaine sur une période de trois semaines, ont été complétées par une version en farsi de l’échelle de dépression gériatrique à 15 items. Les scores de dépression moyens ont diminué de manière significative, passant de 8,18 (écart type 1,20) avant l’intervention à 6,73 (écart type 1,20) immédiatement après, et à 7,55 (écart type 1,19) un mois après l’intervention. Lors de l’analyse en fonction des caractéristiques démographiques, seule la situation matrimoniale a révélé une différence statistiquement significative dans les scores de dépression avant et après l’intervention.

¹Department of Mental Health Nursing; ²Department of Public Health; ³Department of Statistics, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran (Correspondence to F. Sharif: This email address is being protected from spambots. You need JavaScript enabled to view it.).

Received: 01/02/08; accepted: 10/06/08

EMHJ, 2010, 16(7): 765-770

Introduction

The rising proportion of elderly people in the population in both developed and developing countries is creating new health care challenges in the 21st century [1–4]. Older age is inevitably accompanied by an increasing risk of physical and psychological disorders. Depression is the most common psychiatric disorders in older people [5], with estimated rates ranging from 10% to 65% [3]. One study in Isfahan, Islamic Republic of Iran found that the rate of depression among older adults was 64.4% [6].

Depression and other mental health disorders can have serious negative outcomes in old age. In addition to reducing the general quality of life, depressive symptoms in older adults have been linked to earlier mortality, greater disability, higher health care utilization, longer length of hospital stay [7], increased risk of infections, falls and injury, poorer nutrition [8] and increased risk of suicide [9]. However, depression is one of the most misdiagnosed, undiagnosed and untreated illnesses experienced by the elderly [5].

As a strategy to avoid antidepressant drugs and their side-effects, psychotherapeutic approaches can provide significant and sustained benefits in terms of improved quality of life for elderly patients. One type of psychotherapy that has been researched is participation in reminiscence groups. This intervention is cost-effective and relatively free from harmful effects [10]. Reminiscence is an activity that can allow elderly people a sense of security through rehearsal of comforting memories, of belonging through sharing, and of self-esteem through confirmation of their uniqueness [11]. Faced with the increasing numbers of elderly people in the population, nurses need to be knowledgeable about reminiscence therapy and its relation to health promotion for the elderly. The aim of this study was to examine the effectiveness of group reminiscence therapy on depression symptoms among community-resident elderly people attending a day centre in Shiraz, Islamic Republic of Iran.

Methods

Study design

The study used a quasi-experimental design, with measurements of depressive symptoms on a group of elderly people before, immediately after and 1 month after the reminiscence therapy intervention.

Study setting and sample

The study was conducted from September to December 2007 at the Jahandidegan centre, a day centre affiliated to Shiraz welfare organization. Established in 1998, the centre has about 4500 registered members aged 55+ years of age (about 3000 aged 60+ years). The members participate voluntarily in various activities at the centre.

The participants for this study were recruited through flyers and by word of mouth. The selection criteria for the study were female and male adults aged 60+ years, who were living in the community (i.e. outside a primary care setting) and who were members of the centre. The exclusion criteria were: having a personal crisis during the intervention (e.g. loss of a significant other) or suffering severe physical or psychological disorder; receiving antidepressant medication; participating in other activities during the intervention (e.g. sports/physical activities, muscle relaxation, yoga or counselling); unmarried; not having orientation to time, place or person; having major depression (GDS-15 score > 10). On the basis of these criteria and taking account of the ratio of males to females and the ratio of participants to non-participants in the programmes, 300 active older adults were selected randomly to complete the depression scale.

Data collection

The instrument used in the study was the 15-item geriatric depression scale (GDS-15), a shorter version of the 30-item GDS [12]. Malakouti et al. have validated a Farsi version the GDS-15 on a community sample [13]. Their results showed that the GDS was an internally consistent measure, with alpha, split-half coefficients and test–retest reliability of 0.90, 0.89 and 0.58 respectively. They concluded that the Farsi version was a valid and reliable screening instrument for major depression in older people in the Islamic Republic of Iran [13].

After an explanation of the aims of the study by the researcher, the 300 members completed the GDS-15 and 50 participants with all the required criteria and GDS-15 score ≤ 10 out of 15 were selected as the study sample for the intervention. All participants in the intervention completed the GDS-15 before the start of the intervention, immediately after the last session and 1 month after the last session of reminiscence therapy. Illiterate participants completed the questionnaire with explanation and help from a co-researcher.

To ensure confidentiality, no direct or indirect identification of the participants was used. The participants and the principal of Jahandidegan centre gave their verbal and written consent for participation in the study.

Intervention

The selected subjects were divided into 5 groups for participation in the group reminiscence sessions (6 sessions were held twice weekly for 3-weeks). For this study, 12 topics were used as a basis for discussion (2 topics per session) and each person separately talked about his or her reminiscences on that topic. The topics used in this study were: young adult life prior to meeting their spouse, first meeting with spouse, courtship process, wedding day, setting up house, housekeeping, married life prior to having children, having children, married life after having children, life after children left home, having grandchildren, life as a spousal caregiver and current life situation. At the end of the session, the researcher summarized the memories of the members and the members were notified about the topics for the next session.

Data analysis

SPSS, version 13 was used for data analysis. The Mann–Whitney test and Kruskal–Wallis test were used for evaluating the correlation between participants’ depression scores and their demographic characteristics. Wilcoxon signed ranks test was used to find out the effect of group reminiscence on the depression of the subjects before and after the intervention.

Results

Out of the final sample of 50 people, complete data were obtained on 9 men and 40 women (1 woman was excluded due to illness). The demographic characteristics of the participants are presented at Table 1.

Table 2  shows the GDS-15 scores of the whole group of older people before and after the group reminiscence intervention. The mean depression score before the intervention was 8.18 [standard deviation (SD) 1.20] and this decreased significantly immediately after the end of the intervention to 6.73 (SD 1.20) (P < 0.001). One month after the intervention the mean depression score had increased to 7.55(SD 1.19), although this was still significantly lower than before the intervention(P < 0.001). Therefore, the decrease in the overall mean depression scores comparing before and immediately after the intervention was 1.45, whereas comparing scores before and 1 month after the intervention the decrease was only 0.63.

Table 1 shows the decreases in GDS-15 scores before and after the intervention by participants’ demographic characteristics and history of medical or mental illness. When analysed by Mann–Whitney and Kruskal–Wallis tests, only marital status had a significant effect on scores. Married people showed a statistically significant decrease in GDS-15 scores immediately after group reminiscence (P < 0.022) and 1 month after the intervention(P < 0.014) compared with before.

Discussion

As the number of elderly people continues to grow, the need for studies to examine effective and accessible mental health treatments becomes ever more pressing. The aim of the present study was to examine the effectiveness of group reminiscence therapy on depression symptoms among community-resident elderly people attending a day centre. Reminiscence therapy is conceptualized as a natural process that enables the elderly to organize and evaluate their life experiences. It is one of the most commonly used approaches to group therapy with the elderly. The discussion about past events, whether joyful or painful, allows group members to become acquainted with one another at a deeper level, promotes the development of group cohesion and permits supportive grieving and the affirmation of accomplishments.

Reminiscence may be used as the central focus of group therapy or as an aspect of an integrated approach [14]. The literature contains many studies which put forth evidence of the adaptive functions of reminiscence therapy. The concept of ego integrity, defined in Erickson’s stage of life model, is often used to promote quality of life in care of the elderly [15]. Butler recognized the value of life review as the primary means of achieving ego integrity. Through the process of reminiscence an individual can make sense of his/her past, enabling him/her to accept the past and recognize its value [16]. As Myerhoff explains, “the integration with earlier stages of being confident provides the sense of ‘continuity and completeness’ that may be considered as an essential developmental task in old age” [17]. Sometimes, suggested Molinari and Reichlin, grappling with the past to accept those conflicts and working through unresolved issues is achieved through reminiscence [18].

In the present study the data analysis revealed a statistically significant decrease in depression scores comparing before, immediately after and 1 month after the intervention. The findings are in accordance with those of Jones, who showed that group reminiscence therapy was an effective treatment for reducing depression in the elderly if it stimulates past memories and conversation among the group members [19]. Gatz identified a number of mechanisms of change that improve the mental health of the elderly: fostering a sense of control, self-efficacy and hope; establishing relationships; providing or clarifying a sense of meaning for the events of life; promoting educational activities and development of skills; and finding new ways of coping [20]. The advantages of group work with older people include reducing loneliness, increasing social interactions and normalizing the process of ageing [21].

We used 12 topics for managing the group reminiscence sessions, with 2 topics per session. The use of themes or topics in reminiscence groups is frequently mentioned in the literature and is recognized as an aid to provide a structure and format for groups [22]. However, there is lack of agreement about the most therapeutically effective topics [23].

Group reminiscence therapy also provides a warm and empathic environment to help the subjects feel free to engage in overt reminiscence. The advantage of group reminiscence may be that it provides the subjects with an opportunity for self-expression. The subjects control the recall process and therefore can downplay or emphasize certain aspects of their lives as desired. The National Institute of Nursing Research stated that cost-effective non-pharmacological methods of reducing depression in elderly people are required and that even small improvements should be viewed as worthwhile [24]. Health professionals, especially nurses, can learn reminiscence therapy as a useful strategy in the care of the elderly. However, to ensure that reminiscence therapy is effective in various settings that are related to older adults, nurses must consider the specific values and experiences of older people in a specific cultural group. Nurses are needed to evaluate and design interventions targeting the mental health needs of older adults, especially those residing in long-term care facilities. Consequently, it seems plausible that strategies for enriching the lives of elderly people are crucial, and that reminiscence offers a method of promoting healthy ageing.

Although a follow-up was done 1 month after the intervention in this study, caution is necessary when interpreting the advantages of group reminiscence because several previous investigations have demonstrated that the affective improvements resulting from reminiscence were more short term than long term [25]. Therefore if reminiscence group therapy is to enhance the lives of the impaired elderly it should be a part of a continuous and ongoing programme.

There were some limitations to the current study. The study was conducted in one geographic area of the city and the sample size was small. Therefore the generalizability of the results to other elderly populations is limited. There was no control group and participation in the pre-test may have an effect on the post-test score of the case sample. Also, subjects with depression scores > 10 were excluded, and so the effect of the therapy on severe depression was not studied. We recommend replicating the study using different group settings, with a larger sample size and using a control group.

We conclude that group reminiscence therapy improves the depression scores of older people attending a day centre. The findings of this study can provide a basis for planning geriatric care in the community and geriatric care centres. Intervention strategies focusing on prevention and improvement of depression in older people need more exploration.

Acknowledgement

Research funding for this study was provided by Shiraz University of Medical Sciences Vice Chancellor for Research.

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