Exploring the Links Between Depression, Integrity, and Hope in the Elderly

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Exploring the Links Between Depression, Integrity, and Hope in the Elderly

http://www.cpa-apc.org/Publications/Archives/CJP/2004/july/chimich.asp

"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).

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