Our study explored the lived experiences of depression and anxiety among Peruvian older adults from low-resource settings. The ideas, concepts, causes, and coping strategies for depression and anxiety overlap. Depression was represented mainly as sadness, loneliness, and lack of desire to do things. The word ‘anxiety,’ in turn, was difficult to define, with the word being associated, in several cases, with a compulsive desire to eat. ‘Nervios,’ and ‘enfermo de los nervios’ were idioms used to describe a worrying state that generates tremor, insomnia, and restlessness. Peruvian older adults indicated that the main causes of depression and anxiety symptoms are constant familial and economic problems, loneliness, loss of independence and past traumatic experiences (childhood). Coping strategies Peruvian older adults use to reduce depression and anxiety symptoms include self-reflection and adaptation, ‘do your part’ (poner de tu parte), and getting emotional support mainly from non-professionals such as relatives, friends, acquaintances, and God/religion.
Peruvian older adults described being depressed by emphasizing emotional symptoms such as sadness, loss of interest, and loneliness, which is consistent with other qualitative studies (15, 26). On the other hand, older adults associated anxiety with compulsive eating, which highlights the feeling of loss of control (27). Some studies have hypothesized that individuals with anxiety symptoms cope by using momentary experiences of pleasure, such as eating, to forget real-life problems (28). Moreover, in the Peruvian sample, while the word anxiety did not trigger answers related to general anxiety disorders (GAD), idioms such as nerves (‘nervios’) did describe a state that includes characteristics of GAD such as restlessness and tremors (29). ‘Nervios’ has been frequently described among Mexicans and other Hispanic countries (26, 30). The study of ‘nervios’ is extensive, and it has been suggested that it is a syndrome of chronic dysphoric mood with somatic complaints (31) whose origins are rooted in social problems (32). Independently of the exact definitions, for some Peruvians older adults, ‘nervios’ were perceived as something that can be mitigated with anxiolytics. Considering the frequency and characteristics of use, ‘nervios’ may be a gateway for exploring symptoms of anxiety in Peruvian and other older Latino populations.
Peruvian older adults described loneliness as a feature of depression and also as precursor for it, which is compatible with several studies of depression in older adults (20, 33). Loneliness has independent detrimental effects on cognition, mobility, and daily life activities (34, 35). Older adults do not require simply the presence of others (in fact, most Peruvian in our study live with their relatives), but also the presence of individuals with whom they can trust, interact, and work together (36). From the point of view of Peruvian older adults, children often do not carry out their inherent duty of taking care of them. Although it is unknown if older adults fostered good relationships with their offspring when they were children, traditional values in Latin America such as family closeness seem difficult to achieve for younger generations, as they often have competing obligations and expectations.
Regarding the perceived link between chronic diseases and depression or anxiety, qualitative studies among older adults from different settings have reported this link (15, 37). Nevertheless, in our sample, what caused stress in Peruvian older adults was not the diseases themselves but the impact on their ability to interact with people and/or to continue doing what they want. This idea is concordant with the WHO patient-centered care emphasis on functional ability and maintenance of independence, rather than multi-morbidity, in older adults (38, 39).
Peruvian older adults stressed the importance of prior traumatic experiences, which are perceived as the origin of depression/anxiety symptoms. We believe that experiencing trauma was common because the majority of our participants came from socially disadvantaged backgrounds. Similarly, a study that explored the experiences of disadvantaged African American women found that women associated the origin of their depression to their history of trauma, including sexual abuse and poverty (40).
Regarding strategies to cope with depression and anxiety in our study, older adults often stated that reducing depressive and anxiety symptoms comes from within themselves. The main ideas was ‘self-reflection and adaptation’ to circumstances you cannot change and ‘doing your part,’ making an effort to feel better. Several studies among older adults have highlighted the importance of oneself in overcoming depression, calling it ‘inner strength’ or ‘self-reliance’ (14, 41, 42). Viewing personal responsibility as key to overcoming depression and anxiety can be seen in two opposing ways: as a potential barrier to health seeking behavior, since someone who sees the solution in their own mind may not recognize the purpose of seeking care from a professional (21), or as a potential gateway to introducing psychological techniques to strengthen cognitive self-coping mechanisms (41).
Coping strategies also included seeking emotional support through interacting with someone he/she trusts. In our study, several participants expressed family problems and were ashamed to disclose their thoughts with relatives because they did not think they would be understood. Similarly, studies in European samples mentioned that older adults did not want to burden relatives with more problems (43), while in a group of Korean-American individuals, it was considered a sign of weakness to share problems with one’s social network (21). In general, our findings suggest that Peruvian older adults are willing to receive support from sources outside their inner family circle. Additionally, religion and God was mentioned as an important way of alleviating negative feelings. Activities such as prayer, talking to a pastor, or going to church were cited as ways to obtain mental strength and reduce depression/anxiety symptoms. Other studies has described an increasing capability to manage difficult situations in individuals with a spiritual relationship with God (44).
The strengths of this study include our leveraging a large project that measured quantitative scores of depression and anxiety, which allowed us to purposively select older adults with a wide range of illness experience of depression and anxiety. In addition, we carried out interviews and data analysis in the native language of the participants, which enabled us to more deeply understand the situations, analogies, experiences and idioms used. Regarding limitations, first, since the parent study excluded older adults that were physically unable to perform spirometry, we may have missed highly dependent older individuals with different illness experiences. Second, since most of our sample were ‘younger old,’ our results could reflect an illness experience closer to the perspectives of younger adults. Nonetheless, we did include seven participants that belonged to the ‘oldest old’ category (≥ 75 year-old). Finally, the sample was composed mainly of low-income Peruvian older adults living in semi-urban areas. Older adults from rural areas or that have better socioeconomic status might have different views of depression and anxiety.
This study has implications for community interventions in older adults. First, mental health initiatives should include common expressions and idioms such as ‘nervios’ that older adults used because it is a gateway to talking about disturbing feelings and somatic symptoms. Second, any intervention that attempts to improve mental health in older adults should address loneliness. Public health researchers and practitioners should treat loneliness as a health problem, which means active screening and provision of effective social and psychological interventions (35). Third, while a comprehensive approach for multi-morbidity is important, special attention should be given to conditions that reduce the capacity of older adults to engage in social interactions. For instance, hearing aids could have a tremendous positive impact for older adults’ daily lives. Fourth, interventions for older adults from underserved areas should systematically screen for childhood traumatic experiences. Attachment-based psychological interventions appear beneficial for individuals with adverse experiences (45). Fifth, personal responsibility to cope with depression and anxiety is a natural coping mechanism. Instead of discouraging it, it may be an opportunity to introduce psychological techniques that can be used for older adults to help themselves. Finally, Peruvian older adults were receptive to obtaining emotional support from non-professionals. Community interventions might incorporate individuals and social groups, working in tandem with the health system, trained to provide mental health care or act as navigators between older adults and health professionals.