Depressive Symptoms in Older People of San Vicente-Cape Verde (Africa)

Depressive symptomatology has been identified as one of the most common psychiatric disorders in the elderly, and there is very little investigation in Cape Verde about this topic. The aim of this study was to assess depressive symptoms in the elderly in São Vicente Cape Verde, aged 65 years and over. It is a cross-sectional descriptive study with a convenience sample. The instruments used were the Geriatric Depression Scale, the Katz index and a socio-demographic questionnaire. A sample of 204 elderly individuals participated in the study. The results indicate that 45.6% of respondents had no depression, 38.7% mild depression, and 15.7% had severe depression. In this study it was also observed that there is a higher incidence of depressive symptoms in women than in men, and among the elderly who are institutionalized compared to the non-institutionalized. The results suggest that depressive symptoms in elderly of São Vicente-Cape Verdeis a problem that needs more comprehensive studies to be able to devise strategies of intervention of this type of symptoms that reduce the longevity and quality of life of older people.


Introduction
The aging of the population is of great interest globally, implying major challenges for society, for services and for individuals who grow older. The increasing incidence of neuropsychiatric disorders in the elderly population, including the cognitive decline, dementia and depression are the most common pathologies [1]. The growth of the older adult population in Africa demands more knowledge about their chronic health problems, such as depression [2]. The issue of aging in Cape Verde is an emerging issue for which are defined some policies and strategies. In 1995 the government presented a set of recommendations by the National Population Policy Statement, with the aim of carrying out a policy for seniors. However, the development of studies on how people age in Cape Verde seems to be an unexplored terrain, which calls for the need for research in this area so that strategies to promote quality of life elders of Cape Verde can be defined.
The cultural context of aging in Cape Verde differs from, for example, the European countries, because the elderly occupy a place of highest privilege. In Cape Verdean culture, it is considered that, in old age, people are holders of cultural and traditional values, and have extensive life experience, playing an important role in the education of grandchildren and performing household chores. The Cape Verdean society is also characterized by the principle of solidarity, well evidenced by the high number of elderly people economically dependent of other family members. However, the majority of older people from Cape Verde depend on their job, pension from the National Institute of Social Security, or a minimum social pension.
The aging process is often associated with losses at various levels, including social, economic, psychological and family. Examples of losses on the social network, for example loss of friends and family, loss of social roles, such as active worker, problems and changes in the level of health and physical appearance among others. However, the majority of older people are able to moderate the impact of this type of losses, changes or life events that may arise during the aging process [3,4] and this is observed because of the fact that the subjective wellbeing in old age does not decrease [5]. However, there is a considerable proportion of older people who have difficulties in this stage of the life cycle, often developing in depressive symptoms.
It is very likely that depression is the leading cause of emotional distress at the end of life, decreasing significantly the quality of life of older people [6][7][8]. According to Blazer [9], a significant proportion of older people, for different reasons, have difficulties at meeting the demands of this phase of development and, often display depressive symptomatology.
However, depression in the elderly often not diagnosed due to its frequent atypical presentation and the fact that it's often presented with co morbidity with other disorders such as dementias, somatization, and low response to antidepressant medication or exacerbation of complaints associated with higher anxiety scores. Apart from major depressive disorder and dysthymia, many varieties of depression have been described as under-symptomatic and / or specific to the elderly [10].Another possible reason for underdiagnosis of depression among older people is the fact that, mistakenly professionals consider that sadness is a part of the aging process. Nonrecognition of depression in old age has several consequences, including compromised quality of life of the elderly and their families, poor prognosis, cognitive decline [11], increased risk of suicide [12]and mortality [13],and decreased physical capacity [14]. These consequences, in addition to compromising the quality of life and health of older people, hinder the provision of care for the elderly, often implying a greater need for formal care and institutionalization of the elderly.
Different studies on the incidence of depression in old age differ significantly in terms of results. Some studies point out to between 15% and 30% [15]. Older people living in institutions tend to have higher rates of depression than elderly community residents. For example, Irigaray and Schneider found that the rate of elderly with depression living in the community is 4.8 to 14.6% and 22.0% in elderly people who are hospitalized or institutionalized. Some authors point out that among the elderly seeking medical treatment in outpatient facilities, in general, rates of depression range from 14% to 52%, and that for the institutionalized elderly, the index ranges from 25% to 80% [16].
The disparity observed in the incidence of depression in old age in different studies can be related, among other factors, to the diversity of instruments used for assessing depressive symptoms in old age. For example, some authors choose specific instruments for depression in old age, such as the Geriatric Depression Scale [17]and others use scales or diagnostic criteria used for the general population. Although the depression in old age is an issue extensively investigated in western cultures, results on the incidence of depression in aging for all countries, including Cape Verde, isn't available.
According to the review of the literature we conducted, the topic of depressive symptoms in elderly of São Vicente -Cape Verde -is not investigated. Considering the relevance of this issue to promote the quality of life in old age, this study aims to: (1) assess depressive symptomatology in the elderly living in Sao Vicente -Cape Verde. We intend to further evaluate and compare depressive symptoms among the elderly: (2) males and females; (3) community-dwelling and institutionalized; (4) with reasonable and low socioeconomic status, and (5) with different levels of education. To this end we established the following hypothesis: H1: Women present higher levels of depressive symptoms than men.
H2: Institutionalized participants present higher levels of depressive symptoms than participants who live in their communities.
H3: Participants with socioeconomic low status present higher levels of depressive symptoms than participants with reasonable socioeconomic status.
H4: Less educated participants present higher levels of depressive symptoms than more educated participants.
Regarding the perception that participants have of their health, the majority (79.9%) of participants think that they have some pathology, and that they have reasonably good health (61.8%). In Table 2 information concerning the general characterization and selfassessment of general health is systematized. Regarding the functionality of the participants, according to the results obtained by using the Katz index, most participants have high functionality levels, as shown in Table 3.  It was also used the Katz Index. This is a scale of Assessment of Activities of Daily Living. This instrument consists of questions about the person's ability to perform day-to-day tasks such as, for example, washing, dressing, using the toilet, move around, to be continent or feed him/herself. The scale consists of 18 items, with multiple choice answers. This scale allows characterizing the degree of autonomy / dependence of the individual in performing tasks inherent and necessary to their daily functioning.

Procedures
The study took place on the island of São Vicente, Republic of Cape Verde which is located 500 km from the West African coast. The project of this investigation, including documentation and tools, was sent to the National Research Ethics Committee for Health of Cape Verde, and was approved. The following applications for authorization to officers, directors and presidents of various institutions which held the collection of the data were made: Doctor Baptista de Sousa Hospital; Health Department; Nursing homes of the Red Cross; Social Development Centers of the island of São Vicente and the Cape Verdean Association for Support of the Elderly. After the authorization of the institutions, we proceeded to a direct contact with the elderly, obtaining an informed consent from all study participants, to ensure all ethical procedures required for this type of work. A pilot application of the instruments to a group of 12 seniors who showed no difficulty in understanding the questions was made. The collection of data was done individually by face to face interviews. We opted for the oral application / reading of instruments in order to facilitate the implementation of instruments and facilitate understanding of the items, since the majority of participants was illiterate. Subsequently, data compilation, analysis and discussion of the results were made.

Statistical analysis
Data analysis was performed with SPSS Statistics 19.0. Basic descriptive analysis and the internal consistency by Cronbach's alpha coefficient for the GDS scale were made. The normality of distribution was analyzed using the Kolmogorov-Smirnov test, yielding a p-value of 0.000, is thus rejecting the null hypothesis, that is, the hypothesis of the distribution is not normal. Assuming that the distribution is not normal, we used the Mann-Whitney U test to test whether levels of depression among older people from different groups were significantly different or not.

Ethical approval
This study was approved by the scientific and ethical committees of the Research Unit of Health and Psychology (UIPES-ISPA, Institute of Applied Psychology in Portugal).
The comparison between men and women, showed statistically significant differences (z=-1675, p=0.000), with higher levels of depressive symptoms among women (M=13:05, SD=6.37) when compared to men (M=11.60, SD=6.23) (   Concerning the comparison between institutionalized elderly participants and residents in the community, the results indicate that the average GDS score for institutionalized elderly was 16.68 (SD=5.66) and for the non-institutionalized it was 12:03 (SD=6.25), which are statistically significant differences (Z=-3,508, p=0.000).
A more detailed analysis of the results at the level of depressive symptoms according to the place of residence indicates that, of the 22 participants (10.8%) living in nursing homes, three participants showed absence of depression, 11 showed mild depression, and 8 showed severe depression. As for the 149 (73.0%) participants who reside with their children or other family members, the results indicate that 72 (35.3%) did not experience depression, 60 (29.4%) had mild depression, and 17 (8.4%) severe depression.
Concerning the comparison of depressive symptoms among older adults with higher and lower economic statuses, the results indicate the existence of statistically significant differences (z=-2367, p=0.000), showing that the elderly with lower economic resources have an average value of depressive symptoms (M=13:26, SD=6.24) higher than that of older people who have a more favorable situation regarding their economic situation (M=11:32, SD=6.36).
Regarding the level of education, when comparing the average levels of depressive symptoms among participants with and without instruction, the results indicate statistically significant differences (z=-3197, p=0.000). The elderly illiterate participants have higher levels of depressive symptomatology (M=13.74, SD=6.44) than the elderly who have some type of instruction (M=10.88, SD=5.86).

Discussion
Taking as reference the generality of the results of different investigations on the incidence of depression in old age, data from this study brings attention to the high number of older people with depressive symptoms in this group of elderly respondents from S. Vicente-Cape Verde. This study shows that 38.7% of participants have mild depression and 15.7% had severe depression. Considering, for example, the results of [20]which points out that, according to the review carried out for a prevalence of depressive symptoms in the elderly between 7.2% and 49%, we find that the results observed in this study are in line with that observed in other countries, but higher than the results obtained by Thapain Ghana and South Africa where the prevalence of mild and severe depression was 6.7% and 2.7% respectively. This result is also higher than stated by different studies, particularly when indicated, for example, in the study of Maciel and War on the Brasilian northeast, indicating a prevalence of depressive symptoms of 25.5%. The results of this study indicate that we need to analyze in more depth and in representative samples of the elderly population of Cape Verde the incidence of depression in old age to ascertain and discuss strategies for assessment and intervention for depression in old age. The high number of older people with depressive symptoms found in this study may, among other factors, be related to the fact that depression does not yet constitute a public health problem in Cape Verde which makes people devalue this important pathology that clearly compromises the quality of life and longevity in old age. relation to depressive symptoms in the general population and in elderly populations. These results are somewhat similar to those found, with older people, which had found 30.1% for women and 15% for men results. The reasons underlying this gender difference discussed widely in the literature lie in biological, cultural and relational reasons, also observed in elderly men and women of Cape Verde. In addition to the causes of biological order that may underlie the psychosocial and cultural level, women are more easily allowed to take the sadness or despondency than men still tend to be associated with one gender role most associated with resistance and invulnerability before life and adversity.
With regard to depressive symptoms in institutionalized elderly, the literature review indicates that there higher depressive symptoms in elderly institutionalized subjects [21], when compared to elderly residing in the community [20]. Based on H2 we can observe that the results found in this sample of elderly Cape Verdeans corroborates the idea that the situation of institutionalization can be a predictor of onset and / or worsening of symptoms in cases of old age. It should be noted however that this difference between institutionalized and noninstitutionalized elderly was not observed in some studies [12]. Although the number of participants who were institutionalized in this study was low (n=22) participated in this study almost all of the S. Vicente institutionalized elderly aged over 65 years. Thus, these results emphasize, once again, the institutional context of care for the elderly as a possible risk factor for the occurrence of depressive symptoms in old age. Although most elderly of S. Vicente -Cape Verdeparticipants in this study, stay with relatives, 73.0% of participants live with their children or other family member, and institutional context seem little normative in the elderly Cape Verdean, these results deserve attention. The results emphasize the need for a thorough descriptive analysis of the user's profile of people who use such services in Cape Verde and contextual variables that may be related to the occurrence of depressive symptoms. Anticipating that the emerging aging population in Cape Verde can generate an increase in demand for such services, like is found in other countries, this work becomes essential for them in order to be seen as promoters of services to better the quality of life for the elderly dependent in Cape Verde.
Based on H3 and H3 we can observe that older people with more disadvantaged economic situation and with lower or no literacy levels which have more depressive symptoms, compared to elderly with better economic situation and more literacy. These results thus suggest that for the elderly surveyed in S. Vicente-Cape Verde, the contexts of greater economic vulnerability and information can directly or indirectly be associated with depressive symptoms in old age. This suggests that both the promoting of psychosocial interventions for better living conditions and access to information may be a strategy to promote mental health in old age.

Conclusion
In short, this study calls attention to the fact that in the group of elderly respondents from S.Vicente -Cape Verdea very significant presence of depressive symptoms was observed. Given the known implications of depressive symptoms in old age in compromising the quality and longevity in old age, these results call for the need for a thorough study of depressive symptoms in old age. As the aging population in Cape Verde is an emerging theme, it is considered that further analysis of this issue with the design and implementation of an epidemiological study could be an important basis for the work to devise policy interventions and promote active aging in Cape Verde.
Chronic illness, such as disability and depression among the aging population, is a growing public health concern in developing countries, including Cape Verde.
This study restricts generalizations, because it was done using a convenience sample. It will be important to analyze how to implement a population-based study or a representative sample of the population in future studies. Another important limitation relates to the instruments used. In Cape Verde the option is at the level of psychological assessment, to use of instruments Portuguese population, since Portuguese language is the official language. The scale used in this study, showed an acceptable internal consistency, however, the question of the appropriateness and psychometric scale used in the study population qualities puts up very urgently. It is recommended the construction and validation studies on instruments there are specific to the Cape Verdean population. Especially when it comes to elderly people, this is an important issue, given the cultural specificities of this group. This is a pioneering study in Sao Vicente -Cape Verde, and this could be the starting point of a necessary work to alert to the need for a broader study regarding the rise of depressive symptoms and mental health in old age.