Sample characteristics
We invited 44 individuals to participate in this study. Nevertheless, five refused to participate due to lack of time or interest. One individual was excluded during the interview due to untreated schizophrenia. As a result, we had a sample of 38 participants (23 women and 15 men). Table 1 describes the social and clinical characteristics of the participants. In all, 31 participants were considered ‘younger old’ (60-74 years) and seven were ‘oldest old’ (≥ 75 years). One man lived alone, while the rest of the participants lived with one or more family members. Eleven people (28.9%) had only depressive symptoms, 11 people had only symptoms of anxiety, and 11 had symptoms of anxiety and depression. Fourteen (41.2%) reported having visited a psychologist or psychiatrist during their lifetime, and seven (21.9%) had taken medications related to depression or anxiety symptoms.
Emerging themes were organized into three main sections: 1) experience and perceptions of depression and anxiety; 2) causes of depression and anxiety; and 3) ways of coping with depression and anxiety (Figure 1).
Experience and perceptions of depression and anxiety
For most participants, the word ‘depression’ was more familiar than ‘anxiety.’ Older adults mentioned that people who are depressed express sadness, a reluctance to do things, and feel lonely, hopeless, and useless. Some older adults said that those feelings can be accompanied by headaches. One woman, who had seen a psychiatrist previously for depression treatment but had no current symptoms of depression/anxiety explained how she felt when she had depression:
‘You do not feel like doing anything and everything seems monotonous, absurd, you do not see meaning in your life …everything, every day is the same’ (61 year-old woman)
Some older adults (7/39) felt such desperation that they mentioned suicidal ideation in their narratives.
‘Last year, as I was crossing a bridge, it crossed my mind what it would like to toss myself over (laughs). Would I kill myself? I thought to myself. Now it scares me, I don’t go to that bridge, I don’t go up there like I used to’ (64 year-old woman)
On the other hand, when we asked, ‘How does a person with anxiety feel?’ or even ‘How do you feel when you are anxious?’ a considerable group (20/38) had no answer and replied ‘I don’t know.’ Among those who replied, the most common response associated with the term ‘anxiety’ was having an uncontrollable desire to eat.
‘That I understand well, that anxiety to eat, [like when] you’re hungry, you’ve had lunch, eaten everything, but you still want food, that’s anxiety.’ (60 year-old woman)
The idioms nerves (‘nervios’), sick from nerves (‘enfermo de los nervios’), and nervousness (‘nerviosismo’) were evoked in roughly half of older adults’ narratives, especially among the oldest old. Those idioms were associated with someone who is severely worried and experience tremor, restlessness, headaches, and sweating.
‘I worried a lot, I have a son that rents his house, and what he earns is not enough to pay, all those things worried me. From anything, I would worry immediately. I am a nervous person, I suffer from nerves, my whole body begins to tremble.’ (Woman, 81 year-old)
Remarkably, two of older adults who had received or were taking anxiolytics mentioned that their physician prescribed them to treat their ‘nervios.’
‘There is a pill that I take that relaxes me a little bit, a little pill that the doctor had given me. [I take them] in the mornings, to relax, to be calm during the day, because otherwise I am desperate, worried, thinking’ (81 year-old woman).
Although we asked about depression and anxiety separately, the vast majority of older adults (20/38) used the word ‘anxiety’ to express how they feel when they are ‘depressed’, and vice versa. Sometimes older adults also used the word ‘stress’ (‘estresado’) to define depression or anxiety, though a small group of participants (4/38) do mentioned the differences between having depression and anxiety.
‘Depression is when you’re already depressed, so you don’t want to do anything. Anxiety is when you are there staring [blankly into space] without knowing what to do’ (69 year-old man)
Causes of depression and anxiety
The principal causes of depression and anxiety expressed by Peruvian older adults followed four themes: ‘family and financial problems,’ ‘loneliness,’ ‘loss of independence’ and ‘past traumatic experiences.’
Family and financial problems
The most common cause of depression/anxiety mentioned was having ‘life problems,’ which usually referred to problems within the family (poor relationships and/or financial constraints). Older adults worried about their own financial situations and also about the situation of relatives. Moreover, most participants live with relatives in the same household (mainly children and extended family), and older persons are often present when disputes or arguments arise.
‘You know, from so much worrying, so much fuss, and your child doesn’t have work, your husband, one worries, you know? So many problems, I think that’s what it comes from, depression’ (64 year-old woman)
Loneliness
Feeling lonely was described as a major cause of depression/anxiety in almost all older adults. It is important to note that here we refer to feeling lonely as opposed to living alone. Older adults indicated it is not enough to simply live in the same place as relatives, to have food or a roof over their heads. Older adults seek a genuine interest in them, their health, and wellbeing from relatives and others in their social network.
‘I feel like alone, that's why I have entered into a state of anxiety…, ‘you feel alone, [your children] never even ask how you are doing. Did you drink something? Did you eat? What did you do today? Nothing, you have children there just for decoration.’ (60 year-old woman)
Most participants stated that children have an inherent duty to take care of their parents, or at least to visit them. Several participants expressed that they worked hard for the sole benefit of their children, giving them as much as they could of themselves. When this inherent duty is not met, loneliness increased:
‘When, for instance, a son that I have, I don’t even know how long it has been, [he] is an official in the air force. It has already been six months since he last visited me. Those things make you sad, because when you raise children, with love even if it’s under [the stresses of] poverty, they are still your children. Later, they forget about you…That [really] affected me, that’s how depression has affected me.’ (61 year-old woman)
Loss of independence
Few older adults directly linked depression or anxiety with having a chronic disease. Nevertheless, chronic disease was highlighted when associated with loss of independence to do activities they want to do. Sensory (auditory and visual) and mobility problems (e.g. chronic back or knee pain) were most distressful, especially among the oldest old. Sensory and mobility problems affect the ability to interact with friends and family members, making them embarrassed and self-conscious, reinforcing isolation from others and feelings of loneliness:
‘[When] my son comes over, he talks with me, sometimes I can’t hear him (laughs), which makes me uncomfortable, and well, [my hearing problem] is never going to be fixed. I tell my wife about it, she tells me not to worry ... but it bothers me’ (80 year-old man)
‘Sometimes I start to think about it, I think my destiny is to live alone, you know? Here, under this roof, … the bad thing is that I can’t see, ...the cataract messed up my vision ... If my vision were ok, I would leave [the house], I would sit outside, or I would go out to the soccer field, or be able to see when someone is passing by..’ (88 year-old man)
Past traumatic experiences
Most of the older adults interviewed (30/38) had vivid memories of traumatic episodes during childhood that they continue to think about in older age, especially women, who mostly reported trauma related to sexual violence. Some men also reported trauma related to work exploitation when they were children or teenagers. We included traumatic experiences as a cause of depression because older adults seem to have unresolved thoughts about those situations that appeared to contribute to increased feelings of loneliness, depression, and anxiety. The following woman almost at the beginning of the interview shared why she thinks she had depressive symptoms:
‘The thing is that this sadness, this feeling, this anger I have had since I was a girl. My mom was not a good person…she made one of those shamans [sexually] abuse me. Ever since, this [experience] has made it impossible for me to be happy. I thought to myself…so many times I asked myself (cries), how could she be my mother and do that to me?’ (63 year-old woman)
Ways of coping with depression and anxiety symptoms
We asked participants what they do to reduce feelings of depression and anxiety. As family problems, loneliness, loss of independence, and past trauma co-exist and interact, the overall coping strategies were to stop thinking too much and to avoid constantly ruminating on their problems. We summarize older adults’ strategies under four rubrics: ‘Self-reflection and adaptation,’ ‘do your part”, and ‘get emotional support’ from different sources.
Self-reflection and adaptation
Some older people mentioned that it is important to self-reflect and accept that some situations may be beyond your control. One older woman summarized this idea by saying that ‘we can’t carry the weight of the whole world’; rather, one must accept certain aspects of life.
‘I didn’t want to live, but I said ‘No, why do I have to be like that? Yes, my daughter has left. Everyone has to leave. [But] no, my children are not my property.’ (70 year-old man)
Do your part (“poner de tu parte”)
Older adults highlighted that people have to do their part as a key step in recovery, to make an effort to think positively. It was a common idea that nobody will recover from having depression/anxiety if a person does not make an effort:
‘To feel better, I have to think about cheering myself up …who can cheer me up? Nobody…I have to just [do it myself], my problem has to be carried by myself alone’ (75 year-old man)
Older people expressed that they often try to distract their minds to avoid thinking too much. People described different ways of distracting themselves such as going out, continuing to work (if one enjoys work), or even doing activities at home (e.g. knitting, watching TV, or listening to the radio).
‘Because (working) is my therapy, yes! Thank God that I like what I do, I love weaving, and I thank the woman who appeared on my path, who taught me and started me in this work, in this trade that I’m very grateful for’ (62 year-old woman)
Get emotional support
Older adults talked about seeking emotional support from different sources, such as in religion/God, family members, acquaintances or people from the community, and health professionals. They mentioned that support (‘apoyo’) is fundamental to recovery. Most participants (35/39) mentioned faith in God as a source of emotional support. Older adults stated that having the support of God relieved them from their problems, made them stronger, and gave them peace. Furthermore, some older adults stated that they do not need psychologists to reduce their symptoms because they have God.
‘My psychologist is God, and I prayed to him every night to take those [feelings] away from me, and little by little, they went away.’ (61 year-old woman)
Some older adults (15/38) said that relatives should help someone distract themselves, do activities together, or cheer them up. Likewise, older adults stated that having close, trustworthy friends helps reduce loneliness and depressive symptoms. A group of older adults (12/38) mentioned that sometimes it is easier and more comfortable to have a conversation with someone other than a relative or close friend. Therefore, some older adults sought out strangers or acquaintances for conversation, as they might give them a more ‘objective’ point of view regarding their problems. A taxi driver explained:
‘What I do sometimes is, since I’m a taxi driver, and someone [mature] and prepared [gets in my taxi] and gives me an opportunity to tell them my problems, I feel relieved, because if not, it stays inside of me. You don’t have anyone, if you tell your family, they will tell someone else, your brother, brother-in-law, and it becomes [gestures “something bigger” with hands], but people that don’t know you, you’ll never see again.’ (63 year-old man)
Some older adults described participating in social groups such as Seniors Clubs (‘Club del Adulto Mayor’), which are composed of peers engaging in leisure activities or participating in religious groups where people can pray together. Older adults in such social groups expressed a sense of support from the group, which seemed to help older adults to stop dwelling on their problems.
‘I like [the Seniors Club], mostly because, as you see here, I am by myself, and at the [Seniors Club], at least, I laugh, I play’ (72 year old woman)
Very few older adults mentioned psychologists as sources of support or relief. Psychiatrists were even less commonly mentioned. Older adults usually reported that they did not share feelings with a physician because ‘[the physicians] do not have time.’ Older adults who had appointments with a mental health professional did not go directly to them but were referred after being seen for a different condition such as heart problems or headaches. Some who had had appointments with a psychologist reported helpful experiences, and some reported ‘it was a waste of time’ because the visit consisted of just talking or revisiting negative experiences.