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Original Article
Effects of group reminiscence on elderly depression: A meta-analysis
Dan Song a, Qin Shen a, Tu-Zhen Xu b, Qiu-Hua Sun a'*
a Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, China
b Department of Nursing, Zhejiang Chinese Medical University, Second Affiliated Hospital, Hangzhou, Zhejiang 310005, China
ARTICLE INFO
ABSTRACT
Article history:
Received 1 June 2014
Received in revised form
10 September 2014
Accepted 13 October 2014
Available online 1 November 2014
Keywords: Meta-analysis Group reminiscence Elderly depression
Background/purpose: The present meta-analysis was performed to evaluate the effectiveness of group reminiscence on depression in elderly patients.
Methods: Published and unpublished randomised controlled trials that assessed the effects of group reminiscence on depression in elderly patients were systematically reviewed using multiple electronic databases. Relative risks for dichotomous data and weighted mean differences for continuous data were calculated with 95% confidence intervals. Results: Ten trials were evaluated. Group reminiscence provided significantly greater relief of depressive symptoms than did the control intervention immediately after and 3 months after the intervention (p < 0.00001). However, this advantage disappeared 6 months after the intervention (p = 0.14). Group reminiscence significantly improved self-esteem and life satisfaction (p < 0.01).
Conclusion: Group reminiscence was associated with short-term depression relief among elderly patients with depression and effectively improved self-esteem and life satisfaction. Higher-quality large-scale randomised controlled trials are needed to confirm these findings.
Copyright © 2014, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/3.0/).
1. Introduction
The mental health of elderly people, especially the high incidence of geriatric depression, has become an issue of increasing concern with the rapid growth of the ageing population [1]. Geriatric depression refers to depressive disorders in people aged >60 years and is mainly characterised by a low
spirit, anxiety, retardation, and bodily discomfort [2]. According to a survey by the American Psychological Association in 2004, the prevalence of geriatric depression in the United States is about 20% [3]. Likewise, studies conducted in China have shown that 13.5%-33.5% of Chinese elderly persons have symptoms of depression [4-6]. Once diagnosed with depression, older persons are more likely to experience a deteriorating quality of life, poor social function, cognitive deficits, an
* Corresponding author.
E-mail address: sqh807@163.com (Q.-H. Sun). Peer review under responsibility of Chinese Nursing Association. http://dx.doi.org/10.1016/jijnss.2014.10.001
2352-0132/Copyright © 2014, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
inactive daily life, increased medical burdens, and possibly an increased risk of suicide and death [7]. Considering the high prevalence of and potential dangers associated with depression in later life, there is a critical need for effective and low-threshold preventive interventions to decrease depressive symptoms in elderly individuals.
Psychotherapy has recently received attention as a strategy to avoid antidepressant drugs and their side effects [8]. One type of psychotherapy that has been studied for this purpose is reminiscence. This intervention is cost-effective and relatively free from harmful effects [9]. The Nursing Interventions Classification defines reminiscence therapy as "using the recall of past events, feelings, and thoughts to facilitate pleasure, quality of life, or adaptation to present circumstances of self-esteem through confirmation of their uniqueness" [10]. Reminiscence therapy is basically divided into individual reminiscence and group reminiscence according to the method by which the therapy is conducted. Individual reminiscence therapy is normally conducted through face-to-face conversation or individual activities. Group reminiscence is mainly conducted through organised group activities in which elderly patients can achieve identification and a sense of belonging [11], which are beneficial for this population. Considering the critical ageing situation and scarcity of community medical resources in developing countries such as China, elucidation of the effects of group reminiscence and application of group reminiscence to Chinese elderly persons with depression is of great clinical and societal value. Therefore, we conducted the present meta-analysis to assess the effect of group reminiscence on geriatric depression and provide research-based evidence for use in nursing practice.
2. Methods
2.1. Inclusion criteria
Studies that assessed the effectiveness of group reminiscence on depression in elderly patients were considered eligible for this meta-analysis if they were randomised controlled trials, involved only >60-year-old participants, and evaluated the participants' depressive situation, self-esteem, and life quality as the primary outcomes of the study.
2.2. Exclusion criteria
Studies involving patients with severe organic mental disorders or other severe bodily illnesses such as stroke or malignant tumours were excluded from this meta-analysis. For trials that were published in duplicate, only the trial with the more detailed information was included in the meta-analysis.
2.3. Search strategy
The following electronic databases were accessed from January 1990 to March 2014: Medline, PubMed, JBI Library, CINAHL, EMBASE, the Cochrane Library, CNKI, VIP, Wanfang, Google, and Google Scholar. These databases were
electronically searched for relevant English and Chinese publications using combinations of the following search terms: "group reminiscence (therapy)," "geriatric depression," and "elderly depression." Trial registries at http:// clinicaltrials.gov and http://www.controlled-trials.com were also searched for unpublished trials. We individually selected potentially relevant studies by screening all retrieved citations and abstracts and agreed on potentially relevant papers to be retrieved in full. Disagreements were resolved by discussion or consensus with a third reviewer. The authors of studies containing incomplete data were contacted to obtain the relevant unpublished data.
2.4. Assessment of methodological quality
The methodological quality of all trials was graded using the Cochrane Handbook, Version 5.1.0, which assesses studies according to the method of randomisation, adequacy of allocation concealment, blinding of outcome assessment, proportion of patients lost to follow-up, application of intention-to-treat analysis, and comparability of baseline data. For each trial, the risk of bias was graded from A to C, where A indicates low risk, B indicates moderate risk, and C indicates high risk. Disagreement was resolved by discussion.
2.5. Data extraction
We independently extracted data from all studies using standardised forms. Data were extracted on study design, sample size, procedure type, intervention data, number and reasons for withdrawals and dropouts, and the outcome variables listed above. Disagreements regarding values or analysis were resolved by discussion.
2.6. Statistical analysis
This meta-analysis was conducted using RevMan 5.2.0 software (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012). The weighted mean difference (WMD) and 95% confidence interval (CI) were calculated for continuous variables, and the pooled odds ratio and 95% CI were calculated for categorical variables. Heterogeneity was evaluated by the I2 test. If I2 < 50%, a fixed-effects model was used; otherwise, a random-effects model was used. Subgroup analysis was undertaken according to the heterogeneous factors considered. A narrative overview was performed when synthesis was inappropriate.
3. Results
3.1. Study selection
The search strategy generated 531 studies. After screening the titles and abstracts, 508 articles were excluded. After reading the full text, a further 13 articles were excluded because they did not meet the inclusion criteria. The remaining 10 trials [12-21] involving 740 patients were included in the meta-analysis. Details of the included trials are summarised in Table 1.
Table 1 - Characteristics of studies included in the meta-analysis.
Author, yr Participants (I/C), n Time Use of antidepressants Intervention Control Time of assessment Endpoints
Gao, 2011 96 (47/49) 6 wk No Group reminiscence, 1 session per wk, 60—90 min per session Traditional mental health education, 1 session every 2 wk, 30-45 min per session End of intervention 1. Depressive symptoms (GDS-Chinese version) 2. Life satisfaction (LSIA)
Feng, 2010 129 (62/67) 6 wk Yes Group reminiscence, 1 session per wk, 90—120 min per session Traditional education of mental health, 1 session every 2 wk, 30-45 min per session End of intervention 1. Depressive symptoms (GDS-Chinese version) 2. Self-esteem (RES)
Wu, 2011 74 (35/39) 12 wk Not mentioned Group reminiscence, 1 session per wk, 60 min per session Traditional mental health education, 1 session per wk, 60 min per session End of intervention 1. Depressive symptoms (GDS-SF) 2. Self-esteem (RES) 3. Life satisfaction (LSIA)
Hsu, 2009 45 (21/24) 8 wk Not mentioned Group reminiscence, 1 session per wk, 60 min per session Traditional mental health education, frequency and intensity not mentioned End of intervention Depressive symptoms (GDS-SF)
Chueh, 2013 22 (11/11) 4 wk Not mentioned Group reminiscence, 2 sessions per wk, 60 min per session Traditional mental health education, frequency and intensity not mentioned End of intervention, 3 and 6 months after intervention Depressive symptoms (GDS)
Chiang, 2010 92 (45/47) 8 wk Not mentioned Group reminiscence, 1 session per wk, 60 min per session Traditional mental health education, frequency and intensity not mentioned End of the intervention, 3 months after the intervention Depressive symptoms CES-D(Center for epidemiological studies depression scale)
Chao, 2006 24 (12/12) 9 wk Not mentioned Group reminiscence, 1 session per wk, 60 min per session Traditional mental health education, frequency and intensity not mentioned End of the intervention 1. Depressive symptoms (GDS-SF) 2. Self-esteem (RES)
Youssef, 1990 42 (21/21) 5 wk Not mentioned Group reminiscence, 1 session per wk, 60 min per session Traditional mental health education, 1 session per wk, 60 min per session End of the intervention 1. Depressive symptoms (BDI) 2. Self-esteem (RES)
Pot, 2010 171 (83/88) 12 wk Not mentioned Group reminiscence, 1 session per wk, 120 min per session Traditional mental health education, frequency and intensity not mentioned End of the intervention, 6 months after the intervention Depressive symptoms CES-D
Jones, 2003 45 (21/24) 3 wk Not mentioned Group reminiscence, 2 sessions per wk, 60 min per session Traditional mental health education, frequency and intensity not mentioned End of the intervention Depressive symptoms GDS)
GDS, Geriatric Depression Scale; GDS-SF, Geriatric Depression Scale-Short Form; GDS-D, ; LSIA, Life Satisfaction Index-A; BDI, Beck Depression Inventory; RES, Rosenberg Self-Esteem Scale.
Table 2 - Evaluation of the methodological quality of the studies included ITT, intention-to-treat.
Study Random effect Blinding Allocation concealment Dropouts and loss ITT analysis Baseline Gra
Gao, 2011 Random number table Not clear Not clear None Not applicable No difference B
Feng, 2010 Random number table Not clear Not clear None Not applicable No difference B
Wu, 2011 Random number table Not clear Not clear None Not applicable No difference B
Hsu, 2009 Random number table Not clear Not clear None Not applicable No difference B
Chueh, 2013 Mentioned, but not described Not clear Not clear None Not applicable No difference B
Chiang, 2010 Random number table Not clear Not clear None Not applicable No difference B
Chao, 2006 Mentioned, but not described Not clear Not clear None Not applicable No difference B
Youssef, 1990 Mentioned, but not described Not clear Not clear None Not applicable No difference B
Pot, 2010 Random number table Not clear Not clear None Not applicable No difference B
Jones, 2003 Mentioned, but not described Not clear Not clear None Not applicable No difference B
3.2. Outcomes of methodological quality analysis
3.2.1. Overall depression alleviation
All 10 trials assessed the effects of group reminiscence on depression alleviation. One trial [21] was excluded due to obvious clinical heterogeneity. Another trial [19] was excluded because the researchers used a measurement technique that differed from those of the other studies; this trial was assessed separately (Table 2).
3.2.2. Immediate depression alleviation
Nine trials assessed the effects of group reminiscence on depression alleviation immediately after the intervention [12-20]. Eight trials used the Geriatric Depression Scale (GDS) to assess depressive symptoms [12-18,20]. The GDS has been modified into several different versions based on its use in different regions. Therefore, we performed a subgroup analysis to eliminate the heterogeneity caused by the use of these
different versions. The heterogeneity test revealed an I2 value of 0%; thus, a fixed-effects model was used. Regardless of which version of the GDS was adopted for assessment, the intervention group exhibited statistically significant alleviation of depressive symptoms (WMD, -4.39; 95% CI, -6.46 to -2.32; p < 0.0001). The trial that was assessed separately [19] used the Beck Depression Inventory and, like the other trials, showed significant improvement in the depressive symptoms in the intervention group (p < 0.05) (Fig. 1).
3.2.3. Long-term depression alleviation Three trials conducted a long-term follow-up assessment of depressive symptoms after the intervention [16,17,20]. A subgroup analysis was performed according to the length of follow-up. The heterogeneity test revealed an I2 value of 50%; thus, a random-effects model was used. Two trials [16,17] compared depressive symptoms 3 months after the intervention and found significant alleviation of depressive
Study or Subgroup
Experimental Mean SD Total
Control Mean SD Total Weight
Mean Difference IV. Fixed. 95% CI
Mean Difference IV. Fixer. 95% CI
1.1.1 GDS-chinese version
Feng 2010 7.8 3.63 62 12.62
Gao 2011 8.07 3.79 47 13.19
Subtotal (95% CI) 109
Heterogeneity: Chi== 0.07, df= 1 (P = 0.79); P = 0% Test for overall effect: Z= 8.87 (P < 0.00001)
4.63 4.65
1.1.2 GDS
Chueh 2013 Subtotal (95% CI) Heterogeneity: Not applicable Test for overall effect: Z = 5.17 (P < 0.00001)
10.09 4.06 11 19.8 4.73 11
1.1.3 CES-D
Chiang 2010 16.18 2.07 45 18.74
Pot 2010 14.97 7.4 83 18.17
Subtotal (95% CI) 128
Heterogeneity: Chi== 0.23, df = 1 (P = 0.64); P = 0i< Test for overall effect: Z= 5.70 (P < 0.00001)
1.1.4 GDS-SF
Chao 2006 Hsu 2009 Wu 2011 Subtotal (95% CI)
2.91 7.9 5.74
2.77 1.7 1.7
10 21 35 66
4.23 9.7 7.44
2.7 8.35
2 2.3 1.82
Heterogeneity: Chi= = 0.15, df = 2 (P = 0.93); P Test for overall effect: Z= 5.26 (P « 0.00001)
67 49 116
10.6% 7.5% 18.1%
-4.82[-6.25,-3.39] -5.12 [-6.81,-3.43] -4.94 [-6.04, -3.85]
1.6% -9.711-13.39,-6.03] 1.6% -9.71 [-13.39, -6.031
10 24 39 73
22.5% 3.6% 26.1%
4.8% 15.7% 33.6% 54.2%
-2.56 [-3.54,-1.58] -3.20 [-5.66,-0.74] -2.65 [ 3.56,-1.74]
-1.32 [-3.44, 0.80] -1.80 [-2.97,-0.63] -1.70 [-2.50,-0.90] -1.70 [-2.33,-1.06J
Total (95% CI) 314
Heterogeneity: ChP = 40.27, df= 7 (P < 0.00001); P= 83% Test for overall effect: Z= 11.21 (P < 0.00001)
Test for subarouo differences: Chi2= 39.82. df= 3 (P < 0.00001). P= 92.5%
335 100.0% -2.66 [-3.13, -2.20]
-20 -10 0 10 20 Favours [experimental] Favours [control]
Fig. 1 - Efficacy of group reminiscence on alleviation of depressive symptoms at the end of the intervention (fixed-effects model).
Study or Submenu
Experimental Control Mean Difference
Mean_SO Total Mean_SD Total Weialit IV. Random. 95% CI
Mean Différence W,Ran<R.n,№ÇI
1.3.1 3 month-follow up
Chiang 2010 1549 199 <5 19 43 2.22 47 431% -3.94 [-4.80.-3.08]
Chueh 2013 11.91 5.72 11 18.29 3.95 1 1 16 4% -6.38 [-10.49,-2 27]
Subtotal (95% CI) 56 58 59.5% 4.30 (-5.99.-2.60) Heterogeneity: T3u*= 0.68. ChP= 1.30. df= 1 (P = 0.25); l*= 23% Test for overall effect: Z= 4 97 (P < 0 00001)
1.3.2 6 month follow up
Chueh 2013 13.86 6.82 11 22.33 4.46 11 13.2% -8.47 [-13.29.-3.65]
Pot 2010 15.12 834 83 17.03 8.71 88 27 2% -1.91 [-4 47,0.65]
Subtotal (95% CI) 94 99 40.5% -4.861-11.26. 1.54] Heterogeneity: Tau*= 17.65; Chi*= 5.56. df = 1 (P = 0.02); l*= 82% Test for overall effect: Z- 1 49 (P = 014)
Total (95% CI) 150 157 100.0% -4.39 [-6.46. -2.321 Heteiogeneity: T3U*= 2.40; Chr= 7.18. df= 3 (P = 0 07); P= 58% Test for overall effect: Z = 415 (P <0 0001) Test for subarouo differences: Chi"= 0.03. df= 1 (P- 0 87). I' = 0%
-100 -50 0 50 100
Favours (experimental] Favouis [control]
Fig. 2 - Follow-up efficacy of group reminiscence on alleviation of depressive symptoms (random-effects model).
symptoms in the intervention group (WMD, -4.39; 95% CI, -6.46 to -2.32; p < 0.0001). Two trials [17,20] compared depressive symptoms 6 months after the intervention and found that the effects of reminiscence therapy on geriatric depression were no longer evident at this time point (WMD, -4.86; 95% CI, -11.26 to -1.54; p = 0.14) (Fig. 2).
3.2.4. Improvement in self-esteem
Two trials [16,18] used the Rosenberg Self-Esteem Scale to compare the level of self-esteem after the intervention. The heterogeneity test revealed an I2 value of 0%; thus, a fixed-effects model was used. The patients in the reminiscence intervention group exhibited a significantly greater improvement in their level of self-esteem than did the patients in the control group (WMD, 1.04; 95% CI, 0.52-1.56; p < 0.0001) (Fig. 3).
3.2.5. Life satisfaction
Two trials [12,16] used the Life Satisfaction Index A to compare the level of life satisfaction after the intervention. The heterogeneity test revealed an I2 value of 0%; thus, a fixed-effects model was used. The patients in the reminiscence therapy group exhibited a significantly greater improvement in their level of life satisfaction than did the patients in the control group (WMD, 1.23; 95% CI, 0.40-2.07; p = 0.004) (Fig. 4).
4. Discussion
Depression is one of the most common psychological problems worldwide and is a powerful predictor of life quality among older persons [22]. However, it is also one of the most misdiagnosed and untreated illnesses in the elderly
population, especially in developing countries [23]. Reminiscence is a naturally occurring process of recalling the past, which is hypothesised to resolve past conflicts and restore the patient's life balance [24]. Reminiscence has been adopted by researchers in various countries for treatment of elderly depression in recent years. This technique has been found to be an effective method by which to improve the detection and treatment rates of depression among elderly patients because it is safe for patients, easy for patients to implement, and easy for researchers and therapists to administer [25-27]. In 2003, a meta-analysis examined the effects of reminiscence on elderly depression and found evidence that reminiscence has advantages in the treatment of depressive symptoms [28]. However, outcomes other than depressive symptoms were not tested; moreover, the effect of group reminiscence was not analysed separately. Considering that group reminiscence may be more applicable in developing countries that lack community medical resources, such as China, we conducted the present meta-analysis to assess the effect of group reminiscence on geriatric depression with the goal of providing research-based evidence useful for nursing practice.
4.1. Effects of group reminiscence on geriatric depression
In the present meta-analysis, group reminiscence was more effective than control interventions for alleviation of depressive symptoms at the end of the intervention. This advantage lasted until 3 months after the intervention, but had disappeared by 6 months after the intervention. Additionally, group reminiscence was superior to control interventions in terms of improvements in self-esteem and life satisfaction.
SliKtvor Subgroup
Experimental Mean SD Total
Control Mean Difference
Mean SD Total Weinlil IV. Fixed, 35'/. CI
Mean Difforenco IV. Fixed. 95'à CI
Chao 2006 Wu 2011
29.18 26 71
12 25.88 35 23.S
1.96 1.67
Total (95% CI) 47
Heterogeneity Chi* = 012. df= 1 (P= 0.72); l"= 0% Test for overall effect: Z= 5.93 (P < 0 00001)
14.3% 85 7%
3.30 (0.78,5.82] 2 81 [1 78. 3.84]
51 100.0% 2.88(1.93,3.83)
-100 -50 0 50 100
Favouis [experimental] Favours [control]
Fig. 3 - Efficacy of group reminiscence on improvement in self-esteem (fixed-effects model).
Experimental Control Mean Difference
Stiiilv or Subgroup Mean SD Total Mean SD Total Weight IV. Fixed. 95% CI
Mean Difference IV. Fixed. 95% CI
Gao 2011 Wu 2011
13.65 4.85 10.49 1.85
13 10 9.21 2.14
Total (95% CI) 82
Heterogeneity: Chi== 0.15, df = 1 (P = 0.70); l== 0% Test for overall effect: Z= 2.90 (P = 0.004)
7.2% 0.65 (-2.45, 3.75] 92.8% 1.28 [0.41,2.15]
88 100.0% 1.23 [0.40, 2.07)
-4 -2 0 2 4 Favours [experimental] Favours [control]
Fig. 4 - Efficacy of group reminiscence on improvement in life satisfaction (fixed-effects model).
Limitations
Only studies published in English and Chinese were included because of language limitations. Additionally, the reliability of the results require confirmation because of the finite study sample. Finally, the included trials were characterized by avoidable clinical heterogeneity, such as differences in the intervention period; this may have led to some bias in the results of the meta-analysis.
4.3. Implications for further study
Group reminiscence is clearly an appropriate option for treatment of geriatric depression because it has significant advantages in terms of alleviation of depressive symptoms, development of self-esteem, and improvement in life satisfaction. However, further studies are needed to confirm the long-term effects of group reminiscence. Due to the lack of research in this area, high-quality randomised trials with large samples are needed to supplement the existing evidence regarding the advantages of group reminiscence. The results of our literature search indicate that the intervention periods and follow-up times of trials performed to date are relatively short. Further studies with longer intervention periods and follow-up times are suggested. This would allow the effects of group reminiscence at different intervention phases to be studied in depth.
Conflicts of interest statement
The authors declare that they have no conflicts of interest.
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