Received date: June 12, 2016; Accepted date: June 29, 2016; Published date: June 30, 2016
Citation: Ali SA, Suhail N, Ali SA. Low Self- Esteem Leads to Depression Among Elderly: Case Study of Nursing Home. J Univer Surg. 2016, 4:2.
Background: Self-esteem is defined as “how we value our self”; it affects our trust and relationships in every part of life. Person with low self-esteem may feel powerless and incompetent about himself/herself. Moreover, low self-esteem operates as a risk factor for depression, which is most common disorder among elderly people both in developed and developing countries, causing multiple behavioral changes as well as may increase the chances of depression and suicide among the elderly people. Objective: The objective of this case study was to understand the problems faced by elderly people in the nursing home and to relate the self-esteem with depression among them. Methods: A face to face in-depth interview was conducted with a 70-year-old female living in the nursing room. Her perceptions for life were explored through a questionnaire. Findings of case study: It was observed that old lady was unable to express herself and was reluctant in sharing her views with interviewer. According to her, she was introverted and was unable to interact socially with other people because of physical disability. She used to feel unworthy and always used to think that she cannot do anything and was not encouraged by her colleagues and always been criticized by others. She was found to be depressed and had no meaning to life. Conclusion: It can be concluded that depression is one of the common problems among geriatric population, attributed to low self-esteem. Based on the personal observation during the interview, it is recommended that such clients should be encouraged, educated and counseled appropriately to enhance their trust and confidence. There should be some mechanism by which a space can be provided to them to interact with people outside their limited circle and to share their problems with their colleagues and relatives if possible. This may enhance their self-esteem and may decrease the chances of depression among elderly.
Self-identification, self-respect and self-esteem is parts of every one’s life. Self-esteem can be defined as how we value our selves and it affects our trust and relationship in every part of our daily life . In contrast, low self-esteem refers to a reflection of central negative views about self and it is important not only for adults but also for children and elderly people . Looking at the population pyramids of various countries, it can be observed that elderly population is growing persistently either due to increased life expectancy or due to advancements in science and technology [3,4]. These demographic and scientific changes have increased the needs of old population which may lead to undesirable consequences if not fulfilled appropriately. Such consequences might include poor quality of life and lower selfesteem, which in result may lead to anxiety and depression . Low self-esteem may predict the depression later in the life of an individual particular in the older age .
Predictors and outcomes of low self-esteem
Various reasons of low self-esteem might have been highlighted in the literature including loneliness/isolation , medical conditions, physical disabilities [7-9], social reasons [9,10], low socioeconomic status  and cultural reasons such as stigma, being unmarried and ashamed [12,13]. Individuals with low self-esteem are more sensitive to denial and have a tendency to withdraw and reduce interpersonal closeness after conflicts, thereby declining attachment, support, and satisfaction in close relationships . Moreover, low self-esteem is considered as a risk factor for depression, which is most common disorder among elderly population both in developed and developing countries , causing multiple behavioral changes [15,16], which may increase the chances of suicide and mortality among the elderly people . It is estimated that about 150 million people worldwide are affected with depression at any moment in time, and one in every five women and one in every eight men experience an episode of major depression over the course of their life [18,19].
Models and theories, relating self-esteem and depression
Different models have been stated in the literature, which relate the self-esteem with depression. These include vulnerability model, which states that low self-esteem is a causal risk factor for depression. According to Beck’s cognitive theory, negative beliefs about the self are not just a symptom of depression but play a critical causal role in its etiology and this was also observed during my clinical rotation. On the other hand, reciprocal relational model states that self-esteem and depression are reciprocally related to each other, while diathesis-stress model states that low self-esteem is a predisposing factor that exerts causal influence only if the person simultaneously experiences life stress . In the face of challenging life circumstances, people with low self-esteem may have fewer coping resources and may prone to spiraling downward depression . Apart from this, low selfesteem may contribute to depressive symptoms through several interpersonal and intra personal pathways. One interpersonal pathway is that few individuals with low self-esteem individuals excessively seek reassurance about their personal worth from friends and relationship partners, increasing the risk of being rejected by their support partners and thus increasing the risk of depression. A second interpersonal pathway is that low selfesteem motivates social avoidance, thereby delaying social reinforcement and social support, which has been linked to depression .
Considering the clinical scenario and based on the personal experience of author, it can be said that low self-esteem may affect elderly’s life and may lead to depression among them. Improving self-esteem and letting old aged people to perform optimally may lead to early recovery and sense of wellbeing . It is essential that along with providing treatment, support and help in the physical aspect of health and attention should also be paid to the psychological needs of the elderly people . It is highly important to build up the confidence and trust of the elderly people, as we experienced with our client too. During initial conversation, we found our client bit hesitant in talking and sharing her views openly. When we personally provided a space and opportunity to our client, she was able to talk and shared her views and problems with us comfortably.
A face to face in-depth interview was conducted with a 70-yearold lady living in one of the nursing homes of Karachi, Pakistan. Through that interview, her perceptions for life were explored through a questionnaire. During interview, it was found that she was unmarried and she belonged to a middle class and had been living in a nursing home for couple of years. She was a registered nurse by occupation, had six family members and suffering from multiple diseases like Diabetes Mellitus, Hypertension and Stoke. During the interview, it was observed that she was unable to express herself and was reluctant in sharing her views. According to her, she was introverted and was unable to interact socially with other people due to her physical disabilities. She used to feel unworthy and always used to curse herself that she cannot do anything. Moreover, she also mentioned that she was not encouraged by her colleagues and had always been criticized by others.
Strategies to overcome the depression among elderly
Older adults, in particular, often experience higher rates of loneliness and social isolation . This occurs for a variety of reasons, including death of social ties, relocation to different types of living and care communities, and limitations in physical and mental health. In addition, age is negatively related to network size, closeness to network members, and number of primary group ties . Thus, it is highly important to identify these causes at early stage to avoid the long term consequences among elderly. Moreover, knowledge about mediating processes between low self-esteem and depression is of vital importance because it may provide possible triggers for interventions aimed at preventing or reducing the depression. Hence different strategies could be proposed to promote mental health of the client within the context of the issue, for example all residents of a nursing home could be encouraged to interact together in a group to share their ideas and views with each other. The interviewer performed exercise by gathering the residents in the group, which was found to be very helpful for both the client and peers. Different positive ways can be taught not only to clients but also to care givers to ensure that self-esteem of the elderly people can be increased .
It has been noted that depression in one person has contagion effects on others close to him/her not only in terms on health but also in terms of their productivity and well-being . Thus it is highly essential that family and community members of the elderly population should also be provided with the information and knowledge regarding the relationship between low self-esteem and depression. Moreover, exercise therapy among older people may be an effective tool to overcome depression and to improve the self-esteem in the long term . In addition to this, promotion and disease prevention programs and strategies should also focus on elderly people to avoid depression among them . Multiple methods with proven effectiveness have been highlighted in the literature including educational, psychotherapeutic, pharmacological, lifestyle, and nutritional interventions. Furthermore, cognitive behavior strategies, interpersonal psychotherapy along with medications (imipramine) prescribed by physician may decrease the risk of depression among elderly . Moreover, core components of effective collaborative care programs can be planned to focus patients identified with depression, measurement-based care, treatment to target, and stepped care in which treatments are systematically adjusted and “stepped up” if patients are not improving as anticipated. Such an approach might dramatically improve patient satisfaction and health outcomes .
Based on the personal observation during the interview, it is recommended that such clients should be encouraged, educated and counseled appropriately to enhance their trust and confidence. There should be some mechanism by which a space can be provided to them to interact with people outside their limited circle and to share their problems with their colleagues and relatives if possible. This may enhance their self-esteem and may decrease the chances of depression .
Strong community and social support networks can be formed through different organizations to arrange some preventive programs for elderly people. Such programs may help the elderly people to feel positive about themselves and about their close relatives. Moreover, policies and laws can be made at national level about the rights of geriatric population, which may bound everyone to take care of the elderly people and to resolve their issues by understanding their psychology without any delay .
Furthermore, focus on risk factors for developing depression in general (sleep disturbance, social isolation, and disabilities associated with medical and neurological disease). In the prodromal phases, it is not yet clear which disorder will develop. Such an approach might extend the focus of prevention and stimulate collaborations among different subfields of prevention of depression .
Finally, it remains unknown what is the most effective strategy to reduce the burden of depression, thus focused research is required to determine which type of prevention would be best to reduce the burden of depression . Thus additional research is needed on how to make these effects sustainable. Furthermore, use of booster sessions and Internet technologies should be explored. Moreover, resilience is associated with favorable treatment outcome in patients with depression and/ or anxiety disorders. In this regard, the identification of specific characteristics related to resilience that could provide targets for resilience-enhancement interventions is needed . Cognitive emotion regulation strategies of refocus on planning, positive reassessment, and less rumination contribute to resilience in patients with depression and anxiety disorders.
Depression is one of the common problems among geriatric population, attributed to low self-esteem. Different models have also explained the relationship between low self-esteem and depression. Such models may help to develop various preventive strategies to build up the confidence and trust of elderly people because elderly people are important assets of our society and without whom this world would be unpleasant.