An audio message arrives via WhatsApp: “If you’re feeling low, lacking energy, and don’t feel like doing anything, choose an activity that interests you and do it, even if you don’t feel like it at the time.” This is an excerpt from one of the 48 messages sent over a six-week period to participants of the Viva Vida program, created by scientists from Brazil and the UK to help elderly patients of Brazil’s national public health system (SUS) deal with depression and to improve their mental health.
Led by Brazilian psychologist Marcia Scazufca of the University of São Paulo (USP) and Chilean psychiatrist Ricardo Araya of King’s College London, the strategy consisted of sending automated audio messages, approximately three minutes in length, to the cell phones of program participants four times a week. Each message was planned to provide information about depression (explaining the symptoms and how they manifest in everyday life) and explain what can be done to feel better (carrying out enjoyable activities, for example) to combat the disorder and to prevent relapses.
Scazufca and her colleagues conducted a pilot version of the program on a group of people aged over 60 treated at basic health centers in Guarulhos, a municipality of Greater São Paulo with 1.3 million inhabitants. To engage participants, the program used narrative techniques and simulated a radio program in which two presenters—Ana and Leo—read letters from fictional characters about how depression affected them and how Viva Vida helped them tackle the disorder. The results, published in the journal Nature Medicine in March, are encouraging and suggest that the approach accelerated the recovery of the participants.
In the test, 298 people with moderate (40%) and severe (60%) depression (levels that make daily activities difficult and deserve medical or psychological attention) were randomly chosen to join a group that received WhatsApp messages for six weeks. Participants were told to keep taking their usual medications, and those undergoing treatment for depression were instructed to continue. They were also given a support number to contact if they had any difficulty receiving or hearing the messages. Another 305 people were randomly selected to be part of the control group, who were sent a single six-minute audio message with information about depression and ways to deal with symptoms. The profile of the participants in both groups was very similar: 82% were aged between 60 and 69, 72% had less than eight years of formal education, and 63% received the minimum monthly wage or less. All were advised to seek care at a basic health center if their symptoms worsened.
In an assessment carried out one and a half months after the end of the program, 109 people in the group (42.4%) that received the messages had recovered from their depression, according to a telephone questionnaire commonly used by primary healthcare services. The same was true of 87 participants (32.2%) from the control group. “The difference of 10 percentage points may seem small, but considering the very low cost of Viva Vida and the very large proportion of the population it could potentially reach, these 10 points could represent millions of untreated people,” says Scazufca. Before the study began, less than 15% of the participants in either group had been diagnosed with depression and were undergoing any type of treatment.
Two months after the program ended, during the second assessment, the difference had disappeared and half of the members of each group were feeling better. According to the authors, the results suggest that the strategy works well in the short term, accelerating recovery. “The improvement might be sustained for longer if people continue to receive messages or other forms of support,” Scazufca surmises.
Depression is a common disorder among the elderly and it can go unnoticed because people think it is just a normal part of aging
Marked by deep and prolonged feelings of sadness, as well as despondency, pessimism, trouble sleeping, and persistent low self-esteem, depression is a common problem among the elderly. In a paper published in the Asian Journal of Psychiatry in 2023, a team led by psychiatrist Yu-Tao Xiang of the University of Macau, China, reviewed data from 55 international epidemiological studies and estimated that globally, depression affects 35% of elderly people — especially in the poorest countries.
“Depression is an extremely common disorder, even more so in elderly people treated in primary care. It can go unnoticed because people think their symptoms are just a normal part of aging,” explains geriatrician Milton Crenitte, technical director of Brazil’s International Longevity Center, a nongovernmental organization that seeks to improve aging policies. “Some situations and events in life, such as loneliness, social isolation, retirement, chronic pain, and awareness that the end of life is approaching, represent risk factors that increase the likelihood of a person developing depression,” says Crenitte, who did not participate in the current study.
In Brazil, the situation appears less serious, although the frequency of the problem has increased in the last decade and the population is aging rapidly (see Pesquisa FAPESP issue nº 254). An analysis published in Epidemiology and Health Services in 2022, led by Maria Carmen Viana, a psychiatrist from the Federal University of Espírito Santo (UFES), indicates that the prevalence of depression among over-sixties increased from 9.5% in 2013 to 11.8% in 2019, reaching 13.2% in the 60 to 64 age group. Studies carried out by Scazufca in deprived areas of Guarulhos, however, suggest that this proportion may be as high as 30% in this population.
Despite its high rate of occurrence, access to treatment is still scarce. Brazil has a high number of health professionals who specialize in mental health, with a total of 347,000 according to the Mental Health Atlas 2020, published by the World Health Organization (WHO). This corresponds to 164 mental health professionals for every 100,000 inhabitants, higher than in half of the richest countries in the world (62/100,000). In Brazil, however, only 7,800 are psychiatrists (2.2% of the total) and 28,900 are psychologists (8.3%). The majority (85%) are other professionals, such as occupational therapists. Furthermore, most of this workforce is concentrated in the southeastern states.
One of the consequences is that most people with depression do not receive adequate treatment consisting of psychotherapy, antidepressants, or a combination of the two. The WHO recommends that this service be initiated by the primary care system, a function performed in Brazil by basic health centers. However, just over half (56% to 62%) of people aged over 60 in the country receive treatment for depression, almost always in the form of medication, according to data from the most recent National Health Survey, published in 2019. The report does not state how many elderly people are undergoing psychotherapy, but the average among all adults with depression is 19%.
When they planned Viva Vida, Scazufca and Araya were aiming to develop an effective and acceptable strategy for the elderly that would be affordable for the health system and would not require the participation of basic health center professionals. The pair had previously tested another mental healthcare strategy for elderly people with low incomes and education levels in Guarulhos called Proactive. The program was based on the idea of sharing tasks, through which professionals who are not specialists in mental health are trained and take on the responsibilities of working with patients to relieve the burden on specialists. Proactive was led by community health agents with support and collaboration from other family health professionals, and its results were even more robust than Viva Vida.
Aline van Langendonck
In the program, carried out in 2019 and 2020, 360 randomly selected over-sixties with moderate to severe depression treated at basic health centers in Guarulhos received home visits from community health workers for 17 weeks. The objective of monitoring patients in their homes was to increase adherence to treatment and provide care for elderly people who find it difficult to get out of bed or move around. During visits, community health workers spoke to participants and used a tablet to show them videos about how to recognize and tackle the symptoms of depression. They then discussed activities the patients could do during the week to help them feel better. In addition to receiving home care, the elderly participants continued with the usual treatment offered by basic health centers. The 355 people in the control group only had access to the standard basic healthcare treatment, comprising medical consultations and drug prescriptions.
In a first assessment carried out eight months after the project was finished, 158 of the 253 people (62.5%) who completed the follow-up process had recovered from their depression. The results, published in The Lancet Healthy Longevity in October 2022, showed that this proportion was much lower in the control group (44%), which did not receive home care. The benefits of the intervention also persisted over time. Four months later, at a second assessment, 60% of the people given psychosocial support at home continued to feel better, compared to 41% in the control group. Furthermore, symptoms of anxiety were reduced and quality of life improved in the patients who received home visits.
Psychiatrist Marcos Antônio Lopes of the Federal University of Santa Catarina (UFSC) believes both studies have merit and either strategy could be adopted by the national public health system. He makes one caveat, however: “Brazil is highly unequal and not everyone has access to tablets and cell phones, which excludes part of the population that needs treatment,” highlights the doctor, who was not involved in the research.
Orestes Forlenza, a USP psychiatrist who did not participate in the Guarulhos-based studies, says that making patients aware of their depression is itself beneficial. “The two studies show nonpharmacological strategies that are useful for tackling depressive conditions and can largely improve the situation of a vulnerable population often deprived of stimuli. They can be used with milder cases that do not require medication, just guidance on changing habits,” he points out. “Initiatives like these are welcome and positive.”
A few years ago, Forlenza and colleagues evaluated how art therapy can affect depression in women over 60 receiving medical care. Up to 40% of the group that participated in 20 weekly 90-minute sessions experienced a reduction of at least 50% in their symptoms, according to the results published in the Brazilian Journal of Psychiatry in 2018. The same occurred with only 4% of women in the control group, who only received medical care.
Scazufca and her team now plan to merge the Viva Vida and Proactive strategies and offer them via the public health system in parts of North and Northeast Brazil. The new program — called Pro Viva Vida — is still under development, but the cities where it will be tested have already been chosen: Araioses in Maranhão; Parnaíba in Piauí; and Careiro and Manacapuru in Amazonas. “Since the results of the clinical trials were effective, we want to quickly and efficiently implement these strategies in smaller and more remote municipalities,” says the researcher. To achieve this, the team will use implementation science (see Pesquisa FAPESP issue nº 312), which aims to accelerate the real-world application of research results. “We will adapt the interventions to the specific circumstances in these new municipalities and shape them according to the challenges that arise,” says Scazufca.
Project
Cluster randomized controlled trial for late life depression in socioeconomically deprived areas of São Paulo, Brazil (nº 17/50094-2); Grant Mechanism Thematic Project; Principal Investigator Marcia Scazufca (USP); Investment R$2,980,721.23.
Scientific articles
SCAZUFCA, M. et al. Self-help mobile messaging intervention for depression among older adults in resource-limited settings: A randomized controlled trial. Nature Medicine. mar. 14, 2024.
CAI, H. et al. Global prevalence of depression in older adults: A systematic review and meta-analysis of epidemiological surveys. Asian Journal of Psychiatry. feb. 2023.
DE ALBUQUERQUE BRITO, V. C. et al. Prevalence of self-reported depression in Brazil: National Health Survey 2019 and 2013. Epidemiologia e Serviços de Saúde. 2022.
SCAZUFCA, M. et al. A task-shared, collaborative care psychosocial intervention for improving depressive symptomatology among older adults in a socioeconomically deprived area of Brazil (Proactive): A pragmatic, two-arm, parallel-group, cluster-randomised controlled trial. The Lancet Healthy Longevity. oct. 2022.
CIASCA, E. C. et al. Art therapy as an adjuvant treatment for depression in elderly women: A randomized controlled trial. Brazilian Journal of Psychiatry. july 2018.
