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Running head: THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 1
Thesis Proposal: Determining the Efficacy of Art Therapy for Mild to Moderately Depressed
Older Adults
Jo-Anne van Draanen
Toronto Art Therapy Institute
May 27th, 2014
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 2
Thesis Proposal: Determining the Efficacy of Art Therapy for Mild to Moderately Depressed
Older Adults
Introduction:
This study proposes to determine whether participation in art therapy for depressed older
adults (between the ages of 68 – 88) living in a long term care facility lowers their level of
depression. Art Therapy may be a viable part of a multi-disciplinary team approach as it is a tool
used to provide individuals with a medium for emotional expression. In particular, it can give
older adults (OA) the opportunity to reduce their social isolation and give them an environment
where autonomy and choice are still options (Waller, 2002).
Problem:
Depression is a significant concern among older adults. Studies show that up to 20% of
Canadian older adults living independently in the community suffer from depression. This
percentage increases to 25% for those older adults with a serious medical illness or those in the
early stages of Alzheimer’s disease. For those older adults living in a long term care facility, the
percentage suffering from depression raises from 30% – 50% (www.cpa.ca).
According to the 2011 census, there are currently over 11 million adults living in Canada
who were born between 1941 and 1965. This is a huge increase from the over 3 million born
between 1919 and 1940. There is a large group of baby boomers who are just entering older
adulthood and today, they can expect to live longer than those in generations before them.
Today the average ago for men is 78 and for women it is 83 (www.cboc.ca). Given the
prevalence of depression in older adults, with this increase in the demographics of older adults
here in Canada, depression may have an overwhelming impact not only on the individuals
affected by this but also on their family, the long-term care facilities where these adults may live
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 3
and our health care system. With a rapidly increasing aging population, the treatment of
depression in this group should be treated as a priority (Rodda, Walker, & Carter, 2011).
Fiske, Wetherell, and Gatz (2009) suggest that “a common pathway to depression in
older adults, regardless of which predisposing risks are most prominent, may be curtailment of
daily activities Accompanying self-critical thinking may exacerbate and maintain a depressed
state” (Fiske, Wetherell, & Gatz, 2009). With this in mind, it could be suggested that adding an
activity with an older adult in and of itself may assist in the lessening or alleviation of the
depressive state they are in. When this activity is art therapy, the benefits may go beyond that of
a simple activity to an opportunity for exploration and growth, an opportunity to work through
past disappointments and to move forward, embracing the ups and downs of life with renewed
confidence.
With older adults in particular, emotional needs may sometimes be overlooked as the
physical health issues they may be experiencing take precedence. Art therapy is one way to
respectfully, efficiently and comprehensively address the emotional needs of older adults. Art
therapy offers the opportunity for healing by providing social connection, and the chance to
express and manage emotions. It allows for deep nonverbal communication possibly for those
for whom verbal communication is a challenge. It offers hope and provides an opportunity to
create meaning through life review (Johnson & Sullivan-Marx, 2006).
Waller (2002) states that older adults often live with consuming levels of hopelessness
and despair due to all the losses they have suffered (for example the end of their working life,
children grown, possible death of a spouse, physical ailments that may limit mobility, loss of
their home etc.) . Art therapy allows them to express their deep sadness at the losses they are
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 4
experiencing. Art therapy is a meeting of the therapeutic process and the creative process. It is
communication that can be felt, seen and heard (Johnson & Sullivan-Marx, 2006).
Aim of Study
This study will attempt to determine whether adding art therapy into the weekly routine
for depressed older adults will assist in decreasing the level of depression they are currently
experiencing. The study hypothesis is that after an eight week art therapy one-on-one
experiential with a qualified art therapist, levels of depression will decrease in older adults
currently suffering from mild to moderate depression.
Research Question
Will eight weeks of one hour a week, individual art therapy sessions decrease mild to
moderate levels of depression in older adults living in a long term care facility?
Rationale
To date, little research has been done on art therapy with adults in a long term care
facility. This proposed research will offer insight into therapeutic alternatives for older adults in
long term care facilities. More specifically, it will suggest ways that may decrease the levels of
depression thereby increasing the quality of life of these older adults. This study will add depth
to the current research done on older adults and depression and will offer a concrete possibility
for assisting in the treatment of depression with this population. This study’s findings can be
transferred into other long term care facilities and also general day programs for older adults.
The study will also offer physicians another treatment modality in treating their older adult
patients who suffer from depression. This study will provide clinical support for the increased
use of art therapy as part of a treatment plan for older adults suffering from depression.
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 5
Addressing the issue of depression with older adults will assist in bringing the issue to the
fore front, thereby helping to dispel the stigma, shame and guilt that sometimes accompanies this
illness in older adults today.
This study will also add additional credence to the field of art therapy, thereby increasing
the awareness and validity of the profession of art therapy. It will enhance and build upon the
current existing research, and expand on a population segment that is current in need of support
for the ever increasing illness of depression.
There are significant implications for the art therapist working with this population as
well. There will be an opportunity to develop and prefect directives which focus on successes
and disappointments, opportunities for coming to terms with one’s life and understanding the
purpose and meaning in life. This research will offer an opportunity to expand the current
understanding of the needs and desires of older adults faced with depression. The study will also
highlight how reflecting and reminiscing over one’s life can be of benefit to older adults. These
findings will be transferable into situations with older adults, other than long term care facilities.
Services such as community day treatment programs, senior’s day care centres, respite programs
or hospital based senior’s programs could all benefit from offering art therapy to older adults.
Definitions of Terms
Older Adults – Men and women, age 65 and older.
Long Term Care Facility - It is a place of residence for people who require continual
nursing care and have significant difficulty coping with the required activities of daily living.
Nurses and nursing aides are available 24 hours a day. A doctor is on staff and visits each
resident on a weekly basis or more often if there is a critical or specific need. Recreation staff
offer daily leisure activities for residents. This facility offers a few single rooms, several double
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 6
rooms and a majority of rooms with four residents per room. Women room with women and
men room with men except in the case of a married couple, in this case they would share a room.
This particular Long Term Care Facility is part of a chain of residences that was founded in
1972. They have homes through-out Ontario and British Columbia. The facility where this
study will be carried out is in Scarborough, Ontario.
Mildly Depressed as defined by the DMS-V – One of the following: depressed mood,
loss of interest and enjoyment in usual activities and / or reduced energy and decreased activity
AND one or two of the following: Reduced self-esteem and confidence, ideas of guilt and
unworthiness, pessimistic thoughts, disturbed sleep, diminished appetite and / or ideas of self
harm.
Moderately Depressed as defined by the DMS-V – One of the following: depressed
mood, loss of interest and enjoyment in usual activities and / or reduced energy and decreased
activity AND two or three of the following: Reduced self-esteem and confidence, ideas of guilt
and unworthiness, pessimistic thoughts, disturbed sleep, diminished appetite and / or ideas of self
harm.
Severely Depressed as defined by the DMS-V – All of the following: depressed mood,
loss of interest and enjoyment in usual activities and / or reduced energy and decreased activity
AND at least three of the following: Reduced self-esteem and confidence, ideas of guilt and
unworthiness, pessimistic thoughts, disturbed sleep, diminished appetite and / or ideas of self
harm.
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 7
Literature Review
Depression in Older Adults
As a society, depression is often seen as part of the natural aging process for older adults
but this is not the case. Older adults do not suffer from depression as a result of aging. Children
leaving home and relocating, and / or the death of a spouse, sibling and / or friends may
contribute to depression in older adults as there is less of a social support network and bonding
relationships may be different or changed. There might also be a change in financial or social
status as adults’ age. Older adults are also faced with decreased mobility often, especially if they
live in a long term care facility. The day to day activities of an older adult living in a long term
care facility would be significantly different to what they would have been accustomed to, once
again, adding to a greater propensity towards depression (Stickle & Onedera, 2006). All of these
examples would be much more a cause for depression than the simple process of aging itself.
Waller (2002) noted: “Living and working with older adults who know that the life they
took for granted is gradually disappearing, that they may be physically and mentally declining
but they do not know how long this will go on for, and that the outcome will be that they will be
totally dependent on others, is hard in itself. Living in environments where they watch others
deteriorate and disappear, and know that is probably going to be their fate, is hellish.” (Waller,
2002, p. 6) This is exactly the situation for those living in long term care facilities. They are
surrounded by their peers who are all in various states of decline. Older adults also experience
on a daily basis, changes that have huge impact such as deteriorating vision and hearing. The
toll that this all takes is huge.
Depression in older adults can be difficult to diagnose as it can be overlooked as a
symptom or another medical condition. Depression worsens an older adult’s experience of
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 8
medical problems and makes it harder for them to recuperate as they tend to become less active
and independent when depressed which can lead to a decline in their overall physical condition
and can lead to greater disability (www.cpa.ca).
With older adults in particular, emotional needs may sometimes be overlooked as the
physical health issues they may be experiencing take precedence. Art therapy is one way to
respectfully, efficiently and comprehensively address the emotional needs of older adults. Art
therapy offers the opportunity for healing by providing social connection, and the chance to
express and manage emotions. It allows for deep nonverbal communication possibly for those
for whom verbal communication is a challenge. It offers hope and provides an opportunity to
create meaning through life review (Johnson & Sullivan-Marx, 2006).
Depression among older adults can occur in response to chronic physical impairments.
Since approximately 80% of older adults have at least one chronic condition, it is easy to see
how this medical condition could add to one’s emotional distress or depression. Conditions
often seen include but are not limited to older adults in Parkinson’s disease, stroke, Alzheimer’s
disease, dementia, cancer, arthritis and sensory loss to name just a few (Stickle & Onedera,
2006).
Research has shown that older adults suffering from depression are more likely to have
been exposed to risk factors as children, such as poverty, and parental separations. Many older
adults with depression may have experienced similar depressions in early life but may have had
better coping resources in the past, such as better physical health, family protection, special skills
or mental health services. Some adults may have been better able to address symptoms related to
depression earlier on in life (Stickle & Onedera, 2006, p. 39). They also found that events like
marital and work-related experiences may be predictive of depression in later life. Achievements
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 9
or life dreams not attained, an unsuccessful marriage may produce shame, disappointment and /
or discouragement.
Studies show that up to 20% of Canadian older adults living independently in the
community suffer from depression. This percentage increases to 25% for those older adults with
a serious medical illness or those in the early stages of Alzheimer’s disease. For those older
adults living in a long term care facility, the percentage suffering from depression raises from
30% – 50% (www.cpa.ca).
According to the 2011 census, there are currently over 11 million adults living in Canada
who were born between 1941 and 1965. This is a huge increase from the over 3 million born
between 1919 and 1940. There is a large group of baby boomers who are just entering older
adulthood and today, they can expect to live longer than those in generations before them
(www.cboc.ca). Given the prevalence of depression in older adults, with this increase in the
demographics of older adults here in Canada, depression may have an overwhelming impact not
only on the individuals affected by this but also on their family, the long-term care facilities
where these adults may live and our health care system. With a rapidly increasing aging
population, the treatment of depression in this group should be treated as a priority (Rodda,
Walker, & Carter, 2011). Finding cost-effective, self-directed, and safe methods to alleviate
and/or prevent depression will assist healthcare providers and others to facilitate health and well-
being in older adults.
Depression is not a sign of weakness nor is it a problem that can be just willed away.
People who are depressed cannot just snap out of it. Without proper treatment, depressive
symptoms can last for months or years and may worsen (Alexopoulos, Katz, Reynolds, & Ross,
2001).
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 10
Depression is an illness that is more than just a sad feeling. Depression in older adults
has wide ranging effects. Specifically, depression in older adults may include physical changes
such as a change in appetite, sleep disturbances, decreased energy and / or stomach upsets. A
change in thinking might also be noted. For instance, avoiding decision making because it is
difficult or obsessive ruminations with a sense of impending doom or a loss in self-confidence
might be evidenced as a sign of depression. Loss of interest in activities that once brought
pleasure or feelings of worthlessness, hopelessness and excessive guilt might become evident.
Crying for no apparent reason or irritability, impatience and anger are also signs of depression.
Changes in behaviour might also indicate depression, for instance withdrawal from social and
leisure activities or a decrease in physical activity, or reduced self-care such as personal
grooming may indicate depression. Any combination of all or some of these symptoms could
indicate depression (www.mooddisorders.ca).
Fiske, Wetherell, and Gatz (2009) suggest that “a common pathway to depression in
older adults, regardless of which predisposing risks are most prominent, may be curtailment of
daily activities Accompanying self-critical thinking may exacerbate and maintain a depressed
state”. It is their belief that life review or reminiscence is not done often enough (Fiske,
Wetherell, & Gatz, 2009). With this in mind, it could be suggested that adding an activity such
as art therapy with an older adult may assist in the lessening or alleviation of the depressive state
they are in. In particular, it would be important to offer art directives that focused on life review
and reminiscence.
Research Pertaining to Art Therapy
There has been some interesting research to date on the validity of art therapy with both
general populations and older adults. Rusted, Sheppard and Waller (2006) in their study using
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 11
art therapy with older adults with dementia, found very positive results. Not only did the quality
of life and depression measures improve, the improvement was also sustained over time. Their
study provides clear evidence of positive and durable benefits with regard to mental alertness,
sociability, physical and social engagement in study participants (Rusted, Sheppard, & Waller,
2006). Likewise, Gussak (2007) in his study on the effectiveness of art therapy in reducing
depression in prison populations, found strong correlations between participation in art therapy
and decreased depression. Improvement in the inmates’ socialization and problem-solving
abilities was also noted (Gussak, 2007). Hanser (1990), Johnson & Sullivan-Marx (2006),
Phillips (2007), Pot, Bohlmeijer, Onrust, Melenhorst, Veerbeek and De Vries (2010) and
Slayton, D’Archer & Kaplan (2010), in their studies or their review of studies, found a positive
correlation with art therapy (or in one case music therapy) and gains in overall sense of well-
being. Participants using art therapy made fewer contacts with mental health providers or
medical specialists. They experienced fewer somatic symptoms and complaints and reduced the
use of medical and mental health services (Slayton, D’Archer, & Kaplan, 2010, p. 116).
Interestingly, older adults who participated in art therapy were found to have fewer falls than
control group members and they were found to use less medication than their control group
counter parts (Johnson & Sullivan-Marx, 2006, & Phillips, 2007).
In considering art therapy with older adults, it is important to take into consideration the
roles of the left and right hemispheres of the brain. The left side of the brain contains the
language center; information processed here is labeled, linear, and orderly. The left hemisphere
functions are considered to be verbal, analytic, rational and abstract. The right side of the brain
is oriented to processing visual-spatial information. Information processed by the right side of
the brain is intuitive, emotional, and spiritual (Malchiodi, 1999, p. 30). The right hemisphere
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 12
main functions are preverbal, synthetic, and concrete. Without words, and using images instead,
information is more likely to be processed on the right side of the brain and to contain emotional
and spiritual truths (Hinz, 2006, p. 17). This is particularly important to keep in mind as many
older adults lose some cognitive abilities. Stroke and Alzheimer’s and / or dementia may well
play a part in the health and well-being of the older adult. With a possible change in how the
older adult has use or uses the right and left hemispheres, art is a medium of expression that is
conducive to working with these changes offers hope and a voice where there might not have
been one before. Art therapy has the ability to bridge the gap between a person’s inner and outer
worlds. Art making allows the non-verbal brain to ‘speak out’ in its own language.
One other benefit of art therapy that should be mentioned here would be in the process of
art making itself. This process, where an older adult is encouraged to try a myriad of different
art materials, where the older adult is able to make decisions for themselves and where they are
given a voice, also builds confidence that they can successfully learn and adjust to roles required
by their present circumstances. Art therapy can be used to support coping skills when they face a
loss of independence, loss of choices, or a loss of health. Older adults can also express
satisfaction over their production of art pieces, adding to a strong sense of self, who they are and
what they are capable of (Johnson & Sullivan-Marx, 2006).
Erik Erikson’s 8 Stages of Psychosocial Development Theory
Erik Erikson, in his Eight Psychosocial Stages of Development Theory, refers to the final
stage, stage eight, which occurs in late adulthood, as the stage of Ego Integrity versus Despair.
In brief, successful resolution of the eighth stage takes place when the individual can accept what
has gone before as inevitable and satisfying, and they realize the meaning and purpose in their
life. They can also accept without fear that death will occur probably in the not too distant
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 13
future. This will result in ego integrity. If a person feels that his or her life has been a failure, and
that it is too late to start in a new direction, then he or she will be filled with despair (Brown &
Lowis, 2003).
This despair that Erikson refers can be seen manifested in the depression that so many
older adults living in long term care facilities are afflicted with. In art therapy, if the desire is to
lessen depression, following Erikson’s Developmental Theory, it would stand to reason that
working towards integrity, and the understanding of the meaning and acceptance of the older
adult’s life, and the acceptance that life was satisfying, would be a logical goal. Using art
therapy to look at a client’s life story with the aim of reviewing and re-authoring that life story,
would allow the older adult to process their life with the benefit of wisdom and hindsight.
Possible Art Therapy Directives for working with Older Adults
Art directives such as life maps would become a visual representation of the life journey
both outwardly traveled and inwardly lived. It would also be a powerful prompt for more
specific reminiscences in the life review process. Creating boxes that were representative of
their inner and outer selves would also allow the older adult to differentiate, understand and
represent both their inner selves and the outer self their share with the world. Possible directives
around smells from the past, houses lived in, and turning points would all allow the older adult to
look over their life in review and find acceptance in their life as they have lived it (Pot et al.,
2010). Using photographs and images found in magazines or created, a memory book might be
created to allow the older adult to process any losses they might be grieving and honouring the
people in their lives (Johnson & Sullivan-Marx, 2006).
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 14
Bringing the Pieces Together
The facts are straightforward: depression in older adults living in long term care facilities
is a common reality. Art therapy has been shown to be effective in lessening depressive
symptoms in older adults. Erik Erikson postulates that the goal for older adults is to resolve the
conflict between ego integrity and despair. Offering a series of art directives that lead the older
adult on a journey of discovery and reconciliation with the goal being to understand the meaning
and acceptance of their life, and the acceptance that life was satisfying would be an effective
method to assist the older adult in decreasing their level of depression.
Research Design
This study will be a single-subject pre / post-test research design which will look at
cause-and-effect relationship between art therapy and depression by comparing individual’s pre-
and post-intervention responses. The same participants will serve as both the experimental and
the control sample. Measures of the baseline condition of depression will be made by a staff
member at a Scarborough Long Term Care Facility (LTCF) using the Geriatric Depression Scale
Short Form. An eight week art therapy one-on-one intervention will be offered to all
participants. At the conclusion of the eight weeks, the same staff member will once again
administer the Geriatric Depression Scale Short Form. The results of the second Geriatric
Depression Scale will then be compared with the first baseline data in order to see if the
treatment effected a change (Kapitan, 2010, p. 58). After each of the eight week sessions, a
visual assessment will also be made by the art therapist and this simple qualitative assessment
will be included with the final findings.
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 15
Sample
Participants for the study will be drawn from residents at a Scarborough Long Term Care
Facility. A group of 39 residents who have received a diagnosis of depressive episode by a
physician at the Long Term Care Facility within the past two years will be approached to see if
they would be interested in participating in this study. Once interest is ascertained, and consent
forms have been signed, the Geriatric Depression Scale will be administered to all those
interested by one of the staff at the long term care facility. A final group of potential participants
will be formed based on a depressive rating (greater than 5) using the Geriatric Depression Scale.
If this final group contains more than 10 potential participants, 10 participants will be randomly
selected from this group by means of computer assisted random selection to participate in the art
therapy sessions. If this group of potential participants is less than 10, the entire group will
participate in the art therapy sessions. These residents will range in age from 68 – 88 years old.
The art therapy sessions will take place over eight weeks at the Scarborough LTCF in one of the
sun rooms at the back of the facility.
Instruments
A variety of art directives will be used, focusing on a life review, offering participants the
opportunity to make meaning of their lives. Quantitative models require structured procedures
that will identify all the interacting variables, in other words, pre-determined directives offered to
each participant in the same order. This would be done in order to reduce error and bias so that
if the premises are correct, the conclusion can be deduced from the data and assumed to be
correct rather than due to extraneous or untested variables (Kapitan, 2010, p. 54).
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 16
If at all possible, the following directives will be used:
Creating a self-portrait;
Creating a piece of art around their life journey, mapping their journey;
Creating art around the idea of boxes that house their inner emotions and what
they show the world on the outside;
Creating art around smells from the past;
Creating art around the community of selves (woman, wife, mother, sister, etc.);
Creating art around the houses they lived in;
Creating art around their weddings (if they were ever married) or the birth of their
children; and
Creating a memory book.
Unfortunately, this may not be possible with this research as the student art therapist will
need to have the option of being spontaneous, using inductive reasoning and the flexibility to
make creative shifts to meet the evolving needs of participants (Kapitan, 2010, p. 54). Along
with the art directives will be a variety of art materials including but not limited to: a variety of
types of paint, clay, crayons, pencil crayons, markers, and collage materials.
The Geriatric Depression Scale, created by Dr. Jerome Yesavage in 1983, will be used as
a pre- and post-test measure for depression. There has been significant research over the years,
all indicating that this tool is highly successful at determining depression in older adults. The
research also has determined that it is best administered by someone other than the older adult
(Almeida & Almeida, 1999; Hermann et al, 1996; Montorio & Izal, 1996). Although there are
several versions of this measure, with the original being a 30 point scale, this scale was revised
in 1986 to a 15 point scale. The validity of the scale remained strong and therefore, for the
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 17
purposes of this study, the 15 point scale, also known as the ‘short form’ will be used as it is as
valid as the long form but more sensitive to the needs and abilities of the older adult population.
See Appendix A.
Procedures
Participants will attend a 60 minute art therapy session once a week for eight weeks.
These sessions may be shorter in duration if needed by the participant. The researcher is aware
that older adults tire easily and can also become confused or disoriented and that might lead to a
shorter time period for the art therapy. Where at all possible, the effort will be made to have the
sessions be consistently set at 60 minutes.
Prior to the sessions beginning, the Geriatric Depression Scale that will be administered
by the facility staff member to each participant individually. They will also sign the necessary
consent forms from the TATI. After the completion of the eight weeks of art therapy, they will
once again complete the Geriatric Depression Scale that will be administered by the same facility
staff member. All forms will be collected by the researcher for analysis at the end of the study.
Risks / Discomforts / Confidentiality
It will be made clear to all participants that they may withdraw at any point in time. The
potential risk of working with difficult emotions will be made clear to all participants and they
will be assured that everything that happens in the art therapy sessions will remain confidential.
It will be stressed to all participants that the only time this confidentiality bond will be broken is
when there is disclosure that the participant is harming others, or that the participants is being
harmed or that the participants is harming or has plans to harm themselves.
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 18
Benefits to Participants and the Long Term Care Facility
This study will offer the participants the opportunity to experience art therapy and the
benefits it provides (increased communication, alternate means to communicate, a relaxing
experience to name just a few). The Scarborough LTCF will benefit from having art therapy
offered to 16 of their clients and also from the study’s outcomes. It is the researcher’s beliefs
that they will see the benefit of offering art therapy to their clients as the level of depression in
these clients will have improved.
Qualifications of Investigator
The investigator for this study is a graduate level student in art therapy. With an
undergraduate degree in Psychology and Sociology and years of experience working with older
adults, including older adults with Aphasia, this researcher is well versed in communication and
engagement strategies for this population. This researcher has been previously published and is
well versed in research methodology.
THESIS PROPOSAL: DETERMINING THE EFFICACY OF ART 19
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Almeida, O., & Almeida, S. (1999). Short Versions of the Geriatric Depression Scale: A Study
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