Psychosocial Stress, Resilience and Depression in Older Adults

*Rabia Dasti

Centre for Clinical Psychology, University of the Punjab, Lahore

Hiba Naeem

Centre for Clinical Psychology, University of the Punjab, Lahore

Faiza Amjad

Govt. Kulliyat-ul-Binat Degree College for Women

The study investigated the relationship between psychosocial stress, resilience and depression among older adults. It was hypothesized that 1) there will be a negative relationship between psychosocial stress and resilience among older adults, 2) there will be a negative relationship between resilience and depression among older adults 3) there would be gender differences regarding stress, depression and resilience among older adults among and 4) the age, religious inclination, physical condition, perceived stress, trait resilience and state resilience would predict depression among older adults. Cross- sectional research design was used. The sample comprised of 90 older adults including 54 men and 36 women (M=69, SD=4.3). The data were collected by employing purposive sampling technique from a suburban area of Lahore city. Elder Life Stress Inventory (Aldwin, 1990), Resilience State Trait Inventory (Hiew, 2002), Geriatric Depression Scale (Yesavage, 1996) and demographic information sheet were administered. Pearson Product Moment Correlation, Independent Sample t-test and Backward Multiple Regression Analysis were used. Results revealed negative relationships between psychosocial stress, resilience and depression. It was also found that perceived stress and resilience were predictors of depression among older adults. Findings call for the need to work on enhancing resilience and reducing psycho-social stressors in the lives of older adults by means of therapeutic interventions and policy-change.

Keywords: Depression, Resilience, Psychosocial stress, Older adults

Birren and Schroots (1995) regarded aging as defined in terms of chronological, biological, psychological and social age. The chronological age covers time elapsed since person’s birth in years, biological age includes changes in bodily systems and their impact on person’s biopsychosocial functioning; the psychological aging encompasses one’s adaptive ability and personality while social age encompasses person’s functionality in social context (Birren & Schroots, 1995). Old age is not a problem in itself but economical, psychological, physical and social problems are also associated with this age can result in substantial burden (Ashiq & Asad, 2017).

According to report of World Health Organization (WHO, 2000), the geriatric population is increasing worldwide at a rate that is incomparable with any other segment of population. According to the prediction of WHO, by 2025, there will be 1.2 billion people who will be 60 years of age and in 2045 the number of older populations will be doubled (Anderson, Courtney, & McAvan, 2006). Ashiq and Asad (2017) reported that population of developing countries comprised of two third of the elderly people. The 1998 census report of Pakistan depicted that population of people over 60 years of age had increased to 7.34 million from 2.92 million in 1961 (Birren, 1969) and by year 2030, it will be increased to 23.76 million (Ashiq & Asad, 2017). As the health facilities are advancing and death rates are going down, the number of years people live is increasing as well, resulting in a greater number of people is a tremendous increase in the number of older adults in the country. In 2002, United Nations estimated that proportion of older people in Pakistan from the year 2000 will increase from 5.8 percent to 7.3 percent in 2025 and in 2050 it will be 12.4 percent (Ali & Kiani, 2003).

Older individuals have greater chance to encounter many life- threatening events including, bereavement, socioeconomic problem, retirement issues, deterioration in memory, physical problems, relationship problem with children, concerns about residence and of physical disability. All these problems contribute to loneliness, stress and depression (Watson & Hall, 2001). As for depression, Australian Bureau of Statistics (2008) reported that 7.3% ofmen and 5.3% of women in general population experience depression in their life time. World Health Organization (2012) conducted a survey in seventeen countries which revealed that 350 million individuals worldwide suffered from depression as well as approximately 1 in 20 individuals had experienced depression in the last one year leading up to the survey. In that survey, depression was the second major health issue in Pakistan. Depression is also highly prevalent among elders in Pakistan as its prevalence rate is reported to be 66% among older individuals (Javed & Mustafa, 2013).

Depression is associated with sad mood, emptiness, hopelessness, loss of interest in pleasurable activities, decrease or increase in appetite and weight, sleep disturbance, fatigue, feelings of worthlessness, reduction in the capacity to concentrate, feeling of guilt and suicidal ideation (American Psychological Association, 2013). Depression is a widespread psychological disorder and generally prevails in the old age population usually being related to negative circumstances, associated with bodily complaints/physical disabilities (Baldwin, 2008; Chiu, Ames, Draper, & Snowdon, 1999) loss of sanity (Beyonblue, 2007) as well as nervousness (Ames, Flynn, Tuckwell, & Harrigan, 1994; Bryant, Jackson, & Ames, 2008). These factors and associated depression increase chances of death and suicides and also aggravates the suffering of caretakers. Moreover, divorced or separated older people are more vulnerable to developing depression as compared to those who remain married (Dhara & Jogsan, 2013). Similarly, in developing nations, domestic or family support is reported to be one of the protective factors against depression among older adults through being a buffer against stress (Bhamani, Karim, & Khan, 2013).

Most of the common stressors that effect older adults are socio economic status, loneliness, familial troubles, dependency, concerns about partner (Casas et al, 2008) persistent pain, physical and psychological problems and persistent need to be cared for(Watson & Hall, 2001). Sleep difficulties along with problems associated with socialization and occupation also contribute to psychological stress (Kaur et al., 2006). Older individuals who remain stressed, experience depression and have a greater chance of having physical problems like heart disease, diabetes and brain organicity affecting memory (WHO, 2001).

As far as dealing with stress is concerned, it has been reported that older individuals with higher resilience are better able to adapt to life problems and troubles (Wagnild & Young, 1993); are happier in their lives and have greater value of life by developing coping resources like resilience (Cohen, Fredrickson, Brown, Mikels, & Conway, 2009), therefore, high resilience reduces the effects of stressful life events in older adults (Lazarus, 1993).

Resilience of an individual is the capacity to take strain or stress fruitfully and sustain psychological welfare in the course of stressful life events (Redl, 1969). There are two types of resilience: trait resilience and state resilience. Trait resilience involves those attributes of an individual which promote adaptation to life through playing a role in decreasing the unconstructive consequence of stress. Trait resilience develops during infancy and teenage (Jacel, 1991). State resilience is regarded as the form of resilience that deals with showing endurance during the difficult situations of life (Jacel, 1991) and can develop over the period of time as social, psychological and situational difficulties in life increase (Kim-Cohen & Turkewitz, 2012).

Researches indicate that individuals who lower level of resilience, experience difficulty in handling the stressful incidents and are also unable to recover from them (Klohnen, 1996; Rutter, 1987). On the other hand, individuals with greater level of resilience show the capability to overcome nervousness, whilst being able to endure aggravation or irritation during stressful times (Carver, 1998; Saarni, 1999). Overall, resilient people show constructive sentiment, optimistic opinion, cheerfulness or hopefulness, adaptable believing pattern, having good humor and religion (Haglund, Nestadt, Cooper, Southwick, & Charney 2007); have the capacity to rebuilt self-respect after any breakdown (Wolin & Wolin, 1989); are more inventive to cope in any stressful situation (Murphy & Moriarty, 1976; Cohler, 1987; Demos, 1989); are more hopeful, lively in their life, more passionate, inquiring the new events and have more constructive emotions (Block & Kremen, 1996; Klohnen, 1996).

Moreover, Edward and Hall (2012) have been of the view that resilience empowers elder people to continually prosper in this planet of confusion, transformation and continuous sickness. Resilience in later life has been recognized as an element that can aid in leading a prosperous older year, and to attain and sustain a feeling of welfare when faced with problematic situations associated with older life (Young, Frick, & Phelan, 2009).

Luthar, Cicchetti, and Becker (2000) in their study found that individuals with high resilience have the ability to control or manage the adverse and negative psychosocial stressors, be it danger and threat, without becoming threatened. Moreover, it was also found in several studies that high level of resilience predicts low levels of depression and stress (Rizzo & Buckwalter, 2012; Hagen & Stiles, 2010; Cheryl, John, & Graham, 2000).

As evident from above, resilience has been studied with regards to stress generally; and its implications for psycho-social stress have not been explored separately especially for older adults.

Objective of the Study

• To explore the relationship between psychosocial stress, resilience and depression in older adults.

Hypotheses of the Study

• There will be a negative relationship between psychosocial stress and resilience in older adults.
• There will be a negative relationship between resilience and depression in older adults.
• There will be gender differences regarding stress, depression and resilience in older adults.
• Age, religious inclination, physical condition, perceived stress, trait resilience and state resilience will predict depression in older adults.

Method

Research Design

Cross sectional research design was used.

Sample

The participants of present study were 90 older adults including men (n= 54) and women (n= 36) aged 65 years and above (Mage = 69, SD=4.3) and were permanent residents of a suburban area attached to the city of Lahore. The data was collected by employing purposive sampling strategy. Majority of the participants were married, lived with their children in a joint family system and reported physical illness and did not report any psychological illness. None had a  history  of  or  current  cognitive  impairment.  Majority  of  the participants were from a Muslim background and were practicing their faith.

Assessment Measures

Demographic Questionnaire. A demographic questionnaire was developed by the researcher to gain information regarding the participant’s age, education, religious affiliation, gender, marital status, relationships with spouse and children, marital history, current living status, retirement, family system, as well as physical and psychological health.

Elder Life Stress Inventory (ELSI; Aldwin, 1990). ELSI is used to assess stress in later life. The reliability of the scale is .82. The scale consisted of 31 items. The responses of the scale are on a 6-point scale where 0= did not occur and 4= exactly true. The reliability of ELSI in the present study was .86.

Resilience State Trait Inventory (Hiew, 2002). The scale was translated into Urdu by Kausar and Jabeen (2009). It consists of two main subscales: State Resilience Scale (15 items) and Trait Resilience Scale (18 items). The alpha reliability of the overall scale in the present study was .84, of state resilience scale was .63 and of trait resilience scale was .88.

Geriatric Depression Scale (GDS; Yesavage, 1996). The GDS, developed by Yesavage assesses depression among elder individual, has 30-items and individual responds on “yes” or “no” categories. The cronbach alpha reliability of the scale in present study was .82.

Procedure

Permission for using and translating questionnaire for the present study was sought from the respective authors. Standard procedure was used for the translation of the questionnaire into Urdu language. Elder Life Stress Inventory and Geriatric Depression Scale were translated into Urdu to administer it on selected population. Permission for data collection from Allama Iqbal Town, Lahore was taken from the town administrator. Pilot study was done on twenty participants. Then, the main study was carried out. During the main study, participants were approached at their homes. After taking their consent, the questionnaires were administered individually. The questionnaires were administered orally with illiterate participants.

Ethical Consideration

• Permissions for using the tools were sought from
• Permission for the data collection from the administrative of the town was taken
• Participants were given the information regarding the nature and purpose of the study.
• Consent was taken from
• Participants were assured about the discretion of their
• Participants were given the right that they can withdraw from the

Results

Table 1

Descriptive Statistics of the Participants (N=90)

Demographics             f          %           f            %

Men (n=54)     Women (n=36)

Table1 indicates that majority of the participants were living with their children, had medium family size and satisfactory relationships with their children. The spouse of most of the participants were alive and had satisfactory relationship with them. Most male participants were retired and most female participants were housewife. Most of the participants were physically ill and unsatisfied with their physical condition. Majority of the participants reported to be suffering from heart problem and Arthritis, and were taking allopathic treatment for their problems.

Table 2

Relationship between Elder Life Stress, Geriatric Depression and Resilience among older adults (N=90)

Note. N=90, *p <.05. **p <.01.

The table 2 showed significant positive correlation between elder life stress and depression. Significant negative relationship between depression and resilience was found.

Table 3

Independent Sample t-test Determining Gender Differences in Psychosocial Stress, Resilience and Depression among Older Adults (N=90)

Note. CI= confidence Interval; LL Lower Limit; UL= Upper Limit; ELSI= Elder Life Stress Inventory; GDS= Geriatric Depression Scale; R= resilience

Table 3 indicated that men and women did not differ significantly in perception of psychosocial stress, depression and resilience.

Table 4

Multiple     Regression     Analysis     (Backward    Method)     Predicting Resilience and Psychosocial Stress from Depression

Note. *p<0.05. **p<0.01. ***p<.001.

Using the backward multiple regression analysis, age, religious inclination, physical condition, psychosocial stress and state and trait resilience were taken as predictors and the outcome variable was depression. The final model depicted that only two of the five predictors i.e. psychosocial stress and trait resilience were significant predictors of depression, while others were not significant. Psychosocial stress was found to be significant positive predictor of depression while trait resilience was found to be a significant negative predictor of depression. The model was significant.

Discussion

The present research aimed to study the relationships among psychosocial stress, resilience and depression in older population. The older adults participated in the research were of 65 years of age or above which was in line with the age range of participants of studies conducted by Pierini and Stuifbergen (2012), Margaret (2010) and Niekrek (2008) on older people. Moreover, the descriptive analysis of present study depicted that majority of older people were living with their children, were married, had satisfactory relationship with their spouse  and  mostly,  male  participants  were  retired  and  female participants were house wives which was in accordance with the study conducted in Karachi by Mubeen and Qureshi (2012).

The result are consistent with the Kobasa and Puccetti (1982) study revealing that resilient people show more adaptive behavior when they face life adversities. Similarly, stress victims with greater level of resilience can survive well, have the ability to thrive and to control or manage the adverse and negative behaviors in the face of danger and threat without becoming puzzled and threatened (Luthar, Cicchetti, & Becker, 2000; Taylor & Brown, 2006), and can face the life stressors in more adaptive manner and live a successful life (Rutter, 1990). Resilience is also associated with mental health (Luthar, Cicchetti, & Becker 2000; Rutter, 1985). Stress and life- threatening events come in an individual’s life in the form of relationship problems, diseases and financial crisis, and resilient individuals show optimism in face of stressors and do not experience any emotional trauma (Theoral & Rahe, 1971) or prolonged stress.

The result of present study also confirmed the second hypothesis that depression is negatively related to resilience which is supported by the research findings of Wagnild and Young (1990), Ryff et al. (1998), Hardy et al. (2004), and Wagnild (2003). Resilience is dynamic process. In the time of life-threatening situations, individuals show positive adaptation when they were facing traumatic and stressful events which decreased the chances of acquiring depression (Rizzo & Buckwalter, 2012). Moreover, resilience among older individuals highlights their potentials to settle or cope with depression in the presence of adverse life situations (Meht et al., 2008).

The findings of present study did not support third hypothesis and revealed non-significant gender differences in the perceived stress, depression and resilience. Previous literature suggests that gender differences are specific to the nature of stress that individual faces (Breslau, Davis, Andreski, Petersonand, & Schultz, 1997). Furthermore, Berkman et al. (1986) was of the view that gender differences in depression decreases in old age as both men and women become equally exposed to the societal, financial pressures such as lower levels of education and income, greater vulnerability to illnesses and more chances of going through widowhood.

In present study, it was hypothesized that age, gender, religious inclination, physical condition, perceived stress and resilience will predict depression among older adults. The results of current study partially supported the hypothesis and revealed that resilience was a negative significant predictor of depression, which is in line with the research findings of Blazer, Hughes, and George (1987). Furthermore, in current study, it was found that perceived stress was positive significant predictor of depression which is consistent with the research findings of Scott et al. (1993), Kessler (1997) and Mirescu et al. (2006). Researches also suggested that daily stressors influence well-being, directly relates with the physical and emotional functioning and cause daily persistent irritation, restlessness and serious stress reaction which can lead towards depression (Bolger, DeLongis, Kessler, & Schilling, 1989; Lazarus, 1993; Almeida, Wethington, & Kessler, 2002; Zautra, 2003; Almeida, 2005). Moreover, Blazer and Hybels (2005) investigated that stressful situations predict depression symptoms among elderly people. Social and psychological factors may increase and decrease the level of depression but the individuals who have high resilience were generally able to cope with daily life problem in a better way, can overcome life threatening situations and live a peaceful life. However, Beck (1967) emphasized that the content of instinctive negative thoughts arising after the stressful incident play a vital role in causing depression. These cognitions may result in promoting resilience.

Conclusions

Results of present study revealed negative correlations between psychosocial stress and resilience as well as between depression and resilience. Results also indicated that there were no gender differences in the perception of stress and depression. Perceived stress and resilience also predicted depression among older adults.

Limitations and Suggestions

• There was overrepresentation of older people belonging to middle socio-economic status in the sample. A more representative sample from all socio-economic classes can help to address this issue in the future research.
• A comparative study can be devised comparing the elderly people living in community with those residing in old homes.
• Other variables like social support and spirituality can also be studied in relation to the variables of the current study.

Implications of Research Findings

This study can help to create awareness programs about how resilience is likely to help elderly cope with emotional disturbance in the face of a stressor. It can also guide clinical psychologists and policy makers to device effective strategies to enhance the resilience of this vulnerable group of people.

References

Aldwin, C. M., Spiro, A., Levenson, M. R., & Bossé, R. (1989). Longitudinal findings from the normative aging study: I. Does mental health change with age? Psychology and Aging, 4(3), 295-306. doi: 10.1037/0882-7974.4.3.295.

Ali, S. M., & Kiani, M. F. K. (2003). Ageing and poverty in Pakistan (No. 2003: 18). Pakistan Institute of Development Economics. Islamabad: Pakistan .

Almeida, D.M., Wethington, E., & Kessler, R.C. (2002). The Daily Inventory of Stressful Experiences: An interview-based approach for measuring daily stressors. Assessment, 9, 41-

55.doi: 10.1177/1073191102009001006.

Almeida, M. D. (2005). Resilience and vulnerability to daily stressors assessed via diary methods. Psychological Science, 14(2), 62-doi: 10.1111/j.0963-7214.2005. 00336.x.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental Disorders (5^th ed.). Washington, DC: Aurthor.

Ashiq, U., & Asad, A.Z. (2017). The rising old age problem in Pakistan. Journal of the Research Society of Pakistan, 54(2), 325-333. Retrieved from: http://pu.edu.pk/images/journal/ history/PDF-FILES/23-Paper_54_2_17.pdf.

Australian Bureau of Statistics. (2008). National Survey of Mental Health and Wellbeing: Summary of results (ABS Catalogue No. 4326.0). Retrieved from: http://www.abs. gov.au/ausstats/abs@.nsf/mf/4326.0.

Baldwin, R., Jacoby, R., Oppenheimer, C., Dening, T., & Thomas, A. (2008). Oxford textbook of old age psychiatry. Mood Disorders: Depressive Disorders, 529-556.

Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New

Berkman, L. F., Berkman, C. S., Kasl, S., Freeman Jr, D. H., Leo, L., Ostfeld, A. M., ... & Brody, J. A. (1986). Depressive symptoms in relation to physical health and functioning in the elderly. American journal of epidemiology, 124(3), 372-388.

Bhamani, A. M., Karim, S. M., & Khan, M. M. (2013). Depression in the Elderly in Karachi, Pakistan: A cross sectional study. BMC Psychiatry, 13,181. doi: 1471-244X/13/181.

Birren, J.E. (1969). Principle of research on aging. Chicago: University of Chicago Press.

Birren, J.E., & Schroots, J.F. (1995). History, concepts and theory in the Psychology of Aging (4^th Edition). San Diego: Academic Press.

Blazer, D., Hughes, J., & George, M. (1987). The Association of age and depression among the elderly: An epidemiologic exploration. Journal of Gerontology: Medical Sciences, 46(6), 210-215. doi: 10.1093/geronj/46.6.m210.

Blazer, D., Hybels, C. F. (2005). Origins of depression in later life. Psychological        Medicine.                                     35,1-12.                 doi: 10.1017/S0033291705004411.

Bolger, N., Delongis, K., Kessler, R. C., & Schiling, A. (1989). A framework for studying personality in the stress process. Journal of Personality and Social Psychology, 69, 890–902. doi: 10.1037//0022-3514.69.5.890.

Breslau, N., Davis, G.C., Andreski, P., Peterson, E.L., & Schultz, L. (1997).  Sex  differences  in  posttraumatic  stress  disorder.

Archives      of      General      Psychiatry,      54,      1044–1048. doi:10.1001/archpsyc.1997.01830230082012.

Carver, C.S. (1998). Resilience and thriving: Issues, models and linkages. Journal of Social Issues,54, 245–266. doi: 10.1111/0022-4537.641998064.

Chiu, E., Ames, D., Draper, B., & Snowdon, J. (1999). Depressive disorders in the elderly: A review. In M. Maj & N. Sartorius (Eds.), Depressive disorders. Chi Chester: John Wiley.

Cohen, A. M., Fredrickson, L. B., Mikels, A. J., Bron, L.S., &

Conway,     M.     A.     (2009).     Emotion,     9(3),      361-368. doi:10.1037/a0015952

Cohler, B. J. (1987). Adversity, resilience, and the study of lives. The Invulnerable Child, 18(6), 363–424. Retrieved from https://www.amazon.com/s?k=9780898622270&i

=stripbooks&linkCode=qs

Demos, E. V. (1989). Resiliency in infancy. In T. F. Dugan & R. Coles (Eds.), The child in our times: Studies in the development of resiliency (p. 3–22). Brunner/Mazel.

Dhara, D. R., & Jogsan, Y. A. (2013). Depression and psychological well-being in old age. Journal of Psychology & Psychotherapy, 3(3), 117

doi: 10.1016/j.jamda. 2008.11.003.

Edward, K., & Hall, G. (2012) Burnout in the caring nurse: Learning resilient behaviors. British Journal of Nursing, 16(4), 240–

242.doi:10.12968/bjon.2007.16.4.22987

Fu, S. Y. K., Anderson, D., Courtney, M., & McAvan, B. (2006). The relationship between country of residence, gender and the quality of life in Australian and Taiwanese midlife residents. Social Indicators Research, 79(1), 25-49.

Hagen, K. & Stiles, C. (2010). The relationship between resilience and levels of anxiety, depression, and obsessive-compulsive symptoms in adolescents, Clinical Psychology and Psychotherapy, 18(4), 314–321.

Haglund, M. E., Nestadt, P. S., Cooper, N. S., Southwick, S. M., & Charney, D. S. (2007). Psychobiological mechanisms of resilience: Relevance to prevention and treatment of stress- related      psychopathology. Development                  and psychopathology, 19(3), 889-920.

Hiew, C. C. (2000). Measurement of resilience development: Preliminary results with a State-Trait Resilience Inventory. Journal of Learning and Curriculum Development, 1, 111-117. Retrieved from https://ci.nii.ac.jp/naid/10019251223/.

Jacel, J. (1991). State and trait resilience: different perspective of resilience. Australian journal of Psychology, 36 (7), 8-10. doi: 10.1002/jcop.21811.

Javed, S., & Mustafa, N. (2013). Prevalence of Depression in various demographic variables among elderly. Open Access Scientific Reports, 2(1), 1–4. Retrieved from https://jemds. com/ data_pdf/1_swapnil%20jain%20(1).pdf.

Kaur, M., Kaur, A., Saggu, A., Kaur, A., Kaur, A., Kaur, D., Sood, B. & Kaur, S. (2006). Comparative Study on Psychosocial Stresses among Urban and Rural Geriatric Population in Selected Area of District Ludhiana. Nursing and Midwifery Research  Journal,  3(2),  79-83.  doi:  10.4103/0019-

5545.171852.

Kessler, R. C. (1997). Social factors in psychopathology: stress, social support, and coping processes. Annual Review of Psychology, 36, 531–572. doi: 10.1146/annurev.ps. 36.020185.002531.

Kim-Cohen, J. & Turkewitz, R. (2012). Resilience and measured gene–environment interactions. Development and Psychopathology. 24(4), 1297–1306.

King-Casas, B., Sharp, C., Lomax-Bream, L., Lohrenz, T., Fonagy, P., & Montague, P. R. (2008). The rupture and repair of cooperation in borderline personality disorder. Science, 321(3), 806-810.

Klohnen, E. C. (1996). Conceptual analysis and measurement of the construct of ego resiliency. Journal of Personality and Social Psychology,    70,    1067–1079.    doi:10.1037/0022-

3514.70.5.1067.

Kobasa, S. C., & Puccetti, M. C. (1982). Personality and social resources in stress resistance. Journal of Personality and Social Psychology, 45, 839–850. doi: 10.1037/0022-3514.45.4.839.

Lazarus, R.S. (1993). From psychological stress to the emotions: A history of changing                                                outlooks. Annual Review of Psychology,44,      1–21.                                           Retrieved        from https://www.annualreviews.org

/doi/abs/10.1146/annurev.ps.44.020193.000245.

Lengacher, C. A., Kip, K. E., Barta, M., Post-White, J., Jacobsen, P. B., Groer, M., ... & Loftus, L. (2012). A pilot study evaluating the effect of mindfulness-based stress reduction on psychological status, physical status, salivary cortisol, and interleukin-6 among advanced-stage cancer patients and their caregivers. Journal of Holistic Nursing, 30(3), 170-185.

Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child  Development,  71(3),  543-562.  doi:  10.1111/1467-

8624.00164.

Mirescu, C., & Gould, E. (2006). Stress and adult neurogenesis. Hippocampus, 16(3),                                                                     233-238.             doi: 10.1002/hipo.20155.

Mubeen, M. S., & Qureshi, N. S. (2012). Prevalence of Depression Among Community Dwelling Elderly in Karachi, Pakistan. Iran Journal of Psychiatry and Behavioral Science, 6(2), 84-Retrieved from      https://www.ncbi.nlm.nih.gov/pmc

/articles/PMC3940012/pdf/ijpbs-006-084.pdf.

Murphy, L. B., & Moriarty, A. E. (1976). Vulnerability, coping and growth from infancy to adolescence. Journal of Psychology, 2, 99-123. Retrieved from https://www.jaacap.org /article/S0002- 7138(09)62311-6/pdf.

Pierini, D., & Stuifbergen, A. (2012). Psychological resilience and depressive symptoms in older adults diagnosed with post-polio syndrome. NIH Public access, 35(4), 167-175. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3432643

/pdf/nihms-399314.pdf

Redl, F. (1969). When we deal with children. New York: Free Press. Rizzo, A., Buckwalter, J. G., John, B., Newman, B., Parsons, T.,

Kenny, P., & Williams, J. (2012). STRIVE: Stress Resilience In Virtual Environments: a pre-deployment VR system for training emotional coping skills and assessing chronic and acute stress responses. Studies in health technology and informatics, 173, 379-385.

Rutter M. (1990). Resilience in the face of adversity: Protective factors and resistance to psychiatric disorder. British Journal of Psychiatry,147, 598-611. doi:10.1192/bjp.147 .6.59.

Rutter, M. (1985). Resilience in the face of adversity: Protective factors and resistance to Psychiatric disorder. British Journal of Psychiatry, 147, 598-611. doi:10.1192/bjp.147.6. 598.

Rutter, M. (1987). Psychosocial resilience and protective mechanisms. American Journal of Orthopsychiatry, 57, 316–331. Retrieved from https://psycnet.apa.org/buy/2013-42839-001.

Ryff, C. D., Singer, B. Love, G. D. (1998). Resilience in adulthood and later life: Defining features and dynamic processes. In Integrative Approach, J. Lomranz (Ed.), Handbook of Aging and Mental Health (pp. 69–96). New York: Plenum Press.

Saarni, C. (1999). The interface of emotional development with social context. In M. Lewis, J. Haviland-Jones & L. Feldman Barrett (Eds.), The Handbook of Emotions (3rd ed.), (pp. 332-347). New York: Guilford Press.

Scott, B., Freese, L., Jeremy, J., Korten, A., Long, J., &Henderson, S. (1993). The Australian national survey of mental health and well-being. British Journal of Psychiatry,177, 325-330. doi: 10.1177/0022146512471197

Taylor, J. D., Brown, H. (2006). Illusion and well-being: a social psychological perspective on mental health. Psychological Bulletin,       103,                   193-210.      Retrieved                        from https://www.ncbi.nlm.nih.gov/pubmed/3283814

Wagnild, G. (2003). Resilience and successful aging: Comparison among low and high income older adults. Journal of Gerontological Nursing, 29(12), 42-49. doi:10.3928/0098 9134-

20031201-09

Wagnild, G. M., & Young, H. M. (1993). Development and psychometric evaluation of the Resilience Scale. Journal of Nursing Measurement, 1(2), 165-178. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/7850498

Wagnild, G., & Young, H. (1990). Resilience among older women. Journal of Nursing Scholarship, 22(4), 252-255. Retrieved from https://sigmapubs.onlinelibrary

.wiley.com/doi/abs/10.1111/j.1547-5069.1990.tb00224.x

Watson, C. & Hall, S.E. (2001). Older people and the social determinants of health. Australasian Journal on Ageing, 20, 23-

26. Retrieved from https://onlinelibrary .wiley.com/doi/epdf/10. 1111/j.1741-6612.2001.tb00395.x

Wolin, S. & Wolin, S.J. (1989). Resilience among Youth Growing Up in Substance Abusing Families. Pediatric Clinics of North America, 42(2), 415-429. doi: 10.1016/s0031-3955(16)38955-6

World Health Organization. (2000). Estimates of healthy life expectancy for 191 countries in 2000: Methods and results. Global Program on Evidence for Health Policy Discussion, 38, 1-55.

World Health Organization. (2001). Conquering Depression: You Can Get Out Of the Blues. South-East Asia: World Health Organization Regional Office.

World Health Organization. (2012). International Classification of Diseases and Related Health Problems (ICD-9), Geneva: WHO.

Yesavage, J. A., Roomi, J., Baldwin, R. C., & Connoly, M. J. (1996). Development and validation of a geriatric depression screening scale, a preliminary report. Journal of Psychiatric Research, 17, 37-49. doi: 10.1016/0022-3956(82)90033-4

Young, Y., Frick, K. D., & Phelan, E. A. (2009). Can successful aging and chronic illness coexist in the same individual? A multidimensional concept of successful aging. Journal of the American Medical Directors Association, 10(2), 87-92.

Zautra, A.J. (2003). Emotions, stress, and health. New York: Oxford University Press.