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Depression frequently affects older adults with chronic illnesses, reducing their quality of life. In Thailand, limited access to mental health services increases the need for preventive interventions. The SMART (Smile, Mindfulness, Attitude, Relax, and Thinking) Elderly Program aimed to assess its effectiveness in preventing depression among older adults.
Methods
Quasi-experimental research design with a repeated-measures approach was used with two groups. The study included 80 older adults diagnosed by a physician with noncommunicable diseases and a depression score of 7 to 12 on the Thai Geriatric Depression Scale (TGDS), indicating risk for depression. Participants were assigned to two groups through multi-stage sampling. The intervention group (n=40) participated in a 6-week SMART Elderly Program, while the control group (n=40) received standard treatment and a handbook for depression prevention. Evaluations took place through in-person interviews at baseline, post-intervention, and at a 3-month follow-up. Data were analyzed using descriptive statistics and repeated measures analysis of variance.
Results
The analysis showed statistically significant differences in knowledge about depression, attitudes toward depression, and TGDS scores between the intervention and control groups at the 3-month follow-up (P<0.001). In the intervention group, these measures also changed significantly from baseline to the 3-month follow-up (P<0.001).
Conclusion
The SMART Elderly Program significantly reduced depressive symptoms in older adults with chronic illnesses. These results support its use in community health practice and inform health policy to improve preventive mental health care for older adults.
The global increase in the older adult population creates significant challenges, with many countries, including Thailand, rapidly becoming aging societies [1]. Older adults often have difficulty adjusting to aging, which leads to complex health and psychosocial problems [2]. Noncommunicable diseases (NCDs) are the leading causes of death worldwide, accounting for 74.0% of global mortality, or about 41 million deaths each year, with over 80.0% occurring in low- and middle-income countries [3]. One in three adults worldwide has multiple chronic conditions, which often result in frequent hospitalizations and long-term care needs. In Thailand, NCDs cause over 75.0% of all deaths and are major contributors to years lived with disability, especially hypertension, diabetes, ischemic heart disease, stroke, and chronic kidney disease [4]. More than 25.0% of Thai adults aged 60 years and older are diagnosed with at least one NCD, and many have comorbidities [5], increasing their risk for mental health problems, particularly depression. However, depression among chronically ill older adults in Thailand remains underdiagnosed and undertreated because of stigma, limited mental health resources, and a lack of community-based interventions [6].
Depression is a common mental health disorder that significantly affects emotional, physical, and social well-being [7]. More than 280 million people worldwide experience depression, making it a leading cause of disability [7]. Among older adults, depression is especially concerning because its symptoms are often subtle, frequently underdiagnosed, and closely associated with chronic illnesses and functional decline. The global prevalence of depression in older adults is estimated at 5.7%, but rates differ depending on comorbidities and access to healthcare. In Thailand, national data indicate that 10.0% to 20.0% of older adults have depressive symptoms, highlighting a growing public health concern [8]. Depression in this group is often missed because symptoms such as persistent sadness, fatigue, changes in appetite or sleep, difficulty concentrating, and feelings of worthlessness can resemble normal aging or chronic disease [9].
Older adults with chronic illnesses face a higher risk of depressive symptoms because of the burden of long-term diseases and psychosocial stressors. Preventive mental health programs are essential to support emotional well-being and lower depression risk in this group. Although global attention to mental health in aging populations is increasing, depression among older adults with chronic illnesses remains under-recognized, especially in community settings. In Thailand, while several programs address NCDs, there are still few preventive mental health interventions specifically for older adults with chronic conditions [8,9]. Most current initiatives focus on pharmacological treatment or general mental health promotion, with limited use of behavioral change theories or structured community-based approaches [10].
Few studies have rigorously evaluated theory-driven interventions for depression prevention in this group [11,12]. In the Central Region of Thailand, which has a growing aging population and both urban and rural communities, older adults often experience chronic illnesses such as hypertension and diabetes, along with limited access to mental health services. To address this issue, the SMART (Smile, Mindfulness, Attitude, Relax, and Thinking) Elderly Program was developed as a culturally tailored intervention based on the Knowledge–Attitude–Practice (KAP) model [13] and Bandura Self-Efficacy Theory [14]. The program aimed to translate knowledge into health-promoting behaviors and strengthen self-efficacy in managing emotional well-being. This study evaluated the program’s effectiveness in preventing depression among older adults with chronic illnesses in Central Thailand, providing evidence-based insights to guide public health strategies and mental health policies that support healthy aging.
Methods
Ethics statement
Ethical approval was obtained from the Valaya Alongkorn Rajabhat University under the Royal Patronage Ethics Committee (IRB No. 0017/2024; COA No. 0073/2024), approved on September 10, 2024. The study followed the Declaration of Helsinki. All older adult participants provided written informed consent before participation. The research team ensured that participation was voluntary and informed participants of their right to withdraw from the study at any time.
Study design
This study used a quasi-experimental design with repeated measures involving two groups, and findings are reported according to the CONSORT (Consolidated Standards of Reporting Trials) checklist. The aim was to compare mean scores for knowledge about depression, attitudes toward depression, and the Thai Geriatric Depression Scale (TGDS) between the intervention and control groups. The intervention group participated in a 6-week SMART Elderly Program, with one session per week for six sessions. The control group received standard treatment for chronic diseases and a handbook for depression prevention over the same period. The primary hypothesis was that respondents in the SMART Elderly Program would have significantly lower depression scores, as measured by TGDS, than those receiving standard treatment and a handbook for depression prevention at post-intervention and at a 3-month follow-up.
Setting
This study took place in Sing Buri Province, Central Thailand, which consistently reports the highest depression rates among older adults and increasing morbidity, especially among those with NCDs. As a predominantly rural area, Sing Buri faces challenges such as social isolation resulting from the outmigration of younger family members and limited access to mental health services and preventive programs, which further increase the mental health burden in its aging population.
Participants
The researchers screened adults aged 60 years or older who were registered and receiving ongoing treatment for chronic illnesses at chronic disease clinics of Subdistrict Health Promoting Hospitals in Sing Buri Province, Central Thailand. Eligible participants had at least one physician-diagnosed chronic condition, such as hypertension, diabetes, or dyslipidemia. Screening and participant identification took place from August 1 to August 31, 2024, before the program’s implementation. The TGDS, the standard screening tool for depression among older adults in Thailand, was used to identify individuals at risk for depression. Participants with TGDS scores of 7 to 12 were classified as not currently depressed but at risk of developing depressive symptoms. Individuals with higher scores in this range were considered more likely to develop depression in the future without preventive intervention. The researchers confirmed all eligibility information by reviewing medical records and conducting brief interviews. Participants who met the inclusion criteria and gave informed consent were enrolled in the study. This process ensured that the SMART Elderly Program targeted older adults at increased risk for depression while maintaining methodological rigor and data validity. Exclusion criteria included inability to attend all program sessions, physician-diagnosed depression or other mental disorders, and chronic disease complications that limited participation (e.g., disability, paralysis, or terminal-stage cancer).
Sampling
A multi-stage sampling method was used. First, two districts were randomly selected from six in Sing Buri Province, Central Thailand: Bang Rachan District (intervention group) and Khai Bang Rachan District (control group). Both districts have similar characteristics, including a high proportion of older adults, comparable mental health burdens, and similar geographic and lifestyle conditions. Second, purposive sampling was used to select one subdistrict from each district: Phakthan Sub-district for the intervention group and Tha Kham Sub-district for the control group. A total of 128 older adults were identified; 48 were excluded because they did not meet the inclusion criteria (n=19), declined participation (n=21), or for other reasons (n=8). The final sample included 80 participants, with 40 in the intervention group and 40 in the control group.
Interventions
The SMART Elderly Program was designed to prevent depression in older adults with chronic illnesses, based on the KAP model [13] and Bandura Self-Efficacy Theory [14]. The program first increased participants’ knowledge about depression and chronic disease management. It then encouraged positive attitudes through group discussions, experience-sharing, and role models. The program also supported health-promoting practices, such as physical activity, mindfulness, and social engagement. Self-efficacy strategies were included throughout to strengthen participants’ confidence in using knowledge and maintaining behavioral changes in daily life. The researchers initially drafted the intervention program using these theoretical frameworks, and a panel of three experts in psychology, family medicine, and public health reviewed it. Their feedback on content, structure, and strategies led to revisions that improved the program’s clarity, relevance, and validity. This expert review process ensured the intervention was appropriate for the target older adult population.
This study implemented a six-session program with 1-hour activities held every Saturday for 6 weeks. Using the S-M-A-R-T framework, the intervention provided accurate information about depression and its connection to chronic illness, promoted positive attitudes toward mental health and self-care, encouraged sustainable health behaviors, and increased participants’ confidence in managing their health. Sessions included a program introduction, depression prevention education, counseling, and stress-reducing activities such as light exercise and group games. Active engagement supported understanding, self-reflection, and motivation to apply new skills, aiming to reduce depression risk and improve well-being.
The SMART Elderly Program, described in Table 1, began with pre-test assessments using a general information questionnaire, a depression knowledge questionnaire, and the TGDS. The program included six sessions. Session 1, Smile (S), promoted social interaction, provided information about depression, and supported memory through enjoyable activities. Session 2, Mindfulness (M), focused on training attention and focus to encourage calmness and sensory awareness. Session 3, Attitude (A), encouraged positive thinking, emotional understanding, and idea sharing. Session 4, Relax (R), aimed to reduce stress, build unity and trust, and support memory and observation. Session 5, Thinking (T), encouraged analytical thinking, cognitive evaluation, and mental well-being. Session 6, Summarize, identified challenges to depression prevention and motivated ongoing participation in support group activities.
The control group received routine chronic disease care and an informational handbook on depression prevention, which included its definition, risk factors, symptoms, health effects, prevention strategies, stress management, positive thinking, social support, and guidance for seeking help. The handbook aimed to increase awareness and support self-care. The control group completed the same baseline, post-intervention, and 3-month follow-up assessments as the intervention group using a questionnaire. Both groups were followed for 3 months after implementation. Researchers assessed depressive symptoms, stress levels, and self-management behaviors at baseline, post-intervention, and 3-month follow-up to evaluate short-term effects and the sustainability of emotional improvements.
Sample size
The sample size for the F-test was determined using G*Power software (Heinrich-Heine-Universität Düsseldorf) by selecting the analysis of variance (ANOVA): repeated measures, within-between interaction statistical test. Calculations used a 95% confidence level (type I error rate=0.05), statistical power of 95%, allowable error margin of 0.05, and effect size of 0.182 [15]. The final sample included 80 participants, with 40 in the intervention group and 40 in the control group.
Instrument
The study used four instruments. Parts 1 to 3 were developed by the researchers based on literature and prior studies [13-15], and reliability testing showed acceptable internal consistency. Part 4 was the TGDS, a standard validated tool for screening depression in older adults in Thailand. A panel of three experts in family medicine, public health, and psychology assessed face validity by evaluating each item for language clarity and contextual appropriateness for older adults with chronic illnesses. After expert feedback, minor revisions were made to simplify terms, rephrase complex sentences, and improve cultural sensitivity. Validity was further confirmed using the Index of Item-Objective Congruence (IOC). Reliability was tested in a pilot study with 30 older adults from the same region, who were not included in the main study, with results reported as Cronbach’s alpha or Kuder-Richardson-20 (KR-20).
Part 1: general information questionnaire. This section included six items on gender, age, marital status, occupation, monthly income, and underlying diseases, using both multiple-choice and open-ended questions. The IOC was 0.89.
Part 2: knowledge about depression assessment. This section contained 15 yes/no questions to assess knowledge of depression. Each correct answer received 1 point; incorrect answers received 0 points. Scores were classified according to Bloom’s criteria [16] as high (12–15), moderate (9–11), and low (0–8). The IOC was 0.91, and reliability (KR-20) was 0.96.
Part 3: attitude toward depression scale. This scale included 10 items with response options of Agree, Uncertain, and Disagree. Positive statements were scored 3-2-1, while negative statements were reverse scored. Attitude levels were classified according to Best criteria [17]: very positive (2.34–3.00), moderate (1.67–2.33), and low (1.00–1.66). The IOC was 0.90, and reliability, measured by Cronbach’s alpha, was 0.92.
Part 4: TGDS. This standardized tool, developed by Train the Brain Forum Thailand [18], assessed depressive symptoms in older adults. The TGDS includes 30 self-report items evaluating participants’ feelings over the past week. The total score ranges from 0 to 30, with 0 to 12 points indicating no depression, 13 to 18 points indicating mild depression, 19 to 24 points indicating moderate depression, and 25 to 30 points indicating severe depression. The TGDS showed validity with an IOC of 0.93 [18], and reliability with a Cronbach’s alpha coefficient of 0.96.
Blinding
No blinding was used in this study because both the intervention and control groups were predefined, and the nature of the SMART Elderly Program did not allow for participant blinding. Trained health professionals, who were independent of the program implementation team, conducted all assessments through in-person interviews. The authors coded and analyzed the responses using predefined criteria and statistical procedures to maintain objectivity and data integrity.
Bias
To improve internal validity and reduce bias in this quasi-experimental study, several measures were used. Strict inclusion and exclusion criteria ensured a balanced sample without overrepresentation of any subgroup. Baseline comparability between intervention and control groups was confirmed using chi-square tests, which showed no significant differences (P>0.05). Data collectors received standardized training to maintain consistency in administering questionnaires. Outcome variables were assessed at three time points (baseline, post-intervention, and 3-month follow-up) to capture changes over time related to the intervention.
Data collection
The researchers worked with community health centers and local networks in Central Thailand to recruit older adults with chronic illnesses for both groups. Approvals came from local authorities and health personnel. Eligible participants were screened using predefined criteria, and written informed consent was obtained. The intervention group participated in the 6-week SMART Elderly Program. The control group received standard chronic disease care and a self-guided depression prevention handbook. Data were collected from September 2024 to January 2025 at three time points: baseline, post-intervention, and 3-month follow-up.
Statistical analysis
Data analysis used IBM SPSS ver. 29.0.1 (IBM Corp.) with a significance level of 0.05. Descriptive statistics summarized demographic and key variables. Baseline categorical differences between groups were tested with a chi-square test. Repeated-measures ANOVA assessed the effects of the SMART Elderly Program on depression prevention. Assumptions were checked: the Kolmogorov-Smirnov test confirmed normality (P>0.05), Levene test confirmed homogeneity of variance (P>0.05), and Mauchly test of sphericity guided adjustments when violated, with the sphericity assumed correction applied. Post-hoc comparisons used the Bonferroni correction to control for multiple comparisons, ensuring valid evaluation of within- and between-group differences over time.
Results
Participant flow
A total of 128 older adults with chronic illnesses were screened for eligibility at the chronic disease clinics of Subdistrict Health Promoting Hospitals in both study areas. Of these, 48 were excluded because they did not meet inclusion criteria (n=19), declined to participate (n=21), or for other reasons (n=8). Eighty eligible participants were enrolled and equally assigned to the intervention (n=40) and control (n=40) groups. All participants completed assessments at baseline, post-intervention, and at the 3-month follow-up, with no dropouts during the study (Figure 1).
Baseline data
Table 2 shows that, although the intervention and control groups were assigned by subdistrict and the sample size was modest, there were no significant differences in baseline characteristics between the groups (P>0.05), indicating reasonable comparability at baseline. Most participants were female (65.0%), with a mean age of 64.4 years (standard deviation [SD]=3.43), and most (87.5%) were aged 60 to 69 years. Over 60% were married, and 66.3% had a monthly income of Thai baht 10,000 or less. The most common occupations were farming (40.0%) and hired labor (28.7%). Chronic illnesses were highly prevalent, with diabetes mellitus and hypertension each affecting 71.3% of participants, followed by dyslipidemia at 56.2%.
TGDS scores measured at three time points
Table 3 shows that all participants in both groups had baseline TGDS scores of 7 to 12, indicating no depression but a risk for depression. The intervention group had a mean TGDS score of 11.55 (SD=0.87) at baseline, 8.38 (SD=1.51) post-intervention, and 5.95 (SD=1.74) at the 3-month follow-up. The control group had mean scores of 11.40 (SD=0.98) at baseline, 9.63 (SD=1.95) postintervention, and 9.72 (SD=1.90) at the 3-month follow-up. These results indicate that the intervention reduced depressive symptoms over time compared with the control group.
Effects of the SMART Elderly Program on knowledge about depression
Table 4 shows that the SMART Elderly Program significantly improved depression knowledge among older adults with chronic illnesses. Between-group analysis found a strong effect (F(1, 78)=42.22, P<0.001), and within-subjects analysis confirmed significant improvement over time (P<0.001). Mauchly test supported the sphericity assumption (P>0.05). These findings indicate a significant time-by-group interaction, demonstrating the program’s effectiveness. Post hoc analysis with Bonferroni correction showed no significant difference in depression knowledge at baseline (mean difference=–0.575, P>0.05) (Table 5). However, the intervention group had significantly higher scores post-intervention (mean difference=1.125, P=0.013) and at the 3-month follow-up (mean difference=5.025, P<0.001), indicating that the SMART Elderly Program led to sustained improvement in knowledge.
Effects of the SMART Elderly Program on attitudes toward depression
A significant difference in attitude toward depression was found between groups (F(1, 78)=18.75, P<0.001), with sphericity assumed (P>0.05). Within-subjects analysis showed significant improvement over time (P<0.001), indicating a strong time-by-intervention interaction (Table 4). Post hoc Bonferroni tests showed no baseline difference in attitude toward depression between groups (mean difference=–0.450, P>0.05). However, the intervention group showed significant improvement at post-intervention (mean difference=1.250, P=0.003) and at 3-month follow-up (mean difference=2.700, P<0.001) compared to the control group (Table 5). Therefore, the intervention group’s attitude improved significantly more than that of the control group.
Effects of the SMART Elderly Program on TGDS scores
There was a significant difference in TGDS scores between groups (F(1, 78)=75.97, P<0.001), with Mauchly test supporting sphericity (P>0.05). Within-subjects analysis showed significant changes over time in the intervention group (P<0.001), indicating a strong interaction effect (Table 4). Post hoc Bonferroni comparisons found no baseline difference (mean difference=0.150, P>0.05), but significant reductions in TGDS scores in the intervention group at post-intervention (mean difference=–1.250, P=0.002) and at 3-month follow-up (mean difference=–3.775, P<0.001) compared to controls (Table 5). Therefore, the intervention group’s depression scores improved significantly more than those of the control group.
Discussion
This study shows that the SMART Elderly Program significantly increased depression knowledge among older adults with chronic illnesses, with the intervention group’s scores rising more than those of the control group. These results support the effectiveness of structured, community-based education in improving mental health literacy, which is important for early detection, timely intervention, and reducing stigma [19]. The difference between groups highlights the value of targeted education in helping older adults recognize symptoms and seek support. These findings are consistent with previous research indicating that tailored health education increases awareness and supports depression prevention in aging populations [20,21].
The SMART Elderly Program significantly improved attitudes toward depression among older adults with chronic illnesses, with the intervention group demonstrating greater acceptance and understanding than the control group. Positive attitude changes are essential for reducing stigma, promoting help-seeking, and encouraging open discussions about mental health, especially among older adults who face cultural and informational barriers [22]. This success highlights the value of targeted mental health education in community interventions. These findings are consistent with previous studies that identify attitude improvement as key to early detection and prevention of depression in vulnerable populations with chronic illnesses [23,24].
This study shows that the SMART Elderly Program significantly reduced depression risk among older adults with chronic illnesses, as indicated by a greater decrease in TGDS scores in the intervention group compared to controls. Based on the KAP model [13] and Bandura Self-Efficacy Theory [14], the six-session program addressed cognitive, emotional, and behavioral factors important for depression prevention. The sessions encouraged social interaction, emotional regulation, positive thinking, stress reduction, cognitive restructuring, and group support. Consistent with the KAP model, increased knowledge improved attitudes and health-promoting behaviors, which supported better coping and reduced depressive symptoms. Bandura theory emphasized increasing self-efficacy through activities that build confidence, problem-solving skills, and emotional management, enabling participants to manage their mental health effectively [25,26]. At the 3-month follow-up, participants continued to show lower TGDS scores, improved self-management, and reduced stress, confirming the program’s lasting effects.
These findings are consistent with previous research indicating that structured mental health education combined with interactive activities effectively reduces depressive symptoms in older adults. Community-based programs that emphasize mindfulness, positive psychology, and social participation have significantly improved psychological well-being and lowered depression scores in older adults with chronic illnesses [27,28]. Similar to this study, these interventions aim to enhance knowledge, shift attitudes, and develop practical skills, highlighting the value of comprehensive mental health promotion approaches [29,30]. The results support the effectiveness of structured, theory-based interventions such as the SMART Elderly Program in preventing depression among older adults with chronic illnesses. By improving mental health knowledge, attitudes, and self-efficacy, the program provides a comprehensive strategy to reduce depression risk, which is essential for promoting healthy aging and quality of life. The significant reduction in TGDS scores demonstrates the importance of early intervention before depressive symptoms worsen.
The SMART Elderly Program included six weekly 1-hour sessions based on the S-M-A-R-T framework. The sessions provided education on depression and chronic illness, promoted self-care and healthy behaviors, and used counseling and stress-reducing activities to support understanding, reflection, and motivation to reduce depression risk. Implementing the program in clinical settings requires trained personnel, such as nurses, health educators, and community health volunteers, to deliver sessions, facilitate activities, monitor progress, and provide follow-up. Necessary resources include educational materials, TGDS screening tools, space for group activities, and basic exercise equipment. Integrating the weekly sessions with routine clinic operations requires careful planning. Potential barriers include staff workload, participants’ personal obligations or transportation issues, and differences in staff training, which may affect program fidelity. Addressing these challenges through flexible scheduling, volunteer support, concise training, and clear session guidelines can help ensure the feasibility, sustainability, and successful implementation of the SMART Elderly Program in primary care settings.
Limitations
This study has several limitations. First, it was conducted in a specific community in Central Thailand, which limits generalizability to other regions or cultures. Second, the relatively small sample size may have reduced statistical power and limited the detection of subtle group differences. Third, using self-reported questionnaires for knowledge and attitudes may have introduced response bias or inaccuracies due to recall or social desirability.
Recommendations for future research
Future research should use larger and more diverse samples to improve generalizability across regions and older adult populations. Researchers should also extend follow-up beyond 3 months to assess the long-term effects of the SMART Elderly Program. Additional outcomes, such as quality of life, social participation, and physical health, should be examined. Qualitative studies are needed to explore participants’ experiences, barriers, and suggestions for program improvement.
Implications for family medicine and public health concerns
This study highlights the important role of family medicine and public health in preventing depression among older adults with chronic illnesses. First, primary care providers should conduct routine depression screening using tools such as the TGDS for early detection. Second, integrating programs such as the SMART Elderly Program into community care can improve mental health literacy, attitudes, and self-efficacy. Third, ongoing follow-up by healthcare teams supports self-care and reduces the risk of depression. Finally, collaboration among healthcare providers, community leaders, and families is necessary to maintain mental health promotion and improve healthy aging and quality of life.
Notes
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Acknowledgments
We sincerely thank all participants in this study for their cooperation, enthusiasm, and dedication to the SMART Elderly Program. We also thank the local health authorities and community leaders in Central Thailand for their support and collaboration throughout the research.
Funding
None.
Data availability
The datasets are not publicly available but can be obtained from the corresponding author upon reasonable request.
Author contribution
Conceptualization: P Toopboochakorn, P Tanthanapanyakorn, NN, PH, WL. Data acquisition: P Toopboochakorn, P Tanthanapanyakorn, NN, PH, WJ. Review: P Toopboochakorn, P Tanthanapanyakorn, WJ. Tool development: P Toopboochakorn, P Tanthanapanyakorn, NN. Formal analysis and data interpretation: P Toopboochakorn, P Tanthanapanyakorn, NN. Investigation: P Toopboochakorn, NN, PH, WJ. Methodology: all authors. Project administration: P Tanthanapanyakorn. Resources: P Tanthanapanyakorn, NN. Supervision: P Tanthanapanyakorn. Validation: P Toopboochakorn, P Tanthanapanyakorn. Visualization: P Toopboochakorn, P Tanthanapanyakorn. Project administration: P Toopboochakorn, P Tanthanapanyakorn. Writing–original draft: P Tanthanapanyakorn. Writing–review & editing: P Tanthanapanyakorn. Final approval of the manuscript: all authors.
Figure. 1.
Flowchart for the study. SMART, Smile, Mindfulness, Attitude, Relax, Thinking.
Table 1.
Details and implementation of the SMART Elderly Program
Session
Objective
Activity
Session 1: Smile (S)
1. To inform participants about the objectives of the program.
1. Greet participants and explain the objectives of the program.
2. To provide knowledge and understanding about depression.
2. Educate the meaning of depression, its causes, and prevention methods.
3. To promote smiles through engaging and enjoyable activities.
3. Eye contact game: participants pair up and sit facing each other. They must maintain eye contact without blinking; whoever blinks first loses. Laughing is also prohibited; anyone who laughs first is considered the loser.
4. To enhance participants’ memory.
4. Picture-based charades: a fun activity where participants guess words based on pictures.
5. Whisper the word game: participants are divided into groups and seated in a long row. The researcher whispers a word to the first person in each row, who then whispers it to the next person, and so on until it reaches the last person.
Session 2: Mindfulness (M)
1. To practice meditation that requires concentration, focus, and determination.
1. A short meditation session to allow the brain to relax by sitting with eyes closed and hands gently clasped together for 10 minutes.
2. To raise cultivate a calm mind and maintain mindfulness and wisdom at all times.
2. Two-hand coordination exercise: the instructor demonstrated, and participants followed the movements to practice mindfulness and reduce stress.
3. Take me home activity: participants guide their friend’s “home” by drawing a line through the maze as shown in the picture. This activity helps improve concentration and decision-making.
Session 3: Attitude (A)
1. To foster a more positive attitude.
1. Positive thinking to overcome stress activity: provide knowledge about self-management during stressful situations using educational materials such as posters.
2. To encourage the exchange of ideas with others.
2. Past… present… future activity. Participants written down what made them happy in the past, reflect on whether they are happy with their present life, and express what they would like to do in the future to bring happiness.
3. To promote understanding of emotions that can lead to depression.
3. Joyful jigsaw activity: a jigsaw puzzle activity designed to promote positive thinking and help participants understand the emotions that can lead to depression.
Session 4: Relax (R)
1. To promote relaxation and reduce stress among participants.
1. Move a little, brighten your life: a 20–30-minute light aerobic exercise session with music to reduce stress and enhance mood.
2. To foster unity and build trust among participants.
2. Finger dance activity: participants paired up, pressing hands together while keeping fingers connected, performed in three 3-minute rounds to foster coordination, attention, and social interaction.
3. To develop observation skills and stimulate memory of the samples.
3. Guess the drawing game: participants took turns drawing sequentially without seeing the original prompt; the last person guessed the drawing, enhancing memory, observation, and group collaboration.
Session 5: Thinking (T)
1. To encourage analytical thinking, evaluate thought processes, and promote mental health while reinforcing knowledge.
1. Joyful bingo activity: participants used bingo cards and tokens, matching images randomly drawn by the researcher to practice attention and pattern recognition.
2. Color by number activity: participants colored numbered sections according to their own chosen colors, fostering decision-making, planning, and creativity.
3. Color guessing game: how well do you know colors? Participants identified the actual color of displayed names, promoting focus, cognitive processing, and mental agility.
Session 6: Summarize
1. To identify problems and obstacles to depression prevention.
1. A session to review essential knowledge regarding depression.
2. To encourage participants to engage in sustaining the support group activities.
2. Brainstorming past activity problems: older adults were written down the problems or obstacles they experienced during previous activities, along with suggested solutions.
3. Establishing the Singburi Depression Prevention Club: a communitybased club was formed with participation from local stakeholders, village health volunteers, and model older adults with good mental health who served as club leaders.
4. Make agreements on depression prevention drafted and proposed to community leaders and health officials for endorsement and implementation.
Values represent mean differences between the intervention and control groups.
SE, standard error; TGDS, Thai Geriatric Depression Scale.
*P<0.05 (Statistical significance).
a)Bonferroni-adjusted for multiple comparisons; significant difference.
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Preventing depression in older adults with chronic illnesses through the SMART Elderly Program: a quasi-experimental study in Central Thailand
Figure. 1. Flowchart for the study. SMART, Smile, Mindfulness, Attitude, Relax, Thinking.
Graphical abstract
Figure. 1.
Graphical abstract
Preventing depression in older adults with chronic illnesses through the SMART Elderly Program: a quasi-experimental study in Central Thailand
Session
Objective
Activity
Session 1: Smile (S)
1. To inform participants about the objectives of the program.
1. Greet participants and explain the objectives of the program.
2. To provide knowledge and understanding about depression.
2. Educate the meaning of depression, its causes, and prevention methods.
3. To promote smiles through engaging and enjoyable activities.
3. Eye contact game: participants pair up and sit facing each other. They must maintain eye contact without blinking; whoever blinks first loses. Laughing is also prohibited; anyone who laughs first is considered the loser.
4. To enhance participants’ memory.
4. Picture-based charades: a fun activity where participants guess words based on pictures.
5. Whisper the word game: participants are divided into groups and seated in a long row. The researcher whispers a word to the first person in each row, who then whispers it to the next person, and so on until it reaches the last person.
Session 2: Mindfulness (M)
1. To practice meditation that requires concentration, focus, and determination.
1. A short meditation session to allow the brain to relax by sitting with eyes closed and hands gently clasped together for 10 minutes.
2. To raise cultivate a calm mind and maintain mindfulness and wisdom at all times.
2. Two-hand coordination exercise: the instructor demonstrated, and participants followed the movements to practice mindfulness and reduce stress.
3. Take me home activity: participants guide their friend’s “home” by drawing a line through the maze as shown in the picture. This activity helps improve concentration and decision-making.
Session 3: Attitude (A)
1. To foster a more positive attitude.
1. Positive thinking to overcome stress activity: provide knowledge about self-management during stressful situations using educational materials such as posters.
2. To encourage the exchange of ideas with others.
2. Past… present… future activity. Participants written down what made them happy in the past, reflect on whether they are happy with their present life, and express what they would like to do in the future to bring happiness.
3. To promote understanding of emotions that can lead to depression.
3. Joyful jigsaw activity: a jigsaw puzzle activity designed to promote positive thinking and help participants understand the emotions that can lead to depression.
Session 4: Relax (R)
1. To promote relaxation and reduce stress among participants.
1. Move a little, brighten your life: a 20–30-minute light aerobic exercise session with music to reduce stress and enhance mood.
2. To foster unity and build trust among participants.
2. Finger dance activity: participants paired up, pressing hands together while keeping fingers connected, performed in three 3-minute rounds to foster coordination, attention, and social interaction.
3. To develop observation skills and stimulate memory of the samples.
3. Guess the drawing game: participants took turns drawing sequentially without seeing the original prompt; the last person guessed the drawing, enhancing memory, observation, and group collaboration.
Session 5: Thinking (T)
1. To encourage analytical thinking, evaluate thought processes, and promote mental health while reinforcing knowledge.
1. Joyful bingo activity: participants used bingo cards and tokens, matching images randomly drawn by the researcher to practice attention and pattern recognition.
2. Color by number activity: participants colored numbered sections according to their own chosen colors, fostering decision-making, planning, and creativity.
3. Color guessing game: how well do you know colors? Participants identified the actual color of displayed names, promoting focus, cognitive processing, and mental agility.
Session 6: Summarize
1. To identify problems and obstacles to depression prevention.
1. A session to review essential knowledge regarding depression.
2. To encourage participants to engage in sustaining the support group activities.
2. Brainstorming past activity problems: older adults were written down the problems or obstacles they experienced during previous activities, along with suggested solutions.
3. Establishing the Singburi Depression Prevention Club: a communitybased club was formed with participation from local stakeholders, village health volunteers, and model older adults with good mental health who served as club leaders.
4. Make agreements on depression prevention drafted and proposed to community leaders and health officials for endorsement and implementation.
Variable
Total (n=80)
Intervention group (n=40)
Control group (n=40)
P-valuea)
Sex
0.061
Male
28 (35.0)
10 (25.0)
18 (45.0)
Female
52 (65.0)
30 (75.0)
22 (55.0)
Age (y)
0.499
60–69
70 (87.5)
34 (85.0)
36 (90.0)
≥70
10 (12.5)
6 (15.0)
4 (10.0)
Mean age (y)
64.4±3.43
64.5±3.65
64.0±3.22
Marital status
0.557
Married
49 (61.2)
26 (65.0)
23 (57.5)
Single
14 (17.5)
4 (10.0)
10 (25.0)
Divorced/separated
17 (21.3)
10 (25.0)
7 (17.5)
Monthly income (THB)
0.398
≤5,000
18 (22.5)
11 (27.5)
7 (17.5)
5,000–10,000
35 (43.8)
18 (45.0)
17 (42.5)
≥10,000
27 (33.7)
11 (27.5)
16 (40.0)
Occupation
0.555
Merchant/business
15 (18.8)
9 (22.5)
6 (15.0)
Hired labor
23 (28.7)
9 (22.5)
14 (35.0)
Farmer
32 (40.0)
16 (40.0)
16 (40.0)
Retired/unemployed
10 (12.5)
6 (15.0)
4 (10.0)
Hypertension
0.805
Yes
57 (71.3)
29 (72.5)
28 (70.0)
No
23 (28.7)
11 (27.5)
12 (30.0)
Diabetes
0.805
Yes
57 (71.3)
28 (70.0)
29 (72.5)
No
23 (28.7)
12 (30.0)
11 (27.5)
Dyslipidemia
0.499
Yes
45 (56.2)
24 (60.0)
21 (52.5)
No
35 (43.8)
16 (40.0)
19 (47.5)
Time
Intervention group (n=40)
Control group (n=40)
Baseline
11.55±0.87 (9–12)
11.40±0.98 (8–12)
Post-intervention
8.38±1.51 (5–11)
9.63±1.95 (3–12)
3-month follow-up
5.95±1.74 (2–10)
9.72±1.90 (4–12)
Outcome variable
SS
df
MS
F-test
P-value
Knowledge about depression
Between subject
Intervention
207.20
1
207.20
42.22
<0.001*
Error (between-group-error)
382.79
78
4.91
Within subject
Time
873.30
2
437.15
103.54
<0.001*
Intervention×time
329.73
2
164.87
39.05
<0.001*
Error (within-group-error)
658.63
156
4.22
Attitudes toward depression
Between subject
Intervention
81.67
1
81.67
18.57
<0.001*
Error (between-group-error)
342.98
78
4.39
Within subject
Time
236.10
2
118.05
36.65
<0.001*
Intervention×time
99.43
2
49.72
15.43
<0.001*
Error (within-group-error)
502.47
156
3.22
TGDS score
Between subject
Intervention
158.44
1
158.44
75.97
<0.001*
Error (between-group-error)
164.62
78
2.11
Within subject
Time
552.22
2
276.11
107.28
<0.001*
Intervention×time
158.27
2
79.14
30.75
<0.001*
Error (within-group-error)
401.50
156
2.57
Time
Mean difference
SE
P-valuea)
Knowledge about depression
Baseline
–0.575
0.464
0.219
Post-intervention
1.125
0.445
0.013*
3-month follow-up
5.025
0.505
<0.001*
Attitudes toward depression
Baseline
–0.450
0.354
0.208
Post-intervention
1.250
0.414
0.003*
3-month follow-up
2.700
0.495
<0.001*
TGDS scores
Baseline
0.150
0.208
0.473
Post-intervention
–1.250
0.391
0.002*
3-month follow-up
–3.775
0.408
<0.001*
Table 1. Details and implementation of the SMART Elderly Program
, Nanthawan Nilpayak2
