Music, dhikr, and deep breathing technique to decrease depression level in older adults: Evidence-based practice in Depok City, Indonesia

Depression is a mental health problem that affects the elderly. As meeting the spiritual needs of depressed older people is important, a spiritual approach nursing intervention must be applied to reduce the level of depression in this population. This study proposed an integrated spiritual nursing approach through music therapy, dhikr, and deep breathing to improve depression levels among the elderly living in Cisalak Pasar, Depok City, in 2019. The research method used was a case study of an evidence-based practice using the Geriatric Depression Scale. The study sample consisted of 106 elderly, who were recruited by purposive sampling. The average depression scores among the elderly were 4.79 and 2.48 before and after the intervention, respectively, indicating that the mean depression score decreased by 2.31. The independent t-test results obtained a p-value < 0.05, demonstrating the positive influence of the proposed spiritual approach nursing intervention on the level of depression among the subjects. A spiritual approach nursing intervention program through music therapy, dhikr, and deep breathing reduced the level of depression in the elderly. Thus, such an approach can be used as an intervention option in dealing with depression problems in the elderly.

include low economic status, lack of ability, and the occurrence of unexpected events and several daily problems continuously and simultaneously. Such long-term problems cannot be easily overcome, and these are compounded by an environment that cannot help solve such problems (Miller, 2012). These risk factors and the changes brought on by aging can lead to negative functional consequences for the elderly, such as the occurrence of psychological problems like loneliness.
Past studies have shown that the loneliness experienced by the elderly could increase the severity of chronic illnesses (Barlow, Liu, & Wrosch, 2015;Warner, Roberts, Jeanblanc, & Adams, 2019). Loneliness among the elderly has an impact on their physical health.
Unfortunately, loneliness and chronic diseases may subsequently develop into depression if such conditions persist for a long time. Depression is a severe psychological problem that affects the health of the elderly. A study reported that the depression experienced by the elderly in Korea was associated with their chronic diseases (Park, Park, Yang, & Chung, 2016). Studies have suggested that depression is the cause of the high incidence of suicide among the elderly.
For example, Wallace, (2008) reported that 15% of the depression cases among the elderly led to suicide.
The development of depression in the elderly is closely related to aging, specifically the changes in the brain and in the nervous and neuroendocrine systems. Aging causes all bodily functions and systems to decline. In the nervous and neuroendocrine systems, aging facilitates the increase in plasma levels of cortisol, triggering the onset of stress. Stress suffered over a long period later evolves into depression. Furthermore, changes in the brain include anatomical changes (e.g., presence of lesions), brain neurophysiological changes (e.g., decreased cerebral blood flow), and impaired circadian rhythm (sleep patterns), which can trigger the onset of depression in the elderly (Miller, 2012). The onset of depression is very likely among the elderly; thus, it is necessary to gain a further understanding of the prevalence of depression in this population.
At present, the elderly group suffering from depression makes up 7% of the total world population. Globally, depression has been identified as a significant cause of morbidity in 14% of the elderly (WHO, 2017). Furthermore, depression in older people is higher in developing countries. According to in 2018 data published by RISKESDAS, 6.1% of the Indonesian population aged over 15 years suffer from depression, among which the elderly comprise 5% of this population (Ministry of Health, 2017).
Meanwhile, overcoming depression-related problems can be done by carrying out various activities that stimulate the spirituality of the elderly. Music therapy, one of many interventions employed, has been proven to reduce the level of depression among this group (Ilmi, 2014).
Another study reported decreased depression levels through music therapy and reminiscence therapy integrated with reality orientation techniques in patients with mild Alzheimer's disease (Onieva-zafra et al., 2018). Moreover, listening to music is a nursing intervention that has been proven effective in reducing chronic osteoarthritis pain in the elderly (McCaffrey & Freeman, 2003).
Apart from reducing the level of depression, music therapy can improve other aspects of psychological health. Music therapy has been carried out in China for as many as eight 30minute sessions for a period of four weeks using four types of classical music at a frequency of 60-80 beats/minute (Lee, Chan, & Mok, 2010). This has been used as an intervention program to overcome depression among the elderly. However, other interventions are needed to ensure that holistic therapy is provided. Therefore, a spiritual aspect must be integrated into intervention programs meant to address depression.
Spirituality is an essential aspect of the lives of older adults. In reality, spirituality encompasses all aspects of life, namely mind, body, and spirit, which are internalized and realized onto oneself, with all aspects being united and connected (Eliopoulos, 2010). The Indonesian elderly suffering from chronic diseases often surrender themselves to God believing that their disease is part of their divine destiny (Bahtiar, Sahar, & Wiarsih, 2020). A study found that the faith of the elderly can facilitate their acceptance of the disease, improve their coping strategies, increase their inner strength, foster hope and a sense of self-responsibility, and enable them to find meaning and purpose in life (Nabolsi & Carson, 2011). Conversely, for the elderly with chronic diseases, having low levels of spirituality accompanied by depressive symptoms is significantly associated with the second year of chronic diseases (Ballew et al., 2012). Previous research has closely related spirituality to depression in the elderly. Therefore, handling depression in the elderly requires the integration of spiritual intervention programs, such as dhikr therapy.
Dhikr interventions have been carried out in several studies, which reported positive effects on the subjects' psychological problems. One study reported a decrease in the level of depression in the elderly from severe to moderate levels after implementing dhikr music therapy (Umamah & Fabiyanti, 2018). Similarly, another study revealed that dhikr therapy induced calmness in the elderly, thus reducing their anxiety levels (Nida, 2014). Another work reported a significant difference in the level of peace of mind experienced by the elderly before and after receiving dhikr training (Kumala, Kusprayogi, & Nashori, 2017). The implementation of Vipassana meditation and humming in prayer with a Buddhist doctrinal approach from Thailand has also shown an increase in elderly spirituality after four months of intervention delivered thrice a week (Wang, Lin, & Hsieh, 2011). However, the authors only provided dhikr therapy without integrating other therapies into the program; thus, the therapy was not holistic.
A study on a kind of deep breathing intervention found that such a therapy improved lung function in clients and provided psychological comfort effects on multiple sclerosis patients (Westerdahl et al., 2016). Deep breathing intervention has also been found to reduce anxiety levels in clients with bipolar disorder (Serafim et al., 2019). These results indicate that this kind of intervention has a positive impact on the physiological and psychological conditions of those who receive it.
In the current study, an initial assessment survey was conducted in 2018 in the Cisalak Pasar sub-district among 90 elderly using the Geriatric Depression Scale (GDS) instrument. Results show that, among these older adults, as many as 40 people (44.4%) experience mild depression, 45 people (50%) experience moderate depression, and 5 people (5.6%) suffer from severe depression.
Several conditions also existed among the elderly in the community, including lack of motivation to take medicine, lack of enthusiasm to go through life, feeling tortured, and inability to adapt to chronic disease conditions. Older adults complain a great deal about pain and suffering due to the symptoms of their chronic disease. Furthermore, their socioeconomic problems also contribute as major stressors. These psychological problems, if they last for a long time, will cause the elderly to become discouraged, indifferent, and feel helpless, thus leading to depression. If such a situation is not handled properly, this may lead to suicide.
Many previous research results provide an overview of the interventions applied in the treatment of the elderly with depression. However, these were individual treatments and were not integrated with other forms of intervention. To date, no study has published results regarding a more comprehensive intervention for the handling of depression problems in the elderly. Therefore, necessary modifications and the combination of existing interventions are needed to address the psychosocial problems of the elderly, especially in terms of reducing their depression levels. The forms of intervention that can be done to prevent psychosocial disorders and reduce depression include music therapy, dhikr, and deep breathing coupled with the support of the family and community.
Previous research has proposed various individual interventions to help the elderly overcome depression. Yet, such interventions were not applied using a holistic approach.
Therefore, a comprehensive intervention involving music therapy, dhikr, and deep breath integration was developed in the current study to reduce the level of depression among the elderly.

Design, population and samples
This study implemented evidence-based practice conducted for eight months in the Cisalak Pasar sub-district, Depok City, West Java, Indonesia. The population in this study consisted of the elderly residing in the Cisalak Pasar sub-district. Cisalak Pasar was chosen, because many of the elderly with signs of depression, as determined though the initial assessment survey, came from this place. The sample consisted of 106 elderly participants suffering from various levels of depression. The inclusion criteria were as follows: 60 years old and above, showed mild to moderate levels of depression, lived in Cisalak Pasar village, and can communicate verbally. Those who had severe depression and were experiencing cognitive and hearing disorders were excluded in this study.

Research instrument and analysis
GDS was used to measure the level of depression in the elderly with a Cronbach's alpha value of 0.920. Analysis was conducted using SPSS version 21. Independent t-test was used to analyse the effect of the spiritual approach intervention on the level of depression among the sample.
The knowledge, attitudes, and skills of the elderly group were also analysed.
The intervention began in September 2018 and lasted until April 2019. Initial screening was conducted to measure the level of depression in the elderly and inform the respondents about the study objectives. Older adults with depression who met the requirements were organized into small groups of 10-20 elderly people. Every older adult who fulfills the criteria was asked if he/she was willing to take part in the intervention for eight weeks delivered once a week.
Once they reply in the affirmative, an agreement was made for the time and place of intervention. The group received education regarding the management of depression for one session. The next session involved the implementation of music therapy, dhikr, and deep breathing for seven sessions at 30 minutes per session. Music therapy, dhikr, and deep breathing were carried out simultaneously. After completing all the intervention sessions, the author internalized the data for two weeks before the final evaluation.

Results and Discussion
The implementation of the intervention began with a health screening of depression levels in the elderly groups. The interventional activity aimed to determine the target population for screening. Nurses determined the use of valid and reliable instruments using the GDS. The nurses then performed a scheduling meeting for the health screening process. They explained the purpose of the health screening to the elderly groups. Then, the nurses provided information on the results of the screening test. The next intervention was focused on providing health education about the problem of depression among the elderly group members.
The health education began with nurses formulating the goals of the program to address depression-related problems among the elderly. Then, the nurses identified the resources to be used (room and equipment) before the intervention was implemented. When the health education was conducted, the nurses emphasized the benefits of positive health care and the adverse effects of elderly depressive problems. Furthermore, methods of lectures and demonstrations were given to convey information on the treatment of elderly depression.
Then, along with the elderly, the nurses planned the actual implementation program of the development activities.
The implementation of the intervention began with the educational program planning for the elderly group members. Then, the nurses explained the goals and objectives, the problems to be addressed, as well as the methods, activities, and timeframes required during implementation. The intervention, which lasted for eight weeks, was implemented through music therapy, dhikr, and deep breathing. The elderly groups were involved in the planning, as they were the ones who determined the schedule that would allow them to use their free time with activities that support the handling and prevention of depression in the elderly. The nurses evaluated the program and made modifications for improvement, as needed.
The next intervention involved providing psychological support and information about elderly health to members of the elderly support groups. The activity began by explaining the objectives to the members of the support group. The nurses fostered a pleasant atmosphere and explained the importance of active attendance and participation. They also presented regulations to be followed by all members of the group so as not to create problems that may interfere with the course of activity. During the intervention, the nurses encouraged each participant to convey his/her ideas and knowledge. The nurses emphasized the importance of each activity taking place and helped group members through all stages in the process-from orientation to checking the proximity between members.
The evaluation of the results of the innovation in community nursing care was carried out by measuring the knowledge, attitudes, skills, and depression levels of the elderly participants using the GDS (n = 106) with the following outcome criteria: normal (score = 0-4), mild depression (score = 5-8), moderate depression (score = 9-11), and major depression (score = 12-15). The pre-test and post-test results at the beginning and end of the meeting were also measured. The description of the evaluation of the spiritual approach nursing intervention can be found in Table 1. beats/minute, showed that it can improve the level of depression in the elderly and reduce blood pressure, heart rate, and respiratory frequency (Lee et al., 2010). As for the dhikr therapy carried out in Indonesia involving 28 older adults for eight sessions, the results showed a decrease in the depression rate of the elderly from severe to moderate levels after undergoing dhikr music therapy (Umamah & Fabiyanti, 2018).
Other studies conducted in Indonesia also showed a significant difference in the level of peace of mind reported by elderly participants before and after receiving dhikr training. This study used a sample of only eight people with a meeting duration of seven sessions (Kumala et al., 2017). Similarly, a study on a deep breathing intervention found that it improved lung function and psychological comfort in clients with multiple sclerosis (Westerdahl et al., 2016).

Furthermore, deep breathing interventions have been shown to reduce anxiety levels in clients
with bipolar disorder (Serafim et al., 2019).
Although these studies showed that musical intervention, dhikr, and deep breathing effectively reduced the level of depression in the elderly, such therapies were administered individually and involved only small samples. In comparison, the proposed intervention in the current study combined all three therapies administered simultaneously, thus providing a holistic and comprehensive approach to reducing depression levels among the elderly compared. Furthermore, with 106 participants, the sample was sufficiently large to demonstrate significant findings. Another advantage of this intervention is that it involves worship or dhikr. Therefore, the proposed intervention is better than those that have been reported in previous studies.
Providing spiritual intervention through religious therapy in the form of music therapy, dhikr, and deep breathing is essential. This intervention uses a spiritual approach that is strongly supported by the Depok culture that values religious practices in social life, especially in Cisalak Pasar. Thus, the program may also be implemented in other study groups and in the taklim assembly as well as in mosques and community homes. The extent of elderly participation in such activities is reasonably significant. Furthermore, lecture activities are routinely conducted by some mosques in the research area. This can serve as a potential social capital to support the nurses in their efforts to help the elderly overcome and prevent depression. However, the spiritual service-oriented disease, especially depression, was not introduced to the elderly before this intervention was conducted by the author.
Previous results have shown that music therapy can reduce depression among the elderly as well as reduce blood pressure, heart rate, and respiratory frequency (Zhao, Bai, Bo, & Chi, 2016). As for the remembrance therapy carried out in Indonesia with 28 older adults, the results showed a decrease in the level of depression from severe to moderate levels after completing dhikr music therapy (Umamah & Fabiyanti, 2018). Another study showed a significant difference in the level of peace of mind in the elderly before and after receiving dhikr training. That study used a sample of only eight people with a meeting duration of seven sessions (Kumala et al., 2017). As for the results of a research on deep breathing, the authors found that deep breathing interventions reduced anxiety levels in clients with bipolar disorder (Serafim et al., 2019). However, these studies did not carry out the three therapies simultaneously.
The current intervention consisted of three therapies delivered simultaneously, thus providing a holistic and comprehensive approach to reducing the level of depression in the elderly. Compared with other studies, the sample was also sufficiently large at 106 people.
Religion and the practice of religiosity provide strength and cause feelings of care, selfassurance, attention, and calm as well as provide a source of support in dealing with illness (Grodensky et al., 2015;Jansen-Niemeijer et al., 2017;Kim et al., 2004). Furthermore, religion is not just a factor that can influence happiness and a sense of usefulness for others. If an elderly has a good sense of spirituality, then he/she would not be afraid to face death and can easily accept his/her living conditions, including chronic illnesses (Hamid, 2000).
The intervention applied in the current study used a spiritual approach, which was strongly supported by an influential local culture that valued religious practices in social life, especially in the city of Depok. This is demonstrated by field facts, which show the number of study groups and majelis taklim who received the intervention in the mosques and in their homes. A study concluded that one's faith facilitates one's acceptance of a disease, improves his/her coping strategies, makes him/her understand that seeking medical care does not conflict with beliefs about destiny, increases inner strength, fosters hope and acceptance of self-responsibility, and enables an individual to find meaning and purpose in life (Nabolsi & Carson, 2011). In contrast, among the elderly with chronic diseases, low levels of spirituality accompanied by depressive symptoms are significantly associated in the second year of chronic disease (Ballew et al., 2012). Therefore, these various aspects are essential factors to consider in designing programs to help the elderly overcome depression. Such social capital has the potential to provide support to nurses' efforts in addressing this concern.
Using a spiritual approach in nursing practice is often overlooked. The intervention given by nurses is commonly more focused on the biological and psychological aspects, and other dimensions, such as social and spiritual, are not considered. The spiritual strength is something that is needed by most people in any age group. The activities of listening to lectures, worshiping, and praying are strictly related to the low-risk factors of chronic disease behaviour in the elderly (Linardakis et al., 2015). Religious activities, such as praying, can also affect the elderly overcome depression (Ronneberg, Miller, Dugan, & Porell, 2016). Furthermore, spiritual activities can make depressive elderly people develop positive feelings toward God (Braam et al., 2013). Indeed, spirituality has been shown to play an essential role in helping the elderly reduce their depression level.
Several theories have been proposed to support nursing interventions with a spiritual approach. These support the act of worshiping, which draws one closer to the Almighty and brings a feeling of tranquillity and comfort as well as a sense of guidance and instruction in the face of any condition in life (Bastaman, 2007). Religiosity has a very close relationship to elderly spirituality: if religiosity is actively practiced during an illness, then it will automatically trigger an increase in spirituality in terms of increased positive emotions (Miller, 2012). Having a positive psychological state can help reduce symptom severity of depression (Görges, et al., 2018). Furthermore, spirituality can be felt through one's connectedness with the higher power in the form of activities of prayer, ritual, reverence, meditation, reconciliation, and mystical experience. Overall, the activity of worship and practice of religiosity conducted by individuals can be a source of strength in the face of a disease stressor, thereby inducing a positive effect on a person's psychological state.
The treatment of depression among the elderly in the community requires a comprehensive approach. With its proven effects, music therapy should be combined with other therapies, such as dhikr and deep breathing. Dhikr therapy is chosen as a complementary therapy because it is capable of stimulating views, feelings, and thoughts about one's relationship with the Almighty (God). Furthermore, most of the elderly in Cisalak Pasar have embraced Islam, thus making dhikr therapy the right choice in stimulating spirituality among the elderly.
Dhikr is a belief and a religious ritual often carried out by Muslims, enabling the therapy to be more readily accepted and practiced by the elderly. Furthermore, deep breathing exercises were added to the intervention to provide a relaxing effect. By using breathing exercises that can be done any time, the elderly can easily use this technique to overcome depression.
The application of music intervention, dhikr, and deep breathing demonstrates the effect of using a combination of effective intervention techniques in lowering the level of depression in the elderly. Such an intervention using a holistic approach also obtained satisfactory results in the form of a reduced average level of depression in the elderly. We suggest that interventions meant to target depression should use more than one type of intervention. The use of holistic principles and a combination of several approaches may be applied by health practitioners in addressing the problem of elderly depression in the community. Furthermore, such an intervention also improved the knowledge, attitudes, and skills of the depressive elderly. Thus, the education and intervention program not only improved the level of depression but also positively affected the internal aspects of elderly individuals.
Current efforts that have been done to address and prevent the problem of depression in the elderly are not optimal given that the Health Ministry is mostly focused on the physical problems of the elderly. A form of handling and preventive effort is required, with emphasis on incorporating psychosocial elements and exerting efforts to improve lifestyles and behaviours.
Community nurses also have a role in accurately handling psychosocial problems and providing appropriate nursing care for the elderly with mild to moderate depressive levels. Those with severe depression may be referred to the Ministry. Therefore, community nurses are expected to carry out the treatment of psychosocial problems with an approach that integrates spiritual aspects.
The application of this kind of intervention can benefit the elderly in terms of helping them overcome depression. Field data show that the implementation of community health programs focused on mental health problems is not yet a concern. With the proposed intervention program, the elderly can lower their depressive levels, socialize, and enhance their psychomotor, cognitive, and affective abilities regarding the management of depression.
Another contribution of this research is that it offers a holistic approach to the treatment of elderly depressive problems at the community level. Practically speaking, our findings are beneficial for community health practitioners looking for holistic interventions that especially focus on elderly spirituality.
The holistic intervention integrating music therapy, dhikr, and deep breathing is also effective in enhancing the elderly's knowledge, attitudes, and skills and in lowering the level of depression in this group. Information dissemination campaigns related to depression must be elderly-friendly and include aspects of psychosocial health. In this way, the elderly can receive comprehensive health services that address the problem of depression.
Surprisingly, the findings reveal that most of the depressive elderly are women. This can be attributed to the fact that elder women, compared to older men, are more concerned about their health and want to get treatment according to their needs. It takes more effort for the elderly male to actively participate in healthcare. Furthermore, community knowledge regarding the problem of depression is still lacking. Applying this intervention can improve knowledge on how to handle depression in the elderly, thus augmenting the lack of information related to depression among the elderly.
The public health centre promotes the early detection of depression among the elderly using GDS for at least six months via the elderly nurse program implemented in Cisalak Pasar.
Optimizing early detection and providing educational space and facilitative counselling to the elderly can further support elderly health in these public health centres. Furthermore, providing ongoing guidance to cadres and members of the elderly support group through coaching and motivating as well as recognizing efforts to deal with the problem of depression under the supervision of senior program nurses are also important.
Public health nurses' risk assessment and early detection of depression in elderly groups and their families can benefit from integrative health post (Posyandu)-activities, home visits, and other community activities. It is also necessary to actively involve cadres in the early detection of depression to assist nurses in increasing the number of elderly screening.
Furthermore, nurses must develop their skills by participating in seminars, trainings, workshops, or other scientific activities to support the improvement of mental health services in the community, especially with regards the management of depression among the elderly.
Other findings obtained by health workers in the health service and in the Puskesmas are still inadequate in terms of quantity and quality. The public health centre in the sub-district only has two nurses who are given duties and authority to carry out the service of home visits. In addition, nursing education is still at the vocational level. Thus, the development of nursing education and training by the Depok Health Office regarding the handling and prevention of depression via music intervention, dhikr, and breathing must be done to provide more elderlyfriendly services. The implementation of intervention programs requires the competence of nurses who possess a bachelor's degree in nursing.
The health office needs to formulate a policy on improving the development of elderly mental health services by involving public health nurses who have minimum vocational educational qualification with training. Nurses are expected to carry out early detection services using GDS, which is still rarely implemented in the public health centre. The public health centre also needs to provide counselling services for the elderly.
The application of an intervention program that features musical therapy, dhikr, and deep breathing has some obstacles. For one, it can affect the effectiveness of the intervention in the elderly group through sound disturbances from the surrounding environment. Most interventions were carried out in open spaces, such as in the porches of residents' homes and musholla as well as locations adjacent to the roads. It causes noise from outside to disturb the process intervention. Furthermore, focus training was required for the elderly at the beginning of the intervention. Some older adults said that they could not focus on the intervention, so that the writer tried to improve that during the intervention. After several intervention sessions, the elderly was able to increase their focus, especially during the dhikr therapy, which required more concentration. Finally, most of the participants in the elderly groups who received the intervention were women. This can be because older women are more enthusiastic in joining gathering and interacting activities.

Conclusion
This study concluded that a holistic intervention featuring music therapy, dhikr, and deep breathing reduced the level of depression in the elderly population in the Cisalak Pasar, Depok City, in 2019. Findings show that nurses can easily apply this intervention to the elderly in the community, especially at Posbindu and through home visits, recitations, and other social gathering activities, thus stimulating enthusiasm, increasing social and spiritual interactions, and reducing the level of depression among the elderly.

Author Contribution
Bahtiar conceived of the presented idea. Junaiti Sahar and Widyatuti verified the analytical methods. Junaiti Sahar and Widyatuti encouraged Bahtiar to investigate and supervised the findings of this work. All authors discussed the results and contributed to the final manuscript.