Primary care professionals’ perceptions of depression in older people: a qualitative study
Introduction
The risk factors for depression are similar at all ages (Ranga, George, & Peiper, 1998). However, many of these factors are more common in the lives of older people: loss and grief, social isolation, medical illness and disability and being a care-giver (Jorm, 1998; Roberts, Kaplan, Shema, & Strawbridge, 1997). A majority of people aged over 65 are said to suffer from a chronic medical condition that impairs their ability to function and makes them more vulnerable to depression (Unutzer, Katon, Sullivan, & Miranda, 1999). Depression in older adults is also more likely to follow a chronic course compared with working age adults. Two studies of elderly primary care patients with clinically significant depression reported that approximately 50% had not recovered at follow-up 9–24 months later (Callahan, Hui, Nienaber, Musick, & Tierney, 1994; Unutzer et al., 1999). As in all age groups, depression is associated with increased risk of suicide, with those aged over 75 having the highest rates (Iliffe & Manthorpe, 2005).
However, the growing research literature on the management of depression in later life suggests that there are good grounds for clinical optimism provided that early detection can be improved (Butler & Orrell, 1998). In the UK, as in most health care systems, general practitioners (GP) are the first point of access to health care, directly providing most of the treatment for common mental disorders as well as referral to specialist mental health services. About one quarter to one third of older people attending GP surgeries are depressed (Evans & Katona, 1993; Pfaff & Olmeida, 2005) and the average British GP will have 30 cases of depression among older patients at any time and will see 7–10 new cases per year (Anderson, 2001). Although older people visit their GPs twice as often as younger people, their depression is less likely to be recognised. In the largest reported study in primary care, half of older people with case level depression were identified as such in their medical notes and only 38% of those identified received any treatment or referral (Crawford, Prince, Menezes, & Mann, 1998). Blanchard, Waterreus, and Mann (1994) found that only 14% of the older people identified by their GPs as depressed received anti-depressant medication. Both these studies suggest that lack of response by GPs may be more problematic than lack of recognition. It is worth exploring whether the explanation for the large discrepancies between prevalence, identification and treatment of depression is to be found in the attitudes and behaviour of general practitioners, their older patients or some combination of the two.
Older people are reported to complain rarely of low mood and other psychological symptoms (Brodaty et al., 1991) and the presence of physical illness hinders the identification of psychological difficulties (Odell, Surtees, Wainwright, Commander, & Sashidharan, 1997).
Socio-cultural factors, in particular ethnicity, influence illness beliefs including symptom attribution and mode of presentation. Cultural diversity in patients’ beliefs and responses may explain to some extent why it appears that patients from black and minority ethnic groups are less likely than native-born white patients to have their psychological problems recognised in primary care (Bhui et al., 2003; Comino, Silove, Manicavasagar, Harris, & Harris, 2001).
GPs’ beliefs about ageing have been shown to influence their diagnosis and management of depression in older patients (Collins, Katona, & Orrell, 1995; Orrell, Collins, Shergill, & Katona, 1995). Practice nurses are increasingly expected to be part of the process of management of depression in primary care. In order to formulate strategies to improve recognition and treatment we need a better understanding of the attitudes that underlie interaction between clinicians and older patients.
Section snippets
Method
Individual in-depth interviews were conducted with general practitioners, practice nurses and practice counsellors working in 18 primary care centres in South London. The sample was selected purposively to include professionals working in different settings (single-handed and group practices) serving areas of contrasting socio-economic and ethnic characteristics. The practices were located in five south London boroughs (Lambeth, Southwark, Lewisham, Croydon and Wandsworth). One third of
Participants
Thirty primary care professionals completed an interview: 18 GPs, seven practice nurses (PNs) and five practice counsellors (PCs). Of the GPs, three were single-handed practitioners and 15 worked in group practices. Eight GPs were female and 10 male; six were from south Asian backgrounds, one was Irish and 11 were white British. Their ages ranged from 31 to 64 years. They had worked in general practice from 1.5 to 35 years and in their current practice from 1.5 to 28 years.
All seven nurses were
Conclusion
This paper presents an exploration of the attitudes of primary care doctors, nurses and counsellors that are likely to influence the recognition and treatment of depression in older people. Their perceptions of the beliefs and behaviour of older people were derived from clinical practice in areas of diverse socio-economic, ethnic and cultural characteristics in inner city south London. In this context, the study was intended to identify and enable discussion of key themes in primary care in
Acknowledgements
We are grateful to the primary care professionals who took part in the interviews and to the NHS London Region Research & Development Department for funding the study. The views expressed are the authors’ own.
References (41)
- et al.
Age and depression
Journal of Affective Disorders
(1991) - et al.
Stigma, racism or choice. Why do depressed ethnic elders avoid psychiatrists
Journal of Affective Disorders
(2002) - et al.
Stigma revisited, disclosure of emotional problems in primary care consultations in Wales
Social Science & Medicine
(2003) Depression and anxiety among older Caribbean people in the UK: screening, unmet need and the provision of appropriate services
International Journal of Geriatric Psychiatry
(1996)Treating depression in old age: the reasons to be positive
Age & Ageing
(2001)- et al.
Depressive symptoms in African American medical patients
International Journal of Geriatric Psychiatry
(1995) Depression across cultures
Primary Care Psychiatry
(1996)- et al.
Ethnic variation in pathways to and use of specialist mental health services in the UK. Systematic review
British Journal of Psychiatry
(2003) - et al.
The nature of depression in older people in Inner London and the contact with primary care
British Journal Psychiatry
(1994) - Burroughs, H., Lovell, K., Morley, M., Baldwin, R., Burns, A., Chew-Graham, C. (2006). ‘Justifiable depression’: How...
Late life depression
Current Opinion in Psychiatry
Quality improvement research on late life depression in primary care
Medical Care
Longitudinal study of depression and health services use among elderly primary care patients
Journal of the American Geriatric Society
Managing depression in primary care: another example of the inverse care law?
Family Practice
Management of depression in the elderly by general practitioners: 11 Attitudes to aging and factors affecting practice
Family Practice
Care pathways for south Asian and white people with depressive and anxiety disorders in the community
Social Psychiatry and Psychiatric Epidemiology
Agreement in symptoms of anxiety and depression between patients and GPs: The influence of ethnicity
Family Practice
The recognition and treatment of depression in older people in primary care
International Journal of Geriatric Psychiatry
Prevalence of depressive symptoms in elderly primary care attenders
Dementia
Culture, relativism and the experience of mental distress: South Asian women in Britain
Sociology of Health & Illness
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