Elsevier

Social Science & Medicine

Volume 63, Issue 5, September 2006, Pages 1363-1373
Social Science & Medicine

Primary care professionals’ perceptions of depression in older people: a qualitative study

https://doi.org/10.1016/j.socscimed.2006.03.037Get rights and content

Abstract

An understanding of patients’ perspectives is crucial to improving engagement with health care services. For older people who may not wish to bother medical professionals with problems of living such as depression, such exploration becomes critical. General practitioners (GPs), nurses and counsellors working in 18 South London primary care teams were interviewed about their perceptions of depression in older people. All three professional groups shared a predominantly psychosocial model of the causes of depression. While presentation of somatic symptoms was seen as common in all age groups, identification of depression in older patients was complicated by co-existent physical illnesses. GPs reported that older patients rarely mentioned psychological difficulties, but practice nurses felt that older people were less inhibited in talking to them about “non-medical” problems. Many older people were perceived to regard symptoms of depression as a normal consequence of ageing and not to think it appropriate to mention non-physical problems in a medical consultation. Men were thought to be particularly reluctant to disclose emotional distress and were more vulnerable to severe depression and suicide. Some GPs had mixed feelings about offering medication to address what they believed to be the consequences of loneliness and social isolation. Participants thought that many older people regard depression as a “sign of weakness” and the perceived stigma of mental illness was widely recognised as a barrier to seeking help. Cultural variations in illness beliefs, especially the attribution of symptoms, were thought to profoundly influence the help-seeking behaviour of elders from minority ethnic groups. Families were identified as the main source of both support and distress; and as such their influence could be crucial to the identification and treatment of depression in older people.

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.

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