Depression is prevalent in adults over 65 years (Andreas et al, 2017), often occurring amidst other complex health conditions and life events (Moffatt and Heaven, 2017). Depression has also been associated with cognitive decline (Byers & Yaffe, 2011), and may even mimic dementia in its early stages (Cipriani et al, 2015).
In my experience as a psychology researcher, I have interviewed many older people about their mental health. This has highlighted to me that changes in wellbeing can be a scary and uncertain time for those affected, as well as the families who support them. Awareness and availability of appropriate services are especially important during these times of uncertainty.
For many, including some healthcare professionals, being able to differentiate a rough patch from a clinical condition is difficult, but the distinction is important for accessing care. With up to 40% of older people in primary care estimated to have mental health concerns (Social Care Institute for Excellence, 2006), there is a need for targeted support for people in this age group.
Evidence suggests that talking therapies such as cognitive behaviour therapy (CBT) can be helpful for older people in primary care with depression (Serfarty et al., 2009). However, referrals to mental health support for older people are low (Burns, 2015). Why?
In this review paper, the authors were interested in the qualitative views of healthcare professionals regarding the management and care of older adults with depression. They elected to focus specifically on later-life depression and psychological therapy referrals.
The authors carried out a literature review and provide a thematic overview of studies reporting qualitative data. The search included published articles (in MEDLINE, Embase, PsycINFO, CINAHL, and SSCI databases) and grey literature (E-theses online service). The search terms were not included with the publication.
The authors included journal articles that: involved healthcare professionals in primary or secondary care settings (i.e., GP surgery or psychiatry services), used qualitative methods (i.e., interviews or focus groups), and focused on treatment and management of depression in older adults. Studies were not included if they: were quantitative, combined experiences of people in younger age groups and other health conditions, were not written in English, or focused on the role of carers or other health-related professions.
Of the 27 articles included with the qualitative synthesis, studies were carried out in the UK (n=8), the US (n=8), Australasia (n=5), Scandinavia (n=3), Canada (n=1), India (n=1) and Taiwan (n=1). A quality appraisal was carried out using the Critical Appraisal Skills Programme (2018) checklist, where studies were rated as being “very good” (n=11) “good” (n=7) or “not very good” (n=9).
Methods used in the studies included: interviews (n=18), focus-groups (n=6), combined interviews and focus-group (n=2), ethnography (n=1), conference presentation (n=1), questionnaire (n=1) and case-study (n=1). Healthcare professionals tended to be mostly GPs and nurses in community settings or primary care.
Authors found 5 major themes across the 27 studies included in the review:
1. Avoidance of medicalisation of social circumstances
- Many healthcare professionals were hesitant to over-medicalise responses to life events such as retirement, bereavement, ill health, and moving into care
- Where this issue was described, some were uncertain of the value that an intervention could provide
- Late life depression is challenging in that the boundary between clinical depression and a response to life events can be unclear.
2. Assumptions regarding older people and mental health
- Healthcare professionals made a number of assumptions about older people and mental health. In the case of clinical depression, some felt that older people might normalise their symptoms as part of ageing
- Some felt also that their older patients would not open up about their experiences or be interested in talking therapies
- Depression tended not to be described as an episodic condition that may have appeared earlier in a person’s life course
- Engaging with psychiatric services was perceived to be a last resort and was highly stigmatised.
3. Prioritisation of physical health across healthcare settings
- In almost half of the studies included in the review, the authors found that physical health was often prioritised over mental health
- Many settings had time restraints that prohibited depression management and follow-up
- Depression was viewed by some as a reaction to a primary physical health condition, rather than a separate psychological entity that interacts with physical health
- As a consequence, solutions were less likely to be psychological in nature.
4. The ‘postcode lottery’ of therapeutic options
- Healthcare professionals felt that the provision and appropriateness of services was varied, depending on the geographic location
- Long wait lists, lack of funding and short-term solutions were among some of the key issues identified
- Where access issues were present, social and psychological treatments were less likely to be recommended
- Some were reluctant to identify depression when no service existed to provide follow-on care
- Where appropriate services were available, the need to identify late-life depression was more likely to be acknowledged.
5. Variation in skills, training, and approaches across all settings
- The individual’s interest and confidence level influenced approaches to depression care and management
- When GPs felt confident, they were more likely to raise the topic of depression with their patients
- Some nurses felt confident about identifying depression, while others felt they didn’t have the training to take further action.
The authors described some assumptions about how older adults perceive the subject of depression. They also highlight unequal views of mental health versus physical health. These beliefs seem to influence willingness to raise experiences of depression during consultations. The review highlights the quandaries faced by healthcare professionals in primary care, particularly in areas where funding and access to services are limited.
Depression can be difficult for anyone to talk to a healthcare professional about, irrespective of their age. We don’t always know the journey a person has been on to get to the moment where they do speak out, perhaps for the first time out loud after a lifetime of silence. Creating an atmosphere within a consultation for sharing mental health concerns can be challenging, but could make all the difference for someone in need of support.
Concerns about privacy, confidentiality, stigma or being judged can all act as major barriers to seeking support; however, we cannot assume these issues affect all older people in the same way. In the UK, older people may not seek help for depression in primary care where appointments are scarce, wait times are long, and multiple health concerns present. Many may not be aware or able to self-refer to IAPT without GP referral. Where such complex barriers exist, further conversations about innovations, tailored service provision and resource development must take place.
Strengths and limitations
This review included the perspectives of mainly GPs and nurses, with other healthcare professionals like psychologists and social workers. Studies included with the review were of acceptable quality, with most rated as good or very good upon appraisal. The studies were conducted predominantly in high-income Western settings, so the transferability of findings is likely to be limited.
Implications for practice
Older people can face unique life events, which means mental health services should be tailored appropriately to serve their older clients. Depression misconceptions have consequences, such as greater risk of misdiagnosis or inappropriate intervention (RCPsych, 2018). Assumptions that minimise or erase psychological distress based on age must be addressed in order to improve service utility.
Detecting the early stages of mental ill health is important for improving quality of life in older people (RCPsych, 2018). Primary care settings are aptly placed for such a role, with the added benefit of offering continuity of care to patients (Hedge, Gunputh, & Sinha, 2019). Access to staff training can help to improve knowledge and confidence in providing care for people with later life depression:
We do not have enough specialists in the short term to meet demand, and we need to train and support the wider health and social care workforce to identify mental health issues in older people at an early stage. Across health and care services there will need to be a more informed workforce that better recognises and understands the way mental health problems present in older people, in particular those in primary care, general hospitals, care homes and social care.
– RCPsych, 2018, p.24
There is a need for care options that are effective, evidence-based and appropriate for people over the age of 65. Innovations in psychological therapy, such as online interventions, may help overcome some of the barriers to accessing services. Above all though, local services must exist for people to be referred to after identification and diagnosis.
Conflicts of interest
Frost, R., Beattie, A., Bhanu, C., Walters, K., & Ben-Shlomo, Y. (2019). Management of depression and referral of older people to psychological therapies: a systematic review of qualitative studies. British Journal of General Practice, 69(680), e171-e181. https://doi.org/10.3399/bjgp19X701297
Andreas, S., Schulz, H., Volkert, J., Dehoust, M., Sehner, S., Suling, A., … & Grassi, L. (2017). Prevalence of mental disorders in elderly people: the European MentDis_ICF65+ study. The British Journal of Psychiatry, 210(2), 125-131.
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Serfaty, M. A., Haworth, D., Blanchard, M., Buszewicz, M., Murad, S., & King, M. (2009). Clinical effectiveness of individual cognitive behavioral therapy for depressed older people in primary care: a randomized controlled trial. Archives of General Psychiatry, 66(12), 1332-1340.
Social Care Institute for Excellence (2006) Assessing the Mental Health Needs of Older People (SCIE Guide 3). Accessed 24/09/2019.
The Royal College of Psychiatrists. (2018). Suffering in silence: age inequality in older people’s mental health care. Accessed 24/09/2019.