Why may older people with depression not present to primary care? Messages from secondary analysis of qualitative data

Experience of choice of treatment for adults with depression: a systematic review and meta-synthesis of qualitative research

BACKGROUND

Treatment choices for depression are preference-sensitive (no "single best option"). However, factors or attributes that can enhance or inhibit patient choice have not been fully explored.

AIMS

To synthesize the qualitative literature on facilitators and barriers to treatment choice, from the perspective of people with depression and healthcare practitioners.

METHODS

A systematic literature search identified eligible qualitative studies (Protocol registration no. CRD42019151352). Findings from 56 studies were meta-synthesized using a thematic analysis approach.

RESULTS

Overarching facilitators to treatment choice that resonated with both patients and healthcare practitioners included: a trusting and respectful patient-practitioner relationship; information and guidance tailored to the individual and their preferred level of involvement in the decision-making process; eliciting and incorporating patient preferences and individual needs in order to find the best patient-treatment match. Prominent barriers to treatment choice that emerged were: limited time available to explore treatment options; inadequate mental health training, knowledge, skills, and experience; lack of psychological treatment services and waiting times; inflexibility of services.

CONCLUSIONS

By focusing on the factors identified, practitioners can facilitate patient participation in decision-making, which has the potential to improve engagement with treatment and outcomes for adults with depression.

The acceptability of the Fire and Rescue Service working with primary care to improve identification of mental health problems in older adults. A mixed-method qualitative study

BACKGROUND

Mental ill-health in older adults (aged 60 years and over) is often underdiagnosed and undertreated. Older adults are less likely to access mental health services owing to perceived stigma and fear of being a burden. Non-traditional providers of health care, such as the Fire and Rescue Services (FRS), provide a possible solution to facilitate early detection of problems and help-seeking among older adults, especially in the context of pressured statutory services.

AIM

To examine whether and how FRS Home Fire Safety Visits (HFSV) could be optimised to include detection and signposting for mental health problems - particularly anxiety and depression - in older adults.

DESIGN & SETTING

This mixed-method qualitative study took place in the West Midlands, UK in 2022.

METHOD

This study involved focus groups (n = 24) and interviews with FRS staff (n = 4) to develop an in-depth contextual understanding of he acceptability and feasibility of expanding HFSV to include identification of anxiety and depression.

RESULTS

FRS staff were open to expanding their HFSVs to include mental health, provided they had sufficient training and support from partner agencies in primary and social care settings to accept referrals for service users presenting with symptoms of anxiety and/or depression.

CONCLUSION

The positive reputation of FRS staff and engagement with older adults suggests that HFSV could support the detection of anxiety and depression in older adults, and appropriate signposting to other services including primary care.

Unrecognised depression among older people: a cross-sectional study from Norwegian general practice

BACKGROUND

Depression is common in old age and is associated with disability, increased mortality, and impairment from physical diseases.

AIM

To estimate the prevalence of depression among older patients in Norwegian general practice, to evaluate the extent they talk about it during their consultation, whether it was previously known or suspected by their GP, and how frequently patients with depression visit their GP.

DESIGN & SETTING

Cross-sectional study among patients and GPs at 18 primary care clinics in the south of Norway.

METHOD

Patients aged ≥65 years who visited their GP were asked to complete the Patient Health Questionnaire-9 (PHQ-9). The GPs reported what kind of issues the patient presented at the consultation, if a current depression was known, and the consultation frequency.

RESULTS

Forty-four (11.4%) of 383 patients reported moderate or severe depressive symptoms (PHQ-9 ≥10). Among the cases with data from both patient and GP (n = 369), 38 patients (10.3%) reported moderately depressive symptoms. Of these, only 12 (31.6%) mentioned psychological problems to their GP during their consultation; 12 (31.6%) with previous depression were neither known to the GP nor suspected of currently having depression; and 67.6% of them visited their GP ≥5 times a year.

CONCLUSION

Older patients tend to speak little of their depression to the GP. Almost one in three older patients with moderate depressive symptoms were unrecognised by their GP. Older patients who frequently visit the GP should be suspected of potentially having mental health problems.

Interventions to identify and manage depression delivered by 'nontraditional' providers to community-dwelling older adults: A realist review

BACKGROUND

Mental health problems experienced by older adults (60+ years of age) may remain hidden due to individual and system-level barriers. Opportunities to support early identification and management are therefore crucial. The National Health Service recommends wider public services that are embedded within local communities, but are not traditionally part of the healthcare landscape (i.e., 'nontraditional'), could facilitate engagement with healthcare by members of the public. Evidence for interventions involving Fire and Rescue, Police, Library services and postal workers, as nontraditional providers of mental health services, has not been synthesized previously. This review aims to understand how, why and in what contexts mental health interventions delivered by these nontraditional providers, to older adults, work.

METHODS

A realist review of interventions to identify and/or manage mental health problems (depression with or without anxiety) experienced by older adults. Systematic, cluster and iterative literature searches were conducted. Intervention evidence was appraised for rigour and explanatory relevance and then coded to inform context-mechanism-outcome configurations (CMOCs). A public advisory group supported our initial evidence search strategy and definition of key terms. This review is registered with PROSPERO (CRD42020212498).

RESULTS

Systematic searches revealed a dearth of evidence reporting mental health interventions delivered by nontraditional providers. Our scope was adjusted to consider interventions delivered by Fire and Police services only and for wider health and wellbeing concerns (e.g., dementia, falls prevention, mental health crises). Forty-three pieces of evidence were synthesized. Key themes included: legitimizing expanded roles, focusing on risk, intervention flexibility and organization integration; further subthemes are described. Themes map onto CMOCs and inform a preliminary programme theory. Findings were transposed to mental health contexts.

CONCLUSIONS

Findings highlight challenges and opportunities for Fire and Police services, as nontraditional providers, to deliver interventions that identify and/or manage mental health problems among older adults. Our programme theory explains what could work, how, for whom and also by whom (i.e., which public services). Further empirical evidence is needed to test interventions, understand acceptability and inform implementation.

PATIENT OR PUBLIC CONTRIBUTION

A public advisory group comprising older adults with lived experience of mental health problems and informal caregivers contributed to the original application, reviewed the scope and informed the approach to dissemination.

'I Think it Just Made Everything Very Much More Intense': A Qualitative Secondary Analysis Exploring The Role Of Friends and Family Providing Support to Survivors of Domestic Abuse During The COVID-19 Pandemic

The COVID-19 pandemic, and associated social restrictions, have amplified women's experiences of domestic abuse (DA). In usual times, female DA survivors reach out to those around them (friends, family members, neighbors, and colleagues) for support. Accessing of both professional and informal support by survivors has increased during the pandemic. Informal supporters are often deeply invested and immersed in situations of DA because of the closeness of relationships. The accounts of informal supporters are rarely sought, yet these are people who may have a considerable awareness of what is happening. The aim of this study was to explore how the pandemic had impacted people's assessment of abusive situations and their ability to provide informal support. This paper reports a secondary analysis of qualitative data collected in 2020 in England. The data were gathered in 18 in-depth interviews with people who knew a female friend, relative, neighbor, or colleague who had experienced DA. The age range of participants was 25-69 years, three were men and fifteen were women. A reflexive thematic analysis was carried out. Findings indicated: (i) the pandemic had changed people's ability to read situations and assess risk (ii) perpetrators were exploiting the pandemic to further abuse (iii) within the context of the pandemic there was additional challenge to offering support (iv) informal supporters found creative ways to remain in-touch and to continue offering support. Further research with informal supporters is needed to ascertain how best to support and equip people, without imposing an impossible burden.

An Exploratory Study of the Relative Effects of Various Protective Factors on Depressive Symptoms Among Older People

Objective: The present study investigated the relative importance of various factors found to be negatively associated with depressive symptoms in older adults and assessed the potential moderating effect of sociodemographic characteristics for each factor.

Method: Depressive symptoms were measured with the Center of Epidemiological Studies Depression Scale. Psychological, social, and physical health measures relating to the following factors were also administered: personal growth, purpose in life, self-esteem, self-efficacy, social support, self-rated health, life satisfaction, and physical activity. Multivariate linear regression analysis was used to investigate the most important factors associated with depressive symptoms, and moderation analyses were employed to identify any moderating effects of sociodemographic factors.

Results: Life satisfaction, self-esteem, and purpose in life were found to be negatively associated with depressive symptoms. Only one moderating effect was observed—the negative relationship between life satisfaction and depressive symptoms was significantly stronger among the younger respondents.

Conclusion: These findings suggest that strategies for the prevention or amelioration of depressive symptoms across subgroups of the senior population could be optimized by focusing on enhancing life satisfaction, self-esteem, and purpose in life.

'I wanted to talk about it, but I couldn't', an H70 focus group study about experiencing depression in early late life

BACKGROUND

Knowledge about experiences of depression among younger-old adults from the general population is limited. The aim was to explore experiences of depression in early late life.

METHODS

Sixteen participants in the population-based Gothenburg H70 Birth Cohort Studies (12 women and 4 men) who had reported a history of depression between ages 60-70 took part in focus group discussions (n = 4). Data were analyzed using focus group methodology.

RESULTS

The analysis resulted in the overall theme 'I wanted to talk about it, but I couldn't'. The participants expressed unmet needs of communication about depression with family, friends, and healthcare staff. Participants wanted to know more about the causes and effects of depression, available treatment options and how to avoid recurrence. Lack of knowledge was a source of frustration; trust in health care providers was diminished. Being retired meant that opportunities for communication with co-workers were no longer available, and this made it harder to break negative thought and behavioral patterns. Being depressed meant losing one's normal self, and participants were grieving this. Thoughts of death and suicide were experienced in solitude; knowing that there was an escape could generate a feeling of comfort and control.

CONCLUSIONS

Younger-old adults have expressed a need to talk about their experiences of depression. They would like to know more about available treatments, potential side effects, and how to avoid recurrence. Care providers also need to be aware there is a need for an existential dialogue about death.

A Systematic Review of Older Adults' Attitudes Towards Depression and Its Treatment

BACKGROUND AND OBJECTIVES

Late-life depression is a major societal concern, but older adults' attitudes toward its treatment remain complex. We aimed to explore older adults' views regarding depression and its treatment.

RESEARCH DESIGN AND METHODS

We undertook a systematic review and thematic synthesis of qualitative studies that explored the views of older community-dwelling adults with depression (not actively engaged in treatment), about depression and its treatment. We searched 7 databases (inception-November 2018) and 2 reviewers independently quality-appraised studies using the CASP checklist.

RESULTS

Out of 8,351 records, we included 11 studies for thematic synthesis. Depression was viewed as a normal reaction to life stressors and ageing. Consequently, older adults preferred self-management strategies (e.g., socializing, prayer) that aligned with their lived experiences and self-image. Professional interventions (e.g., antidepressants, psychological therapies) were sometimes considered necessary for more severe depression, but participants had mixed views. Willingness to try treatments was based on a balance of different judgments, including perceptions about potential harm and attitudes based on trust, familiarity, and past experiences. Societal and structural factors, including stigma, ethnicity, and ageism, also influenced treatment attitudes.

DISCUSSION AND IMPLICATIONS

Supporting older adults to self-manage milder depressive symptoms may be more acceptable than professional interventions. Assisting older adults with accessing professional help for more severe symptoms might be better achieved by integrating access to help within familiar, convenient locations to reduce stigma and increase accessibility. Discussing treatment choices using narratives that engage with older adults' lived experiences of depression may lead to greater acceptability and engagement.

Barriers to integrating routine depression screening into community low vision rehabilitation services: a mixed methods study

BACKGROUND

Undetected depression is common in people with low vision and depression screening has been recommended. However, depression screening is a complex procedure for which low vision practitioners need training. This study examined the integration of routine depression screening, using two questions, and referral pathways into a national low vision service in Wales at 6 months following practitioner training, and identified key barriers to implementation.

METHODS

This pre-post single group study employed a convergent mixed methods design to collect quantitative questionnaire and qualitative interview data on low vision practitioners' clinical practice and perceived barriers to implementing depression screening. Forty practitioners completed questionnaires pre-, immediately post- and 6 months post-training and nine engaged in interviews 6 months post-training. Ordinal questionnaire scores were Rasch-transformed into interval-level data before linear regression analyses were performed to determine the change in scores over time and the association between perceived barriers and clinical practice. Thematic Analysis was applied to the interviews and the narrative results merged with the questionnaire findings.

RESULTS

Before training, only one third of practitioners (n = 15) identified depression in low vision patients, increasing to over 90% (n = 37) at 6 months post-training, with a corresponding increase in those using validated depression screening questions from 10% (n = 4) to 80% (n = 32). Six months post-training, practitioners reported taking significantly more action in response to suspected depression (difference in means = 2.77, 95% CI 1.93 to 3.61, p < 0.001) and perceived less barriers to addressing depression (difference in means = - 0.95, 95% CI - 1.32 to - 0.59, p < 0.001). However, the screening questions were not used consistently. Some barriers to implementation remained, including perceived patient reluctance to discuss depression, time constraints and lack of confidence in addressing depression.

CONCLUSIONS

The introduction of depression screening service guidelines and training successfully increased the number of low vision practitioners identifying and addressing depression. However, standardized screening of all low vision attendees has not yet been achieved and several barriers remain. Healthcare services need to address these barriers when considering mental health screening, and further research could focus on the process from the patients' perspective, to determine the desire for and acceptability of screening.

Factors influencing self-management of depression in older adults: a qualitative study

Objectives: A considerable body of work addresses prevalence and treatment options for depression in older adults. However, less is known about their capacity to self-manage their depression. Effective self-management of depression has the potential to improve individuals' quality of life through information, empowerment and perceived control, while enabling more efficient health service utilisation. The aim of this paper was to identify the barriers and facilitators to self-management of depression in older adults.Method: A qualitative study comprising in-depth, semi-structured interviews with 32 older adults with a diagnosis of moderate depression.Results: Three over-arching themes captured the barriers and facilitators to participants' capacity to self-manage their depression. Perspectives on age and depression represented how views of older age and mental health influenced the approach to self-management. Ability to access the health care system concerned the ability to identify and engage with different services and support. Individual capacity for self-management reflected participants' views on and the resources required for effective self-management.Conclusion: This study offers a better understanding of the factors that positively or negatively influence older adults' ability to self-manage their depression. Strategies to improve self-management should address misconceptions about age and depression, and older adults' interest in and capacity to embrace self-management practices.

Children's experiences and needs in situations of domestic violence: A secondary analysis of qualitative data from adult friends and family members of female survivors

Estimates suggest that 15% of children in the United Kingdom have been exposed to at least one form of domestic violence (DV) during their childhood, with more than 3% having witnessed an incident during the past year. This exposure increases the risk of children suffering both short-term and long-term impacts, including effects on their behaviour, social development, physical and mental health, educational attainment and quality of life. In addition, children living in environments where there is DV are at higher risk of maltreatment. Adult relatives and friends of the family often observe the experiences of children in situations of DV, and have the potential to shed light in a way that children and survivors may struggle to articulate, or be reluctant to acknowledge or disclose. Such accounts are largely absent from existing research, and yet bring a perspective which can broaden our understanding of the impact that DV has on children. This paper reports a secondary analysis of qualitative data collected during 21 in-depth interviews with people across the United Kingdom who were a friend or family member of a woman experiencing DV. An inductive thematic analysis was undertaken and the themes generated were as follows: 'the context of DV: a chaotic and unpredictable home life'; 'the roles children assume within households where there is DV including: witness of, victim of and conduit of violence and abuse',; 'the impacts of DV on children'; and 'children's coping and resilience'. The implications of these findings are discussed using a basic needs model lens.

Understanding and managing depression in older people

Clinicians do not always recognise depression in older people as they attribute symptoms to the ageing process and the effects of failing health. Similarly, older people do not always appreciate that their symptoms relate to their mood. Understanding how depression affects older people can improve access to support, thereby improving overall health and quality of life. To ensure these outcomes we need a workforce with excellent communication skills that supports therapeutic relationships, promotes recognition of symptoms, and enhances assessment, diagnosis, treatment and management.

Registered nurses experiences of managing depressive symptoms at care centres for older people: a qualitative descriptive study

BACKGROUND

Depressive symptoms and/or depression are commonly experienced by older people. Both are underdiagnosed, undertreated and regularly overlooked by healthcare professionals. Healthcare facilities for people aged ≥75 years have been in place in Sweden since 2015. The aim of these care centres, which are managed by registered nurses (RNs), is to offer care adjusted to cater to the complex needs and health problems of older people. Although the mental health of older people is prioritised in these centres, research into the experience of RNs of depressive symptoms and/or depression in older people in this setting is limited. Therefore, this study aimed to illuminate RNs, working at care centres for older people, experience of identifying and intervening in cases of depressive symptoms.

METHODS

The data for this qualitative descriptive study were collected through interviews (n = 10) with RNs working at 10 care centres for older people in southern Sweden. The transcribed texts were analysed using inductive content analysis.

RESULTS

The participants' experiences could be understood from four predominant themes: (1) challenging to identify, (2) described interventions, (3) prerequisites for identification, and (4) contextual influences. Key findings were that it was difficult to identify depression as it often manifested as physical symptoms; evidence-based nursing interventions were generally not the first-line treatment used; trust, continuity and the ability of RNs to think laterally; and the context influenced the ability of RNs to manage older people's depressive symptoms and/or depression.

CONCLUSIONS

The process of identifying depressive symptoms and performing an appropriate intervention was found to be complex, especially as older people were reluctant to present at the centres and provided obscure reasons for doing so. A nurse-patient relationship that was built on trust and was characterised by continuity of care was identified as a necessary prerequisite. Appropriate nursing interventions-afforded the same status as pharmacological treatment-are warranted as the first-line treatment of depression. Further research is also needed into efficacious nursing interventions targeting depressive symptoms and/or depression.

Non-traditional support workers delivering a brief psychosocial intervention for older people with anxiety and depression: the NOTEPAD feasibility study

Background

Anxiety and depression often coexist in older people. These disorders are often underdiagnosed and undertreated, and are associated with increased use of health and social care services, and raised mortality. Barriers to diagnosis include the reluctance of older people to present to their general practitioner (GP) with mood symptoms because of the stigma they perceive about mental health problems, and because the treatments offered are not acceptable to them.

Objectives

To refine a community-based psychosocial intervention for older people with anxiety and/or depression so that it can be delivered by non-traditional providers such, as support workers (SWs), in the third sector. To determine whether or not SWs can be trained to deliver this intervention to older people with anxiety and/or depression. To test procedures and determine if it is feasible to recruit and randomise patients, and to conduct a process evaluation to provide essential information to inform a randomised trial.

Design

Three phases, all informed by a patient and public involvement and engagement group. Qualitative work with older people and third-sector providers, plus a consensus group to refine the intervention, training, SW manuals and patient participant materials (phase 1). Recruitment and training of SWs (phase 2). Feasibility study to test recruitment procedures and assess fidelity of delivery of the intervention; and interviews with study participants, SWs and GPs to assess acceptability of the intervention and impact on routine care (phase 3).

Setting

North Staffordshire, in collaboration with Age UK North Staffordshire.

Intervention

A psychosocial intervention, comprising one-to-one contact between older people with anxiety and/or depression and a SW employed by Age UK North Staffordshire, based on the principles of behavioural activation (BA), with encouragement to participate in a group activity.

Results

Initial qualitative work contributed to refinement of the psychosocial intervention. Recruitment (and retention) of the SWs was possible; the training, support materials and manual were acceptable to them, and they delivered the intervention as intended. Recruitment of practices from which to recruit patients was possible, but the recruitment target (100 patients) was not achieved, with 38 older adults randomised. Retention at 4 months was 86%. The study was not powered to demonstrate differences in outcomes. Older people in the intervention arm found the sessions with SWs acceptable, although signposting to, and attending, groups was not valued by all participants. GPs recognised the need for additional care for older people with anxiety and depression, which they could not provide. Participation in the study did not have an impact on routine care, other than responding to the calls from the study team about risk of self-harm. GPs were not aware of the work done by SWs with patients.

Limitations

Target recruitment was not achieved.

Conclusions

Support workers recruited from Age UK employees can be recruited and trained to deliver an intervention, based on the principles of BA, to older people with anxiety and/or depression. The training and supervision model used in the study was acceptable to SWs, and the intervention was acceptable to older people.

Future work

Further development of recruitment strategies is needed before this intervention can be tested in a fully powered randomised controlled trial.

Trial registration

Current Controlled Trials ISRCTN16318986.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 7, No. 25. See the NIHR Journals Library website for further project information.

Synthesizing Qualitative Data Sets to Improve the Design of Trials and Complex Health Interventions: A Worked Example

Qualitative researchers are increasingly reanalyzing and synthesizing data sets from different studies, and this method has now been used across trials to inform trial methodology and delivery. Despite this work, however, limited guidance exists about how this method should be employed. This article details an example in which interview data collected during three primary care depression trials were brought together to explore trial participants' study and treatment journeys. It details the process involved and the decisions made. It also presents findings from this synthesis to illustrate how this method can be used to inform the development of future trials and complex interventions, through raising questions about how researchers currently define and design treatment arms and indicating what factors may improve or hinder participants' engagement with their allocated treatment.

Can support workers from AgeUK deliver an intervention to support older people with anxiety and depression? A qualitative evaluation

BACKGROUND

Anxiety and depression often co-exist. These disorders are under-diagnosed and under-treated, specifically among older people, and lead to increased use of health and social care services and raised mortality. Older people report a reluctance to present to their GP with depression or anxiety symptoms due to perceived stigma about mental health problems, lack of acceptable treatments and the prioritising of physical health problems. Third sector organisations, who work closely with older people in the community, are well-placed to provide additional support. We developed a brief intervention based on principles of Behavioural Activation, with encouragement to participate in a group activity, for delivery by Support Workers from AgeUK. The aim of the study was to examine whether this brief intervention could be delivered to older people with anxiety and/or depression, with sufficient fidelity, and whether this approach was acceptable to patients, GPs and AgeUK Support Workers.

METHODS

Semi-structured interviews with older people with self-reported anxiety and/or depression (who received the intervention), Support Workers and GPs to assess acceptability of the intervention and impact on routine care. A constant comparative approach was used to analyse the data. Intervention sessions between Support Workers and older people were digitally recorded and reviewed by the research team to assess fidelity.

RESULTS

The Support Workers delivered the intervention with fidelity; access to the training maual and ongoing supervision were important. Older people found the intervention acceptable and valued the one-to-one support they received; group activities suggested by Support Workers were not valued by all. GPs recognised the need for additional support for vulnerable older people, but acknowledged they could not provide this support. Participation in the study did not impact on GP routine care, other than responding to the calls from the study team about risk of self-harm.

CONCLUSIONS

Support Workers within AgeUK, can be recruited and trained to deliver an intervention, based on the principles of Behavioural Activation, to older people with anxiety and/or depression. The training and supervision model used in the study was acceptable to Support Workers, and the intervention was acceptable to older people and GPs. This model has the potential to contribute to improving the support and care of older people in primary care with anxiety and depression. Further testing is required in a full trial.

TRIAL REGISTRATION

Trial registration number ISRCTN16318986 . Registered 10/11/2016.

Can Gender and Age Impact on Response Pattern of Depressive Symptoms Among College Students? A Differential Item Functioning Analysis

Background: Self-reported depressive complaints among college students might indicate different degrees of severity of depressive states. Through the framework of item response theory, we aim to describe the pattern of responses to items of the Beck Depression Inventory-II (BDI-II), in terms of endorsement probability and discrimination along the continuum of depression. Potential differential item functioning of the scale items of the BDI-II is investigated, by gender and age, to compare across sub-groups of students. Methods: The 21-item BDI-II was cross-sectionally administered to a representative sample of 12,677 Brazilian college students. Reliability was evaluated based on Cronbach's alpha coefficient. Severity (b _i ) and discrimination (a) parameters of each BDI-II items were calculated through the graded response model. The influence of gender and age were tested for differential item functioning (DIF) within the item response theory-based approach. Results: The BDI-II presented good reliability (α = 0.91). Women and younger students significantly presented a higher likelihood of depression (cut-off > 13) than men and older counterparts. In general, participants endorsed more easily cognitive-somatic items than affective items of the scale. "Guilty feelings," "suicidal thoughts," and "loss of interest in sex" were the items that most likely indicated depression severity (b ≥ 3.60). However, all BDI-II items showed moderate-to-high discrimination (a ≥ 1.32) for depressive state. While two items were flagged for DIF, "crying" and "loss of interest in sex," respectively for gender and age, the global weight of these items on the total score was negligible. Conclusions: Although respondents' gender and age might present influence on response pattern of depressive symptoms, the measures of self-reported symptoms have not inflated severity scores. These findings provide further support to the validity of using BDI-II for assessing depression in academic contexts and highlight the value of considering gender- and age-related common symptoms of depression.

How older adults self-manage distress - does the internet have a role? A qualitative study

BACKGROUND

Anxiety and depression are common in older adults, but often under-recognised by GPs. Rather than perceiving themselves as suffering from anxiety or depression, older adults are more likely to self-identify as experiencing low mood, stress or distress. Older people may also feel responsible for managing their own mood problems. The Internet has the potential to support the self-management of distress through accessing health information or social support.

METHODS

This study was approved by Keele University's ethical review panel. Older adults who self-identified as experiencing distress were recruited from community groups in the West Midlands, England. To generate data, 'think-aloud' methods (including storyboards and an extract from an online forum) were embedded within semi-structured interviews. Thematic analysis, incorporating constant comparison methods, were used for data analysis.

RESULTS

Data saturation was achieved after 18 interviews. All participants reported having access to the Internet, but only a few described using the Internet to obtain general information or to conduct online purchases. Most participants described barriers to Internet use which included: a lack of interest, knowledge and confidence, a fear of technology and no trust in social media sites. Facilitators of Internet use included family encouragement and attending community groups which taught computer use. Female participants reported valuing the social contact provided by attending such groups. The Internet was seen as a source of health information once a GP had diagnosed a physical problem, but was not considered a source of information about distress or mood problems. Participants did not use the Internet to access social support and described a preference for face-to-face communication.

CONCLUSIONS

GPs need to understand how an individual patient utilises the Internet. GPs should explore the self-management strategies already employed by older adults experiencing distress and understand that directing these older people to online support might not be acceptable. Encouraging distressed older adults to attend computer group classes might be useful as this permits face-to-face social contact, and may help to facilitate Internet use in the future.

Talking about depression during interactions with GPs: a qualitative study exploring older people's accounts of their depression narratives

BACKGROUND

Older people can struggle with revealing their depression to GPs and verbalising preferences regarding its management. This contributes to problems for GPs in both detecting and managing depression in primary care. The aim of this study was to explore older people's accounts of how they talk about depression and possible symptoms to improve communication about depression when seeing GPs.

METHODS

Adopting a qualitative Interpretivist methodological approach, semi-structured interviews were conducted by IG based on the principles of grounded theory and situational analysis. GPs working in north east England recruited patients aged over 65 with depression. Data analysis was carried out with a process of constant comparison, and categories were developed via open and axial coding and situational maps. There were three levels of analysis; the first developed open codes which informed the second level of analysis where the typology was developed from axial codes. The typology derived from second level analysis only is presented here as older people's views are rarely reported in isolation.

RESULTS

From the sixteen interviews with older people, it was evident that there were differences in how they understood and accepted their depression and that this influenced what they shared or withheld in their narratives. A typology showing three categories of older people was identified: those who appeared to talk about their depression freely yet struggled to accept aspects of it (Superficial Accepter), those who consolidated their ideas about depression aloud (Striving to Understand) and those who shared minimal detail about their depression and viewed it as part of them rather than a treatable condition (Unable to Articulate). The central finding was that older people's acceptance and understanding of their depression guided their depression narratives.

CONCLUSIONS

This study identified differences between older people in ways they understand, accept and share their depression. Recognising that their depression narratives can change and listening for patterns in what older people share or withhold may help GPs in facilitating communication to better understand the patient when they need to implement alternative approaches to patient management.

Older migrants’ access to healthcare: a thematic synthesis

Purpose

The purpose of this paper is to synthesise data from the existent literature on the experiences of non-western older migrants in Europe in accessing and using healthcare services.

Design/methodology/approach

In total, 1,606 records were reviewed and 12 studies were selected. A thematic synthesis using Thomas and Harden’s approach was conducted.

Findings

The findings resulted in the three overarching themes: traditional discourses under new circumstances; predisposed vulnerabilities of older migrants and the healthcare system; and the conceptualization of health and the roles of healthcare professionals. The authors found that older migrants’ experience of accessing healthcare is influenced by many factors, such as health literacy, differences in healthcare beliefs and language barriers, and is not limited to cultural and traditional discourses of care. Findings reveal that there is a limited body of knowledge on barriers experienced by older migrant women.

Research limitations/implications

The geographical scope of the study and subsequent type of healthcare systems should be taken into account while understanding barriers to care. Another limitation is that although we studied different migrant groups, the authors synthesised barriers experienced by all. Future research could study migrants as separate groups to better understand how previous experiences with healthcare in their home country and specific social, cultural and economic circumstances shape them.

Originality/value

This paper provides a synthesis of the experiences of migrants from non-western countries who moved to a host country with a very different language, culture and healthcare system.

What is the prevalence of untreated depression and death ideation in older people? Data from the Irish Longitudinal Study on Aging

ABSTRACTObjective:Late life depression (LLD) confers significant morbidity and mortality but is well recognized that it often goes undetected or untreated. The objective of this study is to quantify the burden of untreated depression and death ideation (DI) at a population level.

DESIGN

Cross-sectional study ascertaining the prevalence of, and factors associated with, untreated depression and DI.

SETTING

This study, embedded within the Irish Longitudinal Study on Ageing, involves over 7,000 community-dwelling people aged ≥50 years.

MEASUREMENTS

Depression was defined as Centre for Epidemiological Studies Depression scale ≥16 indicating current clinically relevant depressive symptoms or Composite International Diagnostic Interview indicative of major depressive episode within the last year. Participants not prescribed antidepressants/antipsychotics were defined as untreated. To define DI, participants were asked "In the last month, have you felt like you would rather be dead?"

RESULTS

In total, 12% (839/7,055) met criteria for depression with 29% (241/839) on pharmacological therapy. Those with untreated depression were less likely to endorse symptoms of persistent low mood or worthlessness, but there was no difference in age or general practitioner (GP) visits compared to those on treatment. Over 3% (223/7,055) of participants had DI and less than one-third had visited their GP within the last year.

CONCLUSIONS

This study demonstrates that two-thirds of depressed older people are not prescribed antidepressant/antipsychotic therapy. It is important to raise awareness of depression among older people and healthcare professionals, with particular focus on the fact that LLD is not an inevitable consequence of ageing and effective treatment is available.

CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

BACKGROUND

Depression in older adults is common and is associated with poor quality of life, increased morbidity and early mortality, and increased health and social care use. Collaborative care, a low-intensity intervention for depression that is shown to be effective in working-age adults, has not yet been evaluated in older people with depression who are managed in UK primary care. The CollAborative care for Screen-Positive EldeRs (CASPER) plus trial fills the evidence gap identified by the most recent guidelines on depression management.

OBJECTIVES

To establish the clinical effectiveness and cost-effectiveness of collaborative care for older adults with major depressive disorder in primary care.

DESIGN

A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with embedded qualitative study. Participants were automatically randomised by computer, by the York Trials Unit Randomisation Service, on a 1 : 1 basis using simple unstratified randomisation after informed consent and baseline measures were collected. Blinding was not possible.

SETTING

Sixty-nine general practices in the north of England.

PARTICIPANTS

A total of 485 participants aged ≥ 65 years with major depressive disorder.

INTERVENTIONS

A low-intensity intervention of collaborative care, including behavioural activation, delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual general practitioner (GP) care. The control arm received only usual GP care.

MAIN OUTCOME MEASURES

The primary outcome measure was Patient Health Questionnaire-9 items score at 4 months post randomisation. Secondary outcome measures included depression severity and caseness at 12 and 18 months, the EuroQol-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder-7 items, Connor-Davidson Resilience Scale-2 items, a medication questionnaire, objective data and adverse events. Participants were followed up at 12 and 18 months.

RESULTS

In total, 485 participants were randomised (collaborative care, n = 249; usual care, n = 236), with 390 participants (80%: collaborative care, 75%; usual care, 86%) followed up at 4 months, 358 participants (74%: collaborative care, 70%; usual care, 78%) followed up at 12 months and 344 participants (71%: collaborative care, 67%; usual care, 75%) followed up at 18 months. A total of 415 participants were included in primary analysis (collaborative care, n = 198; usual care, n = 217), which revealed a statistically significant effect in favour of collaborative care at the primary end point at 4 months [8.98 vs. 10.90 score points, mean difference 1.92 score points, 95% confidence interval (CI) 0.85 to 2.99 score points; p  < 0.001], equivalent to a standard effect size of 0.34. However, treatment differences were not maintained in the longer term (at 12 months: 0.19 score points, 95% CI -0.92 to 1.29 score points; p = 0.741; at 18 months: < 0.01 score points, 95% CI -1.12 to 1.12 score points; p = 0.997). The study recorded details of all serious adverse events (SAEs), which consisted of 'unscheduled hospitalisation', 'other medically important condition' and 'death'. No SAEs were related to the intervention. Collaborative care showed a small but non-significant increase in quality-adjusted life-years (QALYs) over the 18-month period, with a higher cost. Overall, the mean cost per incremental QALY for collaborative care compared with usual care was £26,016; however, for participants attending six or more sessions, collaborative care appears to represent better value for money (£9876/QALY).

LIMITATIONS

Study limitations are identified at different stages: design (blinding unfeasible, potential contamination), process (relatively low overall consent rate, differential attrition/retention rates) and analysis (no baseline health-care resource cost or secondary/social care data).

CONCLUSION

Collaborative care was effective for older people with case-level depression across a range of outcomes in the short term though the reduction in depression severity was not maintained over the longer term of 12 or 18 months. Participants who received six or more sessions of collaborative care did benefit substantially more than those who received fewer treatment sessions but this difference was not statistically significant.

FUTURE WORK RECOMMENDATIONS

Recommendations for future research include investigating the longer-term effect of the intervention. Depression is a recurrent disorder and it would be useful to assess its impact on relapse and the prevention of future case-level depression.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45842879.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 67. See the NIHR Journals Library website for further project information.

How should we implement collaborative care for older people with depression? A qualitative study using normalisation process theory within the CASPER plus trial

Background

Depression in older people may have a prevalence as high as 20%, and is associated with physical co-morbidities, loss, and loneliness. It is associated with poorer health outcomes and reduced quality of life, and is under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients.

Methods

A qualitative study nested within a randomised controlled trial for older people with moderate to severe depression: the CASPER plus Trial (Care for Screen Positive Elders). We interviewed patient participants, GPs, and case managers (CM) to explore patients’ and professionals’ views on collaborative care developed for older people, and how this model could be implemented at scale. Transcripts were analysed thematically using normalization process theory.

Results

Thirty-three interviews were conducted. Across the three data-sets, four main themes were identified based on the main principles of the Normalization Process Theory: understanding of collaborative care, interaction between patients and professionals, liaison between GPs and case managers, and the potential for implementation.

Conclusions

A telephone-delivered intervention, incorporating behavioural activation, is acceptable to older people with depression, and is deliverable by case managers. The collaborative care framework makes sense to case managers and has the potential to optimize patient outcomes, but implementation requires integration in day to day general practice. Increasing GPs’ understanding of collaborative care might improve liaison and collaboration with case managers, and facilitate the intervention through better support of patients. The CASPER plus model, delivering therapy to older adults with depression by telephone, offers the potential for implementation in a resource-poor health service.

Factors contributing to the recognition of anxiety and depression in general practice

Background

Adequate recognition of anxiety and depression by general practitioners (GPs) can be improved. Research on factors that are associated with recognition is limited and shows mixed results. The aim of this study was to explore which patient and GP characteristics are associated with recognition of anxiety and depression.

Methods

We performed a secondary analysis on data from 444 patients who were recruited for a randomized trial. Recognition of anxiety and depression was defined in terms of information in the medical records, in patients who screened positive on the extended Kessler 10 (EK-10). A total of 10 patient and GP characteristics, measured at baseline, were tested and included in a multilevel regression model to examine their impact on recognition.

Results

Patients who reported a perceived need for psychological care (OR = 2.54, 95% CI 1.60–4.03) and those with higher 4DSQ distress scores (OR = 1.03; 95% CI 1.00–1.07) were more likely to be recognized. In addition, patients’ anxiety or depression was less likely to be recognized when GPs were less confident in their abilities to identify depression (OR = 0.97; 95% CI 0.95–0.99). Patients’ age, chronic medical condition, somatisation, severity of anxiety and depression, and functional status were not associated with the recognition of anxiety and depression.

Conclusions

There is room for improvement of the recognition of anxiety and depression. Quality improvement activities that focus on increasing GPs’ confidence in the ability to identify symptoms of distress, anxiety and depression, as part of care according to guidelines, may improve recognition.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0784-8) contains supplementary material, which is available to authorized users.

A feasibility study for NOn-Traditional providers to support the management of Elderly People with Anxiety and Depression: The NOTEPAD study Protocol

BACKGROUND

Anxiety and depression are common among older people, with up to 20% reporting such symptoms, and the prevalence increases with co-morbid chronic physical health problems. Access to treatment for anxiety and depression in this population is poor due to a combination of factors at the level of patient, practitioner and healthcare system. There is evidence to suggest that older people with anxiety and/or depression may benefit both from one-to-one interventions and group social or educational activities, which reduce loneliness, are participatory and offer some activity. Non-traditional providers (support workers) working within third-sector (voluntary) organisations are a valuable source of expertise within the community but are under-utilised by primary care practitioners. Such a resource could increase access to care, and be less stigmatising and more acceptable for older people.

METHODS

The study is in three phases and this paper describes the protocol for phase III, which will evaluate the feasibility of recruiting general practices and patients into the study, and determine whether support workers can deliver the intervention to older people with sufficient fidelity and whether this approach is acceptable to patients, general practitioners and the third-sector providers. Phase III of the NOTEPAD study is a randomised controlled trial (RCT) that is individually randomised. It recruited participants from approximately six general practices in the UK. In total, 100 participants aged 65 years and over who score 10 or more on PHQ9 or GAD7 for anxiety or depression will be recruited and randomised to the intervention or usual general practice care. A mixed methods approach will be used and follow-up will be conducted 12 weeks post-randomisation.

DISCUSSION

This study will inform the design and methods of a future full-scale RCT.

TRIAL REGISTRATION

ISRCTN, ID: ISRCTN16318986 . Registered 10 November 2016. The ISRCTN registration is in line with the World Health Organization Trial Registration Data Set. The present paper represents the original version of the protocol. Any changes to the protocol will be communicated to ISRCTN.

Pilot randomised controlled trial of focused narrative intervention for moderate to severe depression in palliative care patients: DISCERN trial

BACKGROUND

Depression is poorly detected and sub-optimally managed in palliative care patients, and few trials of psychosocial interventions have been carried out in this group of patients.

AIMS

A pilot trial to determine the effect of a focused narrative intervention on depression in palliative care patients when used in addition to usual care.

DESIGN

Patients scoring 10 or higher on Patient Health Questionnaire-9 randomised to focused narrative intervention in addition to usual care or usual care only and followed up at 2, 4 and 6 weeks. A reduction of five points on Patient Health Questionnaire-9 was regarded as clinically significant response to treatment.

SETTING/PARTICIPANTS

Palliative care patients aged over 18 recruited from hospice day care services - exclusion criteria included an estimated prognosis of 6 weeks or less, cognitive impairment and unable to understand written or spoken English.

RESULTS

Out of 57 participating patients (71% female), with mean age 65.1 years (range 36-88 years), 33 patients were randomised to the intervention and 24 to usual care only. Mean Patient Health Questionnaire-9 score at baseline was 16.4. Patients receiving intervention had greater reduction in Patient Health Questionnaire-9 score at 6-week follow-up ( p = 0.04). Median survival was 157 days for intervention and 102 days for control group patients ( p = 0.07).

CONCLUSION

This pilot trial suggests a focused narrative intervention in palliative care patients with moderate to severe depression can reduce depression scores more than usual care alone. Patients receiving intervention appeared to have longer survival. These results support the need for a fully powered trial.

What do older people experiencing loneliness think about primary care or community based interventions to reduce loneliness? A qualitative study in England

Loneliness in later life is a common problem with poor health outcomes. However, interventions to prevent or ameliorate loneliness have a weak evidence base. The views of older people experiencing or at risk of loneliness in the community are important in identifying features of potential support, but have been little studied. Twenty-eight community dwelling people, aged 65 and over who reported being 'lonely much of the time' or identified as lonely from the de Jong Gierveld six-item loneliness scale in a larger study, participated in in-depth interviews, between June 2013 and May 2014. Views and experiences on seeking support from primary care and community based one-to-one and group based activities, including social and shared interest groups, were explored. Interviews were recorded and transcribed. Thematic analysis was conducted by a multidisciplinary team, including older people. Using two different measures of loneliness enabled a spectrum of loneliness experience to be explored. Two-thirds of the participants were the 'younger old' and all were able to leave their homes independently. Older people with characteristics of loneliness were generally knowledgeable about local social and community resources but, for the majority, community and primary care based services for their loneliness were not considered desirable or helpful at this point in their lives. However, group based activities with a shared interest were thought preferable to one-to-one support (befriending) or groups with a social focus. Descriptions of support as being for loneliness and specific to older people discouraged engagement. Older people experiencing or at risk of loneliness did not consider that primary care has a role in alleviating loneliness because it is not an illness. They thought primary care practitioners lack understanding of non-physical problems and that a good relationship was necessary to discuss sensitive issues like loneliness. For many, loneliness was a complex and private matter that they wished to manage without external support.

Developing a community-based psycho-social intervention with older people and third sector workers for anxiety and depression: a qualitative study

BACKGROUND

One-in-five people in the UK experience anxiety and/or depression in later life. However, anxiety and depression remain poorly detected in older people, particularly in those with chronic physical ill health. In the UK, a stepped care approach, to manage common mental health problems, is advocated which includes service provision from non-statutory organisations (including third/voluntary sector). However, evidence to support such provision, including the most effective interventions, is limited. The qualitative study reported here constitutes the first phase of a feasibility study which aims to assess whether third sector workers can deliver a psychosocial intervention to older people with anxiety and/or depression. The aim of this qualitative study is to explore the views of older people and third sector workers about anxiety and depression among older people in order to refine an intervention to be delivered by third sector workers.

METHODS

Semi-structured interviews with participants recruited through purposive sampling from third sector groups in North Staffordshire. Interviews were digitally recorded with consent, transcribed and analysed using principles of constant comparison.

RESULTS

Nineteen older people and 9 third sector workers were interviewed. Key themes included: multiple forms of loss, mental health as a personal burden to bear, having courage and providing/receiving encouragement, self-worth and the value of group activities, and tensions in existing service provision, including barriers and gaps.

CONCLUSIONS

The experience of loss was seen as central to feelings of anxiety and depression among community-dwelling older people. This study contributes to the evidence pointing to the scale and severity of mental health needs for some older people which can arise from multiple forms of loss, and which present a significant challenge to health, social care and third sector services. The findings informed development of a psychosocial intervention and training for third sector workers to deliver the intervention.

Behavioural activation by mental health nurses for late-life depression in primary care: a randomized controlled trial

BACKGROUND

Depressive symptoms are common in older adults. The effectiveness of pharmacological treatments and the availability of psychological treatments in primary care are limited. A behavioural approach to depression treatment might be beneficial to many older adults but such care is still largely unavailable. Behavioural Activation (BA) protocols are less complicated and more easy to train than other psychological therapies, making them very suitable for delivery by less specialised therapists. The recent introduction of the mental health nurse in primary care centres in the Netherlands has created major opportunities for improving the accessibility of psychological treatments for late-life depression in primary care. BA may thus address the needs of older patients while improving treatment outcome and lowering costs.The primary objective of this study is to compare the effectiveness and cost-effectiveness of BA in comparison with treatment as usual (TAU) for late-life depression in Dutch primary care. A secondary goal is to explore several potential mechanisms of change, as well as predictors and moderators of treatment outcome of BA for late-life depression.

METHODS/DESIGN

Cluster-randomised controlled multicentre trial with two parallel groups: a) behavioural activation, and b) treatment as usual, conducted in primary care centres with a follow-up of 52 weeks. The main inclusion criterion is a PHQ-9 score > 9. Patients are excluded from the trial in case of severe mental illness that requires specialized treatment, high suicide risk, drug and/or alcohol abuse, prior psychotherapy, change in dosage or type of prescribed antidepressants in the previous 12 weeks, or moderate to severe cognitive impairment. The intervention consists of 8 weekly 30-min BA sessions delivered by a trained mental health nurse.

DISCUSSION

We expect BA to be an effective and cost-effective treatment for late-life depression compared to TAU. BA delivered by mental health nurses could increase the availability and accessibility of non-pharmacological treatments for late-life depression in primary care.

TRIAL REGISTRATION

This study is retrospectively registered in the Dutch Clinical Trial Register NTR6013 on August 25th 2016.

'She believed in me'. What patients with depression value in their relationship with practitioners. A secondary analysis of multiple qualitative data sets

BACKGROUND

Clinical guidance promotes the practitioner-patient relationship as integral to good quality person-centred care for patients with depression. However, patients can struggle to engage with practitioners and practitioners have indicated that they want more guidance on how to establish effective relationships with their patients.

OBJECTIVE

To identify what practitioner attributes patients with depression particularly value or find problematic.

METHOD

A secondary analysis of data collected during four qualitative studies, all of which entailed interviewing patients diagnosed with depression about their treatment experiences. Patients in the four studies had received different treatments. These included antidepressants, cognitive behaviour therapy, facilitated physical activity and listening visits. We thematically analysed 32 patient accounts.

RESULTS

We identified two complimentary sets of important practitioner attributes: the first based on the practitioner's bearing; the second based on the practitioner's enabling role. We found that patients value practitioners who consider their individual manner, share relevant personal information, show interest and acceptance, communicate clearly and listen carefully, collaborate on manageable goals and sanction greater patient self-care and self-compassion. It was also evident that patients receiving different treatments value the same practitioner attributes and that when these key practitioner qualities were not evident, patients were liable not to re-attend or comply with treatment.

CONCLUSION

The practitioner attributes that patients with depression most value have a positive impact on their engagement with treatment. Patients emphasise the importance of a practitioner's demeanour and encouragement, rather than the amount of time or specific treatment a practitioner is able to provide.

[Coping strategies of older people with low mood]

BACKGROUND

To gain new insights for support for older people with low mood, we explored the perceptions of 'screenpositive' older people on underlying causes and possible solutions.

DESIGN AND METHOD

We conducted two in-depth interviews with 38 participants (≥77 years) who screened positive for depressive symptoms in general practice. To investigate the influence of the presence of complex health problems, we included 19 persons with and 19 without complex problems. Complex problems were defined as a combination of functional, somatic, psychological or social problems.

RESULTS

All participants used several cognitive, social or practical coping strategies. Four patterns emerged: mastery, acceptance, ambivalence, and need for support. Some participants, especially those with complex problems, were ambivalent about possible interventions.

CONCLUSION

Most older participants perceived their coping strategies as sufficient. General practitioners can support self-management by exploring the (effectiveness of) personal coping strategies, providing information, elaborating on perceptions of risks and discussing alternative options with older persons.

The implications of living with heart failure; the impact on everyday life, family support, co-morbidities and access to healthcare: a secondary qualitative analysis

BACKGROUND

The aim of this study was to use secondary analysis to interrogate a qualitative data set to explore the experiences of patients living with heart failure.

METHODS

The data-set comprised interviews with 11 patients who had participated in an ethnographic study of heart failure focusing on unplanned hospital admissions. Following an initial review of the literature, a framework was developed with which to interrogate the data-set. This was modified in light of analysis of the first two interviews, to focus on the rich data around patients' perceptions of living with heart failure, managing co-morbidities, accessing healthcare and the role of their family and friends, during their illness journey.

RESULTS

Respondents described how the symptoms of heart failure impacted on their daily lives and how disruption of routine activity due to their symptoms caused them to seek medical care. Respondents disclosed the difficulties of living with other illnesses, in addition to their heart failure, particularly managing multiple and complex medication regimes and negotiating multiple appointments; all expressed a desire to return to their pre-morbid, more independent lives. Many respondents described uncertainty around diagnosis and delays in communication from their healthcare providers. The importance of family support was emphasised, but respondents worried about burdening relatives with their illness.

CONCLUSION

Living with heart failure causes disruption to the lives of sufferers. Facilitation of access to healthcare, through good communication between services and having a strong support network of both family and clinicians can reduce the impact of heart failure on the lives of the patient and those around them.

Widespread pain and depression are key modifiable risk factors associated with reduced social participation in older adults: A prospective cohort study in primary care

In older adults, reduced social participation increases the risk of poor health-related quality of life, increased levels of inflammatory markers and cardiovascular disease, and increased mortality. Older adults frequently present to primary care, which offers the potential to deliver interventions at the point of care to increase social participation. The aim of this prospective study was to identify the key modifiable exposures that were associated with reduced social participation in a primary care population of older adults.The study was a population-based prospective cohort study. Participants (n = 1991) were those aged ≥65 years who had completed questionnaires at baseline, and 3 and 6-year follow-ups. Generalized linear mixed modeling framework was used to test for associations between exposures and decreasing social participation over 6 years.At baseline, 44% of participants reported reduced social participation, increasing to 49% and 55% at 3 and 6-year follow-up. Widespread pain and depression had the strongest independent association with reduced social participation over the 6-year follow-up period. The prevalence of reduced social participation for those with widespread pain was 106% (adjusted incidence rate ratio 2.06, 95% confidence interval 1.72, 2.46), higher than for those with no pain. Those with depression had an increased prevalence of 82% (adjusted incidence rate ratio 1.82, 95% confidence interval 1.62, 2.06). These associations persisted in multivariate analysis.Population ageing will be accompanied by increasing numbers of older adults with pain and depression. Future trials should assess whether screening for widespread pain and depression, and targeting appropriate treatment in primary care, increase social participation in older people.

Testing of a Statewide Initiative to Enhance Depression Care in Older Home Care Patients

Late-life depression is becoming increasingly prevalent among older adults in the United States and is predictive of a wide range of negative health-related outcomes. Fourteen home care agencies participated in a quasi-experimental, pre-test, post-test design of a depression screening training program nested within a two-cycle, phased introduction of the intervention. The primary aim of this study was to evaluate the effects of the program at three levels of outcomes: the trainers, the trainees, and the agencies. There was a significant increase in the knowledge and self-efficacy of the trainers and trainees and a trend toward decreased hospitalization.

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background

A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.

Objectives

To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.

Design

Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).

Results

The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.

Conclusions

We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Older people coping with low mood: a qualitative study

BACKGROUND

To gain new insight into support for older people with low mood, the perceptions, strategies, and needs of older people with depressive symptoms were explored.

METHODS

Two in-depth interviews were held with 38 participants (aged ≥77 years) who screened positive for depressive symptoms in general practice. To investigate the influence of the presence of complex health problems, 19 persons with and 19 without complex problems were included. Complex problems were defined as a combination of functional, somatic, psychological or social problems.

RESULTS

All participants used several cognitive, social or practical coping strategies. Four patterns emerged: mastery, acceptance, ambivalence, and need for support. Most participants felt they could deal with their feelings sufficiently, whereas a few participants with complex problems expressed a need for professional support. Some participants, especially those with complex problems, were ambivalent about possible interventions mainly because they feared putting their fragile balance at risk due to changes instigated by an intervention.

CONCLUSION

Most older participants with depressive symptoms perceived their coping strategies to be sufficient. The general practitioners (GPs) can support self-management by talking about the (effectiveness of) personal coping strategies, elaborating on perceptions of risks, providing information, and discussing alternative options with older persons.

Evaluating a complex model designed to increase access to high quality primary mental health care for under-served groups: a multi-method study

BACKGROUND

Many people with mental distress are disadvantaged because care is not available or does not address their needs. In order to increase access to high quality primary mental health care for under-served groups, we created a model of care with three discrete elements: community engagement, primary care training and tailored wellbeing interventions. We have previously demonstrated the individual impact of each element of the model. Here we assess the effectiveness of the combined model in increasing access to and improving the quality of primary mental health care. We test the assumptions that access to the wellbeing interventions is increased by the presence of community engagement and primary care training; and that quality of primary mental health care is increased by the presence of community engagement and the wellbeing interventions.

METHODS

We implemented the model in four under-served localities in North-West England, focusing on older people and minority ethnic populations. Using a quasi-experimental design with no-intervention comparators, we gathered a combination of quantitative and qualitative information. Quantitative information, including referral and recruitment rates for the wellbeing interventions, and practice referrals to mental health services, was analysed descriptively. Qualitative information derived from interview and focus group responses to topic guides from more than 110 participants. Framework analysis was used to generate findings from the qualitative data.

RESULTS

Access to the wellbeing interventions was associated with the presence of the community engagement and the primary care training elements. Referrals to the wellbeing interventions were associated with community engagement, while recruitment was associated with primary care training. Qualitative data suggested that the mechanisms underlying these associations were increased awareness and sense of agency. The quality of primary mental health care was enhanced by information gained from our community mapping activities, and by the offer of access to the wellbeing interventions. There were variable benefits from health practitioner participation in community consultative groups. We also found that participation in the wellbeing interventions led to increased community engagement.

CONCLUSIONS

We explored the interactions between elements of a multilevel intervention and identified important associations and underlying mechanisms. Further research is needed to test the generalisability of the model.

TRIAL REGISTRATION

Current Controlled Trials, reference ISRCTN68572159 . Registered 25 February 2013.

Differential item functioning in the Cambridge Mental Disorders in the Elderly (CAMDEX) Depression Scale across middle age and late life

A long-standing and critical problem in the study of aging and depression is the comparability of measurement across age groups. While psychological measures of depression typically show increased incidence of symptoms with increasing age, rates of depression diagnosis do not show the same age trend. This analysis presents tests of differential item functioning on the depression section of the CAMDEX interview schedule, using factor analysis-derived affective and somatic subscales (McGue & Christensen, 1997). Results for the affective subscale show significant differences in item functioning in the majority of the affective items as a function of age (items "Happy Life," "Lonely," "Nervous" "Worthless," and "Future": χ6(2) = [30.193, 255.971] across items, all p < .0001). Analyses for the somatic subscale show differential item functioning is limited to a single item relating to coping (χ6(2) = 180.754, p < .0001). These results indicate that differences in depression symptoms across age groups are not entirely consistent with a unidimensional depression trait, and that the measurement structure of depression varies over the life span.

Revealing hidden depression in older people: a qualitative study within a randomised controlled trial

BACKGROUND

The prevalence of depressive symptoms in older people may be as high as 20 %. Depression in older people is associated with loss, loneliness and physical co-morbidities; it is known to be under-diagnosed and under-treated. Older people may find it difficult to speak to their GPs about low mood, and GPs may avoid identifying depression due to limited consultation time and referral options for older patients.

METHODS

A nested qualitative study in a randomised controlled trial for older people with moderate to severe depression: the CASPER Plus Trial (Collaborative Care for Screen Positive Elders). We interviewed GPs, case managers (CM) and patient participants to explore perspectives and experiences of delivering and receiving a psychosocial intervention, developed specifically for older adults in primary care, within a collaborative care framework. Transcripts were analysed thematically using principles of constant comparison.

RESULTS

Thirty three interviews were conducted and, across the three data-sets, four main themes were identified: revealing hidden depression, reducing the 'blind spots', opportunity to talk outside the primary care consultation and 'moving on' from depression.

CONCLUSIONS

Depression in older people is commonly hidden, and may coexist with physical conditions that are prioritised by both patients and GPs. Being invited to participate in a trial about depression may allow older people to disclose their feelings, name the problem, and seek help. Offering older people an opportunity to talk outside the primary care consultation is valued by patients and GPs. A psychosocial intervention delivered by a case manager in the primary care setting may fill the gap in the care of older people with depression.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45842879 .

The self-management of longer-term depression: learning from the patient, a qualitative study

BACKGROUND

Depression is a common mental health condition now viewed as chronic or long-term. More than 50 % of people will have at least one further episode of depression after their first, and therefore it requires long-term management. However, little is known about the effectiveness of self-management in depression, in particular from the patients' perspective. This study aimed to understand how people with longer-term depression manage the condition, how services can best support self-management and whether the principles and concepts of the recovery approach would be advantageous.

METHODS

Semi-structured in depth interviews were carried out with 21 participants, recruited from a range of sources using maximum variation sampling. Interpretative Phenomenological Analysis was used by a diverse team comprised of service users, practitioners and academics.

RESULTS

Four super-ordinate themes were found: experience of depression, the self, the wider environment, self-management strategies. Within these, several prominent sub-themes emerged of importance to the participants. These included how aspects of themselves such as hope, confidence and motivation could be powerful agents; and how engaging in a wide range of chosen activities could contribute to their emotional, mental, physical, social, spiritual and creative wellbeing.

CONCLUSIONS

Services in general were not perceived to be useful in specifically facilitating self-management. Increased choice and control were needed and a greater emphasis on an individualised holistic model. Improved information was needed about how to develop strategies and locate resources, especially during the first episode of depression. These concepts echoed those of the recovery approach, which could therefore be seen as valuable in aiding the self-management of depression.

Pulling out all the stops: what motivates 65+ year olds with depressive symptoms to participate in an outreaching preference-led intervention programme?

OBJECTIVES

Many older adults have significant depressive symptoms but few people access care for these. This study explores which personal, clinical and need factors facilitate or hinder acceptance of a new outreaching preference-led intervention programme.

METHODS

From a sample of 9661 community-dwelling 65+ year olds, 244 persons with depressive symptoms according to the Patient Health Questionnaire-9 were included. Data on programme effectiveness in terms of care utilisation were collected. Associations between programme acceptance and personal, clinical and need factors were studied using quantitative (logistic regression analyses) and qualitative methods (semi-structured interviews with 26 subjects, who accepted (n = 20) or declined (n = 6) the programme).

RESULTS

Fifty-six per cent (n = 137) took part in the interventions. Quantitative logistic regression analyses showed that participants were more often female, suffered from more severe depressive symptoms and perceived more loneliness. Qualitative analyses revealed that people accepting the intervention programme felt that medical terms as having a depressed mood were applicable to their situation, more often perceived their symptoms as hindering, felt lonely and more often perceived a need for care. They were more often advised by their general practitioner to participate than individuals who refused the interventions. Many participating individuals did not see a match between the intervention programme and their needs, especially with respect to meeting new people.

CONCLUSION

Many older persons with depressive symptoms did not feel the need to take part in the programme. Providing support in alleviating loneliness and further adaptation to older adults' illness representations and perceptions when discussing depressive symptoms might enhance care utilisation.

Health Resources and Strategies among Employed Women in Norway during Pregnancy and Early Motherhood

The number of women in paid employment is increasing. However, when becoming a mother for the first time, many seem unprepared for the challenge of balancing motherhood and work as well as for the impact on their health. The aim of this study was to investigate the health resources and strategies of employed women in Norway during pregnancy and early motherhood by means of salutogenic theory. A hypothetical-deductive interpretive approach based on Antonovsky's salutogenic theory was applied in a secondary analysis. A total of six themes were identified; three were classified as health resources when experiencing tension and three as health strategies. Salutogenic theory seems to be a useful framework for illuminating the health resources and strategies adopted by employed women who become mothers. The identified health resources when experiencing tension and the health strategies applied may have implications for maternity care professionals and employers in promoting the health of such women and supporting them to combine work and family life.

CASPER plus (CollAborative care in Screen-Positive EldeRs with major depressive disorder): study protocol for a randomised controlled trial

Background

Depression accounts for the greatest disease burden of all mental health disorders, contributes heavily to healthcare costs, and by 2020 is set to become the second largest cause of global disability. Although 10% to 16% of people aged 65 years and over are likely to experience depressive symptoms, the condition is under-diagnosed and often inadequately treated in primary care. Later-life depression is associated with chronic illness and disability, cognitive impairment and social isolation. With a progressively ageing population it becomes increasingly important to refine strategies to identity and manage depression in older people. Currently, management may be limited to the prescription of antidepressants where there may be poor concordance; older people may lack awareness of psychosocial interventions and general practitioners may neglect to offer this treatment option.

Methods/design

CASPER Plus is a multi-centre, randomised controlled trial of a collaborative care intervention for individuals aged 65 years and over experiencing moderate to severe depression. Selected practices in the North of England identify potentially eligible patients and invite them to participate in the study. A diagnostic interview is carried out and participants with major depressive disorder are randomised to either collaborative care or usual care. The recruitment target is 450 participants.

The intervention, behavioural activation and medication management in a collaborative care framework, has been adapted to meet the complex needs of older people. It is delivered over eight to 10 weekly sessions by a case manager liaising with general practitioners.

The trial aims to evaluate the clinical and cost effectiveness of collaborative care in addition to usual GP care versus usual GP care alone. The primary clinical outcome, depression severity, will be measured with the Patient Health Questionnaire-9 (PHQ-9) at baseline, 4, 12 and 18 months. Cost effectiveness analysis will assess health-related quality of life using the SF-12 and EQ-5D and will examine cost-consequences of collaborative care.

A qualitative process evaluation will be undertaken to explore acceptability, gauge the extent to which the intervention is implemented and to explore sustainability beyond the clinical trial.

Discussion

Results will add to existing evidence and a positive outcome may lead to the commissioning of this model of service in primary care.

Trial registration

ISRCTN45842879 (24 July 2012).

Community Engagement in a complex intervention to improve access to primary mental health care for hard-to-reach groups

BACKGROUND

Despite the availability of effective evidence-based treatments for depression and anxiety, many 'harder-to-reach' social and patient groups experience difficulties accessing treatment. We developed a complex intervention, the AMP (Improving Access to Mental Health in Primary Care) programme, which combined community engagement (CE), tailored (individual and group) psychosocial interventions and primary care involvement.

OBJECTIVES

To develop and evaluate a model for community engagement component of the complex intervention. This paper focuses on the development of relationships between stakeholders, their engagement with the issue of access to mental health and with the programme through the CE model.

DESIGN

Our evaluation draws on process data, qualitative interviews and focus groups, brought together through framework analysis to evaluate the issues and challenges encountered.

SETTING & PARTICIPANTS

A case study of the South Asian community project carried out in Longsight in Greater Manchester, United Kingdom.

KEY FINDINGS

Complex problems require multiple local stakeholders to work in concert. Assets based approaches implicitly make demands on scarce time and resources. Community development approaches have many benefits, but perceptions of open-ended investment are a barrier. The time-limited nature of a CE intervention provides an impetus to 'do it now', allowing stakeholders to negotiate their investment over time and accommodating their wider commitments. Both tangible outcomes and recognition of process benefits were vital in maintaining involvement.

CONCLUSIONS

CE interventions can play a key role in improving accessibility and acceptability by engaging patients, the public and practitioners in research and in the local service ecology.

Do those over 80 years of age seek more or less medical help? A qualitative study of health and illness beliefs and behaviour of the oldest old

Increasing longevity and prevalence of long-term conditions contribute to older adults being the greatest users of health services. However, relatively little is known about the health and illness beliefs of the oldest old or how they decide to seek help in response to symptoms. Through analysis of in-depth interviews with day centre attendees aged 80-93, we find that a moral, hierarchical approach to health problems and help-seeking exists; similar to Cornwell's (1984) findings among 50-60 year-olds of a similar social group 30 years ago. However, when acting independently, those in their eighties and nineties report modifying their health and illness beliefs and behaviour, in response to their own perceived old age. Some health problems are 'demedicalised', being increasingly attributed to age and by being self-managed. Others are perceived as potentially more serious, leading to increased consultation with medical services. When obliged to act outside their moral belief-behaviour framework by others, the participants expressed feelings of disempowerment, yet resisted modifying their moral beliefs. This may represent resistance to adopt the 'sick role', while seeking to maintain control over uncertain health as functional dependence and frailty increases. This study furthers theoretical understanding of the health and illness beliefs and behaviour of the oldest old, with important practical implications.