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

Co-designing action-oriented mental health conversations between care providers and ageing Canadians in the community: a participatory mixed-methods study protocol

INTRODUCTION

The mental health of ageing Canadians is a growing concern, particularly post-pandemic. Older adults face systemic ageism and mental health stigma as pervasive barriers to seeking needed mental health support, care and treatment within health and social care systems. These barriers are exacerbated when service providers focus on physical healthcare needs or lack the skills and confidence to talk about and/or address mental health during routine visits. This study aims to co-design and test an evidence-based approach to mental health conversations at the point-of-care in home and community settings with older adults, family and friend caregivers and health and social care providers that could facilitate help-seeking activities and care access.

METHODS AND ANALYSIS

A participatory mixed-methods study design will be applied, guided by a Working Group of experts-by-experience (n=30). Phase 1 engages ageing Canadians in four online workshops (n=60) and a national survey (n=1000) to adapt an evidence-based visual model of mental health for use with older adults in home and community care. Phase 2 includes six co-design workshops with community providers (n=90) in rural and urban sites across three Canadian provinces to co-design tools, resources and processes for enabling the use of the adapted model as a conversation guide. Phase 3 involves pilot and feasibility testing the co-designed conversations with older adult clients of providers from Phase 2 (n=180).

ETHICS AND DISSEMINATION

Phases 1 and 2 of this study have received ethics clearance at the University of Waterloo (ORE #44187), University of British Columbia (#H22-02306) and St. Francis Xavier University (#26075). While an overview of Phase 3 is included, details will rely on Phase 2 outcomes. Knowledge mobilisation activities will include peer-reviewed publications, conference presentations, webinars, newsletters, infographics and policy briefs. Interested audiences may include community organisations, policy and decision-makers and health and social care providers.

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.

The Feasibility of a Mindfulness Intervention for Depression in People with Mild Dementia: A Pilot Randomized Controlled Trial

OBJECTIVES

This preliminary study aimed to establish the feasibility of running an adapted Mindfulness Based Cognitive Therapy (MBCT) intervention for people with mild dementia and depression. It also aimed to conduct an exploratory analysis as to whether the MBCT intervention would lead to greater improvements in measures of depression, anxiety, quality of life and cognition, as compared to treatment as usual (TAU).

METHODS

A single-blind, multisite, feasibility randomized controlled trial was used. People with dementia and depression were recruited from participating memory services. Twenty participants were randomized to either an adapted MBCT and TAU group (n = 10) or TAU (n = 10). Measures of depression, anxiety, quality of life (QOL), and cognition were assessed at baseline and follow-up.

RESULTS

The intervention was feasible in terms of high attendance and low levels of attrition. It was not judged feasible to recruit enough participants within the recruitment time-frame. The MBCT group did not show significant improvements in depression, anxiety, QOL, and cognition at follow-up, as compared to TAU.

CONCLUSION

There is currently inadequate evidence to recommend this adapted MBCT intervention for people with dementia for the treatment of depression within memory services. The MBCT intervention needs redevelopment and piloting before further testing in an RCT.

Prioritization of indicators of the quality of care provided to older adults with frailty by key stakeholders from five canadian provinces

Background

To meet the needs of older adults with frailty better, it is essential to understand which aspects of care are important from their perspective. We therefore sought to assess the importance of a set of quality indicators (QI) for monitoring outcomes in this population.

Methods

In this mixed-method study, key stakeholders completed a survey on the importance of 36 QIs, and then explained their ratings in a semi-structured interview. Stakeholders included older adults with frailty and their caregivers, healthcare providers (HCPs), and healthcare administrators or policy/decision makers (DMs). We conducted descriptive statistical analyses of quantitative variables, and deductive thematic qualitative analyses of interview transcripts.

Results

The 42 participants (8 older adults, 18 HCPs, and 16 DMs) rated six QIs as more important: increasing the patients’ quality of life; increasing healthcare staff skills; decreasing patients’ symptoms; decreasing family caregiver burden; increasing patients’ satisfaction with care; and increasing family doctor continuity of care.

Conclusions

Key stakeholders prioritized QIs that focus on outcomes targeted to patients and caregivers, whereas the current healthcare systems generally focus on processes of care. Quality improvement initiatives should therefore take better account of aspects of care that are important for older adults with frailty, such as having a chance to express their individual goals of care, receiving quality communications from HCPs, or monitoring symptoms that they might not spontaneously describe. Our results point to the need for patient-centred care that is oriented toward quality of life for older adults with frailty.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02843-9.

Depression and Severity of Glaucoma Among Older Adults in Urban and Suburban Areas

PRCIS

Depression increases with severity of visual field defect in older adults with primary open-angle glaucoma (POAG).

PURPOSE

This study aimed to determine the prevalence of depression among patients with POAG and examine the relationship between depression and the severity of POAG in older adults.

MATERIALS AND METHODS

Three hundred and sixty patients with POAG aged 60 years or above were recruited from 2 tertiary centers located in an urban and suburban area. The participants were stratified according to the severity of their glaucoma based on the scores from the modified Advanced Glaucoma Intervention Study (AGIS) to mild, moderate, severe, and end stage. Face-to-face interviews were performed using the Malay Version Geriatric Depression Scale 14 (mGDS-14) questionnaire. Depression is diagnosed when the score is ≥8. One-way analysis of variance was used to compare the subscores between the groups. Multifactorial analysis of variance was also applied with relevant confounding factors.

RESULTS

Depression was detected in 16% of older adults with POAG; a higher percentage of depression was seen in those with end stage disease. There was a significant increase in the mean score of mGDS-14 according to the severity of POAG. There was evidence of an association between depression and severity of visual field defect (P<0.001). There was a significant difference in mGDS-14 score between the pairing of severity of POAG [mild-severe (P=0.003), mild-end stage (P<0.001), moderate-severe (P<0.001), and moderate-end stage (P<0.001)] after adjustment to living conditions, systemic disease, and visual acuity.

CONCLUSION

Ophthalmologists should be aware that older adults with advanced visual field defects in POAG may have depression. The detection of depression is important to ensure adherence and persistence to the treatment of glaucoma.

'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.

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.

Management of depression and referral of older people to psychological therapies: a systematic review of qualitative studies

BACKGROUND

Depressive symptoms are common in later life and increase both the risk of functional and cognitive decline and the use of healthcare services. Despite older people expressing preferences for talking therapies, they are less likely to be referred than younger adults, particularly when aged ≥80 years.

AIM

To explore how healthcare professionals (HCPs) manage older people in relation to depression and referrals to psychological therapies.

DESIGN AND SETTING

Systematic review and thematic synthesis of qualitative studies.

METHOD

MEDLINE, Embase, PsycINFO, CINAHL, and the Social Sciences Citation Index (inception-March 2018) were searched for studies exploring HCPs' views regarding management of late-life depression across all settings. Studies of older people's views or depression management across all ages were excluded.

RESULTS

In total, 27 studies, were included; these predominantly focused on the views of GPs and primary and community care nurses. Many HCPs felt that late-life depression was mainly attributable to social isolation and functional decline, but treatments appropriate for this were limited. Clinicians perceived depression to have associated stigma for older adults, which required time to negotiate. Limited time in consultations and the complexity of needs in later life meant physical health was often prioritised over mental health, particularly in people with frailty. Good management of late-life depression appeared to depend more on the skills and interest of individual GPs and nurses than on any structured approach.

CONCLUSION

Mental ill health needs to be a more-prominent concern in the care of older adults, with greater provision of psychological services tailored to later life. This may facilitate future identification and management of depression.

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.

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.

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 qualitative study on older primary care patients' perspectives on depression and its treatments - potential barriers to and opportunities for managing depression

Background

Depression is one of the most common mental disorders in old age and is associated with various negative health consequences for the affected individual. Studies suggest that patients’ views on depression have an impact on help-seeking behaviour and treatment. It is thus important to investigate the patient’s perspective in order to ascertain optimum management of depression in late life. However, studies on depression and its treatment exploring the perspectives of primary care patients 75 years or older, are rare.

Methods

Qualitative data was collected in semi-structured interviews with 12 primary care patients 75 years of age or older with symptoms of depression. Data was analysed using qualitative content analysis.

Results

The study’s results show the multifaceted views on and treatment of depression in primary care patients 75 years of age or older. Some patients seemed well informed about depression and believed in the efficacy of different treatments, such as medications or psychotherapy. However, some individuals had misconceptions about depression and its treatments. Patients mentioned that they would rather avoid talking about depression within their social network, in part of fear of negative reactions. Furthermore, participants believed that other people had little understanding for people with depression. Patients had different views on the relevance of the general practitioner’s (GP) role in treating depression; some patients believed that the GP had little importance in the treatment of depression.

Conclusions

This study identified positive views of primary care patients 75 years of age or older towards depression as well as views that might hinder optimal treatments. Exemplary implications for an improved management of depression are: educating older adults about depression via age-specific information and having professionals encourage patients in believing that depression is a recognised disorder.

Electronic supplementary material

The online version of this article (10.1186/s12875-017-0684-3) contains supplementary material, which is available to authorized users.

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.

Association of Suicidality and Depression With 5α-Reductase Inhibitors

IMPORTANCE

There have been concerns raised by patients and regulatory agencies regarding serious psychiatric adverse effects associated with 5α-reductase inhibitors.

OBJECTIVE

To determine if there is an increased risk of suicide, self-harm, or depression among older men starting a 5α-reductase inhibitor for prostatic enlargement.

DESIGN, SETTING, AND PARTICIPANTS

A population-based, retrospective, matched cohort study using linked administrative data for 93 197 men ages 66 years or older (median [IQR] age, 75 [70-80] years) in Ontario, Canada, who initiated a new prescription for a 5α-reductase inhibitor during the study period (2003 through 2013). Participants were matched (using a propensity score that included 44 of our 96 covariates that included medical comorbidities, medication usage, and health care system utilization) to an equal number of men not prescribed a 5α-reductase inhibitor.

EXPOSURES

Duration of finasteride or dutasteride usage.

MAIN OUTCOMES AND MEASURES

Suicide. Secondary outcomes were self-harm and depression.

RESULTS

Men who used 5α-reductase inhibitors were not at a significantly increased risk of suicide (HR, 0.88; 95% CI, 0.53-1.45). Risk of self-harm was significantly increased during the initial 18 months after 5α-reductase inhibitor initiation (HR, 1.88; 95% CI, 1.34-2.64), but not thereafter. Incident depression risk was elevated during the initial 18 months after 5α-reductase inhibitor initiation (HR, 1.94; 95% CI, 1.73-2.16), and continued to be elevated, but to a lesser degree, for the remainder of the follow-up period (HR, 1.22; 95% CI, 1.08-1.37). The absolute increases in the event rates for these 2 outcomes were 17 per 100 000 patient-years and 237 per 100 000 patient-years, respectively. The type of 5α-reductase inhibitor (finasteride or dutasteride) did not significantly modify the observed associations with suicide, self-harm, and depression.

CONCLUSIONS AND RELEVANCE

In a large cohort of men ages 66 years or older, we did not demonstrate an increased risk of suicide associated with 5α-reductase inhibitor use. However, the risk of self-harm and depression were increased compared with unexposed men. This is in keeping with postmarketing experience and patient concerns, and discontinuation of the medication in these circ umstances may be appropriate.