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Older people with depression ‘less likely to be referred for psychological therapy’

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“The elderly are being fobbed off with pills for mental health problems instead of receiving therapy,” claims the Mail Online, while The Daily Telegraph reports that “NHS ageism is blocking older people’s access to talking therapies”.

The news reports, and their sensational claims, are based on a new review looking into older people’s experience of seeking help for depression.

Psychological therapies are the treatment of choice for people with mild to moderate depression, yet referrals are very low.

This review looked at 27 studies that used interviews or discussion groups with GPs and community nurses to explore how they manage depression in older people.

The review discussed the main themes identified. Many healthcare professionals felt that depression in older people was often associated with social isolation and physical decline.

The complex needs of many older adults meant that they often had to focus on addressing physical problems, like frailty.

Another issue noted was that access to psychological therapies is highly variable across the UK.

Many said that they faced the “postcode lottery” of being restricted by what was available in their area.

The findings highlight the importance of addressing mental health symptoms in older age, like at any other time in life.

But the review does not provide simple answers that will ensure a massive shift in the management of depression in the elderly in the immediate future. It seems many complex issues need to be addressed.

If you think you’d benefit from therapy, such as cognitive behavioural therapy, you can refer yourself directly to an NHS psychological therapies service. You do not need to see your GP first.

Where did the story come from?

The review was conducted by researchers from University College London and the University of Bristol, and was funded by the National Institute for Health Research School for Public Health Research.

It was published in the peer-reviewed British Journal of General Practice and is free to read online.

The UK media has taken a rather simplistic and unhelpful approach to this type of research, pinning blame on doctors for “fobbing off elderly patients with pills” or putting it down to “NHS ageism”.

This review explores many complex themes that may underlie differences in management of older people, and the solutions might not be so simple.

What kind of research was this?

This systematic review gathered the findings of qualitative studies exploring how healthcare professionals manage older people with depression.

Qualitative studies use methods like interviews or discussion groups with people, include quotes of people’s views, and generally try to come up with overall themes and patterns in their findings.

Depression is reported to affect up to 1 in 10 older adults over the age of 75, while a third may have symptoms of low mood.

Studies have suggested that the vast majority of older people with depression – nearly 90% – are prescribed antidepressants, while referrals for psychological therapies are said to be less than 5%.

Qualitative studies may offer insights into the reasons for low referral rates, but they cannot provide certain answers that will be applicable to all cases.

What did the research involve?

The researchers searched literature databases to identify any qualitative studies that explored healthcare professionals’ (such as GPs and community nurses) views and experiences of managing older adults with depression.

They assessed the studies found and synthesised the information across the studies using different methods, such as coding the text to identify the general themes.

A total of 27 studies were included in the analysis, most of which came from western countries, with 8 from the UK, 8 the US and 5 from Australia.

Most came from primary care settings, like GPs or community nurses.

What were the basic results?

Five main themes were identified.

Avoiding medicalising social circumstances

Many felt that late-life depression had understandable causes that related to ageing, such as social isolation, frailty and physical health issues, so lacked suitable solutions.

Assumptions about older people and mental health

Many felt that older people may “normalise” depression as part of ageing and decline.

Few had discussed, for example, whether older people presenting with depression may have had early or mid-life experiences of the condition.

Prioritising physical health

Healthcare professionals tended to prioritise physical health over mental health. Severe depression may prompt action, but they tended to look at the physical symptoms and the effect they were having.

The ‘postcode lottery’ of treatment options

Psychological therapies were considered appropriate for managing depression in older people, but there were constraints placed by the wide variability in provision from region to region.

Variation in skills, training and approaches of professionals

Differences in the perceived roles and approaches of different healthcare professionals were reported. For example, greater training and experience in managing depression gave greater confidence.

How did the researchers interpret the results?

The researchers concluded: “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.”

Conclusion

This is a valuable insight into the views of different healthcare professionals involved in managing depression.

It may help to offer some explanation about why psychological referrals are so low among older people despite the high prevalence of depression symptoms.

UK guidelines for the management of depression in adults do not give specific recommendations by age.

For mild or moderate symptoms of depression, psychological therapies are recommended as the treatment of choice.

This could be, for example, cognitive behavioural therapy or structured group physical activity programmes.

Antidepressants should be reserved for people with persistent symptoms that have not responded to these methods, more severe symptoms, or those with a history of depression.

The research raised a few potential explanations for why psychological referrals may be low in this age group.

One seems to be the factors often felt to be underlying depression, notably physical health and social isolation.

This means treating the depression alone may not be seen to be addressing the root cause of the problem.

The other notable factor is the “postcode lottery”, or accessibility to psychological therapies.

Cognitive behavioural therapy can be delivered in a range of formats, such as group sessions, one-to-one sessions, or via individual self-help materials or web-based programmes.

But there may be restricted access to therapists in certain areas, and some formats (such as online) may not be suited to all older people.

This means the reasons and solutions for lack of referrals for older people cannot be answered simply.

Find out more about the types of therapies available on the NHS

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