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

Pushpa Nair, MBBS, BSc; Cini Bhanu, MB BChir, MA; Rachael Frost, BSc, MSc, PhD; Marta Buszewicz, MBBS, MA; Kate R. Walters, BMBS, BMedSc, MSc, PhD

Disclosures

Gerontologist. 2020;60(1):e93-e104. 

In This Article

Abstract and Introduction

Abstract

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.

Introduction

Late-life depression is a major societal concern, with depression forecast to be the leading cause of disease burden in developed countries by 2030 (Rodda, Walker, & Carter, 2011). It affects, on average, 7% of 60+-year-olds worldwide (WHO, 2017), and is associated with increased mortality, reduced quality of life, and cognitive and functional decline in 65+-year-olds (Rodda et al., 2011). Depression in this age group is also harder to detect than in younger populations, often presenting with more somatic and atypical symptoms (Katona, 1994; Meeks, Vahia, Lavretsky, Kulkarni, & Jeste, 2011). While there is a decline in the prevalence of major depressive disorder with increasing age (Snowdon, 2001), subthreshold depressive symptoms have a higher prevalence of up to 31.1% in 65+-year-olds, and are also associated with negative health parameters (Meeks et al., 2011; White et al., 2015), despite symptoms reportedly being less severe than for clinically significant depression (Ludvigsson, Milberg, Marcusson, & Wressle, 2014).

The treatment of depression in later life is complex, reflecting the heterogeneity of older populations and the multiple factors involved in experiences of ageing and the development of depression. There is evidence that both antidepressants (Kok, Nolen, & Heeran, 2012) and psychological therapies (Dakin & Areán, 2013; Gould, Coulson, & Howard, 2012) are effective in the general older adult population, although antidepressants appear to be preferentially offered by health professionals (Walters, Falcaro, Freemantle, King, & Ben-Shlomo, 2017). Despite the fact that many older adults report a preference for psychosocial management strategies (Gum et al., 2006), there is in general poorer uptake of all mental health services among older adults. Up to 70% of older adults with mood disorders in the United States do not access mental health services, especially those from ethnic minority and lower socioeconomic status groups (Byers, Areán, & Yaffe, 2012), and in the United Kingdom, access to Increasing Access to Psychological Therapies services for 65+-year-olds is only 5.2%—half as much as for those under 65 (Department of Health, 2013).

There is evidence that many older adults view depression as a normal part of ageing (Barg et al., 2006; Burroughs et al., 2006) and are also more likely to engage with social explanatory models of depression (Givens et al., 2006); hence, formal treatments (e.g., antidepressants, psychological therapies) may not be congruent with patient beliefs. Furthermore, alternative cultural models of depression may coexist at local levels (Holm & Severinsson, 2013; Karasz, 2005). Qualitative research can offer rich insights into how beliefs influence attitudes toward treatments.

Two previous meta-syntheses of qualitative studies exploring older adults' beliefs and attitudes toward depression in later life (Corcoran et al., 2013; Holm & Severinsson, 2013) noted that depression was attributed to a range of causes, encompassing functional decline, social factors, and bereavement, and was associated with stigma. Older adults reported engaging with various treatment strategies, including religion, social activities, and medical treatments. These meta-syntheses have focused on older adults' beliefs about the nature of depression, and our meta-synthesis aimed to build on this to further understand how these beliefs influenced attitudes toward the treatment of depression in later life.

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