How do healthcare professionals manage depression and refer older people to psychological therapies? A systematic review of qualitative studies.

Problem

Depressive symptoms are common in later life and can have a negative impact upon quality of life and physical functioning and lead to increased use of health and social care. Previous studies suggest that the ‘older old’ (e.g. those aged 80+) are less likely to be referred to psychological therapies than those in their late 50s, but are much more likely to be prescribed antidepressants or psychotropic drugs. We aimed to investigate the reasons for this inequity through exploring how healthcare professionals manage older people in relation to depression and referrals to psychological therapies.

Approach

We carried out a meta-synthesis of qualitative studies. We searched eight databases (inception-Dec 2016) and included all types of qualitative studies exploring primary and secondary healthcare professionals’ views regarding depression in older people and its management across both primary and secondary care settings. We excluded studies relating to management across all ages or patients’ views. We thematically synthesised the findings from each paper to develop overarching themes and used the CASP checklist to appraise the quality of each study.

Findings

Twelve studies were included, predominately focussing on general practitioners’ and primary and community care nurses’ views. Studies were primarily carried out in the UK, with small numbers in other Western countries. Across most studies, healthcare professionals principally attributed late-life depression to age-associated functional decline and social isolation. They perceived older people to be reluctant to engage with the idea of depression, which they felt had an associated stigma for this population. Healthcare professionals within the majority of papers believed that physical health needs were prioritised over mental health needs, due to limited appointment times and the complexity of older people’s needs. Most GPs felt confident being the main healthcare professional managing depression, although some nurses thought further training would be helpful. Psychological therapy referrals were limited by a lack of availability and perceptions that they were unsuitable for either older people in general or their associated social/functional issues. GPs therefore more frequently utilised the therapeutic relationship and/or prescribed antidepressants.

Consequences

This systematic review of qualitative studies suggests that late-life depression can be managed within primary care, but needs to be given greater priority when addressing the complex needs of older adults and sufficient staff training is required. Greater provision of tailored and relevant late-life psychological services may facilitate clinicians’ identification, diagnosis and management of depression.