Primary care is on the front line in dealing with older people’s mental health, supporting families and managing people with complex co-morbidities. Older people consult almost twice as often as other age groups⁹ and 22% of older people will have attended their general practitioner (GP) within the last two weeks and 40% may have a mental health problem. In the United Kingdom primary care is a key NHS service provider for care homes, where at least 40% of older people have depression and 50-80% dementia³.

Depression is under-treated in older people with around 5 out of 6 older people with depression receiving no treatment at all. Only one third of older people with depression discuss their symptoms with their GP and less than half of these will receive adequate treatment¹⁰‘¹¹. Most people with mental health problems are managed in primary care with only 6% of older people with depression receiving specialist mental health care.

The literature suggests that diagnostic difficulties of depression in later life occur largely in relation to four areas: patient factors, practitioner factors, organizational factors and societal factors.

Patient Factors

Two-thirds of older people with serious depression have symptoms that fit poorly with current classifications of mood disorders. These classifications have been generated to reflect symptoms observed in younger people, and have inherent limitations for diagnosis of depression in older people whose presentation may differ because of ageing, physical illness or both¹⁰. Thus, older people can present with nonspecific symptoms such as malaise, tiredness or insomnia rather than disclosing depressive symptoms¹². Physical symptoms, in particular pain, are also common and the primary care clinician may feel they represent organic disease. Forgetfulness may also be manifest, leading to concern that the patient has cognitive impairment and early dementia¹³. Older adults may have beliefs that prevent them from seeking help for depression, such as a fear of stigmatization. They may be under the impression that antidepressant medication is addictive¹¹, or they may misattribute symptoms of major depression for ‘old age’, ill-health¹³ or grief. Ethnic elders in particular do not see psychiatric services as appropriate and believe they are primarily for psychosis and violence. People across cultures often present with culturally specific idioms of distress. South Asians often describe their distress using terms such as ‘sinking heart’ or ‘gas in abdomen’ (gola) as a symptom of distress. This may mislead the clinicians, causing them to tend to overlook the psychological distress and focus solely on the physical aspect of the presentation¹⁵.

Practitioner Factors

Primary care practitioners may lack the necessary consultation skills or confidence to correctly diagnose late-life depression. They may be wary of opening a ‘Pandora’s box’ in time-limited consultations and instead collude with the patient in what has been called ‘therapeutic nihilism’¹⁴. In deprived areas primary care physicians have been shown to view depression as a normal response to difficult circumstances, illnesses or life events¹⁶ and depression may be under- diagnosed because of dissatisfaction with the types of treatment that can be offered, especially a lack of availability of psychological interventions¹⁴.

Organizational Factors

The trend in the United Kingdom for mental health services to be ‘carved out’ from mainstream medical services may disadvantage older depressed people who may have difficulties in attending different sites for mental and physical disorders¹⁷. New contractual arrangements for primary care provide no new incentives to offer re-configured services for older people with depression¹⁸.

Societal Factors

The barriers described are likely to be particularly difficult for economically poor and minority populations who tend to have more ill-health and are more disabled. The National Service Framework (Older People)¹⁸ had as its first standard the rooting out of age discrimination. However, little is known about the efficacy or implementation of the Framework at Primary Care Trust level. The 2009 Equality Bill¹ will, if enacted, make age-based discrimination in the provision of health and social care illegal for the first time in the United Kingdom. This Framework will be superseded by the New Horizons initiativeⁿ which stresses the importance of well-being and resilience, prevention and early intervention. The Framework provides a focus on the mental health of older people.

Literature suggests that GPs experience difficulties in negotiating the diagnosis of depression with patients, including older people¹⁴. The Quality and Outcomes Framework (QOF) of the new General Medical Services (GMS) Contract¹⁹ requires that GPs and practice nurses use two screening questions within the previous 15 months with patients with chronic disease in order to increase the detection of depression in patients with diabetes and heart disease:

• ‘During the past month, have you often been bothered by feeling down, depressed or hopeless?’
  
• ‘During the past month, have you often been bothered by having little interest or pleasure in doing things?’

A ‘yes’ to either question is considered a positive test. A ‘no’ response to both questions makes depression highly unlikely.

It would be logical to consider using these screening questions in consultations with other older people who are also at high risk of depression, for example:

• those with recent (<3 months) major physical illness or hospital admission;
  
• patients with chronic illness/long-term conditions;
  
• those in receipt of high levels of home care, including residential care;
  
• people with recent bereavement;
  
• socially isolated people;
  
• people persistently complaining of loneliness; or
  
• patients complaining of persistent sleep problems.

Little evidence has yet been found, however, for this approach²⁰.

There is some evidence²¹ that a further question ‘Is this something you want help with?’ increases the usefulness of the screening questions in practice. It is then suggested that an assessment of severity of the depression is made by the GP using a schedule such as PHQ-9²². In addition it is vital that the GP explores with the patient ideas and plans for self-harm, and factors preventing the patient from acting on such ideas or plans.

Other authors question the usefulness of such a reductionist approach²³ and emphasize the value of professional judgement over the narrow use of schedules²⁴.

Most patients with depression are managed in primary care settings, however, a substantial number of patients are not recognized, and those who are diagnosed often do not receive effective treatment²⁵. There is, however, a good evidence base for the management of depression in older people. There is evidence to show that there are effective pharmacological treatments²⁶ but only one in four depressed older people receive effective pharmacological treatment and less than 10% a talking therapy²⁷ despite the fact that many people express a preference for such treatments²⁸‘²⁹. Evidence for individual psychosocial interventions is presented in Chapter 87, but will be discussed here in the context of what the primary care practitioner can utilize. While a preventative approach to early prevention and detection of depression in older people is being evaluated and has a growing evidence base³⁰