“A Stubborn, Persistent Stigma Surrounds Depression, Creating Barriers to Care”

By Jo Anne Sirey

When accompanying my oldest daughter to her first dentist appointment, I was making small talk with the dentist. She asked what I did for a living. I told her about my research designed to improve the detection and treatment of depression and anxiety among older adults in the community. As she listened, her eyes welled up with tears. She told me about her father, who had been depressed in the final years of his life and had refused care. Looking back, she remembered his fears about talking to a mental health provider and the stigma of being labeled “crazy.” In addition, the family had difficulty insisting he go for a consultation because they couldn’t untangle his medical illness from his aging-related functional losses and the symptoms of depression.

Depression Is Difficult to Detect and Diagnose

Rates of depression nationwide among older adults vary according to the population screened, ranging from 6 percent to 9 percent among primary care patients, to higher rates (13 percent to 15 percent) in older adults receiving homecare services and home-delivered meals, according to three studies (here, here, and here). The Weill Cornell Institute of Geriatric Psychiatry group has found the highest rates (34 percent) of depression among victims of abuse.

Untreated depression can lead to suicide, mortality and increased morbidity. Depression is not a normal part of aging and does not go away by itself. Depression is heterogeneous in later life: some older adults struggle with life-long depression, while others may experience their first episode late in life. It is difficult to know exactly what causes a depression, but it is more common in people who also have other illnesses (such as heart disease or cancer) or whose function becomes limited.

The mental health field has been able to improve its detection of depression and anxiety through the use of brief screening questionnaires. The 9-item Patient Health Questionnaire (PHQ-9) is a valid diagnostic and severity measure for depressive disorder in large clinical studies and for track­ing depression prevalence. It is being used more widely in primary care settings, where most older adults seek and receive care; clinical staff who are not mental health professionals can screen for depression and anxiety using standardized scoring guidelines to determine if a mental health evaluation is warranted. Screening using the PHQ-9 removes the bias from detection.

Stigma Is a Barrier to Care

Once depression is detected, older adults face several barriers to mental health care, but attitude is one of the most significant. Many older adults not only perceive stigma from the community, but also self-stigmatize. Often they feel that they cannot be open about their depression, fearing that someone will tell others about their symptoms.

In a study interviewing older adults with depression seen in primary care settings, the Weill Cornell group found that more than a third of study participants believed that others blamed them for their depression; another 42 percent believed that they were at least partially to blame. Older adults who perceive stigma when initiating depression treatment were more likely to drop out than younger adults, and high prevalence of stigma predicted poor adherence to an antidepressant medication regimen.

Interventions, Service Delivery Models Provide Relief

While older adults may prefer a non-medication approach to anxiety and depression, primary care typically offers medication treatment. Primary care sites usually have staff who can deliver psychotherapy. When faced with an antidepressant, the lack of options may lead to patients’ treatment refusal or nonadherence to the recommended medication. There are many older adults living in community who do not realize that their symptoms may stem from depression. To address the needs of these individuals, the Weill Cornell group has developed innovative strategies and service delivery models to improve engagement among older adults seen in non-mental health settings.

In conducting randomized controlled trials (with support from the National Institute of Mental Health), the group demonstrated that brief interventions integrated into aging service or primary care settings can identify barriers, provide education and help patients collaboratively problem-solve to address barriers, ultimately improving acceptance of mental health referrals and antidepressant adherence. Thus while the stigma remains, brief strategies that address barriers can improve access to and participation in care.

In a more recent project, in collaboration with the New York City Department for the Aging (DFTA), I developed and tested a novel service delivery model that combined culturally sensitive outreach strategies, brief needs assessments and direct community delivery of psychotherapy. In the Sandy Mobilization Assessment, Referral and Treatment for Mental Health (SMART-MH) project, the group used this service delivery model to identify and address the aging service and mental health needs of older adults living in New York City flood zones impacted by Hurricane Sandy.

By partnering with community agencies that service older adults, the SMART-MH interdisciplinary staff led outreach activities (e.g., talks, group discussions, mindfulness and stress-reducing techniques) to introduce the importance of emotional well-being and good mental health in successful aging. SMART-MH clinical staff became regular members of the aging service communities and screened more than 2,800 older adults (in Chinese, Russian, Spanish and English) for mental health needs.

Our team found that 14 percent of older adults had clinically significant depression. Those adults with depression were offered a brief, six-session psychotherapy on site at a senior center. This seamless model of outreach, assessment and service allowed staff to bypass the barriers of referral to other agencies and the stigma of mental health by integrating mental health into aging services.

Education and Awareness Can Erode Stigma

Stigma is not expected to disappear; it may lessen as the baby boomers age, but may also persist as they face ageism and their own vulnerability—only time will tell. On an individual level, professionals can address stigma by reminding themselves and others that successful aging includes managing health, mental health and social connections together, and their interplay is important. Reducing the stigma toward mental illness may take another generation as clinicians and other providers continue to learn about the pervasiveness of mental health need and its impact.

As more people in the spotlight, like journalist Mike Wallace, share their experiences, people will begin to realize that depression can affect anyone and treatment can help. In the interim, professionals who work with older adults can talk about depression and anxiety and their effects, and be sensitive to the impacts of stigma on us all.

Jo Anne Sirey, Ph.D., is professor in the Department of Psychiatry at Weill Cornell Medicine in New York. She can be con-tacted at [email protected].