Major findings of this study can be summarized as follows; (1) about 40% of admissions to the geropsychiatric unit for depression consisted of first-admission patients during the study period, (2) compared to people with prior psychiatric hospitalizations, first timers were more likely to be late onset without current and past psychiatric symptoms, and (3) first timers had seen more physicians than their counterparts in the 6 months before the index admission.
First, this study underscores that undetected, and thus untreated, depression in older adults can develop into full-blown depression requiring inpatient care. The significant portion of all admissions to the geropsychiatric unit for treatment of depression consisted of first admissions, and the mean age of those in the first psychiatric hospitalization
group was 77. Thus, service providers for older adults in diverse settings should incorporate depression detection in their assessment repertoire so that they can adequately intervene, even though it is often very challenging due to competing demands (Munson et al., 2007
). Also, given high mortality and morbidity rates associated with geriatric depression, more efforts should be put into prevention and research to tackle depression among high-risk older adults (Whyte and Rovner, 2006
The high prevalence of both subsyndromal and full-blown major depression has been documented among older adults (Delano-Wood and Abeles, 2005
; Proctor, Morrow-Howell, and Choi, 2006
). Even though many effective treatments for geriatric depression are available, older adults underutilize mental health treatments for depression (Crabb and Hunsley, 2006
; Cuijpers, Straten, and Smit, 2006
; Delano-Wood and Abeles, 2005
; Mandelli et al., 2007
). This study indicates that only 13% of first timers used counseling services in the 6 months prior to the index admission.
Also, additional analysis of the current study data (not shown; details are available upon request) indicates that 35 of the 77 first timers (45.5%) had never had prescribed psychiatric drugs, diagnosis of psychiatric diseases, or psychiatric outpatient treatments before the index hospitalization even though the two groups were not different in terms of the current and lifetime clinical characteristics. Instead, those 35 individuals without any previous psychiatric treatment were less likely to own a home (χ2(1)=5.17, p=.02) and more likely to be African American (Fisher's exact test, p=.04). Thus, among this group of vulnerable older adults, their first mental health treatment was delivered through the inpatient setting, the most expensive and intense form of psychiatric care.
Additionally, even with the high rates of older first-admitted psychiatric inpatients for depression, little is known about the relationship between the anxiety level associated with their first psychiatric hospitalization and their age at admission. Hospitalization, especially first psychiatric admission, involves high levels of distress among patients and family members (Möller-Leimkühler, 2005
; Paparrigopoulos et al., 2006
). However, stress would be much higher among older, first-admitted psychiatric patients than among older inpatients with prior psychiatric admissions or younger first timers.
Second, the results indicate that older depressed patients' history of psychiatric inpatient care corresponds with their current and prior psychiatric needs, as the Andersen model suggests, rather than reflecting different service use paths for a given illness. Namely, first timers had not used psychiatric inpatient care before the index hospitalization because they had not needed such service, not because they had chosen to seek different types of providers when they were younger. In this study, about 90% of all older first-admission patients were late onset. Nevertheless, further research is necessary to assess the delay in seeking treatment for the current episode of depression among people in the first psychiatric hospitalization
group. Studies have shown that a longer period between a first episode of illness and first psychiatric admission (i.e., the duration of an untreated illness) is related to a longer period to remission (Craig et al., 2000
; Naz et al., 2007
). According to Kessler, Olfson, and Berglund (1998), individuals with earlier onset of psychiatric disorders were more likely than those with later onset to contact their mental health providers sooner. Also, people with early onset of psychiatric disorders are likely to be more familiar with the mental health service delivery system.
Third, as discussed previously, the NEM was not supported when the lifetime service use history and course of illness were considered. However, considering the period immediately before the index hospitalization, the results indicate different service use paths between the two groups, thus partially supporting the NEM. In this study, older adults in the first psychiatric hospitalization
group had had more contact with healthcare providers before the index hospitalization, although the two groups were not different in their levels of chronic illnesses and functional impairments at admission. First timers might have seen more physicians to supplement their mental health service needs prior to their first psychiatric hospitalization (i.e., alternative use of physicians for psychiatric symptoms) for reasons such as lack of familiarity with mental health treatments and stigma. This may also be explained with the NEM framework, which emphasizes that people go through different pathways to a formal mental health service during the course of an illness (Pescosolido and Boyer, 1999
). However, our data do not enable us to compare service needs during the six months prior to the index hospitalization between the two groups.
Our findings differ from previous studies that show the connection between a person's primary social network and the timing of his or her first psychiatric hospitalization. As such we found no support for the hypothesis that the help-seeking process is embedded within a social context (Carpentier and White, 2002
), even though the level of social resources was significant bivariately. In addition, higher participation rates in senior centers among those with prior psychiatric hospitalization might reflect the importance of these centers in monitoring older adults with depression.
A future study, replicating this study with a comparison group consisting of people with different psychiatric diagnoses or in different age groups (Mandelli et al., 2007
), would help further our understanding of first-admitted older patients with depression. Connecting this study to existing literature, it would be beneficial to examine the prognosis of depression and service use configurations during the postacute period among late-life, first-admission patients. Among younger adults, first admissions are related to lower readmission rates and better prognoses (Paparrigopoulos et al., 2006
Caution should be taken regarding the sources and availability of data. Regarding the use of hospital and medical records to identify past inpatient psychiatric treatment, these records may not be comprehensive in capturing all the information on prior hospitalizations and may in fact undercount this phenomenon in our sample. Also, studies suggest probable errors in self-reported lifetime recalls of psychiatric illnesses (Kessing, 2006
; Simon and VonKorff, 1995
). Additionally, information on service use in the 6 months prior the current hospitalization was also collected via retrospective self-report. Finally, we do not know whether depression was the primary diagnosis for the participants' previous inpatient service use.
Notwithstanding these limitations, this study contributes to the literature by depicting the proportion and the characteristics of older first-admission patients with depression. This study also incorporates a longitudinal service use component by examining service use paths in the period before depressed patients had received their first inpatient care. Additionally, contrary to many studies that include only first timers, this study also included a comparison group that had received prior psychiatric inpatient.