Our results make it clear that to grasp how older adults in this sample define or conceptualize depression, we must examine how they discuss and assess knowledge drawn from multiple sources—namely, the clinical encounter and life experience. Whereas older adults felt that doctors value “seeing” as a primary and conclusive mode of diagnosing depression and use lists of symptoms to authoritatively name someone as “depressed,” they also suggested that their own “feeling” is an important mode of knowing, that life events and relationships contribute to depression’s etiology, and that there are multiple ways of “being depressed.”
Before discussing our results further, we would like to review limitations. First, participants were recruited from primary care practices and thus might have been more inclined to think of depression in medical terms. On the other hand, participants were interviewed in their homes by nonmedical personnel who were trained to investigate the participants’ perceptions by encouraging personal narratives and probing into topics important to the participants. Second, we did not follow up our open-ended questions with survey questions, which could be used to assess the degree to which patients feel they agree or disagree with their understandings of how doctors define depression. Nevertheless, this study provided us with unique insights into the multiplicity of concepts referenced by the word depressed
, unavailable through survey measures. Finally, we recognize that by only focusing on participants who were identified by their physicians as having moderate depression, we might have a limited view of the heterogeneity of older adults’ beliefs about depression and how they might differ from their perceptions of how physicians view depression. It is plausible that older persons whose physicians feel they have either mild or no depression might have very different ways of contrasting their views on depression with their physician’s as compared to older persons who might have discussed depression with their physician. Physicians might be less likely to diagnose depression in older adults who have different cultural models of depression than their physicians. However, even among those who are recognized as depressed, few engage in or continue with treatment. Previous studies have suggested that elements of cultural models of depression might be associated with current and past treatment seeking, medication adherence, and coping strategies (Brown et al., 2001
). By focusing on how the experience of depression differs from the medical concept of depression among individuals recognized as depressed, we hope to shed some light on potential reasons for this apparent lack of engagement or adherence to medical treatments for depression among older adults.
Based on the fundamental assumption that cultural models affect and motivate the behavior of individuals and groups (D’Andrade & Strauss, 1992
; Holland & Quinn, 1987
), we found it useful to describe a cultural model of depression among this group of older adults. The utility of a cultural models framework to this study lies in its emphasis on the way that individuals incorporate new or seemingly incommensurate kinds of knowledge into their view of depression. Traditional framings of noncompliant or nonadhering patients often suggest that the patient is ignorant of or antagonistic to clinical definitions of depression and clinically sanctioned treatments for the condition. However, in piecing together older adults’ ideas about depression, we note that instead of rejecting medical knowledge wholesale, these individuals complemented it with their own knowledge and fit it into their way of knowing about depression. Rather than being passive or static entities on which clinicians of biomedicine write their diagnoses, the elderly adults at once absorb and modify (or make relevant) the discourses and diagnoses of biomedicine. These discourses and diagnoses are filtered through a sensate and dynamic embodied self (Csordas, 1994
; Lyon & Barbalet, 1995
By shedding light on how older adults view their own illness experiences or engage with depression, we challenge the medicalization of depression and the privileging of seeing over feeling, or sensation over emotion. The notion or entity of depression only exists at the crossroads of life experience and medical diagnosis; depression is always felt and filtered through a lively, unique, and constantly changing body but identified and labeled as depression through a list of abstract symptoms and a clinically validated diagnostic process. The individual schemas of depression among the older adults in our sample have a number of common elements and often incorporate clinical, biomedical notions of depression. In short, older adults added the clinical definition of depression into their own individual experiences of depression located in an embodied self and its everyday context.
The cultural models informing behavior, social relations, and decision making are substantiated by a myriad of sources, including both “expert validation and cultural authority” as well as experiential evidence (Holland & Quinn, 1987
). Whereas older adults might take their doctor’s notion of the definition of depression seriously, they also draw from their own experiences to construct a cultural model for depression that might have important implications for treatment-seeking behavior or compliance. People might even hold multiple components or explanations that might appear contradictory, merging multiple theories or applying one theory to account for one practice and another theory for another practice (Holland & Quinn, 1987
; Kempton, 1987
). Our findings support the suggestion of Darghouth and colleagues that people are particularly likely to maintain multiple explanations and beliefs if no single model fully accounts for the entire experience (Darghouth, Pedersen, Bibeau, & Rousseau, 2006
We suggest that when the clinical definition excludes important aspects of experience or does not successfully or fully solve the problem, older adults draw from other knowledge bases to try to understand, ascribe meaning to, describe, cope with, and address their distress. Although participants view the doctor’s and their own definitions as both explaining one thing (depression), it appeared that different aspects of what depression is were explained by different sources. Specifically, whereas participants often indicated that doctors have authority in knowing about the observable symptoms and suitable medical treatments of depression, broader experiential and cultural wisdom held authority when it came to the causes (linked to sociocultural context), experience, and meaning (individual, moral, social) of depression. When older adults make decisions about what to do when they feel sad, or whether to take medicine for depression, each of these elements constituting an individual’s schema of depression has the potential to be activated and inform behavior.
The valence or salience of the connections or activation pathways will depend on context, among other things. Because of the social establishment of physicians’ dominance in the clinical context, clinician models are likely to hold sway at the time point when depression is diagnosed and labeled. However, once the patient leaves the doctor’s office, he or she once again becomes a person in a broader social context, where multiple other nonclinician models might circulate and be incorporated to varying degrees. In other words, whereas clinical diagnosis might be particularly critical when someone first consults a physician earlier in the help-seeking process, at the time of treatment decision making, the experiential component might be more salient to older adults. Having the physician put the symptoms together to name a diagnosis of depression and perhaps even having an effective treatment is not the whole story for these older adults. Putting emphasis on their experiences and how depression is individually embodied is what makes the diagnosis of depression and any potential suggestions for treatment salient or relevant to any one individual.