In the sections that follow, we first describe the three general approaches that the clinical staff (PCPs and DCMs) used to talk with older men about their depression. We then describe a number of specific strategies, highlighting the theme of family involvement in care and how this strategy was used by clinicians to engage older men in depression care. It is important to emphasize the analytic distinction that we are making between “approach” and “strategy.” In using the term “approach,” we refer to a participant's general philosophy or method in dealing with or in broaching the diagnosis and management of depression among elderly male patients. We thus make an analytical distinction between a health worker's approach and the particular strategies or behaviors that the health worker uses in the course of diagnosing and managing depression. Regardless of the general approach used, all these participants all relied on various strategies to get patients to consider and accept the depression diagnosis and to engage them to initiate and participate in the treatment.
Clinicians’ Approaches to Engaging Older Men
Clinicians told us that building rapport and establishing trust with patients, and often with their families, were essential for successful and effective depression care. In further exploring this issue, it became clear that this rapport and trust was pursued in different ways; PCPs and DCMs had distinct approaches they used with patients when thinking depression may underlie a chief complaint or recurrent office visits. Clinicians emphasized the paramount importance of how depression was framed and the specific language that was used during their discussion with older men to negotiate a way of talking about the problem. Within our sample, there was considerable variability in how clinicians actually went about this clinical task, reflecting in part the value (whether positive or negative) that they placed on the use of the diagnostic term depression. As said by one of our physicians, the term “[depression] ...has got a lot of emotional baggage with it.” Clinicians mentioned that the emotional baggage of depression reflects both lay connotations of the term (e.g., emotions, feelings) as well as the potentially stigmatizing consequences of this for older men5
In further analyzing this variability, we identified three general approaches to building rapport or trust and talking about the problem: 1) an indirect approach in which there was an avoidance of the term depression and a preference for alternative language (“call it something else”), 2) a gradual approach in which patients were brought around to the diagnosis in a slow and measured fashion (“building up to depression”), and 3) a direct approach prioritizing early and sometimes forceful use of term “depression” to educate patients (“shock and awe”).
Indirect Approach: Call It Something Else
A common approach PCPs and DCMs described was an indirect one that focused primarily on discussing depression symptoms (particularly somatic symptoms such as lack of energy or fatigue) without referring to the term depression. This allowed patients to express themselves about how and what they felt in an open-ended fashion and prompted the patient's feedback about potential treatment of the symptoms they endorsed. As one physician told us, “I try to put the patient at ease. To inquire how they are feeling regardless of what the presenting complaint is... getting some sense of how they are feeling on that particular day and giving them the opportunity to talk at some length.” Clinicians who espoused this indirect approach were more likely to continue to circumvent the term depression during their interaction with patients. As a physician with >20 years of experience put it: “sometimes you have to use words other than depression... you could substitute ‘stress,’ and have a pretty good conversation with people.” In a similar light, a DCM said, “I do not think the word depression is a helpful word... particularly for older adults... they really do not like that... so I try to play around [it] a bit...” Clinicians using this indirect approach were particularly mindful of the “baggage” attached to lay conceptions of depression in our culture and the stigma attached to being labeled as depressed, especially for older men.
Most importantly, those who had an indirect style to approaching and managing depression among elderly men tended to focus their discussion in terms of somatic manifestations of depression—one of the strategies we outline later. “I may ask about sleep... I ask about their appetite,” a PCP said, “but really trying to get a feeling about how their mood is in general.” Another physician put it in these words when describing her approach:
I always start by ‘what brings you in today, how are you feeling.’ [I] try to be open-ended... More typically patients in this setting would present with... fairly vague symptoms... or a litany of symptoms... like fatigue, malaise, ‘I just do not feel right,’ lack of energy... poor sleep... that opens the door.
Highlighting this point, a DCM said, “...they can be more willing to admit to physical symptoms, like trouble with sleeping or trouble with eating, being fatigued...” In this way, clinicians used somatic symptoms as a substitute and alternative to the use of the word depression. In summary, clinicians who espoused an indirect approach to initial diagnosis and treatment of depression among elderly male patients tended to rely on subtle talk that emphasized somatic manifestations, sought to treat those symptoms effectively, and avoided the explicit use of depression-like terms.
Gradual Approach: Building Up to Depression
Another common approach clinicians used in managing elderly men whom they suspected might have depression was a gradual one, where they would build up to the actual use of the word depression in the course of several clinic visits or an extended period of time.
Clinicians who had a gradual approach to announcing a depression diagnosis and treatment explained that patients, particularly older men, were more likely to keep “their emotions to themselves” (making initial diagnosis a tricky process) or deny altogether that they are “depressed” but instead say that they are “tired.” “...Just kind of sit with them,” a physician reflected when thinking about the issue, “like peeling a banana, and go through their problems,” indicating a gradual building up to the depression diagnosis and a patient's acceptance of it. Many clinicians mentioned that, patients commonly had misconceptions about anti-depression medication. As a physician told us, “Most of them [patients] tend to say “I don't want to be on this forever. Sometimes they use different terminology like “I do not want to be addicted to it,” or “I do not want to have to rely on it.” Therefore, clinicians who relied on a gradual approach tended first to inquire about how the patient was generally feeling, followed with a discussion and treatment of any somatic symptoms (e.g. sleep trouble, weight gain/loss, headache), and then assessed patient compliance to initial treatment and prognosis throughout an extended period of time. The words of a geriatrician are illustrative:
I am not afraid to let people know to make the diagnosis of depression and to tell people this is what I think they have. But I do tend to wait... see if we could get them some education, kind of get them into treatment modality that allows us to explore things in a way that doesn't mark with depression...
Clinicians discussed using this gradual approach as a way of establishing sufficient rapport and trust to avoid initial patient resistance to depression diagnosis. “So you'd be sort of educating them about depression... how they talk about depression,” said a DCM when asked about her experience with depressed elderly men. Thus, this gradual approach gave PCPs and DMCs more room to educate and negotiate with the patient and make a decision about what treatment works best for them. As one physician told us when discussing his approach:
I often look at my job as giving good information that people understand and then allowing people to make a decision about how they want to manage it. ...If they make a decision that I feel is incorrect, I think about how I presented and try to present it again...I tend to minimize the idea of depression and talk about the symptoms...[which] we can correct with different maneuvers... [if older men resist this] then I try to emphasize that these are signs of depression, that I believe there is... depression here, this is all I have to offer you...
In short, this gradual approach slowly introduced older men to the idea of depression and its symptoms, allowing clinicians to “test the waters” and evaluate how receptive a patient may be to recognizing and accepting this as a diagnosis. In their view, this gradual process was fundamental in their ability to prescribe an effective treatment to depression.
Direct Approach: Shock and Awe
Although there was support for the indirect and gradual approaches among both PCPs and DCMs, we found that only physicians adopted a direct, straight-to-the-point method. “[I] sort of really come at it with both guns firing rather than with my side pistol on the right,” one physician said when asked about how he would approach older men with depressive symptoms. Members of this group would tell patients immediately that they suspected depression and took a more forceful stance at getting the patients to comply with office visits and treatment. Another physician told us:
[I approached them] fairly directly. I...try to stop my spiel... And ask directly ‘what do you think about what I'm saying? I think that a lot of the symptoms you are describing to me fits with depression.
Physicians who pursued a direct approach to depression diagnosis and treatment considered this approach to be the most effective because of older men's resistance to accepting the diagnosis or even initially recognizing that their problems were in fact depressive symptoms. Briefly describing this issue, a physician said:
Most of them [older male patients] do not seem to have much insight, and it takes some coaxing to get them to see the diagnosis. [Even when they may recognize the symptoms] you still have to cajole them into doing something about it or push a medication on them.
Physicians who adopted this style thought that directness ultimately paid off when patients admitted to being depressed. A PCP recalled:
We sat down and explained to him what was happening to him. We kept saying, ‘this is not how you are expected to behave’... We kept hammering at him that this [depression] is what is happening to him and he had to come out...” And, he [the patient eventually said] ‘...you are right. I definitely was depressed.’
This shock and awe approach was, at least partly, successful because many of these physicians would ultimately adopt a medicalizing strategy (something we elaborate in more detail below). In short, physicians endorsing this approach did not shy away from introducing the term depression as soon as they suspected it and persistently continued referring to it until patients accepted the diagnosis.
Strategies for Managing Depression
We now focus on the specific strategies that PCPs and DCMs used to manage depression among elderly male patients. The strategies are as follows: 1) increase monitoring of mood, 2) treat somatic symptoms first, 3) medicalize depression as a pathophysiological illness, and 4) enlist the cooperation of family. We briefly describe the first three strategies—monitoring, treating, and medicalizing—and then focus on the fourth, enlisting family involvement, given that this was the most prominent strategy discussed in our interviews.
It is worth noting that not all clinicians equally used all these strategies (e.g. physicians were more likely to medicalize depression than were DCMs). Likewise, the strategies clinicians put in place depended on their assessment of how a patient reacted to the diagnosis and whether he complied with the prescribed treatment. “You get to a certain point [at an impasse]... you do a little bit of gamesmanship,” one of the physicians explained, “you [as a physician] say ‘we could treat you with medication or bring you back’... [sometimes] it's [about] getting them to come in the first place...”
In other words, clinicians generally changed strategies when they felt the situation had reached a stalemate or realized that their management plan was ineffective. In gerenal, although clinicians alternated, using all of these strategies, they all agreed that enlisting family cooperation was the most effective and powerful strategy in getting patients to accept their depression and comply with the treatment.
One strategy that clinicians relied upon to effectively manage older men with depression was to increase the frequency of their office visits. They did this with the intention of monitoring more closely their patients’ mood and/or compliance with undergoing treatment. More office visits gave physicians the chance to “go over things” in a consistent manner. As a physician said, “the advantage [of seeing] older patients more often is... checking on if they are taking that medication... and seeing if we are getting some results.” In other words, clinicians could keep tabs on progress and potentially change course more readily.
Yet this strategy often proved ineffectual since patients were unlikely to maintain their scheduled visits. Then, once patients came back, clinicians had to “start all over again” without any guaranties that it would work in the future. Finally, clinicians also faced other problems such as insurance coverage, scheduling, and heavy workload when wanting to see their elderly men patients more frequently.
Treat Somatic Symptoms
Typically, clinicians initially attempted to treat depression by therapeutically addressing the myriad of somatic symptoms older men presented, such as trouble with sleep, appetite changes, headaches, aches and pains, and fatigue. By treating somatic symptoms, clinicians attempted to get patients to feel better in a short-term basis with the hope that they would later accept and adhere to an antidepressant treatment (whether pharmacology, psychotherapy, or a combination of these) in the long term. One physician explained, “I typically will focus on the symptoms that are related to depression... fatigue, poor appetite... [I tell patients] ‘we are going to treat these symptoms, these issues that you have’... so hopefully we get [the patients] to feel better right away...”
However, treating somatic symptoms first was not always a straightforward process. Certainly, older patients’ inability to accept the depression diagnosis, and their misconceptions about depression treatment, were in part responsible for this. Above all, patients’ tendency to normalize somatic symptoms or other life changing events (such as the mourning of a spouse) as an expected part of aging precluded them from recognizing that they had depression in the first place.
When other strategies such as increasing frequency of office visits or treating somatic symptoms failed, a majority of clinicians commonly resorted to medicalizing depression. In other words, they fell back on making the “biochemical” or the “brain” argument. As an experienced PCP explained, “Well, for better or for worse, I tend to medicalize it. I think, especially for men, it helps to depict it as a treatable disease...So I try to frame it in the context that it is not different than treating their blood pressure or diabetes...”
Although it is unclear what the pros and cons of this medicalizing strategy may be, when faced with persistent resistance, lack of follow-up, or poor treatment compliance, clinicians presenting depression as a biochemical disorder located in the brain, brings medical legitimacy to the diagnosis, potentially dispelling misconceptions about it as well as likely reducing stigmatization (i.e., it breaks the “depression = craziness” equation). In essence, medicalizing depression moves the onus from the patient (particularly for older men who often may see depression as a personal weakness or flaw) to something biological or pathophysiological that is beyond the patient's control. Medicalization couches depression as a legitimate organic pathology potentially prompts a patient's acceptance of the diagnosis and compliance with treatment. When compared to the other strategies, clinicians reported that medicalizing depression proved very effective, especially when dealing with a particularly “bull-headed” patient or when sensing that a patient had difficulties overcoming the stigma attached to being identified as depressed.
Enlist the Family
Clinicians overwhelmingly agreed that enlisting family support was the most effective strategy in treating depressed older men. A majority of clinicians we interviewed spontaneously shared that their family members were a crucial dimension of depression management among elderly men. With a few exceptions, clinicians typically reported that the family was an asset to their diagnosis and care plan.
Over half of clinicians, especially PCPs, thought that involving the family was one of the most effective strategies for diagnosing and managing depression among elderly men. In their view, the family was a relatively reliable supplier of information regarding a patient's symptoms and behavior. “The family members,” as one of them concluded, “often times have a lot of information...” More specifically, the family could sensitize physicians to the issue of depression as a possible diagnosis. When discussing this, a PCP explained that “often... the relative or wife will tell me that they think the patient is depressed.” It is thus possible that a family's use of the term depression potentially helped clinicians to more easily rule out other diagnoses and interpret presenting symptoms as related to depressed mood.
In addition, clinicians said that the family provided a fairly continuous presence and monitoring away from the clinic, perhaps increasing a patient's visits to the clinic and compliance with physician's treatment orders. For example, clinicians often spoke of “family members reporting on what is going on rather than the patient reporting.” Finally, it serves as an important source of feedback for the physician as family members might not only have ideas about how best to approach a patient but also reaffirm the legitimacy of the diagnosis. In capturing the importance of enlisting family participation, a PCP put it in these terms:
It helps enormously if a family member is there with the patient in the room. It reinforces the whole process for the patient.
According to the clinicians we interviewed, this often proved to be a critical partnership that can, as a DCM said, “help the patient overcome it [depression].” But a minority of clinicians noted that sometimes family members can be an obstacle in the management of depressed elderly men.
In pointing to how family members can “make things worse,” a physician put it this way, “partially, it is the wife that makes it challenging...” Hence, working with an “overbearing family” required not only more negotiation but also that a clinician successfully establish her/his expertise in order to legitimize the depression diagnosis. As one PCP suggested when discussing one of his patients:
It's [difficult] when the wife says [to the patient] ‘you are not depressed... you don't need to take those pills...” So I'll have a spouse totally undermine me.
In these cases, family members can deny or fail to recognize that the patient is in fact depressed, normalize a patient's symptoms as part of the aging process, discourage a patient from maintaining a medication regimen, and even prevent them from seeing the clinician altogether.
Yet clinicians who viewed the family as an obstacle did not altogether deny that family can also be asset. Instead, they recognized that family involvement can be a double-edge sword. In other words, they said that specific circumstances around a patient, his family dynamics, and family members’ personalities can hinder or make more challenging the diagnosis and treatment of depression. In summary, the family embodies a valuable collaborator in the process of getting older men to be diagnosed with the depression, accept their diagnosis, and abide by prescribed treatment. When family and clinician can collaborate, relying on each other for information and monitoring, it proved to be a very valuable partnership, which nonetheless involved concerted efforts from both parties over time. Yet family involvement can also introduce a host of challenges that clinicians must address and cope with in the process.