Patient-centered care is predicated on the notion that patients and their doctors share information and come to a consensus about proceeding with treatment (Stevenson et al., 2000
; Charles et al., 1997
). The providers in our preliminary study described a different process for coming to a decision about treatment for depression with their older patients. Whether or not providers formally or systematically elicit the patients’ beliefs, they appear to either discover or assume that patients do not agree with the prevailing biomedical model. Given that many primary care providers will rely on pharmacotherapy, antidepressants, as first-line treatment, assessing whether the biomedical model holds sway with the patient may be seen by the providers as paramount to successful implementation of the biomedical treatment the doctor has to offer.
We need to consider some potential limitations before discussing the results further. First of all, this is a preliminary study with a small sample size, consistent with an exploratory investigation. Secondly, providers who consented to an interview may have consisted of a sample of providers who were particularly keen to speak to us and may not be representative of all community providers. Nonetheless, providers who have an interest in a study about treating older adults for depression may be particularly informative with regard to factors affecting treatment acceptability. Thirdly, by specifically asking the providers to differentiate between treating older and younger patients we may have inadvertently suggested that there is a difference in approach as opposed to letting the provider tell us whether age was important. However, since we were interested in provider experiences with older patients it seemed important to make the distinction in our line of questioning. While we used the broad term “treatment” in our questioning, most providers focused on medication as a treatment modality in contrast to counseling or referral. However, at least a few of the providers did discuss alternative approaches to depression treatment, such as spiritual counseling.
With respect to discussing treatment with their older patients, the providers rarely mentioned a specific discussion of a range of treatment options or any shared-decision making process. Instead, the providers suggest that medication is the main treatment option they offer and rather than work with patient preferences and explanatory models of depression, they felt the need to “convince” patients that they have a depression and that depression is indeed a medical illness that warrants medical treatment. The need to treat with medication may reflect what primary care providers know best to do, but it may also reflect their dissatisfaction with referrals to mental health specialists (Gallo et al., 1999
; (Kushner et al., 2001
) and limited training in mental health (Williams et al., 1999
). The providers in our sample additionally note that the need to convince older patients stems from the fact that their older patients appear more likely to hold a different explanation for their depression. This idea corresponds to our findings that older adults may consider depression as a consequence of loneliness (Barg et al., 2006
); or as a moral failing (Switzer et al., 2006
), rather than as a disorder requiring treatment with medication. However, just because older patients may have different beliefs about the causal reasons for depression doesn't mean that they won't simultaneously hold other beliefs about depression or be willing to take conventional treatments for depression (Wittink et al., 2008
) especially, if given the chance to discuss and address their explanations of depression.
Despite discussing the need to convince patients about depression, the same providers felt that older patients may be more likely to please the doctor and agree to a recommended treatment. This finding is consistent with studies that show younger patients tend to be more likely to expect active participation in decisions about their care (Guadagnoli & Ward, 1998
), while older patients prefer to defer decision making to the doctor (Charles et al., 1998). However, as one provider in this study noted, agreeing to take a medication does not necessarily mean the patient will, especially if the “biomedical” model of depression, or indeed depression itself doesn't comport with the patient's idea of what is wrong. While the providers in this study seemed very aware of issues that may be more relevant to older adults vis-à-vis depression treatment, such as different beliefs about the causes of depression and possibly decision-making preferences, the providers also hint at frustrations they feel with offering only limited treatment options (in this case, the providers primarily discuss medication management).