The perspectives of older people and GPs on depression in later life and its management : the stories they tell and ways they respond to each other

摘要

Depression in older people is under recognized and under treated in primary care. This is despite symptoms being similar across the lifespan and many older people with depression regularly seeing their general practitioner (GP). Problems specific to its management set it apart from depression in younger people, and include both disparities in the way older people and GPs perceive depression and a shared view that it is a normal part of aging, as well as barriers to the way older people talk about it and the help GPs provide. This evidence indicates a lack of understanding about the ways both groups perceive depression, and how their different situations, positions and needs may influence what they say and do and ways they respond to each other in consultations. The research aim is therefore to explore how older people’s and GPs’ different positions and situations influence the ways they perceive depression. Particular focus is on influences reported by older people over ways they talk about depression and influences reported by GPs over ways they respond. In doing this the study seeks practical solutions to help GPs identify depression in older people and provide them with appropriate help. The methodology and methods of this study are informed by a recent version of grounded theory, Situational Analysis (Clarke, 2005), which is philosophically orientated between symbolic interactionism and social constructionism. Clarke (2005) builds on the work of Strauss and Corbin (1998), assuming a social constructionist approach to grounded theory to enable exploration of how people’s views are formed and how this influences their actions. Theory can be generated and located within changing and multi-faceted contexts by considering the wider situations of both the researcher and the researched and looking at the data from multiple perspectives such as historical, geographical and biographical. Semi structured interviews were conducted with older people and GPs as the main form of data, with the researcher’s (IG’s) observations of interviews as contextual data. Using this approach a theoretical model has been developed to explain how older people and GPs operate in consultations for depression, proposing how different types of older people and GPs are likely to respond to each other. The stories older people report telling about their depression and the ways GPs report responding show the “porous” and “flexible” (Clarke, 2005, p.111) positions they can take in consultations: the interview data suggests that older people can move between stages of understanding and accepting their depression, and GPs can move between styles of working and employ different combinations of skills in response to older people’s stories. This element of change is key to the findings of this study and indicates the fluidity of their positions, where they change depending on what they perceive to be influences over them at the time. This study highlights the importance of recognizing differences between ways older people and GPs operate in consultations and the different factors that influence ways they respond to each other. It suggests how GPs working in different styles might help older people based on the different ways they tell their stories, and a key message is that GPs who can adapt their skills to those needs are likely to be most successful in managing it. For example some older people may need GPs to help them make sense of their problems before they will accept treatment or therapy for depression and others may need GPs to take the lead on decisions when they are at rock bottom. The theoretical model suggests how GPs can quickly identify depression in older people and the stage of depression they are at by the stories they tell, and how they might adapt their skills in response to provide them with the most appropriate help. This is intended as a step towards understanding the reasons underlying what happens in consultations for depression in later life, and finding solutions for problems existing in its management.