Preferences for Depression Treatment Among Elderly Home Health Care Patients

Major depressive disorder and milder forms of depression are disproportionately high among home health care patients, approaching 14% and 11%, respectively (1). Although effective pharmacological (2) and psychological (3,4) treatments exist for depression among older adults, depression remains undertreated in the home care setting (1,5,6) for a variety of reasons, including patient reluctance to initiate and adhere to recommended treatments.

Examination of patient preferences for depression treatment may shed light on this reluctance and may identify subgroups of patients more likely to prefer certain treatments. The majority of research on treatment preferences has been conducted in primary care settings (7–16), and little is known about the mental health treatment approaches preferred by elderly home care patients. A pilot study found that prayer was the most preferred approach identified by elderly patients in long-term care (17). However, personal experience with depression increased patient preference for medication or psychotherapy.

Using cross-sectional data from TRIAD (Training in the Assessment of Depression) of elderly patients newly admitted to home care (18,19), we examined the treatment preferences of this understudied population at high risk of depression. Previous work suggests that depression experience, namely having a diagnosis of major or minor depression or using antidepressant medication (7,12,14,17), is associated with preference for an active treatment, such as antidepressant medication or psychotherapy. We also explored the association between other sociodemographic and clinical variables and preference for an active treatment.

Methods

Overview

The authors conducted a secondary analysis of data collected as part of TRIAD, a nurse-randomized trial of randomly selected patients (18,19). TRIAD was conducted in three Medicare-certified home health care agencies serving patients throughout Westchester County and neighboring locations in New York State. The study was approved by the Weill Cornell Medical College Institutional Review Board. All patients provided written informed consent. Recruitment began in May 2004, and follow-up interviews ended in June 2005.

Study participants

To be eligible for TRIAD, patients had to be older than 65 years, English speaking, and able to give consent. Eligible patients could not have aphasia, hearing impairment, or dementia, according to agency start-of-care records. An additional eligibility criterion was a score greater than 20 on the Mini-Mental State Exam (MMSE) (20), as assessed by study research assistants (see below). As is the case in acute home health care nationwide, no patient had been referred to home care services after discharge from an inpatient psychiatric facility. A designated agency staff person selected the first consecutively admitted eligible patient each week and contacted the patient by telephone to ask for permission to be contacted by research staff about study participation. Researchers contacted 477 patients, of whom 256 (54%) enrolled in the study, 84 (18%) were not eligible, and 120 (25%) refused. Patients were interviewed in their home. The study design and procedures have been described in more detail elsewhere (18). Analyses for the study reported here focused on the baseline interview.

Patient measures

Depression symptoms were assessed by research assistants trained in administering the Structured Clinical Interview for Axis I DSM-IV Disorders (SCID) (21). Diagnoses of major and minor depression were assigned by the study psychiatrist and psychologist after review of symptoms. Current and previous antidepressant use was determined by review of patients' medications and by self-report. Although we were unable to determine whether low-dose antidepressants had been prescribed for purposes other than treating depression, such as for pain management or sleep disturbances, we took the conservative approach of including these approved antidepressants. We created a three-level variable reflecting current antidepressant use, previous but not current use, and no history of use.

Depression treatment preferences were assessed with the Cornell Treatment Preference Index (15), a modified version of a measure used in other primary care studies (22). This measure consists of the question: “Based on your experience and how you feel right now, which of the following treatments would be your 1st choice, 2nd, and 3rd choice?” Participants were asked to select from the following treatment preferences: antidepressant treatment, individual psychotherapy, group psychotherapy, combined antidepressant medication and psychotherapy, herbal remedies, religious or spiritual activities, exercise, another activity, or “do nothing.” If patients were not currently depressed, they were asked to select the treatments they would prefer “if you were suffering from a serious depression.”

The 24-item Hamilton Depression Rating Scale (23) measured depression severity for all participants. Functional status was measured with counts of disability in basic and instrumental activities of daily living (24). Medical morbidity was estimated with the Chronic Disease Score, a measure constructed from medications updated to the 2005 American Hospital Formulary (25). Cognitive impairment was assessed with the MMSE (20). Anxiety was assessed with the Clinical Anxiety Scale (26). “Public stigma” was defined by using the mean of three items reflecting beliefs regarding society's attitudes toward depressed individuals—for example, “Most people would willingly accept a person who has had depression as a close friend” (27). This index was derived from the 12-item stigma scale (27), which has been shown to predict treatment discontinuation among older depressed adults (28). “Personal stigma” was measured by using the same three-item index but replacing “I” with “Most people”—for example, “I would willingly accept a person who has had depression as a close friend.”

Statistical analysis

Univariate analyses with means and standard deviations for continuous variables and frequencies and percentages for categorical variables were used to describe the sample. We report the percentage of patients who chose each depression treatment option as their first choice. We coded these choices into active approaches (medication or psychotherapy) and nonactive or complementary approaches (herbal remedies, religious or spiritual activities, exercise, another activity, or do nothing). We used chi square analyses to test the association between a diagnosis of major or minor depression and patient preference for an active treatment with either medication or psychotherapy. We also used chi square analysis to test the association between our three-level variable (current antidepressant use, previous but not current use, and no history of use) and preference for an active treatment.

We then conducted bivariate analyses to identify associations among other sociodemographic and clinical variables and preference for active treatment, using chi square tests for categorical variables and t tests for continuous variables. Variables that were significant at the .10 level were entered into a multivariate logistic regression to determine independent predictors. History of antidepressant use (current, past, or never) was represented in the regression models by dummy variables. The final model included only the variables that were significant at the .05 level.

Analyses were conducted with SPSS, version 14.0 (29). A two-tailed alpha level of .05 was used for each statistical test.

Results

The ages of the 256 patients enrolled in the study ranged from 65 to 96 years (mean±SD=78.2±7.1). A total of 158 patients (62%) were women, and 41 (16%) identified themselves as being from an ethnic-racial minority group. On average, clinical and functional measures indicated substantial medical morbidity and disability. The mean score on the Chronic Disease Score was 6.2±3.3. The mean number of reported limitations in activities of daily living was 1.4±1.5, and for instrumental activities of daily living the mean was 3.5±1.5.

Nineteen patients (7%) met criteria for major depression as assessed by the SCID, and 22 (9%) met criteria for minor depression. Of the 256 patients, 51 (20%) were currently taking an antidepressant, including five (26%) of the 19 patients with major depression, eight (36%) of the 22 patients with minor depression, and 38 (18%) of the 215 with no depression diagnosis. Twenty-one (8%) of the 256 patients reported previous but not current antidepressant use. No patient reported receiving psychotherapy on admission to home care, whereas 65 (25%) reported previous participation in psychotherapy.

Figure 1 presents data on reported first-choice treatment options. Of the 256 patients, 121 (47%) preferred an active treatment as their first choice (antidepressant medication, psychotherapy, or a combination), and the remaining 135 (53%) preferred a nonactive or complementary treatment approach (such as religious or spiritual activities or exercise). As shown in Table 1, of the 51 patients currently using antidepressants, 77% preferred an active treatment, compared with 57% of the 21 patients with past use of antidepressants and 38% of the 184 patients with no history of use (p<.001). A current diagnosis of major or minor depression was not significantly associated with treatment preference.

Other sociodemographic and clinical variables associated with preference for active treatment at p<.10 were male gender, more years of education, previous psychotherapy, race (white or Hispanic versus black), greater impairment in instrumental activities of daily living, and less personal stigma (Table 1). The final logistic regression model indicated that current antidepressant use, previous psychotherapy, white or Hispanic race, greater impairment in instrumental activities of daily living, and less personal stigma were independently associated with a preference for an active treatment (Table 2). When the sample was limited to participants who were not currently taking an antidepressant, the findings were similar (Table 2).

Discussion

Elderly home care patients expressed a variety of first-choice preferences for depression treatment, ranging from active treatments, to religious or spiritual activities, to doing nothing. Similar proportions of patients preferred antidepressant medication (19%) and psychotherapy (18%). Smaller proportions preferred combined treatment (7%) or group psychotherapy (4%). The most commonly preferred nonactive or complementary approaches were religious or spiritual activities (15%) and exercise (13%). A number of patients (10%) preferred to do nothing in response to depression.

Forty-one patients had a current diagnosis of major or minor depression. Of these, 13 (32%) were currently taking an antidepressant and none were receiving psychotherapy. It may be that many of these patients were not receiving treatment either because they did not want to be treated or because no effort had been made to engage them in decisions about depression care. In addition, a sizable proportion (18%) of patients who were not currently depressed were taking an antidepressant, which may reflect appropriate maintenance treatment for depression or antidepressant prescription for reasons other than depression.

Our hypothesis that preference for an active treatment with either medication or psychotherapy would be related to depression experience was partly confirmed. Patients who were currently taking an antidepressant medication or who had taken one in the past were more likely than patients who had never taken an antidepressant to prefer an active treatment. Patients who were currently taking an antidepressant were nearly four times as likely as those not taking an antidepressant to prefer an active treatment. Previous experience with psychotherapy was also independently associated with preference for an active treatment. These findings are consistent with findings for primary care patients (7,12,14) and long-term home care patients (17). They suggest that the more experience patients have with treatment for depression, the more comfort or interest they have in pursuing (or continuing to pursue) such treatment.

Contrary to our hypothesis, a current diagnosis of major or minor depression was not associated with patient preference for an active treatment nor was our measure of depression severity. We predicted that the more individuals personally felt the distress of depression, the more they would prefer an active treatment approach, particularly compared with patients without depression, for whom the hypothetical clinical scenario regarding depression treatment would be less salient. Our ratings of symptoms, however, may not have captured perceived distress, which has been shown to be a better predictor of treatment initiation and adherence (30,31).

Logistic regression revealed that white or Hispanic versus black patients, those with greater impairment in instrumental activities of daily living, and those with less personal stigma were also more likely to prefer an active treatment. Restricting the sample to participants who were not currently taking an antidepressant yielded similar findings. The finding on race is consistent with previous research showing that black individuals have negative attitudes and beliefs about antidepressant medication in particular (7,10,32) and are less likely than white patients to adhere to depression treatment (33,34). The finding on impairment in instrumental activities may indicate a greater experience with and acceptance of standard medical treatments. However, neither medical burden nor number of medications was associated with preference for active depression treatment. Perhaps impairment in instrumental activities is a better indicator of distress or impairment associated with depression than other medical variables. Alternatively, those who acknowledge a need for help, as exemplified by reports of limitations in instrumental activities of daily living, may be more likely to recognize the value of active depression treatment.

Stigma concerns and negative beliefs about depression and mental health treatment may influence the perception of such treatment as unacceptable and may lead to preferences for nonactive or complementary approaches (35) and to poor medication adherence (28,30). Personal stigma (an individual's attitudes toward depressed individuals) was associated with a preference for active treatment, whereas public stigma (an individual's beliefs about society's attitudes) was not. A study of older adults who were receiving home-delivered meals found that personal stigma may be particularly meaningful for individuals whose functional disabilities result in a smaller social sphere and less concern with society's attitudes (36). Also consistent with this finding, self-stigma but not public stigma was associated with attitudes about mental health treatment among diverse community-dwelling older adults (32). The sociodemographic determinants of stigma among older adults and their impact on the treatment engagement process are promising areas for future investigation.

Limitations of the study include assessment of treatment preferences with a hypothetical question among patients who were not currently depressed. Also, we do not know whether patients who were depressed considered themselves to have a “serious” depression (which was the term used in the hypothetical question) and whether this belief would be related to treatment preference. In addition, actual treatment decisions, initiation, and adherence may differ when patients are presented with real-life treatment choices. Moreover, opportunities for home health care patients to engage in treatment consistent with their preferences may be constrained by practical issues, such as the availability of particular treatment approaches in this setting.

Another study limitation is that the prevalence of depression was relatively low compared with rates in other studies in home care (1); this was partly the result of the aim of this study, which was to collect data for purposes of an intervention rather than to determine prevalence. Our sample from 2004 also had a low rate of antidepressant use (20%) compared with the rate in a more recent home health sample from 2007 (34%) (37). Our rate, however, is higher than that found in a study five years earlier (11%) (1), which reflects an increasing trend over time. Therefore, the distribution of patient preferences in this study may not be generalizable to the current home health care population. Findings on variables associated with treatment preferences, however, should not be affected by the potential sample biases. Another study limitation is that we did not have statistical power to separately examine factors associated with a preference for antidepressant medications and for psychotherapy. Our findings reflect preferences for active treatments in general. Finally, we did not have data on history of depressive disorders, and thus our findings are related to the impact of current depression and previous treatment experience.

Conclusions

Elderly home care patients expressed a wide variety of depression treatment preferences, from active treatments, to religious or spiritual activities, to doing nothing. Home health care services represent a unique opportunity to engage the homebound population, which is characterized by high levels of medical morbidity and disability, in appropriate depression treatment. Our findings shed light on the reluctance of subgroups of home care patients to engage in active treatment. Given the positive impact of meeting patients' depression treatment preferences in primary care settings (15) and the potential value of shared decision-making interventions (38–40), such interventions may also be fruitfully investigated in the home care setting.

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