Satisfaction With General Practitioner Treatment of Depression Among Residents of Aged Care...

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Journal of Aging and Health

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DOI: 10.1177/0898264306286199

2006 18: 435J Aging HealthDavid Mellor, Tanya Davison, Marita McCabe, Kuruvilla George, Kathleen Moore and Chantal Ski

Satisfaction With General Practitioner Treatment of Depression Among Residents of Aged Care Facilities

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10.1177/0898264306286199JOURNAL OF AGING AND HEALTH / June 2006Mellor et al. / DEPRESSION TREATMENT SATISFACTION

Satisfaction With General PractitionerTreatment of Depression AmongResidents of Aged Care Facilities

DAVID MELLORTANYA DAVISONMARITA MCCABE

KURUVILLA GEORGEKATHLEEN MOORE

CHANTAL SKIDeakin University, Australia

Objective: This article investigates consumer perspectives on the treatment fordepression among older people in residential facilities. Method: Aged care residentswho were aware of being treated for depression in the past 6 months (24 women and 7men, mean age = 83 years) participated in an interview that assessed their perspectiveon treatments. Results: Although more than half of the participants in the samplereported overall satisfaction with the medical treatments received for depression,qualitative data provided indications of unsatisfactory service delivery, including per-ceptions of low treatment efficacy, short consultation times, the failure to assess affec-tive symptomatology, and negative responses to residents’ disclosure of symptoms.Discussion: The findings are discussed in relation to previous research on consumersatisfaction with health services and issues that may be pertinent to the elderlydepressed. Training for general practitioners providing treatment in aged care isindicated.

Keywords: elderly; depression; treatment satisfaction

435

AUTHORS’ NOTE: This research described in this article was supported by a grant frombeyondblue, under the National Depression Initiative in Australia. Please send correspondenceregarding this article to David Mellor, School of Psychology, Deakin University, Burwood 3125,Australia; e-mail: [email protected].

JOURNAL OF AGING AND HEALTH, Vol. 18 No. 3, June 2006 435-457DOI: 10.1177/0898264306286199© 2006 Sage Publications



Consumer satisfaction with health care is an important issue for anumber of reasons. Not only does it lead to greater adherence toadvice and commitment to prescribed treatment (Kincey, Bradshaw,& Levy, 1975), but it also informs health care providers on the accept-ability, disseminability, and usefulness of treatment (Krautter & Lock,2004). Consumer satisfaction therefore is not only a central ingredientin determining the effectiveness of treatment; it is also an importantfactor in shaping the health care system (Williams & Calnan, 1991).

In this “age of concern about customer satisfaction and interest inthe patient’s perspective” (Solberg, Fischer, Rush, & Wei, 2003, p. 132),few studies have actually focused on consumer satisfaction withhealth care services, especially in regard to care for psychological dis-tress. Of these, most have either compared the acceptability of differ-ent treatments for particular disorders (e.g., anorexia nervosa,Krautter & Lock, 2004; postnatal depression, Boath, Bradley, &Anthony, 2004), or reported on specific populations (e.g., midlifeAustralian women, Outram, Murphy, & Cockburn, 2004; depressedpeople, Solberg et al., 2003).

Previous research has shown that consumer satisfaction with gen-eral practice is associated with patient perceptions of time spent in theconsultation session (Ogden et al., 2004) and providers’ interpersonaland communication skills (Lewis, 1994; Williams & Calnan, 1991).Other research by Calnan, Almond, and Smith (2003) has found thatthere is a strong positive relationship between age and satisfactionwith general health services (specifically, general practice, hospitalservices, and dental services). They analyzed data obtained throughthe British Social Attitudes Surveys from 1983 to 1999. They foundstrong evidence to support the relationship between ageing and satis-faction with services provided by general practitioners (GP) and hos-pitals, arguing that there is little evidence to suggest that thisrelationship has changed during the years studied.

Although older people may demonstrate high levels of satisfactionwith health services at a general level, little is known about their satis-faction with care in relation to treatment of their emotional problems.This issue is important for two reasons: the increasing numbers ofolder people in Western society and the increased prevalence ofdepression as people get older. These two issues are discussed below.

436 JOURNAL OF AGING AND HEALTH / June 2006



In Western society, generally, the population is aging, and the levelof health care required will increase substantially during the next fewdecades. In Australia, for example, life expectancy has increased dur-ing the past 50 years from 62.9 years to 76.5 years (Hoyert, Kochanek,& Murphy, 1999), and by 2031, 22% of Australia’s population will beabove 65 years of age compared to 12% in 1997 (Australian Bureau ofStatistics, 1999). With this increased life expectancy, older peoplehave become decreasingly constrained by institutional and culturalbarriers (Calnan et al., 2003). Laslett (1987, 1989) uses the term ThirdAge to describe the post–retirement period in which individualsbecome free of responsibility and are able to pursue personal fulfill-ment in accordance with their life plan.

However, this period of life is also characterized by many chal-lenges, such as loss of one’s social environment (e.g., through retire-ment from the paid workforce or geographic relocation of significantothers), loss of contemporaries (death or illness among peers), loss ofa companion with whom to participate in social interactions (widowsand widowers), changing needs of the family, and difficulties withavailability and accessibility of desirable activities (Mott & Riggs,1992). Other factors affecting older adults include poor health andmobility, lack of money, adverse side effects of medication, difficultywith transport, the burden of caring for a significant other, fear for per-sonal safety, and the need of assistance (Rook, 1987). These chal-lenges can have a powerful impact on the well-being of older peopleand are often associated with the second factor that is relevant for ourdiscussion: the increased risk of depressive illness as people get older.

A landmark study by the World Health Organization (Murray &Lopez, 1996) concluded that the significance of illness burden attrib-utable to depressive illness increases with age. This burden isexpected to further increase with the expected demographic shifts,most notably through a greater proportion of the ‘old old’ (Murray &Lopez, 1996). However, as for general population samples, depressedolder people in the community have tended to underuse mental healthservices (Burns & Taube, 1990). Reasons for this include factors relat-ing to the older person themselves, such as poor education about men-tal health problems or available treatments, hopelessness about thepotential for improvement in their mental state, stigma associatedwith mental disorders, or the tendencies among older adults to present

Mellor et al. / DEPRESSION TREATMENT SATISFACTION 437



with somatic rather than affective symptomatology and to attributesymptoms of depression to physical etiology (Alexopoulos et al.,2002; National Institute of Health Consensus Conference, 1992;Rothschild, 1996). Thus, older depressed people tend to be higherusers of general medical services than nondepressed older people are(Callahan, Hui, Nienaber, Musick, & Tierney, 1994; Rowan,Davidson, Campbell, Dobrez, & MacLean, 2002; Waxman, Carner, &Blum, 1983), but even in primary care settings, they are less likelythan younger patients to self-report symptoms of depression (Lynesset al., 1995). Even if they do, it has been found that GPs are reluctant toinform older patients that they are depressed (Rovner et al., 1991). Ifdepression among this population is managed by GPs, satisfactionwith the treatment administered is central to our understanding ofboth treatment use and its effectiveness. As suggested earlier, treat-ment satisfaction has implications for adherence to treatment andhealth service planning; it also has implications for future help-seeking behavior and for the reputation of treatment.

The focus of the present study is on satisfaction with treatment fordepression among older people who are in residential care. The preva-lence of depression among older people living in residential care isreported to be far higher than that found in the general population(Ames, 1991). In a consensus statement, the National Institute ofHealth Consensus Conference (1992) estimated that the prevalence ofmajor depression among older persons in the community is less than3%, whereas the rate of major or minor depression in nursing homes isaround 15% to 25%. Recent research findings estimating the preva-lence of major depression, according to Diagnostic and StatisticalManual of Mental Disorders (DSM) criteria, among nursing homeresidents in the United States have ranged from 9% to 34% (Baker &Miller, 1991; Blank, Gruman, & Robison, 2004; Gerety et al., 1994;Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001). Given the highprevalence of depression among residents of aged care settings (Soon& Levine, 2002), it is important to have a better understanding of theirsatisfaction with services in this area.




Method

PARTICIPANTS

This study was part of a larger project examining the prevalence ofdepression that involved 300 participants in aged care. There are twokinds of aged-care facilities in Australia: nursing homes (high care)and hostels (low care). This study was undertaken in hostels whereresidents are usually frail, but semi-independent. They receive meals,personal care, and various levels of support other than nursing. Chou,Boldy, and Lee (2003) suggest that hostels fall under the category ofcongregate care in the United States.

Participants for the larger study were part of a convenience samplerecruited from hostels located in the eastern suburbs in metropolitanMelbourne. All such facilities in the suburbs were identified and listsdrawn up to group those that were privately operated, governmentoperated, or operated by a charitable organization (e.g., a church).From these groupings, 10 facilities were selected to ensure that partic-ipants represented a range of socioeconomic, religious, and culturalbackgrounds. Facilities ranged in size from 15-bed to 99-bed units,and there was considerable variation in fees, admission criteria, staff-to-resident ratios, activities, available amenities, and the quality of thephysical environment. This variation is typical of the diversity inAustralian metropolitan facilities.

The larger study of the 300 residents aimed to identify the best mea-sure of depression for elderly people. Exclusion criteria included thefollowing: moderate or severe cognitive impairment, diagnosis ofBipolar Affective Disorder or Schizophrenia, severe hearing impair-ment, acute illness, inability to communicate in English, aged lessthan 65 years, or the presence of an intellectual disability. Those resi-dents who met the inclusion criteria engaged in interviews with a clin-ical psychologist and completed a range of depression inventoriesduring a number of sessions. As this current study was concerned withsatisfaction with treatment for depression, we were interested in thesubgroup of the larger sample who knew that they were being treatedfor depression and could comment on this treatment. Review of medi-cal records indicated that 96 of the 300 participants were being treatedfor depression, but only 31 individuals (24 women, 7 men) reported,




when asked in the clinical interview, that they had been treated fordepression during the past 6 months. These 31 participants, who arethe focus of the current study, ranged in age from 67 to 93 years, with amean age of 83.2 years (SD = 6.62 years).

MEASURES

Participants’ age, gender, and prescribed antidepressant medica-tions were determined from their files at the residential facility. Thefollowing measures were then administered.

Structured clinical interview for DSM-IV Axis I Disorders (First,Spitzer, Gibbon, & Williams, 1997). This instrument is asemistructured interview schedule for making DSM-IV Axis diagno-ses (American Psychiatric Association [APA], 1994), which has beenwidely used in clinical and research settings. The items for diagnosingthe Major Depressive Disorder were administered according to theClinician Version (requiring five or more symptoms, including at leastone of (a) depressed mood, or (b) loss of interest or pleasure). No dis-tinction was made between Major Depressive Disorder (single epi-sode) and Major Depressive Disorder (recurrent) because of high lev-els of impaired memory in this sample and the absence of aninformant who had known the resident for a long time or other validsource of psychiatric history. These difficulties also prevented anaccurate assessment of Dysthymic Disorder, which was therefore notconsidered as a possible diagnosis in this study. The items for diag-nosing Minor Depressive Disorder were administered in the sameway, but consistent with the Research Version guidelines, only two tofour symptoms were required to be present, including at least one ofdepressed mood or loss of interest or pleasure. Minor Depressive Dis-order is currently listed in the DSM-IV (APA, 1994) under ‘Criteriasets and Axes Provided for Further Study’ and involves lessimpairment: functioning may be near normal but may requiresignificantly increased effort.

Standardized Mini Mental State Examination (SMMSE; Folstein,Folstein, & McHugh, 1975; Molloy, Alemayehu, & Roberts, 1991).The SMMSE is the most widely used cognitive screening test in older




persons, with 30 items assessing orientation, attention and calcula-tion, immediate and short-term recall, and the production of writtenlanguage and the ability to follow simple written and verbal com-mands. Although the total score should not be used as the sole crite-rion for a diagnosis of dementia, it has demonstrated high sensitivityand specificity (O’Connor et al., 1989), with an established cut-offscore of 23 out of 30 or less for the presence of dementia (Folsteinet al., 1975). However, we chose to use Vertesi et al.’s (2001) morestringent criteria, with scores of 26 and above indicating normal cog-nitive functioning, and scores in the interval 20 to 25 indicating milddementia.

In this study, not all items were able to be completed by many par-ticipants, because of noncognitive factors, most notably hearing andvisual impairment. To prevent these participants from receivingscores lower than their actual cognitive function would imply, theirtotal scores were prorated. This procedure has been previously dem-onstrated as reliable with vision-impaired persons (Reischies &Geiselmann, 1997).

Depression Treatment Satisfaction Questionnaire. Satisfactionwith the provision of depression treatment by primary and specialistmental health services was assessed using a 6-item questionnaire spe-cifically designed for this study, which was administered verballyusing a semistructured interview format. Questions include “How sat-isfied are you with the treatment you received?”, “Did the treatmentyou received make you feel better or worse? Did it improve yourmood?”, “Has the [service provider] spent time talking with you abouthow you are feeling—not your physical health but your generalmood?”, and “Would you like more opportunities to talk about yourfeelings with the [service provider]?” Participants who reported thattheir service provider had talked about their mood were additionallyasked, “How much does the [service provider] talk about how you arefeeling?” and “Do you feel better or worse afterward?” Qualitativedata were recorded, with participants given the opportunity tocomment on their perceptions of mental health service provision.




PROCEDURE

Approval to conduct this study was obtained from Deakin Univer-sity Human Research Ethics Committee and the boards of manage-ment of the participating facilitates. Facility managers then providedlists of residents and assisted the researchers in excluding those resi-dents considered ineligible for participation in the study because ofthe following exclusion criteria: moderate or severe cognitive impair-ment; diagnosis of Bipolar Affective Disorder or Schizophrenia;severe hearing impairment; acute illness; inability to communicate inEnglish; aged less than 65 years; or the presence of an intellectualdisability.

Three hundred facility residents without these exclusion criteriacompleted written forms to indicate informed consent to participate inthe study. In addition, written consent was obtained from the partici-pant’s next-of-kin in the case of those considered unable to giveinformed consent because of cognitive impairment, as determined bythe senior nurse at each facility.

Participants were then interviewed to determine if they could recallan experience of having received pharmacological or nonpharmaco-logical treatment for depression within the previous 6 months. Thirty-one residents (10.3%) reported receiving such treatment and wereasked to provide data on their satisfaction with the treatment, throughcompletion of the Depression Treatment Satisfaction Questionnaireadministered verbally by a clinical psychologist experienced in work-ing with older people with depression. In addition, each participantwas assessed with the appropriate sections of the Structured ClinicalInterview for DSM-IV Axis I Disorders to determine whether theycurrently met criteria for Major Depressive Disorder or MinorDepression Disorder, and the SMMSE to assess their level of cogni-tive functioning.

DATA ANALYSIS

In analyzing the data, the questionnaire responses were exploredby frequencies of responses and categorizations. The interview datawere read by two researchers several times to establish agreed-onthemes in the responses to the questions related to satisfaction. These




themes are reported below and elaborated by way of examples fromthe data.

Results

There was a very low level of awareness of current medical treat-ment among the sample of 300 residents, with less than one quarter(n = 23; 24.0%) of those 96 residents who were actually prescribed anantidepressant medication at the time of interview (as determined byreview of medical records) acknowledging that they were receivingtreatment for depression. Typically, residents reported that they didnot know what medications they were taking or that they did not thinkthey were taking a psychotropic medication. Those who were unawareof their treatment had poorer cognitive functioning—as indicated by alower SMMSE score (Molloy et al., 1991)—than those who wereaware, t(93) = 3.32, p < .001. However, the lack of treatment aware-ness was not only due to cognitive impairment; nearly half of thegroup who were unaware of their antidepressant use (n = 31 out of 73;42.5%) scored within the normal range for cognitive function(SMMSE > 25). Thus, treatment awareness was low, even among resi-dents with normal cognitive function.

Among the 31 participants recruited into the current study—whoall acknowledged treatment of depression within the previous 6months—the assessment of cognitive function using the SMMSE(Molloy et al., 1991) revealed that 20 participants (64.5%) were func-tioning within the normal range (SMMSE scores 26 to 30) and that 10participants (32.2%) had mild cognitive impairment (SMMSE scores20 to 25). One participant refused to complete the cognitiveassessment.

The assessment of depression using the Structured Clinical Inter-view for DSM-IV Axis I Disorders revealed that the sample included15 participants with current Major Depressive Disorder, 5 participantswith Minor Depressive Disorder, and 11 participants who did not cur-rently meet DSM-IV criteria for major or minor depression and whoseillness appeared to have resolved (n = 1) or was being controlled withcurrent antidepressant medication (n = 10).




TREATMENT FOR DEPRESSION

There were no reports of nonmedical treatment by participants,with the exception of 1 participant who had received psychotherapyfrom a clinical psychologist with concurrent medical treatment from aGP. All participants had been treated by their GP, with the exception of1 participant whose depression had been treated by a private psychia-trist only. Two participants had received concurrent treatment fromtheir GP and either a private psychiatrist or the local government AgedPersons Assessment and Treatment Team.

Note that the data on satisfaction with treatment analyzed belowrelate only to GPs, as there were too few data on services provided bypractitioners other than GPs to consider separately. For those 3 partici-pants who had received treatment from more than one service pro-vider, the Depression Treatment Satisfaction Questionnaire wasadministered in relation to the treatment received from the GP. Thecase of the participant who was treated only by a private psychiatrist isnot included. Thus, 30 cases of depression treatment by GPs wereavailable for analysis.

SATISFACTION WITH TREATMENT FOR DEPRESSION

Participants were asked to rate their overall satisfaction with thetreatment they had received from GPs for depression. Nearly half ofthe sample (n = 14; 46.7%) reported they were very satisfied or some-what satisfied with the treatment, whereas 13 participants (43.3%)were very dissatisfied or somewhat dissatisfied (see Table 1). Threeparticipants did not provide a rating.

In general, participants appeared reluctant to give a numerical rat-ing of satisfaction with their GP, preferring to make comments, whichwere subsequently grouped into themes. These qualitative data sug-gested that service provision for residents with depression was moreproblematic than might be concluded through an examination ofnumerical ratings of treatment satisfaction. The major issues seemedto be related to the practitioner’s personal style, the length of consulta-tions, the length of relationship with the practitioner, and level ofexpectation with regard to the treatment.




PRACTITIONER’S PERSONAL STYLE OR ATTRIBUTES

The first theme to emerge from the qualitative data suggested thatpositive ratings of treatment satisfaction were commonly associatedwith perceptions of the practitioner’s personality or manner, with 10satisfied participants describing him or her in terms of “very caringand interested,” “very understanding,” “kind,” “a lovely person”whois “always interested,” and “wants to help.” A variety of positive com-ments about the services offered by their treating practitioner wereelicited from participants, such as “he’ll always give me advice if he’sasked” or “he was the first person to help and to offer advice instead ofjust nodding his head.”

It was common for participants with poor experiences of serviceprovision to make reference to the absence of an ongoing relationshipwith a single GP since their relocation to the residential facility. Eightparticipants made comments such as, “I see lots of different doctorshere . . . don’t know any really well,” “he’s a new doctor . . . I don’twant to talk to him,” “He’s attentive, but I don’t know him that well . . .I can’t understand his accent . . . he doesn’t really know me,” and “hedoesn’t understand how hard it is.” In addition, a small number of par-ticipants (n = 5) reported that their GP made negative comments whenthey disclosed symptoms of depression. These comments included,“you are old and must expect these problems,” “you’re just gettingon,” “change your attitude and get on with things,” and “you just haveto put up with [symptoms of depression],” and “you have to help your-self.” One participant reported, “the message from my doctor is that[treating depression] is too hard” and also that he “brushed off”


Table 1Satisfaction With Treatment for Depression

Number of Cases Percentage

Very satisfied 6 20.0Somewhat satisfied 8 26.7Somewhat dissatisfied 4 13.3Very dissatisfied 9 30.0No rating given 3 10.0

Total 30 100.0



requests to review her medications by family members. Another par-ticipant asked the interviewer to liaise with her GP on her behalf toimprove her treatment, whereas another requested a change of GP.

LENGTH OF CONSULTATION

More than one third (n = 12) of all participants asked to commenton their treatment spontaneously reported a concern with the shortconsultation time provided by their GP, such as “she is only there for 5minutes,” “he’s always in a great hurry,” “he hardly bothers to examineme before he’s edging towards the door,” “he’s in and out like a blow-fly,” and “he’s too busy even for the physical things.” Short consulta-tions were typically not attributed to the negative manner of their prac-titioner: “he is a very nice gentleman, but he’s too busy to spend muchtime with people,” reflecting the limited time available to practitionersas a whole: “they are extremely busy people” who have “too many res-idents to see”; “I wish he had more time, but he’s a busy man.”

LENGTH OF RELATIONSHIP WITH THE PRACTITIONER

The level of satisfaction with treatment for depression was alsoassociated by many participants with the length of the relationshipthat they had had with the practitioner. As might also be expected, thelength of the relationship between the participant and the practitionerwas also related to the perceived qualities of the practitioner. That is,participants had been in long-standing relationships with practi-tioners who had qualities that they liked. There were comments suchas “I’ve been seeing him for 12 years, and like talking to him,” “healways goes out of his way to visit me when I ask, and always has, for40 years . . . even went to [my wife’s] funeral.”

LEVEL OF EXPECTATION REGARDING TREATMENT OUTCOME

A final theme to emerge from the qualitative data was that someparticipants (n = 6) also rated themselves as satisfied with their treat-ment because of low expectations, such as “it could have beenworse . . . nothing can help,” “nothing will make it better . . . I’m wait-ing to die.”




EFFECTIVENESS OF TREATMENT

Participants were asked to comment on their perceptions of theeffectiveness of the treatment they had received for depression. Partic-ipants perceived that close to half of the treatment regimens (n = 14;46.7%) had led to some improvement in their mood (see Table 2). In 9cases (30%) participants reported “no change” in their mood, whereasin 3 cases (10%) participants felt worse after treatment, which qualita-tive data suggested was related to the presence of side effects in 2cases. Four participants were unable to rate treatment effectiveness,feeling unsure of whether a change had occurred, most commonlyobserved among participants who had received treatment duringseveral years.

The validity of participants’ perceptions of treatment effectivenesswas examined through a comparison of the numbers of participants whowere not depressed at the time of the clinical assessment—and who wereassumed to have responded to treatment—and those who weredepressed despite receiving antidepressant medication, using the chi-square statistic. Individuals who reported feeling “a little better” or“much better” were less likely than others to be depressed at interview,χ2(1, n = 30) = 5.66, p < .05. Perceptions of the effectiveness of treat-ment were related to ratings of treatment satisfaction (Pearson’s r =0.59, p < .002), with greater satisfaction reported by those residentswho felt that their mental state had improved through treatment.

Qualitative data suggested that perceptions of low levels of treat-ment effectiveness were related to three themes: lack of knowledge on


Table 2Ratings of Change in Mood Following Treatment

Number of Cases Percentage

A lot better 6 20.0A little better 8 26.7No change 9 30.0A little worse 0 0A lot worse 3 10.0No rating given 4 13.3

Total 30 100.0



the part of the practitioners, a sense of hopelessness, and a denial ofany depressive symptomatology.

LACK OF KNOWLEDGE OF PRACTITIONERS

Although not put in a critical way, some participants (n = 7)reported the belief that the treatment received was ineffective becausethe treating practitioner did not know how to help. To illustrate,although 1 participant felt a lot worse following treatment, she ratedherself as somewhat satisfied with treatment received from her GP,because “[the GP] wants to help, but doesn’t know how . . . I don’tthink tablets will make any difference.”

SENSE OF HOPELESSNESS

Other participants suggested that their condition was in effectuntreatable and felt that their situation was without hope. One partici-pant reported, “[GPs] can’t perform miracles . . . I’m just waiting untilthe Lord takes me,” and “no-one has done anything in the past.”

DENIAL OF DEPRESSIVE SYMPTOMATOLOGY

A small group of participants (n = 3) who reported an absence oftreatment effectiveness denied symptoms of depression in the assess-ment, claiming, “I don’t need antidepressants,” and “I didn’t reallyfeel depressed . . . I kept telling them that . . . I was just upset about[a conflict with another resident].” In these cases, there was no asso-ciation between treatment satisfaction and perceptions of treatmenteffectiveness.

DISCUSSION OF NONPHYSICAL SYMPTOMSWITH PRACTITIONERS

Participants were asked if their practitioner discussed affectivesymptoms during their medical consultation. Data suggested lowrates of discussion of nonphysical symptoms during treatment. In 14cases (46.7%) participants reported that their practitioner never talkedabout their mood or feelings (see Table 3), and only 7 participants




(23.3%) reported that their practitioner regularly discusses affectivesymptoms. Among those participants who had received the opportu-nity to discuss affective symptoms with their practitioner, these dis-cussions were reported to have had a positive impact on their mood in10 cases (62.6%), whereas 1 participant reported a slight negativeimpact (see Table 3) through the triggering of memories of trauma.

Although less than half of the sample (43.3%) reported that theywere satisfied with their current opportunities to discuss their mood,the remaining participants expressed a desire for more opportunitiesto talk about affective symptoms during treatment. There were a vari-ety of reasons offered as to why such issues were not a focus of treat-ment.

LACK OF TIME

Qualitative data provided indications that the main reason GPs donot attend to nonphysical symptoms is that they are perceived to havetoo little time. For example, participants reported that their practi-tioners were “too busy to talk . . . they see too many people here” or


Table 3Amount of Discussion of Affective Symptomatology During Treatment and Ratings of Change inMood Following Discussion

Change in Mood Following Discussion (N)

A Lot A Little No A Little A LotLevel of Discussion Better Better Change Worse Worse Total Percentage

Always talks about my moodor feelings 0 0 0 0 0 0 0.0

Talks quite a lot or regularlyabout my mood or feelings 3 1 2 1 0 7 23.3

Talks only a little or occasionallyabout my mood or feelings 2 4 3 0 0 9 30.0

Total 5 5 5 1 0 16 53.3

Never talks about mymood or feelings 14 46.7

Total 30 100.0



had “not too much time to speak to an individual.” This theme was in asense forgiving of the practitioners’ lack of attention to emotionalissues. Despite this, the desire for more time to discuss emotionalissues remained, as demonstrated by comments such as “I wish I hadmore time.”

LACK OF INTEREST IN EMOTIONAL ISSUES

A second theme emerging from the qualitative data was that thepractitioners were disinterested or avoidant with regard to emotionalissues. For example, participants reported that practitioners are “moreinterested in the physical parts of me.” One participant reported “Inow never talk to her about [depression]. She doesn’t ask. When I try,I’m told to ‘get on with things.’”

FEELINGS OF DISCOMFORT IN DISCUSSINGAFFECTIVE SYMPTOMATOLOGY

Qualitative data suggested that some individuals did not feel com-fortable discussing their depression symptoms. They gave commentssuch as, “Talking about feelings is not normal,” “I don’t feel the needto talk about my feelings, it’s not important,” “I want to keep thesethings private,” “Sometimes, I want to keep my feelings to myself.”

LACK OF EXPECTATION OR FAITH

A final theme to emerge was that of a lack of expectation or faith inthe practitioner. For example, some participants (n = 7) felt that dis-cussion about affective states with their GP was inappropriate orfutile: “I don’t expect them to talk about things,” and “I talk to my fam-ily rather than the doctor.” This may be due to a poor relationship withtheir practitioner in some cases: “He’s new . . . I don’t want to talk to astranger,” and “I don’t want to talk to him . . . I try to avoid him,” or to aperception of practitioner incompetence: “She’s hopeless . . . I’ve nofaith in doctors . . . I don’t bother to talk about things to them.”




Discussion

This research aimed to investigate the satisfaction of older personsin residential care with their treatment for their depressive illness.Although 96 residents from the sample of 300 involved in the largerstudy described earlier were currently prescribed an antidepressantmedication, less than one third of this group were aware that they werereceiving this treatment. The most common presentation was a lack ofawareness of any of their medications (e.g., being unclear about thenames of their daily medications, the drug class, or their function).Although it may be expected that individuals with cognitive impair-ment may be unable to recall such information, nearly half of thosewho were unaware of their treatment evidenced normal cognitivefunction. Participants did not tend to use terms such as depression todescribe their current presentation. Although this may reflect factorssuch a reluctance to disclose mental disorders because of perceivedstigma, such a finding may also indicate that older persons in the sam-ple had received poor psychoeducation about their condition. Thishypothesis, although supported by previous findings that GPs werereluctant to inform older patients that they were depressed (Rovneret al., 1991), requires further investigation.

All of the 31 participants who were aware that they were beingtreated for depression had received pharmacological treatment, typi-cally from their GP. Only 1 participant reported a nonpharmacologicalintervention in addition to the pharmacological intervention. Half ofthe cases of depression treatment had led to an improvement in theirmental state, according to participants, with many expressing a lowexpectation of change. The perceptions held by participants ofwhether the treatment had been effective were related to the indepen-dent DSM-IV diagnosis of depression made at the time of the inter-view. Treatment satisfaction was positively associated with the per-ceived effectiveness of treatment, suggesting that hostel residents cangive valid ratings of treatment response.

Just less than half of the sample reported satisfaction with the treat-ment they had received from their GPs for depression. However, qual-itative data pointed to concerns about short consultation times pro-vided by their GP and poor engagement in relation to nonphysicalsymptoms. This is consistent with findings from other studies (Mor-




rell, Evans, Morris, & Roland, 1986; Williams & Calnan, 1991) thatreport that many patients are dissatisfied with the time spent with theirdoctor. However, the relationship between actual consultation timeand satisfaction may not be as strong as the relationship between per-ceived consultation time and satisfaction (Cape, 2002). Thus, consul-tations that result in higher satisfaction appear to patients to lastlonger, although they are not actually longer. This led Cape (2002) tothe conclusion that patient concerns about time may be as much aboutthe quality of the consultation as about actual time. When the qualityof communication is rated highly, patient satisfaction is higher(Bertakis, 1977). Furthermore, according to Ogden et al., (2004), ifpatients have their emotional needs met and feel listened to and under-stood, regardless of the actual time spent with the doctor, they are sat-isfied not only with the process of the consultation but also with theconsultation length.

Thus, although patient satisfaction with care has been demon-strated to be associated with perceived time and content of consulta-tion, it is also in part determined by patient perceptions of the GP–patient relationship and GPs’ interpersonal skills (Lewis, 1994; Wil-liams & Calnan, 1991). Comments by participants in the current studyhighlighted the importance of these factors, with treatment satisfac-tion being associated with a positive ongoing relationship with a GPwho appeared interested and understanding. Yet this group of hostelresidents receiving treatment for depression reported that less thanone third of their practitioners regularly discussed affective symp-toms, with participants referring to the lack of time available duringmedical consultations or to a perception that their GP appeared disin-terested in their mood. Some participants appeared uncomfortablediscussing such symptoms, which in many cases was associated witha poor relationship with their GP and a perception that such discussionwas inappropriate or futile. This is unfortunate, given that partici-pants’ discussion of affective symptoms with their treating physicianwas associated with a perception of improved mood in 63% of cases.Despite this, only half of the sample desired more opportunities toreview their mood with their GP.

Although many residents talked positively about interactions withtheir GP, the data suggested that levels of care were less than adequate.Participants reported a number of highly negative experiences and low




perceived efficacy of treatment, with a substantial number reportingno change in their mood or feeling worse after treatment, typicallybecause of medication side effects. Of particular concern were reportsby participants of practitioner comments that were suggestive of anageist attitude (e.g., attributing symptoms of depression to be a nor-mal part of ageing or therapeutic nihilism with older depressedpatients). These attitudes were construed by patients as indicative thattheir symptoms would be unlikely to be resolved with treatment.

The low expectation of treatment efficacy among residents wasconcerning and appeared to be related to an acceptance of the careoffered by health services. Short consultation times and a failure todiscuss affective symptoms tended to be expected and accepted bymany participants who did not expect their practitioner to know howto treat their illness effectively. In line with comments made by Calnanet al. (2003), who suggested that older adults tend to have a passiveapproach to health care characterized by acceptance and dependency,our participants were unlikely to demand that their symptoms ofdepression receive appropriate attention in medical consultations.Furthermore, in line with Pollock and Grime’s (2002) findings, ourparticipants were aware of time constraints and were anxious not touse up their doctor’s time.

One issue that arises from this study is the lack of involvement bymental health practitioners, especially those who specialize in treatingthe elderly (geriatrician, geropsychiatrist, geropsychologist), in thetreatment of the participants’ depression. One participant had beentreated only by a private psychiatrist, and another had receivedpsychotherapy from a clinical psychologist concurrent with medicaltreatment from a GP. Two participants had received concurrent treat-ment from their GP and either a private psychiatrist or the local gov-ernment Aged Persons Assessment and Treatment Team. The remain-ing 27 were treated only by their GPs. Given that the participants’dissatisfaction with GPs’ treatment was centered on issues of consul-tation time, the focus on physical symptomotology, and inability orunwillingness to become involved in emotional symptomotology, it isprobable that treatment by mental health professionals would havebeen viewed as more satisfactory by the participants, purely becauseof the way such treatment is delivered. This suggests that greater




efforts need to be made to recruit and maintain trained mental healthworkers in this sector.

Although the sample in our study was not large, it included all par-ticipants from the larger study of 300 hostel residents who were awarethat they were receiving treatment for depression. The combination ofqualitative and quantitative methods was useful, with the qualitativedata informing more on the issue of satisfaction than on quantitativedata. The apparent contradiction between the qualitative data and theparticipants’apparent reluctance to give a low rating of satisfaction toservices received from their GP is consistent with previous research(Calnan et al., 2003) that has demonstrated that quantitative satisfac-tion surveys with older adults have tended to inflate levels of satisfac-tion, with more criticism or ambivalent responses emerging fromqualitative data.

Further studies are required to validate our findings and extend theuse of qualitative methods. All responses in this study were recordedby the interviewer in writing at the time of interview, and Coyle (1999)has cautioned that in such circumstances, specific grievances are morelikely to be recorded. Similarly, it has been suggested by Outram et al.(2004) that when asked to comment on satisfaction with services,responses are more likely to have a negative bias than a positive bias.Although this is consistent with the view that qualitative methods aremore likely than quantitative methods to uncover dissatisfactionsexperienced by older people, it also suggests that such data have thepotential to be biased. In light of these findings, it is essential thatfuture studies also use both quantitative and qualitative methods ofdata collation.

In summary, the poor understanding of their illness demonstratedby older persons with depression in this study and the lack of aware-ness that they are even receiving treatment for depression is concern-ing. The reports by those older people who were aware of their condi-tion and were receiving treatment also raise concerns. They received alow rate of inquiry into affective symptomatology during the shortconsultations provided by their GP and expressed much dissatisfac-tion with their treatment. Education for GPs in the management ofemotional symptomatology among older persons in residential caremay improve consumer perspectives of treatment for depression andalso improve recognition rates for depression. A particular focus on




effective communication could enhance satisfaction, even when con-sultations are necessarily short (Ley, 1990). A more appropriateapproach, however, may be to increase the number of trained mentalhealth workers in the aged care sector, and the challenge for health ser-vice administrators is to find ways to train, recruit, and maintain suchprofessionals in this sector.

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