Breeding ground for depression

The average double decker bus seats 68 passengers. Of these,
about 11 will have depression at some point in their lives. A
startling figure in itself, but one that pales into insignificance
compared with the number of older people in care homes who are
affected by the illness. At least four in 10 – or 27 out of the 68
bus passengers – suffer from depression with most of them going
undiagnosed and untreated.(1)

It is unclear why so many care home residents are depressed. But it
is estimated that only 10-15 per cent of older people in the
community are affected by depression suggesting some link between
being in a care home and suffering from the illness. So are the
residents already depressed when they enter the care home or do
they become depressed as a result of living there?

Research is yet to establish the answer to this, but it would seem
that the reason is based on a combination of factors. For a start,
there is no denying that moving into residential care is a major –
and often unwanted – life change. Significant life events are known
to be a trigger for depression in some individuals. Given that many
new residents will have recently lost important parts of their
lives in quick succession, it is little wonder that they may feel
low.

Martin Green, chief executive of the English Community Care
Association, says: “Often, people come into a care home because
there has been a major trauma in their life and they can’t cope
with life in the community. They may be bereaved or unable to
manage their house, or they may be ill. We need to examine why
people go into care homes as they are the sorts of issues that
would make anyone depressed.”

But it is likely that the care home environment also plays a part.
While there have not been any studies specifically comparing the
impact of different care homes, it is known that, on the whole,
environmental factors play a massive role in the onset of
depression.

The sorts of environmental factors affecting care home residents
have been highlighted in a study by the Department of Health and
Ageing in Australia.(2) The study, which involved 1,758 older
people in 168 care homes, found that they were affected by being
unable to take part in activities, poor relationships with staff
and other residents, and not being visited enough.

What is important is that the depression is detected and
treated.

To this end, much needs to be done, and not just for care home
residents. Depressed older people in the community have a difficult
enough time obtaining support. Nearly two-thirds have never
discussed their depression with their GP and, of those who have,
only half receive therapy or treatment. Less than one in 10 are
referred to specialist mental health services, and in general they
are not offered the range of treatments, such as talking therapies,
that are available to younger clients.

Ageist attitudes from health and social care staff who consider
feeling low as a natural part of the ageing process are partly to
blame.

Andrew McCulloch, chief executive of the Mental Health Foundation,
says: “GPs can have negative attitudes to depression in old age.
They don’t think it’s relevant to intervene. Their attitudes can be
‘you’re in a care home, what do you expect, mate?'”

Moreover, staff in care homes are not always equipped to recognise
the need for a doctor’s intervention. Understaffing means that care
home staff may not spend enough time with a resident to recognise
that they have become depressed, or they may not know residents
well enough to notice a change in their behaviour. In some cases,
depressed residents become the norm.

McCulloch says: “Staff in a care home with depressed people get
used to it and may not react to individuals in the same way. There
will be an institutionalisation effect.”

Improved training on recognising symptoms would go some way to
helping staff detect depression. A randomised trial in the
Netherlands found this to be the case and also found that depressed
residents fared better when staff had undergone training.(3)

But it can be difficult for staff to distinguish depression from
other conditions, particularly dementia. Many of the symptoms, such
as withdrawal from social activities and general apathy, are
similar, and it can be easy to mistake one for the other,
especially in care homes with nursing where at least 70 per cent of
residents have dementia.

Once depression in a resident has been identified, it needs to be
treated promptly. Amanda Thompsell, a consultant old age
psychiatrist who works in a care homes support team for Southwark,
Lambeth and Lewisham primary care trusts in London, receives about
300 referrals each year, and always visits residents in their care
home.

She says residents with depression are usually given medication,
alongside a review of their lifestyle.

“The treatment of depression is not just about medicine, it
involves stimulation. In care homes there is often not that
stimulation,” she says. “You have to address the activities and
interactions going on, otherwise you will not improve the person’s
mood. Most people in care homes don’t do anything at all, maybe
watch a bit of TV but that’s it.”

She believes professionals need to keep the prospect of depression
at the forefront of their minds. “There needs to be regular
screening and we need to ask people how they are feeling and what
they need. We don’t ask often enough or take it seriously when they
say they want to die.”

Few would argue that the issue needs careful consideration, and
research is needed to establish what is going on. That so many care
home residents suffer from depression is worrying enough, but the
fact that most of them go undiagnosed and untreated is simply
unacceptable.

(1) Help the Aged, Depression and Older People: Towards Securing
Well-being in Later Life, 2005
(2) Recognising and Managing Depression in Residents of Aged Care
Homes, Department of Health and Ageing, Australia, 2004
(3) A M Eisses et al “Care staff training in detection of
depression in residential homes for the elderly”, British Journal
of Psychiatry, May 2005

COMPUTER MADE ‘QUITE A DIFFERENCE’  

Eighty-six-year-old Ronald Redman now communicates with his friends
and family by e-mail after taking part in an IT initiative to train
care home residents to use computers.

The scheme is part of Help the Aged’s Sunshine Project to explore
ways of reducing social isolation for people in residential care
after research highlighted the disproportionate number at risk of
depression.

Redman, who lives in Winsford House in Clacton-on-Sea, Essex,
received tuition over 12 weeks on using the internet and e-mail. He
was then assigned a volunteer mentor to help, should problems
arise.

Before taking part in the training, Redman had not used a computer
before. “I’d not have known how to go about it,” he says.

Now he uses the computer in the main lounge of the care home most
days. Learning how to use it has made “quite a bit of difference”
to his life and helped him to maintain – and even increase – his
social contacts.

“One can shop on the computer, discover all sorts of information
and keep in contact with family and friends,” he says. “When I sent
my Christmas cards I happened to indicate that I’ve now got an
e-mail address and I received an e-mail from someone I hadn’t seen
for many years.”

Redman, who is a retired Methodist minister, is in reasonable
health and can go out every day. “But there are others who can’t
get out so frequently and one who doesn’t get out at all. I’m sure
for her the computer means a lot.”