Reducing depression: How older people’s care workers can help

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Abstract
A controlled research study in care homes showed that depression in older people could be reduced by care staff working for 8 – 12 weeks on modest life-improvements, chosen by depressed residents. Care staff followed a simple, structured, joint care-planning approach, which they learned during four training sessions and weekly one-to one mentoring sessions with a mental health specialist. The same approach could be used in other services for older people, like home care.

Promoting service users’ “well-being” was one of the most welcome new themes in the 2006 White Paper, Our Health, Our Care, Our Say. (1) How can social care services bring well-being into their everyday work? Our recently published research gives a very direct answer concerning older people in care homes.(2) If care home assistants supply holistic, person-centred help with a resident’s quality of life, this can actually lift some older people out of clinical depression. While our research was conducted in care homes, the same straightforward approach to older people’s well-being can be used by home care workers, staff in sheltered housing, and other services.

In our controlled study, 87 depressed older people in care homes in Yorkshire were given some regular extra quality time from their main care worker for two to three months. These care workers had previously attended four training sessions with us and were supervised by mental health professionals, like community psychiatric nurses, though the latter never actually met residents. The extra care time was used to work on three or four modest life-improvements, which the resident named as especially important to them. Examples include transport to visit friends, large print books, help to sit outside in warm weather, improvement of hearing aids, or simply time to talk about their feelings.

Those depressed residents, who received this personalised help, showed pronounced improvements on rating scales for depression. Whereas a comparison group of depressed fellow residents in the same care homes, who continued to receive only ordinary care, did not improve. Statistically, there is less than a one in thousand probability that this difference could occur by chance. Factors like anti-depressant medication were not an explanation.

Gains from this straightforward holistic care approach are especially important because depression is so common among older people who use social care services. Typical proportions are 40% in care homes and 25% on home care lists. As well as bereavement, common causes for depression among older people include ailments, like arthritis or sight problems, which restrict a favourite activity – like going out, reading or knitting. Thus the types of help mentioned earlier can address the root causes of some people’s depression.

In this intervention project, an in-depth structured interview explored what mattered most to each participant – see panel one. This was conducted by a regular care worker for that person, who had volunteered for the research, and who implemented the resulting plan for extra help. The training sessions prepared care workers for this care planning process. Often the resulting care plans included getting out and about, enabling contacts with friends or relatives, resuming religious activities or reviving old hobbies. They also often included referral for physical health check-ups or treatments. Thus the interventions combined social and health care.

Greatest improvements on the depression rating scale occurred among residents who had been particularly seriously depressed. The interventions also benefited some people with a combination of depression and mild or moderate dementia – but not people with more advanced dementia. This is probably because dementia could limit the type of help possible.

Care staff were often very enthusiastic about the approach. Afterwards, some thought the holistic care planning approach should be used for all residents, not just for those who were already depressed.

During the intervention period, care staff managed to give the extra care within their ordinary work time by swapping round tasks. But this was clearly difficult and we believe that, for this approach to be sustained, some extra care time needs to be purchased. However, costs need not be large.

This project did not invent a new way of caring. There are always some dedicated care staff who intuitively devise holistic, person-centred help for older people whom they know well. Rather, our project demonstrates a system for reaching depressed service users, who particularly benefit from such care. They may be too depressed or uncommunicative for staff to engage with them, were it not for this structured approach and support from a mentor. Our project also demonstrates a system for promoting this approach among a whole staff team. Very important too, it provides much-sought, scientific proof that such person-centred, holistic help can produce valuable, measurable outcomes for mental health and well-being.

But a notable obstacle exists. This is the stance whereby some local authority purchasers discourage help for well-being, as part of trimming all services which they deem non-essential. As described in the Commission for Social Care Inspection’s 2006 report Time to Care?, they minimise the length of home care visits and limit care to specified physical care tasks (3). Another study of home care described how some purchasers discourage help for older people’s well-being even when cost-free, on grounds of imagined, quite rare risks to efficiency, which are considered more important (4). Behind this can lie a view that only physical care matters for a local authority – and relentless searching for economies as central government fails to increase funding in line with rising need among older people (5).

Such policies miss the whole point of care services. Care is never complete if service users are depressed for lack of the simple, low-cost help with quality of life, which our study found to make such a difference. This holistic approach embodies so much good recent government policy: well-being and choice, older people’s mental health, joint social and health care, and person-centred service. National and local government are wasting a proven opportunity to achieve the professed new goals, if they do not ensure the funding and the will to apply it.

Assistance with the research was received from: Professor Ian Sinclair, Philip Young, Christine Kirk, Maggie Browne, Eryk Grant, Sue Gildener, Professor Ian Russell, Professor Anthony Mann. Assistance with this article from Charles Patmore.

Funded jointly by: National Health Service Executive, Wyeth Laboratories, Sir Halley Stewart Trust, Purey Cust Trust and Jack Brunton Charitable Trust.

References
(1) Our Health, Our Care, Our Say: a new direction for community services, Department of Health, 2006

(2) K J Lyne, S Moxon, I Sinclair, P Young, C Kirk & S Ellison ‘Analysis of a care planning intervention for reducing depression in older people in residential care’, Aging & Mental Health, 10, (4), 394-403, 2006

(3) Time to Care? Commission for Social Care Inspection, 2006

(4) C Patmore & A McNulty Caring for the Whole Person: home care for older people which promotes well-being and choice. Well-being and Choice Publications, 2005

(5) Without a Care? Local Government Association, 2006

Further Information
www.well-beingandchoice.org.uk/ReducingDepression.htm supplies weblinks to comprehensive information about this research project – summary, research reports, and details about intervention methods and the training given to care staff.

These webpages also carry information on accessing the training materials and obtaining bulk copies of a printed four page summary of the research for dissemination within a service.

Author notes
This research project was led by Dr Jake Lyne, Director, Psychology Services, North Yorkshire & York Primary Care Trust. Sallie Moxon was senior researcher.

Contact: Mental Health in Residential Homes Project, Psychology Services, North Yorkshire & York Primary Care Trust, Bootham Park, York YO30 7BY, UK. Tel. 01904-725725

Contact person: Dr Jake Lyne, c/o tracey.daniels@nyypct.nhs.uk