Depression is very common among older people and often goes untreated.  Common causes are loss of relationships through bereavement and loss of role. Another frequent cause of depression in older people is physical disabilities which prevent roles or activities which a person has especially valued. Difficulty in travelling outside one’s home is a common example. Others would be loss of valued activities like needlework, reading or writing through eyesight problems or arthritis.

Depression is especially common within services for older people with many physical disabilities. Surveys have found around 25% of older home care customers to be depressed. Among another such group, older people who live in care homes, the proportion is around 40%.

As life expectancy increases, more people suffer age-related physical disabilities. According to the 2006 White Paper, Our Health, Our Care, Our Say: “One of the greatest long-term challenges facing the health and social care system is to ensure that longer life means more years of health and well-being”. This concerns all services for older people – health services and social care, nursing and care homes, sheltered housing and home-based support services. How can they respond to depressed older people in their care?

This intervention project explored whether depression could be reduced among older people, living in care homes and typically aged over 80, through guiding their regular care staff to assist life-improvements which particularly mattered to an individual. 

14 registered homes for older people in North Yorkshire took part. Just over half of the care workers at these homes volunteered to participate.

First, participating care workers took part in four 3-hour training sessions about depression and older people. These were conducted weekly in the care homes by specialist mental health professionals - see Panel One.

Next, each participating care worker was assigned to one or two residents who were depressed according to the self-report Depression Scale of the Geriatric Mental State Schedule. Where possible, care workers were assigned to residents for whom they were already keyworkers.

An intervention group and a control group

87 depressed residents were thus assigned to a care worker for the intervention project. They were drawn from a total of 114 older residents who all had been assessed as suitable for the project because they were depressed, willing to take part, and did not suffer from severe dementia. For the remaining 27 depressed residents, their regular care workers were not available and there were insufficient care staff to include them. Accordingly, they were studied as a control group. The research team carefully established that there was no difference between them and the 87 residents, who did receive the intervention, in terms of degree of depression, dementia, whether they were receiving anti-depressant medication or any identifiable demographic characteristic. The only difference was that they did not receive the extra help which the project was testing.

The method for intervention  

Each participating care worker was assigned to a Community Psychiatric Nurse or an Occupational Therapist, as a mentor to guide them. Weekly one-to-one contact was available with the mentor. However, the mentor never met the depressed resident whom they were discussing with the care worker.

Eight weeks were assigned for the intervention process, though for around half the recipients it took some weeks longer. First step was for the care worker to conduct a structured interview with the depressed resident. This covered their life history, past and present leisure interests, their strengths, their likes and dislikes, their physical health,  and their relationships in the care home. It also established what currently mattered most to them. Next the resident, with the help of the care worker, identified around three or four specific life-improvements, which the resident desired, and a plan for achieving these. Care workers documented the interview and the intervention plan according to a standard structured format. Often care plans included re-establishing contact with friends or relatives, resuming religious activities, resuming a hobby, supportive listening, or arranging physical health check-ups and treatments – see Panel Two. Almost everyone received some sort of psycho-social help.

Two examples:

• 86 year old Mrs A was depressed and suffered much pain and discomfort from angina and ear infections. She used a wheelchair. She sought help to keep up visits to friends, which mattered greatly to her, but she did not like to keep asking for it. Accordingly a system was set up for supplying an escort on a routine basis for her to visit friends. Likewise she obtained a programme of regular afternoon trips to places of her choice, sometimes with friends. Her wishes were granted for some regular quality time when she could confide in her keyworker. Her keyworker identified Mrs A’s preferences concerning certain routine physical care tasks and briefed other care staff as to her wishes.

• 96 year old Mrs B had been pre-occupied with recent bereavements and problems in selling her house. She responded to the suggestion of having her major hearing problems investigated in order to improve contact with others. Her keyworker encouraged her to restart knitting, once her favourite hobby. They started by Mrs B teaching her keyworker to knit. Mrs B began communicating much more with residents who shared her interest in knitting. Her mood improved considerably both on test scores and in the opinion of relatives and the care home manager.

At four stages during the study, assessments of depression were made for both the 87 depressed residents, who received the intervention, and the control group of 27 depressed residents who did not. These assessments used the self-report Depression Scale of the Geriatric Mental State Schedule. They were conducted by two mental health workers who played no other part in this research and never knew whether a resident was receiving extra help or not.

By twenty weeks after starting, when the intervention programme was completed for all recipients, depression ratings showed pronounced improvement among the 87 person intervention group. Many recipients had ceased to be clinical cases of depression. But there was no such change in the control group. Statistically, there is less than a one in a thousand probability that this difference could occur by chance. Factors like anti-depressant medication were not an explanation.

What sort of people benefited most?

Improvements were most pronounced among people who initially had been more seriously depressed. While residents with the most severe dementia were excluded, participants included some people with varying degrees of dementia. The majority benefited except for a group with moderately severe dementia. This might reflect that dementia limited the type of intervention which care staff could implement with a person.

The views of care staff

Most staff found it a positive experience. Some felt empowered to take much more initiative in how they helped residents. Gains in knowledge and understanding about individual residents were appreciated. In some homes, according to staff, this new approach to depression had influenced workers who had not participated, via staff meetings and informal contact with those who had. Some staff hailed the individualised approach to well-being as desirable for all residents.

Practical issues

Care staff suggested that the intervention best came from a worker with whom the resident had a good relationship – like their keyworker. 

Time for one-to-one contact was very important. It did not always prove possible to conduct the intervention programme tasks alongside established staff routines. Staff often circumvented this by exchanging duties or working extra in their own time. For sustaining this intervention approach, at least a modicum of extra staff time should be allocated.

This study has demonstrated how depression can be reduced among older care home residents through fairly simple interventions. This approach could be applied elsewhere very readily for these reasons:

• It can be used by unqualified staff.

• The necessary training is brief and the materials used are being made available nationally.

• The trainer and mentor roles can be supplied by mental health professionals available in Community Mental Health Teams in many localities.

• The approach has an intuitive, commonsense character which makes it easily grasped and well-liked.

This intervention method could also be applied by home care staff, District Nurses, and staff in sheltered housing. Any service for older people may have many depressed service users who could benefit.

Arguably, the approach also should be investigated for preventing depression, now that it has been shown as effective for reducing it. Some researchers have recommended that those older people, who are encountering seriously disabling illnesses, should routinely receive help to ameliorate the impact of their disabilities with a view to preventing depression. There is evidence of a high prevalence of depression among older people in hospital wards.

Relevance to national policy

This approach offers an evidence-based route towards national policy goals. In the National Service Framework for Older People, it addresses Mental Health in Old Age and Healthy Ageing.  More globally, it implements person-centred care through personalising interventions around the priorities and choices of each individual. It offers a means for implementing in attainable, practical ways the goals of ‘well-being and choice’, affirmed by the 2006 White Paper, Our Health, Our Care, Our Say.  The approach described here might have applications in many services for older people – both residential and domiciliary care, treatment and prevention, both health and social care.

For future application, the following should be noted

• Front-line staff need reasonable amounts of extra time and encouragement to deliver the gains described.

• They need flexibility to address both health and social care goals, according to each service user’s individual priorities.

• Time is required from Community Mental Health Team staff to train and support care workers. This needs to be resourced.

Vindication for holistic, person-centred approaches

This research provides vindication for services which work with older people in a holistic and person-centred way and which include help for quality of life.  It demonstrates how time thus spent can produce measurable and important outcomes.

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