Dr. Munson is affiliated with the Mandel School of Applied Social Sciences, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106-7164 (e-mail: firstname.lastname@example.org). Dr. Proctor, Dr. Morrow-Howell, and Ms. Fedoravicius are with the George Warren Brown School of Social Work, Washington University, St. Louis, Missouri. Dr. Ware is with the Department of Psychiatry, Harvard Medical School, Cambridge, Massachusetts.
The President's New Freedom Commission recommended introducing mental health screening and early intervention in accessible, low-stigma, and high-risk environments, especially among federally funded health and human service systems (1). Recommendations in the report target pervasive problems in the U.S. mental health system, such as persons with a mental disorder not receiving treatment and increased functional disability associated with a fragmented system of care. However, these recommendations may be difficult to implement in social service settings. Mental health problems affect significant proportions of social service clients, but often mental health is not the primary focus of such agencies. Moreover, many human service workers may lack the tools and training required to adequately address depression.
This study sought to understand how case managers in community long-term care, one publicly funded (largely Medicaid) social service system, make sense of depression among their clients and their role in responding to their clients' depression. Community long-term care exists in every U.S. state to address the service needs of low-income older adults with chronic conditions and functional disabilities (2). In many states case managers working in community long-term care are expected to note mental health information. However, given the agency's focus on functional disability, along with its heavy caseloads and limited resources, exact roles and expectations in regard to mental health are unclear.
Depression is common in later life. In community samples 20% to 26% of older adults evidence clinically significant depression (3). A disproportionate number of elders in community long-term care are likely to experience depression as a result of physical dependency and low income. One clinical epidemiological study found that about one-fourth of new clients entering community long-term care have depression (4).
Research underscores the public health burden of depression in our aging society (5). Depression diminishes quality of life, exacerbates physical dependency, and increases medical costs (6). Although efficacious treatments for depression in later life exist, most elders with depression remain untreated (7). Few elders find their way to mental health specialists, and mental disorders often go untreated, or poorly treated, in primary medical care (8). However, growing numbers of elders are served by social services, which have the potential to address depression. Despite the high prevalence of depression in community long-term care, little research has addressed mental disorders in this system.
The challenge of responding to mental disorders in non-mental health settings may be conceptualized as one of competing demands (9). Non-mental health settings have priorities other than depression; if depression is to be addressed, it must compete for attention with other demands that are the focus of the system. In the case of community long-term care, depression competes for attention with clients' pressing functional and psychosocial needs. What appears to be poor depression care may simply be the rational prioritization of competing demands in complex, multiproblem situations (10). Because of case managers' primary role of addressing clients' functional dependencies, this study examined case managers' perceptions of client depression and their views on strategies for addressing depression.
In defining the sample, we sought to represent geographic variation and identify individuals willing to express their views in a group. Thus participants were recruited from three geographically distinct regions chosen to represent rural, suburban, and urban areas of one Midwestern state's community long-term care system. Names of prospective participants were suggested by the managing administrator of each region. Eighteen case managers volunteered to participate in the study: 78% (N=14) were female and 67% (N=12) were white. A study of community long-term care workers in the same state reported similarly high percentages: 87% (N=109) female and 83% (N=105) white. Half (N=9) were from the urban region, 17% (N=3) were from the suburban region, and 33% (N=6) were from the rural region.
An interview guide was developed with four questions: Where do you think responding to a client's depression falls in terms of the client's overall problems? What do you see as the realistic options of getting treatment for clients? What do you see as a realistic role for case managers in responding to depression? What do you see as the biggest barriers to getting services for depressed elders? Additional probes were used to elicit more information. Participants were also asked to envision ways to improve the system's response to depression. Informed consent was completed before each group began. Washington University's human subjects committee approved all study procedures and documents.
Data were generated between February 2003 and April 2003. Focus group meetings lasted between 60 and 90 minutes. Interviews were audiotaped and professionally transcribed. Two researchers took notes. Notes and transcripts were compared to ensure that content was not missed. Members of the research team reported hearing repetition, indicating that the point of saturation had been reached and the amount of data collected was adequate (11).
Grounded theory methods were used to construct content categories and identify relationships among categories (12). Four investigators independently read all transcripts, labeling chunks of text found to be pertinent to the research questions. Investigators then grouped these data elements together on the basis of content similarity and assigned higher-order labels—for example, need for training. This procedure yielded four sets of content categories. Next, investigators collectively compared and contrasted the four sets, reducing them to a single set. Categories were assembled into a codebook. Then, using Nvivo qualitative software, two researchers reread and individually coded one transcript, 25% of the data. When coding discrepancies appeared, decisions were made together regarding how to resolve them. One researcher coded the remaining data. Investigators discussed the coded data, which led to further understanding of the meaning of participant responses. Relationships between categories were examined by the investigators. Through this process, we confirmed categories, or constructs, from previous literature, while adding new categories in order to better understand case managers' views.
Single quotations are utilized to illustrate ideas in this section. [An appendix showing additional quotations is available as an online supplement at ps.psychiatryonline.org.]
Comments such as "more than 50% of my cases have some kind of depression" suggest that community long-term care likely has a high volume of clients that case managers perceive as being depressed.
Previous research suggests a bidirectional relationship between depression and comorbid physical illness and functional status (13). This study uncovered how case managers experience this complexity. "It is sort of passive neglect. … It comes from depression. I have lots of clients who will not eat because of the depression, and essentially, they want to die." This suggests that workers perceive that poor nutrition and wanting to die may be consequences of depression. In contrast, the statement "They are mildly to severely depressed because of their life situation. … Their health has deteriorated. … They don't have control over their situation, and they feel like they can't do anything … so yeah, they are depressed" suggests that workers also view declining physical health as an antecedent of depression.
Researchers debate whether case managers manage care, link to resources, coordinate services, clinically intervene, or provide some combination of these functions (14). "We don't really have the luxury to say, 'Well you are this depressed'. … We have to deal with what we've got right in front of us, and that is the person is maybe living in substandard housing with a very fractured social network or no social network or a limited ability to get around. … We are trying to deal with those issues the best we can with what we've got to work with, which is limited resources." This reflects a view that the primary role of case managers in community long-term care includes managing concerns related to maintaining clients in their homes and linking them to services.
Providers in community long-term care, similar to those in primary care, often serve as "gatekeepers," making referrals and arranging services. City and suburban case managers made statements such as "We refer them to mental health." However, rural workers made statements such as "When I was in a city county, we could call our resources, and you could get some things taken care of. In [this rural county] we beg and plead, and they have no money," suggesting a lack of services. Several rural workers did mention a specific doctor by name that they regarded as helpful in addressing depression. This suggests that rural workers do make referrals, but they are to providers known by name and within a more restricted range of options.
"If we had training … and got updated on the latest drugs … we could do lots of good things for our seniors." Case managers repeatedly expressed a need for specialized knowledge, skills, and training. This further highlights a potential role conflict.
Research in primary care suggests that during service encounters competing priorities exist within the client, clinician, and system domains, which reminds us that managing depression requires active choices among multiple priorities and multiple stakeholders (15). Workers in community long-term care echoed this perspective.
Klinkman (9) suggested that client beliefs and lack of time because of other illnesses may lead to resistance when depression treatment is suggested. "I call them 'country'. … They have lived in a rural area all their life, and they have certain beliefs and superstitions. … They are afraid of doctors. They are afraid of certain kinds of medications." This suggests that providers in community long-term care perceive that cultural beliefs can be a barrier to addressing depression. With regard to other illnesses, one worker paraphrased a client, "I have dialysis three times a week, and then I have to go to the doctor every month, and then I have to do this."
Case managers face the reality that addressing a serious case of depression among one client may take time away from another client. "We could use more training … because unless they specifically say something about their depression, I'm going to see if the house needs cleaning, if they need a bath. … I'm going to look at the practical stuff … and then I got to swim with that." Further, the quote "I'm aware of depression, but we are so driven by time frames and pushing paper" illustrates the sentiment among caseworkers in public systems of care that time constraints and endless paperwork get in the way of depression care.
With regard to payment, one worker reported, "There have been changes in the Medicaid system … it is going to come down to whether they buy medicine or buy groceries." Community resources were also discussed. "Some counties have more resources than others. … [This county] doesn't have a lot of resources." Together, these data suggest that workers in community long-term care perceive competing demands in multiple practice domains that are similar to those found in primary care medicine (15).
Views of depression care varied. City and suburban workers reported service options, saying "We have several doctors who will cut through and make house calls." In contrast, rural workers made statements such as "It said on my resources they actually had to be pulling the trigger before they send help," suggesting fewer available options.
Workers mentioned the importance of interaction when envisioning ways to address depression among their clients. "I think we need more friendly visitors to go in … just talk to them." Others advocated for standardized detection tools. "We could use that geriatric scale tool that we have … we could use that as an option to try to identify a person that is depressed." Others reported, "I think we have a great need for geriatric doctors and nurses."
Despite its primary focus on clients' functional needs, the community long-term care system has high potential to respond to depression. As with public mental health care, community long-term care is state administered with variation across state systems. However, across settings and populations, case managers face the challenge shared by those studied here: they provide the first contact, conduct assessments, and serve as gatekeepers in addressing health, mental health, and psychosocial needs of frail elders.
The President's New Freedom Commission has recommended that systems such as community long-term care introduce systematic screening and early response to mental disorders. Although these recommendations are ideal in theory, data from this study suggest that the implementation of these recommendations in an environment of competing demands will be challenging. Participants evidenced frustration with their limited capacity to respond to depression. They expressed a need for training, more client face time, and depression screening tools. Consistent with the concept of competing demands, depression in community long-term care competes—often unsuccessfully—with pressing physical, functional, and psychosocial needs for the time and attention of both client and providers. Any attempt to improve depression care in community long-term care must consider competing demands, as well as provider needs for specified knowledge, technical capacity, and connections with specialty mental health services.
Although only four focus groups that had a small number of workers were conducted, the data clearly depict the challenges in addressing the mental health needs of clients in this public system of care.
National reports call for changes in our mental health system to address gaps in our current delivery of services. One recommendation is the introduction of mental health screening and evidence-based interventions in social service settings. The study presented here suggests that in order to implement and sustain such changes, it may be critical to redefine case managers' professional role and address the competing demands that hinder their capability to address depression. Simply introducing screening or expecting individual providers to implement changes in their practice will not suffice. Participants identified the need for systemic changes to increase their professional capacity. System administrators will need to provide support for such changes. Trainings may help to provide basic education, or health literacy, regarding depression. Introducing intensively trained depression specialists who can provide direct service and consultation may improve care among depressed elders.
The preparation of this article was supported by the Center for Mental Health Services Research, George Warren Brown School of Social Work, Washington University in St. Louis, and through award 5P30-MH-068579 from the National Institute of Mental Health. The authors thank Jerry Floersch, Ph.D., for comments on this article.
The authors report no competing interests.