The authors are affiliated with the Brown School of Social Work, Washington University, 1 Brookings Dr., Campus Box 1093, St. Louis, MO 63130 (e-mail: ekp@wustl.edu).

Depression is a major chronic illness that affects one-fourth to one-fifth of community-dwelling older adults (1,2). It diminishes quality of life, exacerbates physical and functional dependency (3,4,5,6), and increases medical costs (7,8). Although depression in later life can be effectively treated, most elderly people with depression remain untreated (9). Older adults are vulnerable to mental health service barriers (10), low detection and treatment rates in primary medical care (11,12), and pervasive stigma—their own as well as that from their family members and treatment providers. Depression treatment is further complicated by comorbidity with other problems. Although older adults with functional disability have higher rates of depression (13), they and their providers may demote depression treatment to a lower priority when medical, functional, and psychosocial comorbidities vie for attention (14). Competing demands may diminish depression as a priority concern, thereby contributing to inadequate rates of depression treatment (15).

This study explored depression as a treatment priority among a group of older adults with comorbid conditions. All were receiving public community long-term care. Every U.S. state provides community long-term care. As a public safety net, community long-term care helps low-income people with chronic conditions compensate for functional disabilities by providing case management and supportive in-home services from certified nursing assistants or in-home aides, including personal care; help with physical activities of daily living, such as cooking, cleaning, laundry, and bathing; medication management; and home-delivered meals. Qualification for public community long-term care requires Medicaid eligibility and severe functional impairments that carry risk of nursing home placement. Of new, elderly community long-term care clients, 18% show symptoms of depression, and an additional 7% meet criteria for major depressive disorder, 2.5 times the rate among older adults in general (16). They also experience such psychosocial problems as self-neglect, grief, economic hardship, housing concerns, difficulties accessing health care, and social isolation. Community long-term care is the kind of service system suggested in the report of the President's New Freedom Commission (10) as having high promise to improve treatment of mental disorders in vulnerable populations.

This article reports results of a mixed-methods study with two aims: one, to examine older adults' perceptions of depression in relation to their other life problems, and two, to compare priorities for treating depression with priorities for solving other problems. Effective and durable improvements to mental health care must be shaped by an understanding of client perceptions, preferences, and priorities.

Participants

The study's homogeneous purposeful sample (17) comprised publicly funded community long-term care clients living in their homes, age 60 or older, and with a history of depression. Recruitment letters were mailed to 109 individuals whose depression had been established through a score of 9 or higher on the Center for Epidemiologic Studies Depression Scale or a Diagnostic Interview Schedule diagnosis of major depression in a prior clinical epidemiological study (16) and who consented to follow-up contact. Sixty-six individuals responded to the letters (61%) and agreed to be contacted for the study. Respondents did not differ from nonrespondents by depression presence or absence, education, or gender, but they were significantly older (p=.02) and slightly but not significantly more likely to be white and to live in urban communities. Both studies excluded persons with severe cognitive impairment and non-English-speaking individuals.

Procedures, data collection, and analysis plan

Interviews were conducted from November 2005 through July 2006 in urban and rural regions of one Midwestern state. A telephone screen, completed with all 66 participants who responded to recruitment letters, included demographic and health information, current depression status per the Patient Health Questionnaire-9 (PHQ-9), and current cognitive status per the Short Portable Mental Status Questionnaire (SPMSQ) (18). Those with SPMSQ scores of 4 or greater, reflecting moderate to severe cognitive impairment, were ineligible for the in-depth interview (19).

In-home interviews were conducted with 49 participants. Of the 66 persons screened, two refused to participate further and 15 were ineligible because of cognitive impairment, not meeting the depression criterion of the PHQ-9, or relocation from the region. Five trained and supervised master's-level student research assistants conducted the interviews, which lasted between 15 and 105 minutes and were audiotaped with respondents' permission and transcribed. Participants were paid $20.

Four-part, mixed-methods interviews sought to capture participants' perceptions of the life problems and concerns they experienced, as well as the priority they placed on depression. Part 1 involved listing problems. Participants were asked to identify a maximum of "five biggest problems in your daily life right now." Each of these problems was recorded on an index card, and participants confirmed that the card text accurately stated their problems.

Part 2 was an acknowledgment of depression: To capture participants' perceptions of current depressive symptoms and status, the interviewer introduced an additional card listing only the PHQ-9 depression symptoms endorsed by the participant during the telephone screen. Because this card did not have a preestablished name, the interviewer explored participants' thoughts and acknowledgment of depression to name the card, using such probes as "Have you ever thought that these problems were related to depression?" "Has anyone ever suggested that these problems may be related to depression?" "Other people call this problem nerves, feeling down, and mood; do any of these terms describe this problem for you?" "Is there something else that you would like to call this card?" If an independently generated problem card duplicated symptoms listed on the PHQ-9 card, the texts of these cards were combined on the participant's approval.

Part 3 captured the participant's perception of depression's relationship to other problems. The participant was shown the PHQ-9 card and was asked how his or her other problems and PHQ-9 symptoms were interrelated. Responses were recorded.

Part 4 prioritized depression among other problems. The interviewer asked the participant to rank the life problem cards in order of importance by stating, "These are all the problems from our list and your list that are causing difficulty in your life right now. I want you to think about these problems and pick out the problem you would most want to be resolved or 'fixed.' There is no right or wrong answer." After the participant identified the problem that had the highest priority, the interviewer asked, "what is the next most important problem?" As the participant ranked the problem cards, the interviewer recorded the priority number on each card and then reviewed all cards and asked the participant to confirm the rank order.

The study was approved by both Washington University's Human Subjects Committee and the state's Division of Health and Senior Services Human Subjects committee. Participants gave verbal consent for the telephone screening and written consent for the in-home interview.

Data analysis

Identified problems were coded into categories through an iterative, content-analysis approach (20). Five members of the research team collaboratively reviewed all of the problem cards to develop categories. Two team members then coded the problem cards into the categories, with 90% interrater reliability (κ=.90). A final set of categories enabled quantitative analysis.

Data on participants' perceptions of depression and depression's relationship to other problems were analyzed with NVivo qualitative data analysis software (21) for transcript coding. Using an editing-style analytic approach, coders identified text segments that represented themes related to the study purpose (22). Although derived themes were similar to those developed from respondents' problem categories (family, money, and frustration with medical care), additional categories emerged, such as disappointment and regret with life. The team's project journal was used to track coding practices.

Participants' priority rankings for each problem were scored as follows. For each participant, a relative rank variable was computed for each problem by dividing the original rank by the total number of problems listed by the participant. The relative ranks were then subtracted from 1 to yield a variable ranging from 0 to 1, with 1 reflecting the highest possible relative rank and 0 the lowest. We then identified the problem that each participant considered most important and the problem that each ranked as least important. Rank data, along with data on demographic characteristics, PHQ-9 items, and the problem categories, were analyzed with SAS version 9.1 for Windows (23). Student's t tests and Fisher's exact chi square tests were used to explore the relationship of depression severity to problem categories and ranks. Depression severity was dichotomized, with PHQ-9 scores between 5 and 9 coded as mild and scores of 10 or above coded as moderate to severe as outlined by Kroenke and colleagues (24).

Table 1 presents participants' demographic and mental health information.

Perceptions of depression in relation to other problems

As shown in Table 2, most participants identified health and functioning problems, and about 40% reported emotional problems, such as grief, loneliness, worries, boredom, or memory problems. Financial, family, and health care problems were also common. Identification of only two problems varied by depression severity: functional problems, specifically problems with getting up and around in the home and being unable to do things, were significantly associated with depression severity. Those with mild depression were significantly more likely to identify family problems as having higher priority. Only three people—all moderately or seriously depressed—self-identified depression as a problem.

When shown their PHQ-9 symptom card (completed during the telephone screening), about half of the respondents (53%) labeled the PHQ-9 symptom card as depression or said that someone had suggested they had depression; others were unsure what to call the symptoms or attributed the symptoms to a health condition, grief, or pain, as reflected in such comments as "[This is] just life … yeah, because I let my life go to the point that you know, that … well okay, [there is] little interest or pleasure in doing things," "When you're on fixed income you don't have much money," and "I guess [I'm] disgusted with the way things turned out."

When asked how depression is related to other problems, some participants said that they did not know: "I don't really know. I don't know where the [depression is] coming from, I really don't. I just get like that sometimes and I don't know why. I can't tell you why." And, "I don't know… . Because I had depression for years, I think it's just a normal thing with me, being depressed about things." For others, there were clear connections between depression and the other problems they identified, as reflected in such comments as "I think it's because of my health that I have all this because I feel so down"; "The depression and hopeless feelings is caused from … the things I can't do"; "It's probably because you're expecting to [do] better with your life"; "Just plain loneliness… . Now you wouldn't think I would be lonely with all of these people around, but you are" and "Stretching money to meet the needs … and you want to go here or yonder, … and you don't have the extra money and you can't go."

Priorities of depression and other problems

Nearly half of the participants (40%) ranked health as their first-ranked problem (Table 2). Functioning, emotional well-being, and family problems constituted about one-tenth of participants' first-ranked problems. Only 6% of participants ranked depression as the most important of their problems, whereas 45% ranked it last in importance. Relative rank scores for the various problems were remarkably similar (range=.31—.52) with the notable exception of depression, which had a relative rank score of .19, lowest of all.

The priority of only one problem—money and finances—varied by depression severity. Money was a higher-priority problem for participants with mild depression (mean±SD= .60±.18) than for those with more severe depression (.37±.27; t=2.16, df=16, p<.05). The relationship between depression severity and its own priority ranking approached significance, ranked higher by those with moderate to severe depression than by those with mild depression.

The relatively small, homogeneous sample of older adults studied here limits generalizability. All respondents had participated in a prior study, but the studies had different questions, interviewers, and methods. Given that much literature on depression perception has come from general population studies, this sample provides the important insight of older adults currently experiencing depression.

Consistent with findings of other studies, the depression co-occurred with health problems and functional impairment (25,26,27,28,29,30). But another type of comorbidity—psychosocial—is prominent in these findings. Psychosocial comorbidity comprises social, interpersonal, socioeconomic, family, and environmental issues, as reflected in DSM axis 4 (31). Although psychosocial comorbidity has received less attention from researchers than medical and functional comorbidity, DSM-IV notes that it may trigger or exacerbate a mental disorder, develop as a result of psychopathology, or constitute problems that need to be considered in managing mental disorder (31). Psychosocial problems are more prominent in public systems of care, but their co-occurrence with depression should be explored in other settings because they may be as common as medical problems among older adults and because quality of care for psychosocial needs is poorer among older adults with depression than quality of care for functional, medical, or psychiatric needs (32).

Stigma may help explain the fact that few older adults identified depression spontaneously as one of their problems (7,33,34,35), although participants acknowledged that others had characterized their condition as depression, and the sample had relatively high rates of past and current depression treatment. Their infrequent identification of depression may also reflect their view of its close association with other problems, particularly those pertaining to physical health, social support, physical functioning, and pain—a view consistent with the biopsychosocial perspective (36,37,38) and social models of depression (39), in which depression is viewed as arising from adverse personal and social circumstances that accrue in old age (40). Finally, the low ranking of depression may reflect low self-efficacy and a sense that late-life depression is inevitable.

Co-occurring medical problems may compete for time, attention, and priority among older adults and their mental health care providers (14,15, 41). These findings demonstrate that psychosocial problems also compete strongly—and often successfully—for priority among older adults, suggesting that the acceptance and effectiveness of depression treatment may depend on providers' ability to connect it to problems higher in priority to the older adult.

Older adults with depression experience multiple health, functioning, and psychosocial problems, and services are needed to deal with them (42). Service providers will be challenged to adequately respond to the wide range of problems that co-occur with depression. Engaging older adults in mental health treatment may be complicated by their reluctance to identify depression and by depression's relatively low priority in the mix of competing problems. When depression is seen as a low priority, adherence to mental health treatment may be undermined (43) and risk of treatment dropout may rise (44).

Mental health care providers should elicit older adults' perspectives on depression and approach depression care within a social context, linked to other medical and social services. Depression care may need to be "rationalized," or explained in the framework of psychoeducation or motivational interviewing. Disease management approaches to depression treatment (45,46,47,48,49,50) that include use of a therapeutic alliance, case management, patient education, and problem solving around co-occurring problems may be needed to motivate and engage older adults. Nonspecialty settings such as that studied here may be well positioned to engage older adults in depression treatment. Providers' existing relationship with older adults may help them see the value of treating their depressive symptoms and may help them link with primary medical care and specialty mental health depression care.

The preparation of this article was supported in part by the Center for Mental Health Services Research, George Warren Brown School of Social Work, Washington University in St. Louis, and by award 5P30-MH-068579 from the National Institute of Mental Health.

The authors report no competing interests.