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a Department of Psychiatry, University of California, San Francisco
Correspondence: Patricia A. Areán, PhD, UCSF Department of Psychiatry, 401 Parnassus Avenue, San Francisco, CA 94143. E-mail: pata{at}lppi.ucsf.edu.
Decision Editor: Eleanor S. McConnell, RN, PhD
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Abstract |
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Key Words: Psychological services • Preferences • Older adults • Primary care medicine
Many studies have shown that older adults with mental health needs are greatly underserved (Black, Rabins, German, McGuire, and Roca 1997
; Swartz et al. 1998). Older adults are rarely seen in the specialty mental health sector (Shapiro et al. 1984). Instead, older adults seek help for psychosocial problems in general medical settings (Callahan, Hui, Nienaber, and Musick 1994; Gallo, Ford, and Marino 1995). Because of this utilization pattern, research and policy have turned their focus to integrating mental health services into primary care medicine. This integration increases access to both medication and psychological services by addressing provider and system constraints that typically interfere with the adequate delivery of mental health care in primary care medicine (Unutzer et al. 2001). Among several practice redesign strategies, one method to increase access to mental health services involves training clinic staff in the delivery of state-of-the-art medical and psychological interventions (Arean, Hegel, and Reynolds 2001). The psychological interventions offered in these models include individual brief therapy, group therapy, and psychoeducational classes, all of which have been shown to be efficacious in treatment studies with older adults (Gatz et al. 1998). It is hoped that along with the redesign of the primary care system, the integration of psychological services with medicine will improve the quality of care older people receive in medical settings.
In considering the integration of psychological services into the primary care system, clinics that serve a large number of older patients may wonder whether psychological services would be acceptable to older people, and if so, which type of service should be offered and who should deliver the care. The treatment preference literature is only partially helpful in answering these questions. Although recent research suggests that older people in general find psychological services to be an acceptable treatment alternative, the data from this literature are limited to older people's opinions about treatment, rather than if they themselves would ever use these services (Landreville, Landry, Baillargeon, Guerette, and Matteau 2001; Rokke and Scogin 1995; Speer, Williams, West, and Dupree 1991). Although people may feel that an intervention is beneficial for treating a disease state, this does not necessarily mean they would elect to use the treatment themselves. Thus, we know little about older people's willingness to use psychological services. The preference literature is further limited by the fact that few studies have asked primary care patients about the type of psychological services they would use. Although research on younger primary care patients suggests they have a preference for psychoeducational classes and individual counseling (Alvidrez and Azocar 1999; Arean and Miranda 1997; Cooper-Patrick et al. 1999), no research has yet evaluated whether older primary care patients would state similar preferences for services.
Finally, the literature is even less informative about whom older primary care patients would prefer to talk to about their problems. Research suggests that older primary care patients may be reluctant to use specialty mental health services because of stigma issues, but there is no empirical evidence to suggest that this stigma concern would be evident for services offered in primary care medicine (Arean and Gallagher-Thompson 1996). Although older adults are more likely to talk about a mental health problem during a medical visit than younger adults, this finding does not necessarily suggest that they prefer talking to primary care providers rather than mental health providers about their problems (Gallo, Ford, and Marino 1995). Thus, there is little research to recommend who should deliver psychological services to older primary care patients.
Before primary care clinics can integrate psychological services into their practice, they must first know the proportion of older people who would be willing to attend psychological services, decide which services to provide, and determine which providers should deliver the services. To help elucidate the preferences of older primary care patients, we conducted this study to answer the following questions:
Unlike other preference studies with older adults, this study can answer these questions for patients who are currently showing signs of psychological distress. By asking patients their service preference while they are in need of such services, we can more accurately determine what services older people would accept when the need arises.
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Methods |
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). The larger study used a consecutive sample of adults aged 55 and older selected from four public sector, primary care clinics in San Francisco. Of the 300 eligible patients approached, 221 people agreed to participate and 183 provided preference data. Of these 183 participants, 68 were female (37%), 32 (18%) were African American, 38 (21%) were Hispanic, 97 (48%) were White, and 24 (13%) were Asian. One third (32%) of the sample had three or more acute medical problems in the previous six months, and 46% had three or more chronic medical problems. Table 1 and Table 2 list the demographic features for the total sample.
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Study Design
The larger study was designed to answer several questions about the mental health needs of older medical patients, namely, the epidemiology of mental disorder, use of medical and psychosocial services, and preferences for mental health treatment. Research interviewers administered a survey in English or Spanish containing demographic questions, screening instruments for dementia, depression, alcohol abuse, and anxiety, and questions regarding preference for psychological services. Specific measures include the Short Michigan Alcohol Screening Test (SMAST; Rydon, Redman, Sanson-Fisher, and Reid 1992), the Beck Anxiety Inventory (BAI; Beck and Steer 1988), the Geriatric Depression Scale (GDS; Yesavage et al. 1982), and the Preference for Treatment Survey, a modification of the survey measure used by Arean and Miranda 1996. Because of the prevalence of vision and reading problems in this population, the research interviewers read the questions to the participants and recorded the participants' answers verbatim. The interview took an average of two hours.
Measures
Preference for Treatment Survey
This instrument, created by Arean and Miranda 1996, asks participants specific questions about their preferences for type of psychological services. We modified the original survey by adding questions about provider preference. Participants were asked if they needed help for their everyday problems, whom they would talk to from of a list of providers (primary care physician, nurse, or mental health provider), and if they would attend group therapy for mental health issues. Initially, when participants were asked which provider they would speak to if they had a problem, participants were asked to rank the list of providers in order of preference, but due to participant difficulty in providing rankings, this question was changed to a yes/no format. We also asked if they would attend classes on how to cope with depression, late-life problems, medical problems, or stress. This measure was translated into Spanish using both a forward-backward translation method and a consensus translation. After the instrument had undergone the forward-backward translation, the instrument was reviewed by a group of representative monolingual and bilingual Hispanic older adults, who then came to consensus on the proper translation of the instrument.
Psychological Symptoms
The 30-item GDS was used to determine severity of depression. For our Spanish-speaking sample, we used the Spanish translation by Taussig, Mack, and Henderson 1996, which in this study had good reliability (
= .95). Our estimate of the reliability of this instrument in the study sample was quite similar to those found in other studies ( = .84). We used a score of 15 to detect presence of psychological distress, a score recommended by the creators of the instrument. The BAI was used to assess severity of anxiety symptoms. We used a score of 18 to detect presence of significant anxiety, a score recommended by the authors. This is another self-report questionnaire, consisting of 21 questions that ask the degree to which particular anxiety symptoms have bothered the respondent over the past week. This instrument is a reliable one in older populations ( = .92; Wetherell and Arean 1997). We used the Spanish translation provided by the publisher of the BAI, and also found this translation to be highly reliable ( = .80). The SMAST is a screening for alcohol abuse that consists of 13 true/false questions. A score of 6 or more was used to determine alcohol problems. Our results show that the SMAST is a reliable instrument ( = .89). Spanish translations of the SMAST did not exist at the time of this study. Thus, we translated this instrument using the forward-backward translation method, followed by a consensus confirmation method. The reliability of our Spanish translation of the SMAST was good ( = .79).
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Results |
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Acceptance of Psychological Services
Seventy-nine percent of the sample indicated that they would use a psychological service of one type or another. Specifically, 72% of the sample said they would talk to at least one person on a list of providers if they had a problem. Of those providers, the primary care physician was the most frequently endorsed choice of provider for psychosocial problems, chosen by 61% of the entire sample. Mental health providers and nurses also appeared to be an acceptable choice among all groups in this sample, with as many as 44% of the sample indicating they would talk to these providers about their problems. Men and women showed similar preferences for providers, except that men were less willing to talk to a nurse about their problems (
2 = 4.46, p = .03).
Although more than 70% of the sample indicated that they would speak to a provider about their emotional problems, only 34% said they would participate in group therapy. However, 68% of the sample indicated that they would attend at least one of the psychoeducational class choices on our list. The most popular class was coping with medical illnesses, with 46% of the total sample indicating that they would attend. All other classes were endorsed by about one third of participants: 30% said they would attend classes about depression, 34% classes about stress, and 35% classes about problems in late life. The overall pattern for class preference did not vary by gender.
Acceptance of Psychological Services by Distressed Patients
Participants were considered to be distressed if they had a GDS score of 15 or higher, a BAI score of 18 or higher, or a SMAST score of 4 or higher. We found no demographic differences between the distressed and nondistressed groups in this sample, with the exception of health status. Distressed patients had significantly more chronic illnesses than nondistressed patients (t = 2.34, p < .05). The proportion of distressed people is presented in Table 1 . As shown in Table 3 , 67% of the distressed sample indicated that they would talk to one of the providers listed in the survey, with primary care providers being the provider most preferred (62%), and nurses and mental health providers both endorsed by 47% of the sample. There was no variation in the preference pattern by type of distress, and chi-square analyses revealed no significant differences in preference between distressed and nondistressed groups. Thirty-two percent of the distressed sample indicated that they would attend a group, which was similar to the nondistressed group. The class endorsed by the greatest number of people was the coping with medical illness class, with about 40% saying they would attend this class. Only 25% of the distressed sample would attend a class about depression, 31% would attend a class about coping with problems in late life, and 26% would attend a class about coping with stress. People who were not distressed by our definition expressed similar preferences, with the exception of the coping with medical illnesses class. More of the nondistressed sample would attend this class than the distressed sample (46% vs. 38%).
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Discussion |
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Our data suggesting that older primary care patients find psychological services an acceptable treatment option lend support to more recent studies on mental health treatment preferences in older adults. Although earlier studies show older adults did not find these services to be compelling treatment options (Zivian et al. 1994), more recent research indicates that, when given a choice for the treatment of geriatric depression, older adults will not only find psychological services acceptable, but will state that psychotherapy is more useful than antidepressant medication (Landreville et al. 2001; Rokke and Scogin 1995). These more recent studies are limited by the fact that participants did not rate their own preferences, but rather how useful they believed these treatments would be for older adults in general. However, the consensus between these studies and the current study indicate that there may be a trend toward increasing acceptance of psychological services among current and future cohorts of older adults. This change in the acceptability of psychological services may continue to grow, and thus primary care clinics that will be managing mental health problems in older adults may need to meet this growing demand for psychological services.
In this study, we were able to obtain information on older medical patients' preferred mode of psychological service. Group therapy and psychoeducational classes are often considered to be more efficient uses of staff resources, because a larger number of people can be treated in a shorter period of time. In addition, many mental health providers who treat older people believe that group interventions have the added benefit of social support and opportunities to interact with other older people experiencing similar psychosocial problems (Arean 1993). According to our data, however, only a third of the distressed sample would attend a group, while a majority indicated a preference for individual counseling and psychoeducational classes. This suggests that clinics with limited resources may consider the use of psychoeducational classes over group therapies in order to reach more older people in need. Further, our data on preferences for psychoeducational class topics indicates that while a class focused on coping with medical illnesses could potentially be used by a large proportion of older medical patients, only a small proportion of psychologically distressed primary care patients would attend this class. This finding suggests that older adults who are experiencing a significant number of psychiatric symptoms may be more interested in classes that address those symptoms. This finding has been found to be true in other studies regarding mental health treatment preference in younger populations (Alvidrez and Azocar 1999; Arean and Miranda 1996).
As an alternative to psycheducational classes, primary care clinics could offer individual counseling, because a majority of the people in this study indicated they would attend this type of service. There are several brief psychotherapy models designed for the primary care practice for older medical patients (for a review of these interventions, please see Stanley 2001). These interventions are all designed to be amenable to primary care practice and can be delivered by mental health and specially trained nonmental health professionals. In sum, our data suggest that to reach the largest number of older people in need of psychological services, individual counseling and/or psychoeducational classes may need to be part of the primary care clinic's armamentarium.
Our data on older patients' provider preference indicate that most patients would speak to their primary care provider about their problems and that more than half would speak with a mental health provider or nurse. This finding is in concert with others' studies that have found younger primary care patients are also willing to speak with mental health providers about their psychosocial problems (Kiraly, Coulton, and Graham 1982; Mickus, Colenda, and Hogan 2000). Because so many older patients in this study said they would go to their primary care provider for help, clinics considering the addition of psychological services should consider hiring mental health staff or training nurses in the use of psychological interventions and potentially involving the primary care provider in the initial stages of treatment. For instance, primary care providers could provide initial education about mental health services provided in the clinic and encourage the older patient to utilize these services. Our data further suggest that clinics may want to consider having a range of providers who can provide psychological services to accommodate patients who have a preference for provider type. In this study, men were less likely to say they would talk to a nurse about mental health issues, indicating a preference for mental health providers. Given the suicide rate in older men, clinics adding psychological services may be able to treat more of this high-risk population if mental health specialists are integrated into the primary care system.
A final important finding was that preference for psychological treatment did not vary by degree of psychological distress; participants who were highly symptomatic were not more or less likely to say they would use psychological services overall. One explanation for this finding is treatment preferences may not vary as a function of distress; those who do not find psychological services useful in general may not be more inclined to use them when they are distressed. Research on the preference for life-sustaining treatment shows that preferences for these interventions remain relatively stable despite change in health status: Most people who do not wish to use life-sustaining means prior to the onset of illness tend not to change their minds once they are ill (Danis, Garrett, Harris, and Patrick 1994; Everhart and Pearlman 1990; Gready et al. 2000; Kohut et al. 1997). This finding is particularly important because it suggests that preferences for treatment expressed by older adults who are not currently seeking treatment may accurately reflect their preferences once they feel they are in need. Research on the stability of mental health treatment preference over time is needed to confirm this interpretation of the data. Future research incorporating perceived need for services, as well as actual use of services, may help to elucidate this issue further.
A few caveats should be mentioned to better interpret the data presented here. First, the sample in this study is drawn from an urban setting in which many mental health resources are available for low-income elders. The data in this study may not fully describe the experience of older adults in rural settings, where services are limited and mental health utilization is consequently much lower (Bowling, Farquhar, and Browne 1991). Second, all data here are obtained through self-report. Although older people may indicate preferences for certain kinds of treatment, when actually presented with choices, their behavior may differ from their stated preferences. Third, our question about use of individual services may not accurately reflect a preference for therapy. Participants were asked if they would speak with any of a list of providers if they were having a problem. This could be interpreted as a one-time discussion or ongoing treatment. Although we cannot say with certainty that older adults would seek psychotherapy from the providers with whom they are willing to speak, it is still useful to know that older adults would be open to discussing mental health issues with a physician, mental health worker, or nurse.
Fourth, we did not assess level of interest in medication for mental health problems. Our primary goal was to assess interest in and acceptability of psychological treatments that could be added to existing primary care services. We did not include medication because it is already a routine component of the mental health treatment provided in primary care. We anticipated that most clinics would not ask patients to choose between treatments, but rather present them with the different treatment options available. For this reason, pitting psychological services against medication seemed to be an arbitrary exercise. Fifth, because participants had difficulty rank ordering their preference for different treatment options, preference was largely measured by the percentage endorsing each option rather than within-subject ranking of choices. Nevertheless, the results of this study are important because of the lack of systematic data on older patient preferences for type of treatment and provider preference.
Finally, these data should only be construed as applicable to the current cohort of older adults. As discussed above, treatment preferences may change as the current cohort of younger adults, who have more exposure to mental health treatment, ages. It is difficult to predict whether future cohorts of older people will be more or less amenable to psychological interventions, particularly given the increased use of antidepressant medication in the United States.
Despite the limitations discussed above, the results of this study add to the literature on the acceptability of psychological services in older primary care patients. Innovations in the integration of mental health services into primary care settings have recently attempted to incorporate psychological services as an alternative treatment option for older patients who do not wish to be treated with medication. The older adults in this study indicate that they would accept these services if offered to them, in particular individual counseling and psychoeducational classes.
Practice Concepts
The Forum
Book Reviews
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Acknowledgments |
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Received for publication April 12, 2001. Accepted for publication October 31, 2001.
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