Geriatric Considerations for Collaborative Care for Depression in Rural Populations

As the baby boom generation reaches the age of retirement, projections predict a steady increase in the older population reaching 80.8 million in 2040 ¹. The census bureau reports that upwards of 20% of older adults in the U.S. currently live in rural areas. In some states, the faction of older adults is higher, reaching a proportion of 50% of their rural population ¹. This growing cohort exhibits rates of mental health conditions comparable to their urban counterparts, with one in five older adults reporting a mental health disorder, most commonly depression, anxiety, or cognitive impairment ². However, several studies warn of alarming shortages in the mental health workforce across rural areas around the country ^{3, 4}. Thus, the weight of mental health care in these underserved areas falls disproportionately on primary care clinics ⁵. In fact, primary care physicians are the primary mental health provider for two-thirds of patients living with depression in the United States ⁶. Given the prevalence of late-life depression (LLD), innovative models of care are necessary to adequately treat rural older adults receiving mental health treatment in the primary care setting.

The authors of this paper examine a possible solution: the Collaborative Care Model (CoCM) ⁷. Through a measurement-based care approach, CoCM consists of a consult-based approach, where a behavioral case manager and a psychiatric consultant are available to aid primary care physicians in diagnosing and establishing an adequate treatment plan for patients presenting with mental health concerns ⁷. While several studies had previously demonstrated the efficacy of CoCM, this paper is unique in its comparison of treatment outcomes in depression care between older (65+ years) and younger (18–64 years) adults in low-resource rural settings. This study may be limited in that the majority of participants only received one episode of care in the process, however the results show significant improvement in depressive symptomatology on the PHQ-9 when compared to younger adults ⁷. This analysis suggests that CoCM could potentially tackle the dire lack of mental health services in rural areas through a more restrictive but efficient use of psychiatric resources. This is particularly relevant given the complexity and the difficulty in properly identifying and treating LLD.

Renn et al. propose that the inherent flexibility of this care model allowed it to be successfully implemented in all ages. Although the clinical staff providing collaborative care did not have training specific for geriatric mental health, there are geriatric-related considerations that should be taken into account when treating depression in older adults. This includes factoring the pharmacodynamic changes that occur with aging which affects the appropriateness of certain pharmacologic treatments (such at Qtc prolongation with certain medications or anticholinergic properties of other medications). Also, screening and recognizing cognitive impairment is essential given the bidirectional relationship between cognitive functioning and depression ⁸.

While the criteria for diagnosing depression are identical across age groups, LLD can be more challenging to identify and effectively treat due to its chronic nature and more frequent relapses. LLD is also associated with poor treatment adherence and is often accompanied by a myriad of medical comorbidities and disability. In fact, depression prevalence has been shown to increase with overall medical burden ⁹. Many presenting symptoms for depression (ex: fatigue, sleep disturbances) are non-specific and are shared with other common geriatric conditions. They can also constitute commonly encountered side effects to a variety of medications, which is particularly challenging in the setting of polypharmacy. These realities could help explain the difficulties faced by general practitioners in properly identifying and treating LLD. One meta-analysis showed that primary care physicians were less successful at diagnosing depression in older adults than younger people, only identifying less than half of LLD cases ¹⁰. Comparable results would be expected at the federally qualified health centers (FQHCs) where the study is conducted and where one in five rural adults receives medical care ¹¹.

The authors indicate that the older adults in this study received additional follow up and had a longer treatment duration compared to the younger patients. This is a significant finding in the context of LLD which may require longer to treat (10–12 weeks compared to 4–6 weeks) ¹². Furthermore, LLD-specific considerations should include follow up after remission given the higher likelihood of relapse ¹³.

As the demand for behavioral health services continues to rapidly grow at FHCQs, several challenges remain for the successful management of LLD ¹¹. In order to improve diagnosis and treatment outcomes, it is necessary to consider the social factors specific to older adults living in rural locations ^{14, 15}. This population is more likely to have a lower socioeconomic status (SES) which can affect their prognosis ^{1, 15}. In fact, individuals with LLD and lower SES have been shown to have higher morbidity and mortality than individuals with LLD and higher SES ¹⁶.

Gender disparities also exist in the presentation of LLD: men are less likely than women to report typical depressive symptoms such as low mood or anhedonia ¹⁷. These differences in presentation could be attributed to cultural components, such as persistent “traditional” views on masculinity in the older generations and the pervasive stigma surrounding chronic mental illnesses ¹⁷. Additionally, grief is common in older adults and may complicate depression diagnosis and treatment ¹⁸. A comprehensive assessment that is not limited to the biological and psychological components of LLD but also includes the social context is therefore necessary for its effective diagnosis and treatment. CoCM could provide that through its multi-professional approach to patient care with the inclusion of a behavioral health care manager and communication with a psychiatric consultant as part of the treatment team ^{7, 15}.