toms to a physical illness (Heithoff, 1995; Knauper and Wittchen, 1994). Further, older patients are often non-adherent with depression medications (NIH Consensus Development Panel on Depression in Late Life, 1992), taking only 50–70 percent of prescribed doses. Their low adherence to depression medications results partly from cost, from polypharmacy (i.e., reluctance to add another medication to the substantial number they have to take for other disorders), and from sensory and cognitive impairment (US DHHS, 1999).
One unexplored reason for lower treatment adherence or dropout may also be a mismatch between clinicians and patients in treatment preferences. Primary care physicians treating older people overwhelming prefer to prescribe medications rather than psychotherapy (Kaplan et al., 1999). Yet people with depression who attend primary care prefer counseling over medication—a finding based on a mixed age population (Dwight-Johnson et al., 2000). There are no studies that directly assess older people’s preferences for treatment and analyze findings by gender.
The detection of suicidality in older persons is a major opportunity considering that older people frequently make contact with their primary care physician before suicide. Some studies suggest that up to 70 percent of older people visit their clinician within 30 days of death (Barraclough, 1971; Caine et al., 1996; Conwell et al., 1991). Primary care clinicians are strongly in favor of suicidal assessment in depressed older patients (Harman et al., 2001a). Yet suicidality is complex to recognize in older persons for two main reasons: co-morbidities and infrequency of contacts with mental health specialists (Caine and Conwell, 2001). Co-morbid chronic illnesses are common in older people, they increase risk for depression and suicide, and they make symptom presentation more complicated to disentangle (US DHHS, 1999). To make accurate diagnoses, clinicians have to sort through symptoms of physical illness, depressive symptoms, and side effects of medications. When assessing for suicidality, only 44 percent of primary care providers ask about firearms access, despite the fact that firearms are the method of choice in older suicides (Kaplan et al., 1999). In this survey, general internal medicine physicians were the least likely primary care specialty to ask about firearms and reported the least confidence in assessing and treating suicidality. There is more recent evidence of improvement in physician attitudes about asking older patients about firearms access (Harman et al., 2001a).
There are no professional guidelines for screening older people for depression, substance abuse, or suicidality; however, the Surgeon General’s National Plan calls for screening as a minimum standard of care for hospice and nursing homes supported by Medicaid and Medicare.