Health Watch: Depression in America's Institutionalized Elderly

According to Eckert and Lambert (2002), "The psychological and emotional needs of older adults have been virtually ignored over the past century . . .by the year 2020, the second most disabling disease for the elderly will be depression" (p.5). Unfortunately, in primary care and long term care settings, depression continues to be under-diagnosed and under-treated (Ellen, 2001). Interventions that address depression in America's institutionalized elders are greatly needed and long overdue.

Social Networks and Social Support
Over the course of their lifetimes, the elderly will experience a natural, gradual deterioration of their lifelong social networks. Unfortunately, the loss of life long partners, spouses, and friends often leads to isolation and may trigger depression for this target group (GMHF, 2007). Therefore, an intervention that augments existing social networks and creates new ones might be beneficial for lessening the effects of depression among the institutionalized elderly. This article will describe how a health educator or administrator might use social networks and social support constructs to create a peer support network that offers emotional, informational, instrumental, and appraisal types of support within the extended care facility.

Incorporating social networks and social support concepts into an intervention can be very beneficial. Though these concepts do not themselves constitute theories, they do provide evidence for the link between health and social relationships (Heaney & Israel, 2002). The term social network refers to "a person-centered web of social relationships" and social support refers to "aid and assistance exchanged through social relationships and interpersonal transactions" (Heaney & Israel, 2002, p.187) Social networks and support concepts help us understand health behaviors, as well as guide designs for interventions that attempt to change health behaviors. Framed conceptually, social networks and support are believed to be the "starting point or initiator of a causal flow toward health outcomes" with many relationships exerting a reciprocal influence on those outcomes (Heaney & Israel, 2002).

Strengths and Weaknesses
There are both strengths and weaknesses that must be considered when applying the social networks and support concepts to an intervention. One strength of the social networks and support concepts is they can be applied to a myriad of health behaviors. They can also be applied across multiple levels of influence (Heaney & Israel, 2002). However, a weakness is that "there is unlikely to be a generic social network intervention that is effective for everyone" (Heaney & Israel, 2002, p. 205).

Use of Theory
The following is a conceptualization for a program intervention based on social networks and social support concepts. This particular intervention seeks to enhance the social networks of the depressed elderly in long term care facilities by developing new social linkages (Heaney & Israel, 2002). Fortunately, the community naturally shares many of the social networks and support concepts that define a strong network such as: having members who are similar ages and income levels (homogeneity), having those members be physically confined to a definite space or tight knit (geographic dispersion), and having members interact multiple times daily (density) (Heaney & Israel, 2002).

Intervention: To begin, the Geriatric Depression Scale (GDS) will be administered to elderly patients as a screening tool. The GDS is a simple, self-rating depression scale for screening depression in the elderly population (Merck Manual of Geriatrics, 2007) and (Ellen, 2001). In this intervention, the GDS will identify those patients who may have depression but have not already had this finding confirmed by a physician. For those who already have an affirmative depression diagnosis, it will simply provide a baseline measurement of severity. In order to be considered for participation in this intervention, patients must have taken the GDS and had the finding confirmed by a physician at some point. Patient interviews will be conducted to elicit additional program baseline measurements, such as perceived support and personal resource inventories (Hegelson, Schulz, &Yasko, 1999), for comparison at the intervention's conclusion.

The intervention's elderly population will be split into two groups: those lacking social networks and support, and those who perceive they have sufficient networks and support. Elderly residents in the intervention who indicate a lack of support will be placed in residential peer activity groups, while those with strong networks will undergo group educational discussions to enhance personal resources (esteem, perceived control). The goal of the residential activity group intervention would be to help the elderly meet and interact with their neighbors who also make their homes in the facility. Through physically appropriate social activities, such as Bingo Nights, domino or card tournaments, reading groups, or knitting classes, the elders in the facility will be able to form new friendships and enhance their social networks. Elders will meet in their selected residential activity groups 2-3 times per a week for 45 minutes to an hour.

Those who indicate the presence of a strong social network and feel that the support they are receiving is adequate, will participate in educational discussion groups that seek to improve coping skills and esteem. These educational discussion groups will also meet 2-3 times per week for 45 minutes.

Evidence that the Intervention will assist with the Problem
The intervention described above would be extremely beneficial to institutionalized elders who find themselves depressed. The enhancement of social support networks has been found to help a wide range health problems ranging from cancer to divorce (Hegelson, Schulz, &Yasko, 1999). Dean, Kolody and Wood (1990) agree that interventions for improving the social networks of the depressed elderly have also been successful. The above intervention should be helpful because, according to Thoits (1995), an individual's social network and support linkages "may help them reinterpret events or problems in a more positive and constructive light (as cited in Heaney & Israel, 2002, p. 189). This type of "reinterpreting" is critical for combating depression in any age group. Though the exact mechanisms by which social support and social networks contribute to the health of a person are not well defined, research has continued to validate their importance.

The enhancement of personal resources is very important whether individuals feel their networks are adequate or inadequate. However, research suggests that enhancing these resources has the greatest benefits for those who already have firmly, established networks. According to Hegelson et al. (1999), it was shown that an educational intervention increased self-esteem, body image, perceived control, and reduced uncertainty about the illness compared to peer discussions. For those with inadequate networks, peer groups were found to be most fulfilling (Hegelson et al., 1999). Though this study was done on older women with breast cancer, it would be interesting to see if the same logic holds for the depressed elderly population

Potential for Empirical Testing
Research had proven that improving social networks and social support is an effective method for improving health, particularly poor health brought on by depression. However, since not much attention has been given to mental health issues among the elderly, the entire gamut of geriatric health issues would benefit from empirical testing. According to Gallant (2003) out of all of the social support literature (29 studies/articles) discussing the management of chronic illness, in particular, her team found only three that were directed toward the elderly population. She writes. "Given the enormous prevalence of chronic illness among older adults, a great focus on this population is needed" (188).

Social support and self-management practices among the depressed elderly would be an important area of research for health professionals to consider. It would be interesting to see if Hegelson et al.'s (1999) finding, that some types of people benefit from or are harmed by support interventions that provide specific types of support (emotional, physical, instrumental), held true for the institutionalized elderly population.

References
Eckert, L. & Lambert, A. (2002). Beating the senior blues: How to feel better and enjoy life again. Oakland: New Harbinger Publishers.

Ellen, E.F. (2001). Detecting and treating geriatric depression. Geriatric Times. 2 (3). Retrieved March 27^th, 2007 from www.geriatrictimes.com/html/g010506.html.

Gallant, M. P. (2003). The influence of social support on chronic illness self-management: A review and directions for research. Health Education & Behavior, 30, 170-195.

Geriatric Mental Health Foundation. (2007). Depression in late life: Not a natural part of aging. Retrieved March 1^st from http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_latelife.html

Helgeson VS, Cohen S, Schulz R, Yasko J. 2000. Group support interventions for women with breast cancer: Who benefits from what? Health Psychol19(2): 107-114.
Merck Manual of Geriatrics, The. (2007). Psychiatric disorders: Depression chapter 33. Retrieved March 31^st, 2007 from http://www.merck.com/mrkshared/mmg/sec4/ch33/ch33a.jsp

Heaney, C.A., Israel, B.A. (2002). Social Networks and Social Support. In K. Glanz, B. Rimer, & F.M. Lewis, (Eds.) Health Behavior and Health Education. (pp.185-209) San Francisco: Jossey- Bass.