A qualitative study on general practitioners' perspectives on late-life depression in Singapore-part I: patient presentations and behaviours

Abstract

Background: Detection and management of late-life depression largely relies on primary care. Yet in Singapore, older adults are unlikely to seek help for their mental health from their primary care providers. This qualitative descriptive study explores how late-life depression manifests to general practitioners (GPs) in the Singaporean primary care setting.

Methods: Twenty-eight private GPs practicing in Singapore were asked about their clinical experience with late-life depression during semi-structured group and individual discussions conducted online. Participants were purposively sampled across age, gender, and ethnicity (Chinese, Malay, Indian). Transcripts were analysed with reflexive thematic analysis.

Findings: To GPs, depression in older patients often manifests through somatic symptoms or subtle behavioural changes, only detectable through follow-ups or collateral history. GPs reported that older patients attribute depressive symptoms to normal ageing or do not mention them, particularly within an Asian culture encouraging stoic endurance. GPs perceived late-life depression as reactions to ageing-related stressors, with male, low-income, or institutionalised patients being at particular risk of insidious, severe depression. GPs noted ethnic differences regarding families' involvement in care, which they described as helpful, but sometimes stress-provoking for patients. Fear of burdensomeness or loss of autonomy/social role could prompt rejection of diagnosis and treatment in patients. GPs considered good patient-doctor rapport as a facilitator at every step of the care process, noting more favourable prognosis in care-concordant patients.

Interpretation: Depression in older adults in Singapore can be covert, with favourable outcomes relying on GPs' ability to pick up on subtle changes, assess patients holistically, and build rapport with patients and families.

Funding: This work was funded by the Division of Family Medicine Research Capabilities Building Budget under the project "Technology and Compassion: Improving Patient Outcomes Through Data Analytics and Patients' Voice in Primary Care" [NUHSRO/2022/049/NUSMed/DFM].

Keywords: Community mental health; Cross-cultural psychiatry; Geriatric psychiatry; Late-life depression; Old age; Primary care; Singapore.

Fig. 1

Schematic representation of main themes, subthemes, and meta-themes. Note. The themes progress from the top meta-theme “Encountering depression” to the bottom meta-theme “Dealing with depression”. Under each meta-theme, the theme on the right (in shades of green) explores GPs’ own impressions of late-life depression whereas the themes on the left (in shades of purple) describe patient perspectives as perceived by the GP. Themes are presented in bolded, white font and are further divided into two to three subthemes each, represented in italic font. The theme “Initial clinical picture as seen by the GP” (top right corner) details how depressive symptoms in older patients present to the GP initially. The theme “Construing patient perceptions of symptoms” (top left corner) describes GPs’ understanding of how patients perceive their symptoms. The theme “Understanding patient reactions to depression” (bottom left corner) details GPs’ comprehension of how older patients process the notion of having depression. The theme “Patient progression followed by the GP” explores GPs’ experience with late-life depression’s evolution. Finally, the theme “Patient-GP rapport” (central arrow) links the two meta-themes together by describing the relational factors between the patient and the GP that play a role at each stage.