Teoría de aprendizaje, enseñanza y evaluación

Accessing Support is rarely a straightforward strategy, and typically requires that the

person first overcomes personal and/or external barriers. Overcoming barriers represents the ways in which specific impediments to help-seeking were addressed. This usually occurs in the order in which they are encountered (Stanhope & Henwood, 2014). In the current study, Overcoming barriers was achieved through the sub-strategies of Resolving

personal barriers and Addressing external barriers.

Resolving personal barriers

The most common personal barrier identified by participants was Struggling to become

self-motivated to seek help. However, the inclusion criteria for the current study required

that participants were currently receiving professional treatment and/or support for depression. This indicated that participants had successfully motivated themselves to obtain a diagnosis of depression.

I think, I think, I think, I think. I procrastinate, procrastinate, procrastinate, procrastinate, so my thinking doesn’t get converted well enough into doing.

(Sean, 74 years)

For some, getting motivated depended on whether they were “having a good day”.166

Several reported that, on a bad day, their first challenge was to motivate themselves to get out of bed in the morning. To overcome this challenge, they typically considered what they would say to someone else facing the same problem, or focussed on the knowledge that they would feel better after getting out of bed and engaging in a certain activity.

I’ve had to push when I get really, really, really depressed. If I was talking to someone else, I’d say, “Get out of your pyjamas!”, or “Buy some flowers, or go

out and do something!” (Priscilla, 77 years)

Participants also faced an ongoing challenge of remaining motivated to optimise their physical and mental health over the medium and long term.

If I think back to those times when I was at my blackest, there would be days when I could barely walk. I was heavy and stiff and sore. But I would push myself to go swimming, because I just knew on some level it was something positive.

(Evan, 66 years)

I’m sure there are things out there that I would enjoy doing, but I’m just not

doing them through lack of motivation. (Bea, 67 years)

Although she acknowledged its influence on her mental health, Bea found it challenging to improve her physical health. However, a recent article in her local community newspaper about treatment options for depression had provided the impetus for her to contact a low-cost counselling service, through which she hoped to enlist support to maintain a healthier lifestyle through exercise and diet.

Another personal barrier concerned stigma. Although participants had overcome public self-stigma to seek help, several were still grappling with self-stigma.167 Hence, their fundamental views and knowledge of depression determined how a diagnosis was sought initially. Some avoided referring to their depression by name.

166 _{For people with depression, “having a good day” might comprise feeling energetic, getting things done at home, engaging in} activities outside the home and/or participating in group activities (Ahlström, Skärsäter, & Danielson, 2009).

I do have a sense of stigma about depression, I do really. [Without using the word ‘depression’], I’d say, “I’ll just take a day off today from all the things that

I normally do.” The trigger [impetus to seek help] was when I went into the

office and broke down … my colleague took me to the doctor and she [doctor]

immediately said, “Oh, you’re depressed.” (Priscilla, 77 years)

Personal barriers to Accessing Support were frequently overcome by external rather than internal motivation. For some participants, having a network of informal, or social, support played a role in their motivation. Sandra, for example, described how it was the prospect of an unexpected visitor arriving at her home that frequently prompted her to get out of bed in the morning.

Some days, I don’t want to get out of bed, but I’ve made a couple of neighbour friends and it’s only the thought that they might call me or call around, that I get out of bed and have a shower. If I hadn’t met anybody, I probably would spend

a lot of time in bed. (Sandra, 67 years)

Like Sandra, it was an external influence that motivated Vera and Bea to get going in the mornings—their pets. Several had pets who provided them with companionship and joy, while motivating them to get out of bed and to engage in physical activity.

If it wasn’t for my dog, I don’t know if I’d get out of bed, which is a bit scary. I’d rather get up and make a cup of tea and go back to bed, but we have to run

outside, so she gets me up. (Vera, 69 years)

I get up, have a shower, have breakfast. Feed the dog, feed the cat. I look after

my animals first … that often gets me back on track. (Bea, 67 years)

The benefits of pet ownership to people with depression—and other illnesses—are well documented (Cacioppo & Hawkley, 2009; Muldoon, Kuhns, Supple, Jacobson, & Garofalo, 2017). Although participants did not make a direct association between caring for a pet and their experience of depression, it was apparent from the data that having a pet provided impetus to get out of bed in the morning and required physical activity from participants. In addition, having a pet often led to casual conversations with others, when they were walking the dog or obtaining services for an animal.

Once they had motivated themselves into action, participants sought to access and engage with appropriate services and support. Generally, their first step was to obtain information

about depression and appropriate services, which, in turn, allowed them to actively participate in optimising their well-being.

Addressing external barriers

The most commonly reported external barriers encountered by participants wishing to harness support were stigma of depression in older age, ageism and difficulty accessing formal support. These barriers are consistent with those listed in the literature (Conner et al., 2015; Corrigan et al., 2015; Makris et al., 2015; Ouchida & Lachs, 2015). Although issues related to language and culture are common barriers to accessing support (McCann, Mugavin, Renzaho, & Lubman, 2016), they were not identified by participants.

Stigma associated with mental health issues, including depression, is one of the most common barriers to enlisting support (Conner et al., 2015).168 _{Most participants in the}

current study had experienced public stigma at some point. However, they noted a shift in community views, as information on mental health in general, and depression in particular, had become more available.

I think there is a stigma, because it’s perceived as being a mental illness. “He’s

got depression … he’s mentally ill … keep away from him.” (Vince, 74 years)

Thanks to the Internet, the whole world is being exposed to the concepts and the facts [about depression]. (Pete, 75 years)

Notwithstanding how stigma may prevent or delay help-seeking, participation in the current study required individuals to be receiving formal treatment for depression.169 The fact that participants had engaged with a health professional to receive a diagnosis and ongoing support indicated that they had managed to overcome the complex elements that constitute stigma. For most participants, the two main strategies for Addressing external

barriers related to stigma had been to identify and enlist the support of a GP who was

understanding and knowledgeable about depression, and to exercise judgement about sharing the diagnosis and experience of depression within informal networks.

168 _{Stigma is addressed in detail at 2.3.3.1 (Help-seeking barriers).} 169 _{See 4.5.2.1 (Selection and recruitment of participants).}

As far as GPs and things are concerned, it’s trial and error and you just have to

ask people and suss [check] them out. I’m dealing with something that I’ve had

for 50 years. (Lorna, 68 years)

Overall, participants had reached a point at which their quality of life was being compromised by their undiagnosed depression. The search for a diagnosis and treatment for their undiagnosed depression became more important than any experience or fear of stigma. To illustrate, Vince described how he had overcome stigma by realising that his overall quality of life was more important than a fear of being judged.

I couldn’t get out of bed. I’d be lying there arguing with myself to get out of bed.

I’d lie there until 3 o’clock. And so I went over and saw [my GP]. He just picked

it [depression] straight away. I think there is a stigma, but it doesn’t particularly

worry me now. As long as I know about it [depression] now, it [stigma] doesn’t

worry me. (Vince, 74 years)

Those who felt they were treated differently because of their age found Accessing Support

even more challenging. Numerous examples were given of health professionals, especially GPs and psychiatrists, patronising participants, listening less to their views and cutting short the clinical consultation time spent with them. This raises concerns of ageism within healthcare professions (Ouchida & Lachs, 2015).

I think they [health professionals] are only too happy to treat you as if you

deserve less consideration, or as if you're less intelligent [because of your age].

(Gillian, 73 years)

Those whose depression symptoms had initially been attributed to their age, or confused with “normal ageing”, felt that their age had been a barrier to receiving a timely diagnosis and treatment.

I don't know if it's my age. They [GPs] just didn't think there was anything wrong.

Getting the diagnosis [of depression] was the biggest relief I've had for 15 years

… because, see I thought my heart was “crook” [bad]. (Roger, 82 years)

If you get a doctor that truly is interested in you, never let them go, because

they’re rare at this stage of the game [age]. Everybody treats us like we’re old

Ageism as a barrier to accessing support was also indicated by the limited treatment options offered to participants. Although all participants had initially been prescribed antidepressants, few had been referred for psychotherapy. Laidlaw et al. (2008) suggest that relatively low referrals for psychotherapy may reflect the erroneous belief that older adults are less likely than younger adults to benefit from this therapy.

[GPs] could send you off for counselling, but I’ve never been sent off for counselling. I’ve never had a GP suggest that I go for counselling or any other

form of psychological anything. I’ve always sorted it out myself. (Sue, 68 years)

Another barrier to be overcome by participants wishing to enlist support for depression concerned the complex concept of access. In the current context, access concerned affordability, physical accessibility—such as availability in a specific geographical area—and acceptability of healthcare services. Consistent with the literature (Haralambous et al., 2009; Patterson-Kane & Quirk, 2014), issues of geographical availability of formal support were most apparent for participants who were living outside the metropolitan area, particularly those in smaller regional or rural communities.170

Most of the GPs are very second rate. The further you go out from the city centre,

the worse the quality becomes. (Marina, 65 years)

You can’t do it [get better] without good professional help, but it’s pretty hard

to find … you have to really keep chipping away at it. (Adam, 66 years)

No participants had received formal support from mental health nurses. There was little to no awareness of the role of mental health nurses, nor an understanding of how to access them. Consequently, additional barriers to formal support included long waiting times and difficulties establishing new relationships when health professionals relocated or retired.

The trouble is getting to see [my GP]. You’ve got to be sick three months in

advance to try and get him, you know? So, the problem I find these days is actually making an appointment, being able to get an appointment. That’s the

tricky thing. (Vince, 74 years)

My GP is younger than me, but will no doubt be retiring in the not too distant future. We get on very well together. He and I are of a similar mind and I value

170 _{No participants in the current study lived in remote communities, where support and treatment for mental health issues have been} identified as major challenges (Haralambous et al., 2009).

and trust his judgment. When he does retire, I have no idea what I’ll do. (Vernon, 76 years)

In examining the various aspects of access, Gulliford et al. (2002) highlight the fundamental concept of meeting the needs of different groups of people with equivalent needs. However, even individuals with equivalent needs have their own priorities, values and preferences for support. Thus, each participant’s concept and experience of access was complex and subjective, and strategies to overcome barriers to accessing support were highly individualised.

There are various organisations that can help. I don’t want this to sound sexist, but some might be for women, some might be for men. It depends. See, men think

totally differently to us, very differently. (Sarah, 71 years)

It depends on what sort of counselling you have, but it’s got be an active relationship. You know, we ought to be given an opportunity to assess who is going to provide us with the best support. I think we’ve got to be able to know

which counsellor is going to suit our needs. (Rita, 67 years)

Financial barriers to formal support were identified by several. Notwithstanding a correlation between financial strain and depression (Almeida et al., 2012), none attributed their financial circumstances as a cause of their depression. However, several indicated that they had to carefully manage their financials, in order to access support.

Wherever possible, I go to one of the free services. I went to a woman

[psychologist] who charged $120 for 40 minutes. I can't afford that! That sort of

thing is just right out [unaffordable]. (Bea, 67 years)

Maintaining private health insurance coverage was one of the main strategies for overcoming issues relating to financial access to support, although this depended on the type of cover they subscribed to. Another strategy for overcoming financial constraints was to restrict themselves to “bulk billing” services,171 while others sought low-cost or no-cost services.

171 _{In Australia, bulk billing occurs when health professionals accept the government’s Medicare benefit as full payment for a service,} as outlined in the Medicare Benefits Schedule (Department of Human Services, 2016). For health professionals who request a greater fee than the Medicare benefit, individuals must contribute to the payment. This out-of-pocket expense, commonly referred to as a “gap payment”, is the amount to be paid, over and above what is received back from Medicare or a private health insurer.

I still keep private health insurance, which is getting so expensive. My GP bulk bills me, you know. It must be difficult if you have to pay a huge amount of money.

I don’t have enough money coming in. (Erica, 70 years)